Transcript gastrointestinal nursing

GASTROINTESTINAL
NURSING
Digestive Tract Disorders
2015
The quality of our lives
improves immensely when
there is at least one other
person who is willing to
listen to our troubles.
—Mihaly Csikszentmihalyi
© Kagan Publishing
Anatomy and Physiology of the Digestive
Tract
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Mouth
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Pharynx
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Muscular structure shared by the digestive and respiratory tracts
It joins the mouth and nasal passages to the esophagus
Esophagus
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Where teeth, tongue, and salivary glands begin food digestion
Long muscular tube that passes through the diaphragm into the
stomach
Stomach
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Churns and mixes food with gastric secretions until a semiliquid
mass called chyme
Anatomy and Physiology of the Digestive
Tract
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Small intestine
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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
Anatomy and Physiology of the Digestive
Tract
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Large intestine and anus
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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
Age-Related Changes
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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
Nursing Assessment and
Health History
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?? 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???
Diagnostic Tests &
Procedures
Gastrointestinal
System
Stool Specimens
O&P
 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)
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Esophagoscopy
Gastroscopy
Gastroduodenoscopy
EGD
ERCP
ENDOSCOPIC TESTS ( for
lower GI system)
 Colonoscopy
 Proctoscopy
 Sigmoidoscopy
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
Therapeutic Measures &
Related Nursing
Interventions
With GI Patients
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??
Types of Tubes
 Nasogastric
- (NG)
 Gastrostomy – (G-tube)
 Jejunal – (J-tube)
 Percutaneous – (PEG)
Figu
Total Parenteral Nutrition –
(TPN)
 Nutritionally
complete
 Used when GI system not
functioning
 Short or long term
Figu
Critical Thinking Exercise
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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 patient’s fingerstick blood
glucose is 250 mg/dl, and the patient’s
temp is 102 F and the nurse notes puralent
drainage at the catheter insertion site.
Pre-Op Nursing
Interventions
For GI surgery patients
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
Digestive Disorders
Medical Anorexia
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Loss of Appetite Caused by:
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Nausea, decreased sense of taste or smell,
mouth disorders, and medications
Emotional problems such as anxiety,
depression, or disturbing thoughts
Anorexia
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Medical diagnosis
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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
Anorexia
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Assessment
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Record chronic and recent illnesses,
hospitalizations, medications, and allergies
Female patient’s obstetric history
Symptoms: pain, nausea, dyspnea, extreme
fatigue
The functional assessment reveals patterns of
activity and rest, usual dietary patterns, current
stressors, and coping strategies—all can affect
appetite
Anorexia
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Interventions
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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
Obesity
 20%
over ideal body wt.
 Morbid obesity= 2X
normal body wt.
http://www.medscape.com/featur
es/slideshow/future-ofhealth/obesity?src=emailthis
Complications
CV disease
 Diabetes
 Respiratory difficulties
 Musculoskeletal problems
 Emotional and social
isolation
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Causes
Caloric intake > expenditure
 Heredity
 Emotional stress/psychosocial
factors
 Slowed metabolism
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Medical Management
 Weight
reduction diet
 Exercise
 Medication
 Counseling
Surgical Treatment
 RNYGBP
 VBG
 LBP
 Liposuction
 Dumping
Syndrome
Show what you know…
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List 3 Nursing Diagnosis & related Nursing
Interventions for the:
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OBESE PATIENT
Disorders of the Mouth
Dental Caries
 Destructive
process of tooth
decay
 Causes:
 Bacteria
 Poor oral hygiene
Prevention
 Frequent brushing and
flossing
 Dentist visit 2X/yr
 Good nutrition
 Fluoride
Treatment
 Removal
of diseases
portion of tooth and filling
 May need dentures
 If untreated, may lead to
periodontal disease
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
DISORDERS OF THE
TEETH & GUMS
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…
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Assessment…?
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Nursing Diagnosis….?
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Interventions….?
Oral Cancer
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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
Risk Factors
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Tobacco use
Alcohol use
Poor nutrition
Chronic irritation
http://www.oralcancerfoundation.org/
dental/slide_show.htm
Treatment
Chemo
Radiation
Surgery
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
Esophageal Cancer
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Not common, poor
prognosis
Middle or lower portion of
esophagus
No known cause
Predisposing Factors
 Cigarette
smoking
 Excessive alcohol intake
 Poor oral hygiene
 Eating spicy foods
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
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Assessment….?
Nursing Diagnosis….?
Interventions….?
Nutrition
Anxiety
Risk for infection, injury
Esophageal Diverticulum
 Esophageal
out-pouching
 Zenker’s Diverticulum
 “Bad breath” due to
accumulation of food in
diverticulum
http://en.wikipedia.org/wiki/Zenk
er's_diverticulum
Treatment
 Bland
diet
 Antacids
 Anti-emetics
 Surgery
Pre-Op Nursing
Measures
 Semi-fowlers
 Small
meals
 Loose clothing
Disorders Affecting
Digestion
And Absorption
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
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
Medical Treatment
Avoid increased intraabdominal 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
Nissen Fundoplication
THINK !!
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Describe your Post-Op Nrsg
Interventions for this patient?
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” ???
Signs & Symptoms
 Burning
sensation that
moves up and down,
commonly after meals
 Intermittent dysphagia
 belching
Med Treatment &
Nrsg Care
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Same as for hiatal hernia
Drug therapy may include:
Zantac, Reglan, Prilosec &
antacids
Fundoplication if required
Patient Teaching
 Avoid
ASA and NSAIDS
 Chew food well
 Avoid eating 2 hrs. before
bedtime
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
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…..
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List 3 Nursing Diagnosis and related
interventions when caring for the patient
with gastritis
What teaching would you do with this
patient???
Peptic Ulcer
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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
Causes
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Bacterium H. pylori
ASA, NSAIDS
Physical trauma (shock,burns)
Foods or conditions that cause
excessive gastric acid secretions
Comparison of Peptic Ulcers
GASTRIC
DUODENAL
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Incidence
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Incidence
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Ulcer depth
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Ulcer depth
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S/S
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S/S
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Complications
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Complications
Very Important Patient
Teaching
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1) Limit milk products
2) No baking soda
Complications of Peptic Ulcers
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Hemorrhage
Perforation
Peritonitis
Obstruction
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
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Dumping syndrome pg. 813
Sx occur within 20 min of eating
Bloating, flatulence, cramps &
diarrhea
Diaphoresis, anxious, shaky
Malabsorption--> Malnutrition
THINK…
 What
teaching would you
provide to the patient
experiencing Dumping
Syndrome??
Stomach Cancer
 “Silent
neoplasm”
 Poor prognosis
 No early s/s
 Late s/s: vomiting, ascites,
abd. Mass, enlarged liver
Risk Factors
 H-pylori
infection
 Pernicious anemia
 Chronic gastritis
 Family history
Treatment
 Chemo
 Radiation
 Surgery
Health Promotion Considerations
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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???/
Disorders Affecting
ABSORPTION &
ELIMINATION
Malabsorption
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1)
2)
Intestinal absorption of
nutrients is reduced
Two examples are:
Celiac sprue/disease
Lactase deficiency
Signs & Symptoms
 Steatorrhea
 Malnutrition
& weight loss
 Abdominal pain, cramping
 Bloating
 diarrhea
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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THAT’S IT…!!
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YOUR DONE
WITH GI UNIT 1
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ON TO UNIT 2…..