Transcript Gastrointestinal System

Gastrointestinal System
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JUSTINE WILLMAN, MED, MSN, RN
2016
Alimentary Canal (REVIEW)
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 30 feet long
 Mouth, pharynx,
esophagus, small
intestine, large intestine
and anus
 Accessory organs: teeth,
tongue, liver, gallbladder,
pancreas, salivary glands
 What term is used for the
movement of food down
the digestive tract?
Common GI Diagnostic Exams
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 Upper GI study: x-rays of esophagus, stomach, duodenum with barium
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contrast (drink contrast)
Barium swallow: barium contrast oral prior to radiology studies views the
action of swallowing
EGD (endoscopy): scope into the mouth, down into the stomach and
duodenum
Barium enema study: cleansing enema, barium enema, stool light color
until barium is passed
Colonoscopy: scope from anus to cecum
Occult blood test (fecal or gastric contents): to detect the smallest
evidence of a GI bleed
CEA blood test: elevation indicates malignancy in the abdominal area, non
specific.
EGD
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Colonoscopy
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Barium Swallow
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Occult Blood
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Conditions & Diseases
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STOMACH & SMALL INTESTINE
Nausea
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 When so significant can be treated as an inpatient or an outpatient with
anti-nauseas such as, Reglan and/or Zofran
Pharmacology
Give 0.20 mg/kg of Reglan IM now.
Pt weight: 164 lbs
Based on what you have on
Stock (R) how much volume will
You administer?
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 Typically presents with burning
GERD (reflux)
Gastroesophageal
Reflux Disease
Stomach acid backs
up into the esophagus
sensation in the chest, and
regurgitation of food
 Foods that aggravate the gastric
sphincter:
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Chocolate, Caffeine, Spearmint,
Peppermint, Fatty foods, Cola , Milk,
Citrus juices
 Additional aggravators:
o Obesity, pregnancy, smoking, alcohol use
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GERD
treatment
Although GERD has
become extremely
common especially
with American diets
and obesity,
prolonged acid reflux
can cause cellular
changes and lead to
Barrett’s esophagus, a
precancerous
condition
 TX: Change diet & habits that aggravate
reflux including the avoidance of over
eating, exercise or laying flat after
eating.
 H2 antagonists: Tagamet, Pepcid,
Zantac
 Proton pump inhibitors: Protonix,
Prevacid, Nexium
 Rarely, surgical correction to strengthen
sphincter
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 Presents with dull burning, gnawing pain of the
Gastric &
Duodenal Ulcers
Ulcerations of the
stomach or duodenal
lining, often causes by
the bacteria, H. Pylori .
Tobacco, large
amounts of NSAIDS &
increased acid
secretion also
contribute to ulcers
midline epigastric region, Feeling distended &
nauseated are also common.
 At times, symptoms subside after eating when
acid is absorbed by the food.
 DX: with symptoms, EGD, presence of H pylori
 Pharmacological treatment:
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Antacids such as TUMS
H2 blockers such as Pepcid
Proton pump inhibitors such as Nexium
Carafate (Sucralfate) to coat lining
 Treat H pylori with antibiotics as ordered, reduce
or eliminate other aggravators, rarely surgery.
 Teach client about signs and symptoms of GI
bleed & to call physician if they suspect a bleed.
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Bleeding Ulcer
This picture (R )
shows ulcerations
deep enough that
blood vessels are
exposed allowing for
blood loss (upper GI
bleed). Location of
ulcer and size of
exposed vessel
determines the
amount of blood loss
and severity of
condition.
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Stomach Surgery
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As stated earlier, rarely surgical intervention is done to treat or
prevent stomach ulcers due to excessive acid and ulceration in
the stomach. The most common client with stomach surgical
intervention today are those seeking gastric bypass. Not only
does it remove or detour the majority of the stomach, it reduces
the amount of stomach acid that would normally go into the gut
to aid digestion. The 2 common procedures of gastric bypass
are:
 Billroth I: Where the fundus of stomach is attached to
duodenum
 Billroth II: Where the fundus is attached to jejunum
(visual on next page)
Gastric Bypass- Billroth
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Billroth I
Billroth II
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Dumping
Syndrome
Rapid emptying of
stomach contents into
intestines. 50% of bypass
clients experience this
complication
Presents with nausea,
pain, diaphoresis and
diarrhea
Educate client to eat small
meals during the day,
avoid fluids during meals,
but recline after meals to
slow food from entering
the intestines too early
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Critical Thinking - I
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 What do you think is the greatest cause of recurring ulcers?
 After referring to your drug guide, what would you teach a
client newly diagnosed with GERD about the following
prescriptions? (classification, mechanism of action,
considerations & when to call the physician)
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20 mg Pepcid by mouth, b.i.d.
TUMS PRN as needed
 Antacids such as TUMS are not to be taken at the same time
as other medications, why is this so?
Upper GI Scenario
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 A client is admitted to your med/surg floor directly from her
physician’s office with dyspepsia, consistent dull ache in her
epigastric area, fatigue, heartburn after eating and dark
colored stools. Labs reveal a red blood cell count (RBC) of
2.85, hemoglobin of 8 grams and hematocrit of 23.7% (H&H).
 Based on her presentation and lab work, what is her likely
diagnosis (DX)?
 What nursing DXs might be relevant for her?
 In what priority would you list your nursing DXs?
Upper GI Scenario- continued
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 What additional diagnostics could be ordered to confirm the
medical DX?
 The client takes a calcium supplement, multivitamin and
Celebrex daily and has recently added Pepto bismol as needed
for her dyspepsia. What medication education would you
focus on with this client?
 Knowing what you do about this diagnosis, what is the
expected treatment and what is your focus for discharge
instructions?
NCLEX Practice
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 A patient newly diagnosed with gastric ulcer has been prescribed Carafate.
The nurse explains that this medication will have which of the following
beneficial effects for the client?
 It will act as a stool softener to reduce ulcers
 It will help relieve nausea and vomiting
 It will protect erosions from stomach acid
 It will reduce GI spasms
Disorders of the Intestines
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INFECTIONS
IRRITABLE BOWEL SYNDROME (IBS)
ULCERATIVE COLITIS
CROHN’S
APPENDICITIS
DIVERTICULITIS & DIVERTICULOSIS
HIATAL HERNIA
INTESTINAL OBSTRUCTION
COLORECTAL CANCER
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 What is a likely cause of a clostridium difficile
Infections
infection?
 What can be done to best prevent this infection?
Oral transmissions,
poor hand washing
Most common
infections diarrheas:
C.difficile
Salmonella & Shigella
Giardia lamblia
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 Did you know that our intestines play a large
Irritable Bowel
Syndrome (IBS)
Very common, some
link to anxious people
Combination of
chronic and recurrent
GI symptoms such as
intestinal pain,
abdominal pain during
or after passing stool,
gas, diarrhea,
constipation and
abdominal distention
No permanent
damage is done to the
intestinal lining
role in our immunity? Alterations in intestinal
health can impact our body’s ability to fight
infections.
 American diet, stress and anxiety can alter the
normal flora of the gut, reducing good bacteria
and allowing for yeast to overgrow in the gut.
This is a common cause of IBS.
 Treatment incudes:
 Increase fiber and reduce fast food and
simple sugars
 Anti anxiety medication
 Relaxation techniques
 Restoration of good flora with probiotics
 Increase fluids
 Daily exercise
Ulcerative Colitis (UC)
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Presentation
Treatment
 Inflammation of the bowel often
 Corticosteroids such as prednisone,
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caused by E coli
Psychosomatic factors aggravate
symptoms
Presents with purulent, often bloody
drainage and stool from bowel,
polyps and scarring of the intestinal
lining may form
May interrupt bowel absorption
At times, lining can become so thin
may perforate
Risk of colon cancer raises 50% after
10-15 years of UC
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antibiotics such as ciprofloxacin and
metronidazole
Antidiarrheal for diarrhea
Diet: high protein, exclude dairy and
spicy food, low residue diet
Identify stress factors
Possibly surgical removal of diseased
portion of bowel, place ileostomy or
colostomy
Ulcerative Colitis
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Crohn’s Disease
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 Less common than ulcerative colitis
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& believed to be autoimmune, more
common in ages 15-30
Causes inflammation, ulcers &
scarring of segments of the GI tract
from the mouth to the anus
Presents with nausea, diarrhea,
abdominal pain, weight loss & fever
Later on, malnutrition, dehydration
and electrolyte imbalance
Stool contains fat (steatorrhea)
Fistulas often form within bowel, to
urinary or vagina/anal areas
Creates a cobblestone pattern in the
bowel seen upon scope
Malabsorption is major problem
with small intestine involvement
 DX: barium enema, cobblestone
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pattern findings on scope
TX: Corticosteroids such as
prednisone, antibiotics such as
ciprofloxacin and metronidazole,
multi vitamin, B12 injections, an
immunosuppressive such as
methotrexate and anti-nausea meds
such as Reglan or Zofran
Diet changes: exclude lactose,
broccoli, asparagus, caffeine,
concentrated fruit juices, carbonated
drinks and fatty foods
Promote high protein diet
Possible surgical resection, bypass
the diseased bowel
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Critical Thinking
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 Why do you think a fever is commonly associated with Crohn’s disease?
 After referring to your drug guide, what would you focus on for
medication preparation and client teaching for a newly diagnosed Crohn’s
client on the following prescriptions? (classification, mechanism of action,
considerations & when to call the physician)
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Prednisone 60 mg po daily
Daily metronidazole 20 mg/kg/day
Methotrexate 25 mg IM weekly
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Appendicitis
Inflammation of the
vermiform appendix
Usually acute, perforates
if untreated, can cause
peritonitis
How do you assess for
appendicitis?
DX: high WBC, CT scan
TX: Surgical removal,
avoid rupture, antibiotics
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 Pouch like herniation's through the
Diverticulosis
muscular layer of the colon
 More common over age 50
 Results from low residue diet, list some
foods that are high residue.
 DX: CT, colonoscopy
 Create an At Risk For nursing diagnosis
that would be appropriate for this
condition.
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 Knowing what we do about
Diverticulitis
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diverticulosis, and using your medical
term breakdown skills, what do you
think diverticulitis is?
May lead to narrowing of colon
May cause an obstruction
Presents with lower left quad pain, high
WBC, gas, blood in stool, distention, N/V
DX: How do you think this is diagnosed?
TX: How do you think it is treated?
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Hiatal Hernia
Results from weakness
of the diaphragm or
esophagus
Protrusion of the
stomach through the
diaphragm
Presents with no
symptoms or GERD
40% of population
develop this condition
Surgery if the stomach is
being strangled
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Cholelithiasis
(Gall Stones)
Cholecystitis (Gall
bladder
inflammation)
N/V, indigestion belching,
flatulence, epigastric pain
that radiates 2-4 hours
after eating fatty food
Lithotripsy or surgery
Education regarding
decrease in fatty foods
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Intestinal
Obstruction
How do you property
assess the abdomen?
List 5 assessment findings
that would indicate an
obstruction has started in
your client.
Common early
presentation: cramping
abdominal pain
Later: bowel becomes
fatigued, decreased to
absent bowel sounds,
increased abdominal pain
DX: x-ray
 Result when GI contents cannot pass
 Requires prompt treatment, why?
 Mechanical obstruction: Volvulus
(twisting) adhesion, abscess, etc.
 Non-mechanical obstructions: loss of
normal peristaltic function in a part or
all of the intestine, called what?
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Bowel Obstruction Scenario
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Physician orders:
 Place NG to low intermittent suction (LIS)
 Labs: Draw serum electrolytes daily
 Intake and output
 Normal saline @ 100 mL/hr
 IV Zofran 4 mg Q6 hours
 IM morphine sulfate, 6 mg Q 8
Explain the reasoning behind the above orders. What are your
nursing concerns and considerations when implementing them?
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 Malignant growth in the rectum or colon
 3rd most prevalent cancer in the US, why do you think
Colorectal Cancer
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this is so?
HX of ulcerative colitis, diverticulosis, polyps, family
history
Presents with no symptoms, early on then bowel
changes, excessive gas and abdominal cramps, rectal
bleeding, ascites, weight loss.
DX: digital exam, colonoscopy, CT
TX: radiation, chemo, surgery
Common nursing care includes: NG, accurate I&O,
pain management, emotional support, surgical prep.
Watch for and prevent ileus/obstruction, signs of
infection
GI Post Operative Patient Care
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 Vitals:
 Infection:
 Fluid volume (overload & deficit):
 Wound care:
 Colostomy – Stoma care and teaching:
 Incentive Spirometer use / Ambulation:
 Expected diet orders:
 NG care: insert and removal:
Exam Prep
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 Learn new vocabulary discussed on PowerPoint
 Put yourself in the nurse’s role- what could you delegate, prioritize, etc.?
 Practice NCLEX style questions on the GI systems, selected conditions &
medications listed for you.
 Study the content (including medications) with application to the Nursing Process
 Review:
 GI Assessment
 Medication administration
 Normal vital signs for adults
 Stoma care
 Problem solve (abnormal finding, change is status) plan of care based on
assessment data (think what if & why)
 NG insertion & tube feeding skills from lab