Transcript GI Problems and Ineterventionsx

Gastrointestinal
Problems &
Ineterventions
Presented by Joanna Shedd, MS, CNS,
RN
Digestive system
• Alimentary canal
– Mouth to anus
• Accessory organs
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Salivary glands
Liver
Gallbladder
Pancreas
GI tract – Digestion
• Mechanical and
chemical
changes food
undergoes
• Stomach
– Fundus
– Body
– Pylorus
Mucosa Layer
• Lines alimentary canal
• Surface area for acids, bases, mucus, &
enzymes
• Mucosa is folded with grooves and pits
Peristalsis
• Movement propelled along
GI tract
• Rhythmic layer of smooth
muscle
• Absorption of nutrients
and water during
peristalsis
GI tract
• Prevent reflux
• Sphincter muscles
– Cardiac
– Pyloric
• Regulate the
stomach and
duodenal opening
Stomach secretions
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HCl
Bicarbonate
Pepsinogen
Intrinsic factor
Mucus
Prostaglandins
Prostaglandins
• Cause the arteries to
widen or constrict
• Influence blood clotting
• Stimulate pain nerve
endings
• Reduce stomach acid
secretion
• Relieve asthma
Primary glands
• Cardiac
• Pyloric
• Gastric – largest in number
Gastric gland
• Chief cells
• Secretes pepsinogen
(inactive form of
pepsin)
• Activated at a pH of 2
• Breaks down proteins
in diet
Gastric gland
• Parietal cells
• Secrete 1 – 3L of HCl in
the lining of stomach
• Keeps pH between 1 and
4 to properly digest food
• Secrete intrinsic factor –
needed to absorb B12
• Primary site of action for
drugs
Gastric Juice
• Combined secretions
from Chief cells and
Parietal cells
• Most acidic fluid in body
• pH 1.5-3.5
Disease processes
• Gastritis – inflammation of mucosa
• GERD – gastroesophageal reflux disease
• Peptic ulcer disease – break in gastric
mucosa
• Gastric
• Duodenal
• Heliobacter pylori – gram negative
bacillus
Gastritis
• Inflammation of
the gastric or
stomach mucosa
• Acute or chronic
Pathophysiology
• Gastric mucous
membrane becomes
edematous
• Hyperemia occurs
• Mucosa undergoes
superficial erosion
• Potential for
hemorrage
Gastroesophageal Reflux Disease
• Weakening of esophageal sphincter
• Inflammation or erosion of esophageal mucosa
• Reflux of acid from the stomach into the
esophagus
• Associated with obesity
• Similar symptoms as hiatal hernia
Symptoms of GERD
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Heartburn with belching
Heartburn after fatty or acidic foods
Increased burning if laying down after eating
Can lead to esophagitis or ulcers or strictures
Pts frequently self treat with OTC meds
Risk factors for Peptic Ulcer
(PUD)
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Family hx of PUD
Blood type O
Smoking
Caffeine
Drugs: glucocorticoids,
ASA, NSAIDs
• Excessive psychological
stress
• Infection with H. pylori
Symptoms of Duodenal
Ulcer
• Gnawing or burning upper
abd pain
• Pain disappears with food
intake
• Nighttime abd pain
• Nausea/ vomiting
• Hemataemesis
• Black, tarry stools
Symptoms of Gastric
Ulcer
• Pain may continue even
after a meal
• Anorexia
• Weight loss
• Vomiting
• Less common than
duodenal
mass
ulcer
Non-pharmacologic Tx of
PUD
• Lifestyle changes
• Stop smoking, alcohol
use
• Reduce stress
• Herbal: Ginger
Pharmacologic Treatment (Tx)
• Goals: immediate relief from
symptoms
• Healing of the ulcer
• Prevent future recurrence
• Medication will depend on:
– Disease
– Severity of symptoms
– Over-the-counter (OTC) vs.
prescription (Rx)
H2 Receptor Antagonists
• H1 – allergy
• H2 – increases acid secretion in stomach
• Competitively block H2 receptor of acid
producing parietal cells
H2 Receptor Antagonists
• Increase gastric pH
• Reduces the volume of gastric acid
secretion
• Reduce the concentration of the
secretions
H2 Antagonists – Uses
• Hypersecretion of stomach
acids
• Gastro-esophageal reflux
• Treatment and prophylaxis of
duodenal ulcers
• Prevention of upper GI bleed
in critically ill patients
• Adjunctive therapy for NSAID
use
H2 Antagonists – Nursing
• Decrease absorption of drugs that
require an acidic GI environment
• Decrease absorption of H2 Antagonist
with antacids
• Assess GI discomfort
• Periodic evaluation of blood counts,
gastric acid tests, renal/ hepatic tests
H2 Antagonists – Nursing
• Elderly – CNS effects of drowsiness,
dizziness, confusion, headache
• Liver and kidney function – may need
smaller doses with impaired function
• Decrease absorption of vitamin B12 with
prolonged use – increase in diet
• Iron supplements
H2 Antagonists – Education
• Take last dose at
bedtime - better
suppression of nocturnal
acid
• Raise HOB for GERD
clients to decrease reflux
• Safety / fall precautions
• No meal intake 2 hours
prior to sleep
H2 Antagonists – Education
• No caffeine, alcohol,
harsh spices,
chocolate, or
peppermint in diet
• No smoking
• No ASA
• Call MD for bloody
stools or increased
abdominal pain
Proton pump inhibitors
• Binds irreversibly the
hydorgen/ K+ adenosine
triphosphatase (H+, K+ATPase) enzyme on the
secretory surface of
gastric parietal cell
• Blocks the final step in
acid production
Proton pump inhibitors (PPIs)
• Inhibits both basal and
stimulated gastric acid
secretion
• Blocks over 90% of 24
hour acid secretion
• Can make patient
achlorhydric (without
acid)
PPIs – Uses
• GERD maintenance therapy
• Long term treatment of active duodenal
ulcer (Prilosec)
• Active benign gastric ulcers
• Treatment for H. Pylori (Prilosec/ Prevacid)
• Hypersecretory condition – Zollinger-Ellison
syndrome
PPIs – Nursing
• Monitor for GI symptoms or
headache
• Effect of med – decreased GI
reflux or heartburn
• Frequency, consistency, and
color of stools
• Report GI bleeding, abd. pain
& heartburn
PPIs – Education
• Take meds prior to meals
• Do not crush or chew
• Difficulty swallowing, open
capsules sprinkle on food
• Can give with antacids
• If given NG, flush with lots of
water
PPIs – Education
• No smoking, alcohol use,
foods that cause gastric
discomfort
• Beneficial bacteria –
yogurt or acidophilus
• Sleep with HOB elevated
– 30 degrees
Antacids
• Chemical compounds that
buffer or neutralize HCl in the
stomach
• Increases gastric pH
• Stimulate mucus,
prostaglandins, and
bicarbonate secretion in
gastric glands
• Decreases pepsin activity
Antacids – Uses
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Hyperacidity related to PUD
GERD
Heartburn
Replacement of minerals –
Calcium
• Usually has rapid onset of
action and lasts 20-40 min if
patient is fasting
Antacids – Adverse
• Systemic alkalosis – rare, will
take a lot of meds
• Sodium overload
• Rebound acid production after
discontinuance
• Renal calculi
• Decrease, bind or inactivate
many drugs
Antacids – Nursing
• Baseline assessment of patient’s pain/
nutritional status
• Sensitivity to medications containing metals
• Document response to medication
• Document frequency and consistency of
stools
Antacids – Nursing
• Monitor urinary pH, Ca, lytes,
PO4
• Renal failure – avoid Mag based
meds
• Heart failure and HTN – avoid Na
based meds
• NSAIDs – common adjunctive
therapy
Antacids – Education
• Liquid antacids > than tablets to
neutralize acid
• Liquid antacids diminish appetite
• Shake liquid preps thoroughly
• Full glass of water after taking
meds
• If giving through NG, flush with
lots of water
Antacids – Education
• Adhere to therapy schedule
• Dosing schedule important: 2 hours after
other meds, 1 hour prior
• Stools may appear white
• Check expiration of antacid
• Identify source of gastric discomfort and
educate to prevent recurrence
Helicobacter pylori
• Associated with ulcers
and gastric cancer
• Neutralizes high acidity
around it
• Sticks to gastric mucosa
• Elimination of organism
assists with healing
Treatment of H. pylori
• Antibiotics – Biaxin,
Amoxicillin, Flagyl,
Tetracycline
• Bismuth – Pepto Bismol
or Tritec
• H2 antagonist – Zantac
OR PPI – Protonix
• Treatment time 7-14
days
Cytoprotective agents
• Carafate – sulfated sucrose and aluminum
hydroxide (antacid)
• Forms thick, gel-like resistant shield in ulcer
crater
• Does not affect acid secretion
Carafate – Nursing
• Assess abdominal pain
• Fluid and electrolyte
balances
• Gastric pH (>5 desired)
• Altered absorption with
antacids
• Risk of aluminum toxicity
Carafate – Education
• Give on empty stomach
• Antacids 30 minutes
before or after Carafate
• Up to 2 hours between
carafate and other meds
• 4-8 weeks for optimal
ulcer healing
Cytoprotective Agents –
Cytotec
• Synthetic prostaglandin
• Decreases gastric acid
secretion
• Increase gastric
cytoprotective mucus
• Increase bicarbonate
Cytotec – Uses
• Prevents gastric ulcers associated with
NSAID use
• Used in combination with methotrexate
for surgically induced abortions
Cytotec – Nursing
• Assess GI pain/ discomfort
• Assess frequency, consistency, and color
of stools
• Start the same time as NSAID therapy
starts
Cytotec – Nursing
• Can be given with antacids
• Use with magnesium antacids
can cause diarrhea
• Call for diarrhea episodes >1
week
• Therapy – 4 weeks unless
healing documented by
endoscopic exam
Lower Digestive tract
• Small intestine – chyme
aids in further digestion
– Duodenum
– Jejunum
– Ileum
• Large intestine/ colon
Lower digestive tract
• Activation of
parasympathetic  increase
peristalsis
• Colon receives chyme in
fluid state
• Reabsorption of water
• Excrete waste material
• Host flora – bacteria & fungi
Constipation
• Waste material in colon for
long time, too much water
reabsorbed
• r/t lack of exercise, poor
food and fluid intake,
medications that reduce
intestinal motility
Constipation
• Common post-op
complication
• Seen more frequently in
elderly
• seek treatment with painful
BM with severe straining
• Can lead to complete bowel
obstruction
Foods causing constipation
• Alcohol
• Foods with high content of
white flour
• Dairy
• Chocolate
Laxatives
• Treatment of constipation
• Abnormal, infrequent, and difficult
passage of feces through the lower GI
tract
• Used as prep for medical procedures
• Used to facilitating removal of
unwanted substances from the body
Laxatives – promote bowel by:
• [Constipation is a symptom,
not a disease]
• Affecting fecal consistency
• Increasing fecal movement
through colon
• Removing stool from the
rectum
• Cathartic – stronger, more
complete emptying
Bulk-forming laxatives
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Act like fiber naturally in diet
Absorb water into intestine
Increases bulk, distends bowel
Initiates reflex bowel activity
Used to prevent constipation
Bulk-Forming – Nursing
• Give with at least 2 glasses
of water/ fluid
• Give right away, do not wait
• Make sure patient can
swallow to reduce risk of
blockage
• Take at different time than
meds to ensure proper
absorption
Stool softener
• Docusate salts – Colace,
Dialose, Surfak
• Helps avoid straining for
medical or surgical
situations
• Softening of fecal impacts
• Facilitates bowel of
anorectal conditions
Stimulant
• Stimulate nerves that
innervate intestine
• Irritate bowel
• Increased peristalsis
• Increases fluid in the colon
• Increases bulk, softens
stool
Stimulant
• Acute
constipation
• Diagnostic preps
• Surgical preps
Stimulant – Nursing
• Rapid and potent effects
• Safety precautions – need for
BRP assist
• Combo therapy with osmotics
and enemas for preps
• Assess for dehydration – IV
fluids
• Changes in vital signs
Laxatives – Nursing
• Document frequency,
consistency, and color
of stools
• Vital signs
• Patient comfort during
defecation
• Review medical history
for causative factors
Laxatives – Nursing
• Bowel status by careful
assessment
• Suppositories – go past
anal sphincter
• Enemas – lay on left
side, ask patient to hold
as long as possible
• Avoid habitual use of
laxatives
Diarrhea
• Abnormal frequent passage
of loose stools
• Usually increased fluidity
and weight
• Increased stool water
excretion
Diarrhea
• May be caused by
medications
• Infections of the bowel
• Prolonged use of antibiotics –
kills flora
• Overgrowth of opportunistic
organisms
Diarrhea – Disease Processes
• Crohn’s – ulcers in small
intestine
• Ulcerative colitis – ulcers in
large intestine
• Irritable bowel syndrome
(IBS) – spastic colon or
mucous colitis – lower GI
tract
Drug therapy for Diarrhea
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Dependent on causative agent
Antibiotic/ anti-parasitic
Anti-inflammatory
Stop offending drug
Lower offending drug
Substitute offending drug
Opioids
• Most effective treatment
• Decreases bowel motility
• Slow peristalsis  increase
fluid/ electrolyte
reabsorption in intestines
• Reduce pain associated with
diarrhea and rectal spasms
• Reduces stool frequency and
volume
Opioids – Nursing
• Safety for BRP
• Abdominal
assessment –
effectiveness of
drugs
• Stop meds once
diarrhea resolved
• Call if bloody stools
Motofen
Anti-diarrheals – Nursing
• Determine cause of
diarrhea
• Monitor stools for
frequency and consistency
• Bowel sounds
Emetics – Emetic center
• Located in medulla oblongata
Emetics – Emetic center
• Stimulated by:
– Smells
– Strong emotion
– Severe pain
– Increased intracranial
pressure
– Labyrinthine disturbances
– Endocrine disturbances
– Toxic reactions to drugs
Emetic center
• Stimulus involve
neurotransmitters
• Vagal and/or sympathetic
afferent nerve transmission
• Once activated – impulses
sent to:
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Diaphragm
Stomach muscles
Esophagus
Salivary glands
Antihistamines
• Promethazine (Phenergan)
• Meclizine (Antivert, Dramamine)
• Diphenhydramine (Benadryl)
Antihistamines – Uses
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Motion sickness
Non-productive cough
Sedation
Rhinitis
Allergy symptoms
Nausea/ vomiting
Antihistamines – Nursing
• If to prevent nausea, give
30 minutes prior to noxious
stimulus
• If for sleep, safety
precautions
• Document effectiveness
• Phenergan not compatible
with LR IV solution
Cannabinoids
• Inhibitory effects in reticular
formation, thalamus, and
cerebral cortex
• Synthetic derivative of
tetrahydrocannabinol Marijuana
• Dronabinol (Marinol)
• Nabilone (Cesamet)
Cannabinoids – Uses
• Nausea/ vomiting associated with chemo
• Anorexia/ weight loss in AIDS patients
(stimulate appetite)
• Glaucoma
Cannabinoids – Adverse
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Drowsiness
Confusion
Euphoria
Visual disturbances
Speech difficulty
Cannabinoids – Nursing
• Vital signs – increase HR, decrease temp
• Decreases REM sleep
• Risk of drug abuse high
Cannabinoids – Nursing
• Can have withdrawal symptoms if
stopped abruptly: irritability, insomnia,
restlessness, diaphoresis
• Drug-induced mood or behavior changes
Uses
• Commonly used for prevention
of nausea vomiting in cancer
therapy
• Decadron – push slowly, can
give “crotch itch”
• Emend – newest class of drugs
used after chemo
Anti-emetics – Nursing
• Find cause of vomiting
• NG tube if patient unconscious and
vomiting
• Safety precautions for drowsiness
• Amount, color, consistency of emesis
Emetics
• Acts on the same
centers as anti-emetics
• Opposite action
• Ipecac
Emetics – Uses
• Treatment of oral drug overdose
• Treatment of oral poisoning
Emetics – Nursing
• Assess vitals and LOC
• Call poison control before
giving Ipecac
• Vomiting is never induced in
an unconscious patient
• Watch for aspiration of
emesis
• Used for strychnine
poisoning may precipitate
seizures
Emetics – Nursing
• Document amount, color, character of
emesis
• Monitor VS before and after
administration
• Monitor drug levels for toxicity
Emetics – Nursing
• Follow syrup with water
• Maintain fluid/ electrolyte balance
• Do not give with charcoal as charcoal will
absorb emetic component of ipecac
Emetics – Education
• If kept at home, read
directions
• Poison control center
number by phone
• Keep out of reach of small
children
• Never give to unconscious
person
Charcoal
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Used for tx of upset stomach
Used for tx of flatulence
Lower cholesterol levels
Treat cholestasis
Used for tx of poisonings
Absorbs content
Can be put directly on wounds
for healing
Inflammatory Bowel Disease
• Ulcerative colitis
• Crohn’s disease
• Incidence increasing
• Women=Men
• 15-30 and 50-70
• Cause unknown
• Risk factors: FH, Jewish descent
Crohn’s Disease
• Inflammation of GI tract
extending through all
layers
• Distal ileum and ascending
colon
• Remissions and
exacerbations
• Fissure, fistulas, abscess
Signs & Symptoms: Crohn’s
Disease
• RLQ pain-unrelieved with defecation
• Diarrhea
• Crampy abdominal pain
• Occurs after meals
• Weight loss
• Malnutrition
• anemia
Signs & Symptoms Crohn’s
Disease
• Stools less frequent and are semisolid
• Usually no blood in stool
• Steatorrhea if small bowel is affected
• RLQ cramping my mimic
appendicitis, pain is diffuse
Diagnostics: Crohn’s
Disease
• Sigmoidoscopy
• UGI with barium-”string sign” in
terminal ileum
• Biopsy
Ulcerative Colitis
• Affects superficial colon mucosa
• Multiple ulcers
• Inflammation
• Starts in the rectum can advance
through entire colon
Signs & Symptoms:
Ulcerative Colitis
• Exacerbations and remissions of
inflammation
• Weight loss
• Bleeding mild to severe
• Anemia
• Fatigue
• LLQ pain, tenesmus
• Extra-intestinal manifestations: skin,
eye, joint, liver
Signs & Symptoms:
Ulcerative Colitis
• Frequent diarrhea
• Stool contains mucous,
blood and pus
• Abdominal cramping
prior to bowel
movement
• Fluid and electrolyte loss
• Potential precursor to
colon cancer
Diagnostics: Ulcerative
Colitis
• CBC-anemia
• OB tests +
• Leukocytosis
• Decreased albumin
• Electrolyte imbalance
• Sigmoidoscopy
• biopsy
Meds for IBD
• Initially may have TPN
• Antibiotics (esp with
Crohn’s)
– Flagyl
• Immunomodulation
– Methotrexate
Meds for IBD
• Acute stages:
– Anti-diarrheals
– Sedatives (prior to
procedures
– Anti-perastaltics
• diphenoxylate
Pharmacologic Management
• Aminosalicylates (antiInflammatories
– Sulfasalazine/ Azulfadine
– Olsalazine/ Dipentum
– Mesalamine/ Asacol or
Pentasa
– Balsalazide/ Colazal
Colazal
Meds for IBD
• Corticosteroids
– Prednisone
• Monoclonal antibodies
– Infliximab/Remicade
– Natalizumab/ Tysabri
Meds for IBD
• Immunosuppressives
(Immune modifiers)
– Azothioprine/ Imuran
– Mercaptopurine/
Purinethol
– Cyclosporine/
Sandimmune
Nursing Interventions: IBD
• Promote rest
• Support groups/coping
• Self management
• Pain relief: anticholenergic 30”
before meals. Dicyclomine.
• Nutrition
• Decrease anxiety
• Follow up care
Management of IBD
• Decrease inflammation
• Suppress immune response
• Bowel rest
• Minimize complications
• Nutritional support
• Medications
• Surgery: total colectomy, ileostomy