Transcript Nursing Care of Patients with Alterations in the GI tract

Nursing Care of Patients with
Alterations in the GI tract
C. Cummings RN,EdD
A & P of GI system
GI tract
• Hollow muscular tube, lumen surrounded by 4
tissue layers:
– Mucosa- innermost, thin layer of smooth muscle
and exocrine cells (layer that sloughs off w/ ulcerative colitis)
– Submucosa- connective tissue
– Muscularis- smooth muscle
– Serosa- outermost, connective tissue
GI tract
• Function:
– Secretion- secretes HCL acid, digestive enzymes
– Digestion- mechanical and chemical, food is
broken down to chyme
– Absorption- from GI tract to blood supply
– Motility
– Elimination
– (absorbs all the minerals, w/out a GI tract you will
die… stomach has pH of about 2… very acidic… if
it leaks out it will cause big problems)
GI tract
• Nerve Supply
– Intrinsic stimulation by myenteric plexus in smooth
muscle and submucosa plexus in inner layer
– Autonomic system- Parasympathetic stimulation by
vagus nerve, connects with intrinsic system
• Vagus-stimulates motor and secretory activity and relaxes
spinchters
– Sympathetic system- thoracic and lumbar splanchnic
nerves slows movement, inhibits secretions and
contracts spinchters
– (Parasympathetic slows down the GI tract… fight or
flight… don’t have to go to bathroom while trying to
save yourself)
Nerves of GI tract
Mouth
• Function:
– Mastication, taste, begin movement
– Glands produce 1 L of saliva/day
– Saliva contains mucin and salivary amylase with begins to break
down CHO
– Oral preparatory phase- food is softened, made into a “bolus”
and tongue moves to the back of the mouth
– Oral phase- tongue presses bolus against hard palate, elevates
the larynx and forces the food bolus to the pharynx, triggering
swallowing (coughing opens the flap)
– Pharyngeal phase- soft palate elevates and seals nasal cavity,
inhibits respirations and allows esophagus to open
– Esophageal phase- is when bolus enter at cricopharyngeal
juncture, peristalsis now takes food to the stomach
– All this takes about 10 seconds !
Esophagus
• Canal about 10 in long, passes through the center of the
diaphragm
• Upper end is the upper esophageal sphincter, at rest it is
closed to prevent air from entering the esophagus
• Lower end is the lower esophageal sphincter, it sits at the
gastroesophageal junction, at rest it is closed to prevent reflux
of gastric contents, this is where GERD occurs (problems w/
the LES… doesn’t shut all the way, chocolate & pepermint
keeps the sphincter open, large bolus of food can keep it
open… GERD)
• Function- to propel food and fluids and prevent reflux
• Mucous is secreted to move the food along
• Cardiac sphincter of the stomach opens to allow the food to
enter
Stomach
• Digestive and endocrine organ, in midline and LUQ
• Four regions:
– Cardia- narrow part that is distal to the gastroesophageal
junction (part closest to the heart)
– Fundus- left above the GE junction
– Body or corpus- largest area
– Antrum- pylorus, is the distal portion and is separated from the
duodenum by the pyloric sphincter, prevents backflow from the
duodenum (at end)
– Surface is covered in rugae or folds and have smooth muscle for
motility
– Has intrinsic and extrinsic nerves
– (reglan stimulates the vagus nerve, causes contractions… gets
food out of the stomack)
Function:
Stomach
Parietal cells secrete HCL acid and intrinsic factor, which absorbs
B 12, without it, what anemia can occur? Pernicious anemia…
makes you weak & tired… red beefy tounge, B12 injections &
pill… pill not as effective… water soluble vitamin
Chief cells secrete Pepsinogenpepsin (breakdown enzyme)
Cephalic phase- sight, smell and taste of food, regulated by vagus,
begin secretory and contractile activity
Gastric phase- G cells in the antrum secrete gastrin, which causes
HCL and pepsinogen to be released. HCL changes pepsinogen to
pepsin, which digest proteins. Mucous and Bicarb
(prostoglandins) are secreted to protect the stomach wall (from
the acid produced)
Intestinal phase- chyme produced empties into the duodenum
and causes distention, this produces secretin, which stops the
acid production and gastric motility !
Stomach
Small Intestine
• Longest portion of the GI tract, 16-19 ft.
• Made up of 3 sections:
– Duodenum- first 12” and is attached to the pylorus. The CBD
(common bile duct) and pancreatic duct join to form the
ampulla of Vater and empty into the duodenum at the duodenal
papilla. This surrounded by a muscle, called the Sphincter of
Oddi
– Jejunum- middle 8 ft portion
– Ileum- last 8-12 ft. The ileocecal valve separates the ileum form
the cecum of the large intestine
– Inner lining is made up of intestinal villi and folds of mucosa and
submucosa for digestion.
– (all 3 sections for digestion)
Small Intestine
• 3 main functions:
– Movement- mixing and peristalsis
• Moves chyme by segmental contractions and mixes
with enzymes
– Digestion- enzymes produced by the intestinal
cells make:
• Enterokinase, peptidases, lactase, maltase and sucrase
• Help to digest CHO, proteins and lipids
– Absorption- absorbs most of the nutrients from
food, takes 3-10 hours for the contents to pass
through
• Major organ for absorption
Small intestine
Large Intestine
• Ileocecal valve to the anus, 5-6’, lined with
columnar epithelium tha thas absorptive and
mucous cells.
• Cecum- is the beginning, dilated pouch like
structure, appendix is attached to the base
• Colon has 4 divisions:
– Ascending, transverse, descending and sigmoid
• Rectum- last 6-8” to the sphincter muscles and
anus
• Main function is absorption of water (problem w/
ileostomy… watery feces b/c water hasn’t been
absorbed yet)
Large Intestine
• Function:
– Movement- segmental contractions, to allow time
for the water and electrolytes to be absorbed
– Absorption- absorbs most of water and
electrolytes, reduces fluid volume of chyme and
creates a more solid mass for elimination
– Elimination- 3-4 strong peristaltic contraction /day
triggered by colonic distention in proximal large
intestine to propel contents to rectum, until urge
to defecate.
Nursing Assessment
• Family history- GI disorders, cancer
• Personal history- what kinds of things?
• Diet history- anorexia, dyspepsia- what is that? What
should you question them on for diet history?
• Health history- diarrhea, constipation, # and color of
stools, change in wt. or appetite
• Abdominal pain–
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P- precipitating
Q-quality- how intense, severe, type
R-region or radiation
S- severity scale- 0-10
T-timing- when did it first occur, duration and frequency
Physical Assessment
• Abdomen:
– Inspection- skin, symmetry, rashes, lesions, scars
– Auscultation- all four quadrants, normally heard in 515 seconds, normal, hypoactive or hyperactive, listen
1 full minute. What is borborygmus (very hyperactive
bowel sounds)? Why would bruits be heard? (aortic)
Why would there not be bowel sounds heard?
– Percussion- tympanic- air filled, dull- organ
– Palpation- light and deep palpation, masses,
tenderness, look for guarding (w/ appendicitis, no
pain felt until you release… McMurry’s sign)
Lab tests
• CBC- anemia
• Oncofetal antigens- CA19-9
and CEA (carciniogenic
embryonic antigen), used to
monitor for cancer in the GI
tract
• Ca- decreased in
malabsorption
• K – decreased with
vomiting, diarrhea
• (also decreased Magnesium
can be a problem)
• Xylose absorptiondecreased indicates
possible malabsorption in
the small intesting (tells if you
can absorb carbs… not common
& won’t ask question about)
• Stool for Occult blood
• Stool for ova and parasiteinfection
• Stool for fecal fat- increased
with Crohn’s disease and
malabsorption
•
•
Radiology
Abdominal films- air in bowel and
masses
Upper GI and small bowel- pharynx
to duodenojejunal junction, barium
swallow and SBFT
– NPO 8 hours before, drink
barium, then lie, stand and turn
in multiple directions to view
movement of barium
– SBFT- drink more barium and
view passage
– After drink fluids to pass
barium
– (almost all the tests need GI
prep, get rid of stool, gas & free
air so when you put dye in you
can see… NPO 8 hrs before
test)
• Barium enema
– Large intestine, done for
obstructions, masses, not done
is perforated colon or fistulas
– Only clear liquids for 12-24
hours prior, NPO, given bowel
prep like Golytely
– Insert rectal catheter with a
balloon and give 500-1500 ml
of barium and hold
– Can be uncomfortable, must
take a laxative after
– (eat or drink chalk dye)
– (Must get rid of the barium
afterwards… prep afterwards,
will turn to concrete if it stays
in gut)
Diagnostic Tests
• EGD- esophagogastroduodenoscopy (what I saw in GI lab)
• Visualize esophagus to duodenum, NPO prior, given versed
and fentanyl, maybe cetacaine to inhibit gag reflex, pass tube
and visualize structures, can take biopsies
• Gag reflex may not return for 1-2 hours after, so no eating or
drinking until then (put tounge blad in throat to see if it
returned)
• Colonoscopy- large bowel, take biopsies and remove polyps,
have a bowel prep prior, given versed and fentanyl prior;
Capsule enteroscopy is now done to visualize, apply a data
recorder to the abdomen and the patient swallows the
capsule
• Proctosigmoidoscopy- like colonoscopy, only a rigid tube, less
invasive and does not require the cleansing of the
colonoscopy
Colonoscopy
Case Study
• 72 year old male admitted with chest pain and
nausea. He states that he awakens in the night
with pain in his chest and nausea.
• What would you do first to evaluate his
condition?
• What diseases could he have? (GERD, hiatal
hernia, ulcer)
• What kind of lab work would you like to obtain?
(cardiac enzymes, CBC, electrolytes)
• What past medical history do you need? (heart
problems, GERD, GI bleed, what did he eat, when
did he eat, drink alcohol
Case Study
• Your patient starts to have hematemesis.
• What does this mean? (GI bleed)
• Is this life-threatening? (yes, lots of elderly
die from GI bleed)
• What interventions should be done? (give
blood & normal saline, will probably have to
go to surgery to fix problems… cut out part of
stomach that is bleeding)
• What could have caused this condition? (if
peritonitis, can get massive infection,
mesentary is aggravated by blood & other
stuff, makes stomach pull in fluid from other
areas, get rigid boardlike abdomen (TEST
QUESTION)
Case Study
• It is determined that your patient can be treated nonsurgically. What medications would be given? (should
have 3) Protonix, prilosec & nexium (proton pump
inhibitor, stimulates parietal cells) H2 (histamine)
blockers, zantac, axid & pepsic… there will be many test
questions about meds on exam!!! Also give an antacid
(malox, gaviscon… seep in stomach, bicab based & coat
stomach & bring up pH level) Reglan can help to empty
stomach (prokinetic med)
• What type of teaching would be done for prevention?
(cut down on alcohol, smoking, no spicy foods, take
zantac before you eat)
• If he needed surgery, what could have been done?
Esophageal Problems
• GERD- gastroesophageal reflux disease (most common
esophageal problem… obesity… eating too much)
• Reflux causes esophageal mucosa to be irritated by the
effects of gastric and duodenal contents, results in
inflammation
• Causes:
– Inappropriate relaxation of the LES, sphincter tone is decreased
(pH of 2 coming into esophagus where pH is normally much
higher)
– Irritation from refluxed material
– Delayed gastric emptying, gastric volume or intra-abdominal
pressure is increased
– Abnormal esophageal clearance
GERD
• Refluxed material has a pH of 1.5-2, whereas
the esophagus normally has a pH of 6-8
erosive esophagitis, once inflammed, the
mucosa can’t eliminate the material as
quickly. This leads to increased blood flow
and more erosion. Gastric acid and Pepsin
cause the tissue injury.
• Can lead to Barrett’s epithelium- thicker, but
can be cancerous, can also cause hemorrhage,
aspiration pneumonia, asthma, laryngitis and
dental deterioration.
GERD
GERD
• Physical Manifestations:
– Dyspepsia- heartburn, substernal or retrosternal
burning that moves up and down in wavelike
fashion, pain may radiate to neck or jaw or back,
worsens when bends over, strains or lies on their
back, occurs after meals and last 1-2 hours,
helped by fluids (to flush, but don’t drink fluid w/
the meal… drink afterwards) and staying upright
– Regurgitation- food entering throat without
nausea, watch for cough (classic sign), hoarseness
or wheezing (because of aspiration into lung…
biggest GI complication is aspiration)
– Hypersalivation- water brash in response to
reflux, fluid without sour or bitter taste
GERD
• Physical Manifestations
– Dysphagia and Odynophagia- difficulty swallowing,
esophagus may be narrowed by inflammation or tumor,
odynophagia- means what?
– Chronic cough, mostly at night
– Atypical chest pain
– Belching and flatulence or bloating
• Diagnosis:
– Endoscopy, 24 hour ambulatory pH monitoring- pass a
small tube into esophagus and monitor pH levels
GERD
• Nursing Diagnoses:
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–
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What diagnoses would apply to these patients?
1. altered nutrition
2. risk for dehydraion
3. electrolyte imbalance
4. acute pain (maybe)
• Interventions:
– Diet therapy- what type of dietary modifications would be
appropriate?
– Certain foods decrease LES pressure- chocolate, fat and mints.
Also, smoking and alcohol decrease
– Spicy foods irritate the esophagus and Carbonated can increase
gastric pressure
GERD
• Lifestyle changes:
– How should they sleep? (propped up on pillows)
– What things increase intra-abdominal pressure?
(ascites, liver failure, cancer in GI tract, obesity,
pregnancy, Cushing’s, renal failure… fluid presses on
stomach & gives GERD, respiratory problems)
• Drug therapy:
– Goal is to inhibit gastric acid secretion, accelerate
gastric emptying and protect the gastric mucosa
– Antacids:
• Elevate the pH and deactivate pepsin, good for heartburn,
take 1 hour before and 2-3 hr after a meal
• Name 2 antacids. (malox, mylanta, gaviscon)
GERD
• Drug therapy:
– Histamine Receptor Antagonists
• Decrease acid, help promote healing of the esophagus
• Name 2 common ones sold OTC (generic ends in “dine”)
– Proton Pump Inhibitors
• Main treatment for GERD, long acting inhibition of
gastric acid secretions by inhibiting protom pump of
parietal cell, can reduce by 90%/ day
• Name 2 proton pump inhibitors (generic ends in “zole”
once a day or q 12 h at most))
• Other therapies:
GERD
– Consider medications that may lower LES pressure (make it
worse)- oral contraceptives, anticholinergics, sedative,
tranquilizers, B-adrenergic agonists, nitrates and Ca channel
blockers (they all slow gut movement, then reflux occurs as
food stays longer in stomach)
– Prokinetic drugs- for emptying and peristalsis- metoclopramide
(reglan)
– Endoscopic:
• Enteryx procedure- spongy material in LES to tighten it Stretta
procedure- radiofrequency energy through needles to inhibit the
vagus nerve
– Surgical:
• Laparoscopic Nissen Fundoplication (main surgical procedure for
GERD, takes stomach muscle up & wrap around esophagus to
make it able to tighten, used a lot for hiatal hernia)
• Angelchik esophageal antireflux- anchors the LES in the abdomen
to increase sphincter pressure (not as common)
Hiatal Hernia
• Protrusion of stomach through the esophagus
• Sliding or Rolling hernias
• Symptoms are similar to GERD patient (pain 1 to 2 hours
after you eat… usually will vomit non digested food…
food hasn’t even gotten into the stomach)
• Nonsurgical management is like GERD
• Surgical:
– Lap Nissen Fundoplication (same as GERD)- reinforces the LES,
wraps a portion of the stomach around the distal esophagus to
anchor it
– Post op- risk for bleeding (biggest risk), infection and respiratory
complications (don’t want to take a deep breath b/c it hurts
• Have an NGT, begin PO once BS return
• Watch for gas-bloat syndrome and air swallowing
• MAY GET questions about when can you eat… must have bowel
sounds return before eating TEST!!!
Nursing Diagnosis: GERD
• Impaired Nutrition: less than body requirements
– What things can be done to improve their intake and decrease
pain?
– What would be the expected outcomes?
– How would you monitor their progress? (albumin to check
intake)
• Acute Pain r/t irritation of the esophagus
– What interventions can be performed?
• Risk for aspiration r/t reflux of gastric contents
– How can you determine that this does not occur?
Peptic Ulcer Disease
• Mucosal lesion of the stomach or duodenum
• Peptic (any type of GI ulcer) can be gastric
(top) or duodenal (bottom)
• PUD- gastric mucosal defenses become
impaired and they can no longer protect the
epithelium from acid and pepsin
• Three main types of ulcers:
– Gastric
– Duodenal
– Stress (school, life, surgery)
Peptic Ulcers
Gastric Ulcers
• Gastric mucosa is protected by mucous and bicarbonate
that maintain a normal pH on the gastric tissue and
protects it from acid
• Gastromucosal prostaglandins increase the barrier’s
resistance to ulceration by producing mucous (aspirin &
NSAIDS inhibit prostaglandins… irritates GI)
• Integrity is improved by a rich blood supply to the
mucosa
• If there is a break in the mucosal barrier, HCL acid
damages the epithelium. Gastric ulcers result from backdiffusion of acid or dysfunction of the pyloric sphincter.
Gastric Ulcers
• If the pyloric sphincter doesn’t function, bile
backs up into the stomach, produces H+ ion back
diffusion and  mucosal inflammation
• Toxic agents and bile destroy the lipid plasma
membrane of the mucosa. Delayed gastric
emptying also affects. What drug can be given to
improve emptying?
• Gastric Ulcers are deep and penetrating and
usually are in the lesser curvature of the stomach,
near the pylorus
• (high fat & protein meals stay in stomach MUCH
longer & aggravate… BRAT diet settles … bananas,
rice, applesause & tea)
Duodenal Ulcers
• Occur in the first portion of the duodenum.
• Deep lesions that penetrate through the mucosa and submucosa into
the muscle layer. The floor of the ulcer consists of a necrotic area on
granulation tissue and surrounded by fibrosis
• High gastric acid secretion, pH levels are low for long periods
• Protein rich meals, calcium and vagal excitation stimulate acid
secretion
• Hypersecretion, rapid emptying of food from stomach reduces the
buffering effect of food and delivers a large acid bolus to the
duodenum
• Inhibitory secretory mechanisms and pancreatic secretion may be
insufficient to control the acid
• Many patients have H. pylori infection. H. pylori produces urease
changes urea to ammonia, H+ ions released contribute to damage
(bacteria release hydrogen ions, greater acid levels)
Stress Ulcers
• Acute gastric mucosal lesions occurring after
and acute medical crisis or trauma
• Associated with head injury, major surgery,
burns, respiratory failure, shock and sepsis
• Bleeding is the principle manifestation
• Multifocal areas often in the proximal portion
of the stomach and duodenum
• Usually elevated HCL acid levels and hospital
stay longer than 11 days
• (trauma, GI tract slows down, acid just sitting
in stomach, causing trouble)
Complications of Ulcers
• Hemorrhage:
– 15-25% of patients with PUD, most serious
complication
– Most often with gastric ulcers and elderly
– After initial bleed, 40% have a recurrence if
untreated, especially if H. pylori untreated and no
H2 antagonist
– Have Hematemesis- bleeding at or above the
duodenojejunal junction
– Smaller amounts of bleeding are seen as melena
(blood in stool), more often seen in duodenal
ulcers, stool may appear black.
Complications of Ulcers
• Perforation (biggest complication)
– Gastric or duodenal may perforate or bleed
– Stomach or duodenal contents can leak into the abdomen, acid
peptic juice, bile and pancreatic juice empty through the
anterior wall of the stomach into the peritoneal cavity
– Sudden, sharp pain in midepigastric region and spread over the
abdomen
– Amount of pain correlates with the amount and type of GI
contents spilled
– Abdomen is tender, rigid and boardlike, go into a fetal position
to decrease tension of abdomen
– Chemical peritonitis, bacterial septicemia and hypovolemic
shock follow paralytic ileus and possible death KNOW******
Complications of Ulcers
• Pyloric obstruction
– Small number of patients, vomiting caused by stasis
and gastric dilation
– Obstruction occurs at the pylorus and is caused by
scarring, edema, and/or inflammation
– Gastric outlet obstruction abdominal bloating,
nausea and vomiting (between pyloris & duodenum…
can’t pass the food, narrowing)
– May go into metabolic alkalosis from loss of large
quantities of acid gastric juice (H+ and Cl-)
– Hypokalemia may result from the vomiting
Complications of Ulcers
• Intractable disease
– Disease may recur throughout life, stressors, inability to adhere
to therapy, no longer responds to management
• Cause:
– Use of NSAID’s- break down the mucosal barrier and disrupt the
protection by COX inhibition. Cause the depletion of
prostaglandins, have a high rate of recurrence
– Drugs such as Theophylline, corticosteroids (prednisone) and
caffeine stimulate HCL acid production
– H pylori infection is transmitted person to person
– 50% of people with PUD have a first or second line relative with
PUD, usually the same type of ulcer
Physical Manifestations
• Epigastric tenderness, midline between the umbilicus
and xiphoid process
• May begin as hyperactive BS, then diminish if perforation
• Dyspepsia- discomfort around the epigastrium, sharp,
burning or gnawing
– Gastric- occurs in upper epigastrium with localization to the left
of the midline and may be relieved by food (1 to 2 hrs after eat,
relieved by food that neutralizes…)
– Duodenal- located to the right of the epigastrium, occurs 90 min
to 3 hours after eating and awaken at night, may be aggravated
by spicy foods, onions, alcohol, caffeine and ASA, NSAIDS (just
remember the pain will be later & more midline & to the right)
Physical Manifestations
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Vomiting may occur
Appetite is maintained, unless pyloric obstruction occurs
Fluid volume deficit, if bleeding, take orthostatic BPs
Watch for Hematemesis and melena
Monitor H & H
Dx- barium swallow and EGD
Test for H. pylori is IgG serologic testing and urea breath
testing
Nursing Diagnoses
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Name 5 diagnoses r/t PUD
1.
2.
3.
4.
5.
What would be an expected outcome for this
disorder?
Nursing Interventions
• Drug Therapy
– Goals: Provide pain relief, eradicate H. pylori, heal
ulcerations, prevent recurrence
– Eliminate H. pylori- triple treatment: TEST QUEST
• Bismuth product (pepto-bismol, antacids to coat the
stomach) or a a proton pump inhibitor (prilosec) and
two antibiotics (metronidazole (Flagyl) and tetracycline
or amoxicillin)
• May have to take medications 4 x’s/day for 14 days and
often they don’t complete the series
Nursing Interventions
• Drug therapy:
– Hyposecretory drugs- reduce gastric acid
secretions
• Antisecretory agents- proton pump inhibitors, “zole”
ending, suppress H, K-ATP ase enzyme system of gastric
acid production, can be given IV or PO
• H2 receptor antagonists- block histamine-stimulated
gastric secretions, “dine” ending
• Prostaglandin analogues- reduce gastric acid secretion
and enhance gastric mucosal resistance to tissue injury,
Misoprostol (Cytotec, coats GI tract) helps prevent
NSAID induced ulcers, does cause uterine contraction
and can not be given to pregnant women
Nursing Interventions
• Antacids
– Buffer gastric acid and prevent formation of pepsin, heal
duodenal ulcers
– Aluminum hydroxides (may cause constipation) and magnesium
hydroxide, may affect those with renal impairment (Mg causes
diarrhea, malox)
– Take 2 hours after meals to reduce the H+ion load
– Calcium carbonate (TUMS) is an antacid, but it triggers gastrin
release and causes a rebound acid secretion
– Antacids can interact with other drugs- tetracycline, dilantin,
also may have a high sodium content
• Mucosal Barrier fortifiers- sucralfate (Carafate) supplies
a protect coating by forming a complex with proteins,
binds with bile acids and pepsin, should be given on an
empty stomach and not within 1 hour of eating or taking
antacids
Nursing Interventions
• Diet therapy
– Bland diet may help to relieve symptoms
– Food may help to neutralize acids, rebound may
follow when more acid is released
– Avoid foods that stimulate gastric acid release
– They are??
– Yoga for stress relief, herbals, such as licorice and
vitamins may help
Gastrointestinal Bleeding
• What would be a nursing diagnosis for GI
Bleeding?
• 1. hypovolemia, anemai, altered tissue
perfusion
• 2. altered oxygenation (lack of blood), acute
pain….
• What would be the expected outcome and
how would you know that this was met?
Gastrointestinal Bleeding
• Hypovolemia Management
– Monitor vital signs and I&O, assess for bleeding and
vomiting, monitor CBC
– Fluid and electrolyte replacement is necessary, usually
NSS or LR, may give PRBC’s or FFP
– Watch for signs of shock, what are they?? (drop in BP
& elevated HR)
• Bleeding reduction
– Monitor labs, insert and NGT to decompress the
stomach, give an H2 blocker, may need gastric lavage,
what is that??
– Ice lavage, cold saline, irrigate & then suction it back
out… thought to stop the bleeding in the stomach)
Nursing Interventions for GI bleeding
• Endoscopic therapy
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EGD, can do:
cautery on the bleeding sites
inject a sclerosing agent with diluted epipherine
Laser therapy
Clip the bleeding vessel
• Somastatin Analogue- Sandostatin (given IV &
also used to stop diarrhea) may be used to
suppress gastric acid secretion on parietal and
chief cells, vasoconstricts the splanchnic arteries
which reduce hemorrhage
Surgical management of GI bleeding
• MIG- minimally invasive gastrectomy- laproscopic to
remove chronic gastric ulcer or treat hemorrhage, make
several small incisions, may partially remove the stomach
and/or vagotomy to control acid secretion
• Gastroenterostomy- creates a passage between the body
of the stomach and jejunum, reduces motor activity in
the pyloroduodenal area, diverts acid, a vagotomy (cut
nerves) may be done with it to decrease secretion. Can
do truncal, selective or proximal. Billroth I- connect to
duodenum, Billroth II connects to jejunum
• Pyloroplasty- widens the exit of the pylorus and empties
the stomach
Billroth 1
Postop care for GI surgery
• NGT management
• Monitor for complications of:
– Dumping syndrome- vasomotor symptoms, rapid emptying of
gastric contents into the small intestine, shifts fluid into the gut
and cause abdominal distention, 30 min after eating have
vertigo, tachycardia, syncope, sweating, pallor, palpitations. 90
min later have excessive amount of insulin released, this
dizziness, palpitations, diaphoresis and confusion
– Should eat smaller amounts, take less liquid with food, high
protein and fat, low CHO diet, sandostatin may be given and
pectin with food
– (Stomach doesn’t know the stomach is smaller after
surgerystomach thinks there is too much sugar (high carb or
high sugar) and the pancreas releases too much insluin… pt goes
into hypoglycemia… diaphoretic, cold, clammy, tachycardic
Postop Care of GI surgery
• Reflux gastropathy- bile reflux, when pylorus is
bypassed, bile in stomach and have abdominal
discomfort and vomiting
• Delayed gastric emptying- usually resolves in 1 week,
edema at the anastomosis or adhesions may occur,
hypokalemia, hypoproteinemia and hyponatremia may
also cause
• Afferent loop syndrome- duodenal loop is partially
obstructed, pancreatic and biliary secretions fill the
intestinal loop, it becomes distended painful
contractions, bloating and pain 20-60 min after eating (a
lot of N & V after you eat… )
Post op GI surgery
• Recurrent ulceration- occurs in 5% of patients, may have
ulcers at the anastomosis
• Nutritional management:
– Deficiencies of B12, folic acid and iron
– Impaired Ca metabolism and reduced absorption of Ca and
vitamin D
– Shortage of intrinsic factor, r/t the resection and rapid emptying
of the food
–  pernicious anemia- weak, anemic, atrophic glossitis- beefy
shiny tongue
– Give back B12 and folic acid
Pernicious anemia
Irritable Bowel Syndrome
• Chronic GI disorder, with chronic or recurrent
diarrhea, constipation, abdominal pain and
bloating
• Spastic colon, impairment of the motor/sensory
function diarrhea alternating with constipation
• Usually begin as a young adult
• Stress, anxiety and familial factors may
predispose patient
• (from spastic colon & stress… Parasympathetic is
not stimulated… gut slows down… constipation
with diarrhea)
IBS
• Assessment:
– History of bowel pattern
– Manning criteria- abdominal pain relieved by
defection, abdominal distention, sensation of
incomplete evacuation of stool, presence of
mucus with the stool (don’t have to remember
this)
– Pain in LLQ and cramps, may be tenderness and
air in bowels
– Dx- flexible sigmoidoscopy or colonoscopy if >40
– Barium enema
IBS
• Interventions
– Diet therapy- limit caffeine, alcohol, beverages with
sorbitol (artificial sweetners), take in fiber and bulk,
30-40 gm/day
– Drug therapy:
• Bulk forming laxatives (Metamucil)
• antidiarrheals (loperamide, immodium, make sure they
regulate how often… can cause severe constipation & dilated
bowels if they take it too often)
• anticholinergics (bentyl, to decrease GI spasms)
• antidepressants (elavil)
• 5-HT4 agonists(Zelnorm, stops GI tract pain & cramping) for
prokinetic activity (allow to pass smoother), imitates
serotonin to stimulate peristalsis
– Stress management- relaxation techniques
– (big problem is what they eat… need more fruits &
veggies, fat is bad, need more fiber
Nursing Diagnoses
• Constipation r/t low residue diet and stress
– What can be done to manage this?
• Diarrhea r/t increased motility of intestines
– How can this be corrected or treated?
• What can be done to correct constipation and
impaction? (better to take fiber than a
laxitive)
• What role may analgesics play in constipation?
• (Opiods slow down gut a lot)
Colorectal Cancer
• 95% are adenocarcinomas, most come from
adenomatous polyps
• 2/3 occur in rectosigmoid region
• Can metastasize through blood and lymph, liver most
common site with 15-30% spread there, can also go to
the lungs, brain, bones and adrenals
• May form fistulas into bladder and vagina
• Genetics- autosomal dominant disorder- familial
adenomatous polyposis (multiple polyps) only 1%, 100%
malignant, usually starting at age 20. Also, hereditary
nonpolyposis colorectal cancer- autosomal dominant,
10% of cancers, develop by age 45
• (colon cancer treated w/ chemo.. Major complication is
diarrhea & bleeding… colon cancer, 3rd leading cause of
death… spreads easily to liver, lungs-most common)
Colorectal cancer
• 75% have no known cause (diet thought to
have a lot to do w/ it)
• Age is a risk factor
• Dietary- decreased bowel emptying time,
foods with carcinogens- red meat, fatty food,
fried meats and fish, concentrated sweets
• High fat diet increases bile acid secretion and
anaerobic bacteria
• Irritable bowel diseases can make you more
prone to colorectal cancer
• Third most common malignancy
Colorectal cancer
• Manifestations:
– Rectal bleeding, anemia and change in stool
– Gas pains, cramping or incomplete evacuation
– Hematochezia- bright red blood when in rectum
– Tumors can grow large when in upper abdomen,
mostly liquid stool, more pain when in lower
– Tests- stool for occult blood, CEA, barium enema,
CT of abdomen
– Colonoscopy or sigmoidoscopy
Colorectal cancer
• Nursing Diagnoses- Name 4 diagnoses, associated
with colorectal cancer
• 1. anxiety
• 2. anticipatory grieving
• 3. altered elimination, pain,
• 4. impaired nutrition
• What would be the expected outcomes?
• (“this is the one that will be altered elimination &
impaired nutrition”)
Colorectal cancer
• Nonsurgical management:
– Duke’s staging classification
• A- tumor has penetrated into, but not through the bowel wall
• B- tumor has penetrated through the bowel wall
• C-tumor has penetrated through the bowel wall and there is
lymph node involvement
• D- tumor has metastasized to distant sites
• Radiation therapy (problem is it can’t be localized to
gut… often have problems w/ other areas, will change
normal cells & make them cancerous… leukemia later)
• Drug therapy- chemotherapy IV 5-FU and leucovorin,
side effects are diarrhea, mucositis, leucopenia and
mouth ulcers (stomatitis, affect, mouth all GI, diarrhea, N
& V & bone marrow suppression)
– Eloxatin, Camptosar, Avastin (closes off blood vessles from
tumor… finds rapidly growing cells & shuts off their blood
supply) are also being used, along with monoclonal antibodiescetuximab
Colorectal cancer
• Surgical management:
– Colon resection- removal of tumor and lymph nodes
– Colectomy- colon removal
– Abdominal perineal resection (A & P)- removes
sigmoid colon, rectum and anus, colostomy is
performed (colostomy & superpubic cath for life…
very invasive procedure)
– Colostomies may be ascending, descending, sigmoid,
transverse or double barreled (if majority of colon has
to be taken out..)
– Stool returned depends on the site of the colostomy
Colostomy
Colorectal cancer
• Postoperative Care:
– Colostomy management
• What types of nursing diagnoses may accompany this
procedure?
• How should the stoma appear?
• Report any bleeding, breakdown of the sutures from the wall
and signs of ischemia or necrosis
– Wound care management- JP drains, monitor for
infection
– Fluid volume deficit and electrolyte imbalance
– (empty bag when 1/3 to ½ full, keep it dry, w/
descending colostomy they can put a cap on it & don’t
have to wear a bag all the time)
Colorectal cancer
• Teaching:
– Colostomy care- what kinds of things should be
covered? (change bag every 7 days)
– Dietary measures to control stool and gas, what
would they be? (no beer, broccoli, gas forming
foods)
– Psychological adjustment to the colostomy, what
diagnosis relates to this?
– Grief and family coping- what resources may be
needed?
– Genetic testing if familial type
Intestinal Obstruction
• Partial or complete
• Mechanical- bowel is physically obstructed by adhesions,
tumors (food or adhesions… )
• Nonmechanical- paralytic ileus or adynamic ileus,
neuromuscular distrubance- slow movement or backup
(could be from anesthesia or narcotics)
• Contents accumulate at or above the obstruction
distention, peristalsis increases to aid movement,
stimulates more secretions more distention edema
of the bowel, increased capillary permeability
• (metabolic alkalosis, can die from shock… too much can
can make you acidotic … stomach pH)
Intestinal Obstruction
• Plasma leaks into the peritoneal cavity and trapped fluid
decreases the absorption of fluid and electrolytes into
the vascular space reduced blood volume and
electrolyte imbalances, can  hypovolemic shock
• Can also lead to metabolic alkalosis if high and there is a
loss of gastric acid, if low, metabolic acidosis occurs with
the loss of alkaline fluids
• Bacterial peritonitis and septic shock can also occur from
the release of endotoxins
Intestinal Obstruction
• Adhesions account for 45-60%, r/t scar tissue
• Intussusception- telescoping bowel (slides
inside itself) and volvulus- twisting of the
bowel
• Paralytic ileus (usually from meds or surgery)decreased peristalsis from trauma, toxin or
autonomic, can result from surgery, MI’s, rib
fracture, pneumonia, peritonitis and vascular
insufficiency from heart failure or shock
Intestinal Obstruction
• Assessment:
– History of symptoms and occurrence
– Abdominal pain and cramping
– Obstipation, vomiting with brown and foul
smelling
– Borborygni above the obstruction, then absent
– Abdominal distention and tympanic abdomen
– Abdominal films and CT of abdomen
– WBC elevated in some cases
Intestinal Obstruction
• Nonsurgical management:
– NGT to decompress to LCS (remove contents)
– Nasointestinal tubes- Miller-Abbott, mercury balloons and
migrate down the intestine by peristalsis, don’t irrigate with
fluid- it will increase edema at the obstruction
– Fluid and electrolyte replacement- NPO, give NSS or LR, replace
K (always replace K)
– Pain control- not normally given, opioids mask pain and
peritonitis
– Antibiotics if suspect perforation
• Surgical management:
– Exploratory laparotomy
Case Study
• 24 year old female admitted with frequent
bloody diarrhea stools, weight loss and anemia.
• What do you suspect? Colitis, crones disease
• What labwork should you do? CBC, platelet,
chemistry K & Mg)
• What treatment may be needed? (diet, meds to
decrease inflammation… related to some process
that has cause the bowel to swell…
autoimmune… allergic reaction in the gut)
Case Study
• Your patient tells you that the diarrhea has been
occurring for months.
• How do you differentiate between U.C. and Crohn’s
disease?
• Colitis is the colon, crone’s disease can be anywhere in
the bowel…
• ulcerative colitis is the sloughing of the inner layer… lots
of bleeding & diarrhea
• Pt w/ crones disease: more complications: invades all 3
or 4 layers of the gut… bouts of constipation w/
diarrhea…, can have fistula into rectum & bladder… more
complications than colitis
• What may be her treatment options? Surgery to resect &
possibly ostomy
Case Study
• How do you help your patient decide about a
colostomy?
Pt. education
• If she does want a colostomy, what type of teaching
needs to be done?
Chronic Inflammatory Bowel Disease
• Ulcerative Colitis and Crohn’s
• Ulcerative Colitis:
– Remissions and exacerbations
– Loose stools with blood and mucous 10-20/day
– Poor absorption of nutrients and thickening of the
colon wall
– Abdominal distention and cramping
– Complications are: hemorrhage, perforation,
fistulas and nutritional deficiencies
– May be familial tendency, inflammation r/t
response to normal flora
Chronic Inflammatory Bowel Disease
• Crohn’s disease
– Terminal ileum, patching involvement through all
layers of the bowel
– Deep fissures and ulcers occur
– 5-8 loose stools/day, rarely bloody
– Complications are:
• Fistulas (biggest problem), nutritional deficiencies
– Cause is thought to be mycobacterium
paratuberculosis, genetic predisposition
Ulcerative Colitis
• Manifestations:
– Abdominal pain, bloody diarrhea, tenesmusuncontrolled straining
– Dx- barium enema
• Nursing Diagnoses:
– Diarrhea r/t inflammation of the bowel
– Acute and chronic pain
– Imbalance nutrition: less than body requirements
– Disturbed body image
Ulcerative Colitis
• Diarrhea management– Drugs- salicylate compounds- Sulfasalazine
(Azulfidine) inhibits prostaglandins to reduce
inflammation, also use Asacol, Pentasa
– Corticosteroids- Prednisone to decrease edema
– Immunosuppressive- cyclosporine
– Antidiarrheals
– Monoclonal antibody- Remicade neutralizes the
activity of tumor necrosis factor and prevents
toxic megacolon (gut stops & fills up w/ toxins…
can kill you w/in matter of days)
Ulcerative Colitis
• Diet therapy:
– NPO at first, then TPN, may have low fiber or low
residue, what foods would be included? (salad,
raw veggies…)
• Surgical management:
– Total Proctocolectomy with permanent Ileostomy
– Total colectomy with a continent ileostomy
– Total colectomy with ileoanal anastomosis and
ileoanal reservoir or pouch
• Postop- teaching for ostomy, pain control and
monitoring for GI bleeding and fluid volume
deficit
• A Colostomy is when only part of the large
intestine is removed whereas an Ileostomy
involves the removal of the whole of the large
intestine and often the rectum as well. The
distinguishing feature between a colostomy
and an ileostomy is that in a colostomy, the
stoma is made out of the large bowel and the
stoma is therefore a little bigger than for an
ileostomy where the stoma is made from the
small intestine. Both colostomies and
ileostomies can either be permanent or
temporary. A Urostomy is when the bladder is
bypassed or removed
• Historically, the standard operation for
ulcerative colitis has been removal of the
entire colon, rectum, and anus. This operation
is called a proctocolectomy (Illustration A) and
may be performed in one or more stages. It
cures the disease and removes all risk of
developing cancer in the colon or rectum.
However, this operation requires creation of a
Brooke ileostomy (bringing the end of the
remaining bowel through the abdomen wall,
Illustration B) and chronic use of an appliance
on the abdominal wall to collect waste from
the bowel
Crohn’s Disease
• Aggravated by bacterial infection, inflammation and
smoking
• History of fever, abdominal pain and loose stools, weight
loss
• Steatorrhea is common- fatty stools
• Fistulas may occur between bladder and vagina
• Drug therapy- same as UC, except may take
metronidazole (Flagyl for anaerobic bacteria in gut) if
fistulas and imuran as an immunosuppressant
• Diet therapy- may be on TPN, supplements like ensure,
vivonex
Crohn’s Disease
• Monitor for fistulas- infections, skin problems,
malnutrition, fluid and electrolyte imbalances
• Fluid and electrolyte therapy- what would this
entail?
• Name one antidiarrheal.
• Surgical management:
– Bowel resections
– Fistula repairs
– Ileostomies may also be required to rest the bowel
or repair damaged areas.