39 - EBOOK: Gastrointestinal Therapeutic Procedures

What are "Gastrointestinal therapeutic procedures?"

Gastrointestinal therapeutic procedures are performed for maintenance of nutritional intake, treatment of gastrointestinal obstructions and other disorders, and treatment of obesity.

Ileostomy: Pattern of output

› Continuous output

Ileostomy: Normal Postoperative Output

› Less than 1,000 mL/day › Can be bile-colored and liquid

Bariatric Surgeries - Complications: Dehydration

■ Monitor for excessive thirst and concentrated urine. ■ Provide adequate fluid.

A nurse is contributing to the plan of care for a client who is receiving a continuous enteral feeding. What actions should the nurse contribute to the plan? A. Indications for the Procedure: Identify three indications. B. Complications: Identify two complications and potential causes. C. Nursing Actions: Identify nursing actions for each complication.

Indications for the Procedure: ● Intubation ● Clients who cannot maintain adequate oral nutritional intake and need supplementation (stroke, Advanced Parkinson's disease, multiple sclerosis, cancer) Complications: ● Overfeeding resulting from client unable to digest amount of feeding given ● Diarrhea resulting from concentration of feeding ● Pneumonia resulting from aspiration of feeding Nursing Actions: ● Overfeeding ◯ Check residual every 4 to 6 hr. Follow protocol for withholding excess residual volumes (typically 100 to 200 mL). Resume feeding at prescribed reduced rate. ● Diarrhea ◯ Slow rate of feeding and notify the provider. Confer with the dietitian. Provide skin care and protection. ● Pneumonia

Enteral Feedings - Complications: Overfeeding/Nursing Action

Overfeeding results from infusion of greater quantity of feeding than can be readily digested by the client, resulting in abdominal distention, nausea, and vomiting. ■ Nursing Actions: ☐ Check residual every 4 to 6 hr. ☐ Follow protocol for withholding excess residual volumes (typically 100 to 200 mL). ☐ Withhold feeding and resume at the prescribed reduced rate.

Enteral Feedings - Complications: Aspiration pneumonia/Nursing Action

Pneumonia can occur secondary to aspiration of feeding. ■ Nursing Actions: ☐ Stop the feeding. ☐ Turn the client to his side and suction the airway. Administer oxygen if indicated. ☐ Monitor vital signs for an elevated temperature. ☐ Auscultate breath sounds for increased congestion. ☐ Notify the provider and obtain a chest x-ray if prescribed.

Sigmoid Colostomy: Pattern of output

› Resumes a pattern similar to the preoperative pattern

Bariatric Surgeries - Nursing Actions

■ Encourage client to express emotions about eating behaviors, weight, and weight loss to identify psychosocial factors related to obesity. ■ Arrange for availability of a bariatric bed and mechanical lifting devices to prevent client/staff injury.

Bariatric Surgeries - Post-procedure/Client Education

■ Instruct the client on limitations regarding liquids or pureed foods for the first 6 weeks, as well as the volume that can be consumed (often not to exceed 1 cup). ■ Client is instructed to walk daily for at least 30 min. ■ Remind the client that overeating can dilate the surgically created pouch, causing weight to be regained. ■ Instruct the client to take vitamin and mineral supplements.

Ostomies - Preprocedure: Nursing Actions

◯ Nursing Actions - Determine the client's readiness for the procedure.

What is "Ileostomy?"

-a surgical opening into the ileum to drain stool

What is "Colostomy?"

-a surgical opening into the large intestine to drain stool

What is "Ascites?"

-an abnormal accumulation of protein-rich fluid in the abdominal cavity most often caused by cirrhosis of the liver. The result is increased abdominal girth and distention. *Online: Ascites is the build-up of fluid in the abdomen. This fluid buildup causes swelling that usually develops over a few weeks, although it can also happen in just a few days. Ascites is very uncomfortable and causes nausea, tiredness, breathlessness, and a feeling of being full

What is "Enteral Feedings?"

-when a client can no longer take adequate nutrition orally.

What's "Paracentesis?"

A paracentesis is performed by inserting a needle or trocar through the abdominal wall into the peritoneal cavity. The therapeutic goal is relief of abdominal ascites pressure. ◯ A paracentesis can be performed in a provider's office, outpatient center, or acute care setting at the bedside. ◯ Once drained, ascitic fluid can be sent for laboratory culture.

A nurse is caring for a client who has acute diverticulitis. The nurse notes that the nasogastric (NG) tube is draining green liquid bile (meaning, the tube is in the stomach). Which of the following actions should the nurse implement? A. Document the findings. B. Irrigate the NG tube. C. Determine the last bowel movement. D. Insert the NG tube another 2 inches.

A. Document the findings: The nurse should take no action and document the findings because green liquid bile draining from the NG is an expected finding.

What is "Ostomies?"

An ostomy is a surgical opening from the inside of the body to the outside and can be located in various areas of the body. Ostomies can be permanent or temporary. ◯ A stoma is the artificial opening created during the ostomy surgery. ◯ The main types of ostomies performed in the abdominal area: ■ Ileostomy - a surgical opening into the ileum to drain stool ■ Colostomy - a surgical opening into the large intestine to drain stool

A nurse is providing care to a client who is 1 day postoperative paracentesis. The nurse observes clear, pale-yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention? A. Place a clean towel near the drainage site. B. Apply a dry, sterile dressing. C. Attach an ostomy bag. D. Place the client in a supine position.

B. Apply a dry, sterile dressing: The nurse should apply a sterile dressing to contain the drainage and allow continuous monitoring of color and quantity.

What is "Bariatric Surgeries?"

Bariatric surgeries are a treatment for morbid obesity when other weight control methods have failed. ◯ Bariatric surgeries reduce the functional size of the stomach. ◯ Many clients will undergo plastic surgery to remove excess skin following weight loss.

A nurse is reinforcing discharge teaching with a client who is 3 days postoperative for a transverse colostomy. Which of the following should be included in the instructions? A. Mucus will be present in stool for 5 to 7 days after surgery. B. Expect 500 to 1,000 mL of semi-liquid stool after 2 weeks. C. Stoma should be moist and pink. D. Change the ostomy bag when it is 3⁄4 full.

C. Stoma should be moist and pink: A pink, moist stoma is an expected finding with a transverse colostomy.

A nurse is checking the stoma of a client with a new colostomy and notes that the stoma appears pale. Which of the following actions should the nurse take? A. Check the client's temperature. B. Wash the area with warm water. C. Gently massage around the stoma. D. Prepare the client for surgery.

D. Prepare the client for surgery: A pale stoma indicates that the circulation is compromised and immediate intervention is necessary. The nurse should prepare the client for surgery.

Enteral Feedings - Complications: Diarrhea/Nursing Action

Diarrhea occurs secondary to concentration of feeding or its constituents. ■ Nursing Actions: ☐ Slow rate of feeding and notify the provider. ☐ Confer with the dietitian. ☐ Provide skin care and protection.

What is "Nasogastric Decompression?"

Nasogastric decompression is a procedure done for clients who have an intestinal obstruction. To perform decompression, insert an NG tube with suction until relief of the obstruction. *By inserting a nasogastric tube, you are gaining access to the stomach and its contents. This enables you to drain gastric contents, decompress the stomach, obtain a specimen of the gastric contents, or introduce a passage into the GI tract. This will allow you to treat gastric immobility, and bowel obstruction.

Ostomies - Complications: Stomal ischemia/necrosis - Nursing Actions & Client Education

The stomal appearance normally should be pink or red and moist. ☐ Signs of stomal ischemia (Reduced blood flow) are pale pink or bluish/purple color and dry appearance. ☐ If the stoma appears black or purple in color, this indicates a serious impairment of blood flow and requires immediate intervention. ■ Nursing Actions - Obtain vital signs, oxygen saturation, and current laboratory results. Notify the provider or surgeon of unexpected findings. ■ Client Education - Instruct the client to watch for indications of stomal ischemia/necrosis (Death of cells or tissue through disease or injury.).

What is "Total Parenteral Nutrition (TPN)?"

Total parenteral nutrition (TPN) is a hypertonic IV bolus solution. The purpose of TPN administration is to "prevent or correct nutritional deficiencies and minimize the adverse effects of malnourishment." ◯ TPN administration is usually through a central line or a peripherally inserted central (PICC) line. ◯ TPN contains complete nutrition, including calories (in a high concentration [20% to 50%] of dextrose), lipids/essential fatty acids, protein, electrolytes, vitamins, and trace elements. ◯ Partial parenteral nutrition or peripheral parenteral nutrition (PPN) is intended for 'short-term use.'

Transverse Colostomy: Postoperative changes in output

› After several days to weeks, output will become more stool-like, semi-formed,or formed.

Ileostomy: Postoperative changes in output

› After several days to weeks, output will decrease to approximately 500 to 1,000 mL/day. › Becomes more paste-like as the small intestine assumes the absorptive function of the large intestine.

Sigmoid Colostomy: Postoperative changes in output

› After several days to weeks, output will resemble semi-formed stool.

Transverse Colostomy: Pattern of output

› Resumes a pattern similar to the preoperative pattern

Transverse Colostomy: Normal Postoperative Output

› Small semi-liquid with some mucus 2 to 3 days after surgery › Blood can be present in the first few days after surgery

Sigmoid Colostomy: Normal Postoperative Output

› Small to moderate amount of mucus with semi-formed stool 4 to 5 daysafter surgery

Bariatric Surgeries - Complications: Malabsorption/malnutrition & Nursing Action

■ Because bariatric surgeries reduce the size of the stomach or bypass portions of the intestinal tract, fewer nutrients will be ingested and absorbed. ◯ Nursing Actions: ☐ Monitor the client's tolerance of increasing amounts of food and fluids.

Paracentesis - Complications/Bladder perforation. Nursing Actions & Client Education

■ Bladder perforation is a rare but possible complication. (It can result in numerous sequelae including hemorrhage, TURS, infection, the need for urgent open surgery, tumor spillage, peritonitis, and death) ■ Manifestations include hematuria, low or no urine output, suprapubic pain and/or distention, symptoms of cystitis, and fever. ■ Nursing Actions - If a bladder perforation is suspected, notify the provider immediately. ■ Client Education - Inform the client to report manifestations as described above.

Ostomies - Postprocedure: Nursing Actions

■ Check the type and fit of the ostomy appliance. Monitor for leakage (risk to skin integrity). Fit the ostomy appliance based on the following. ☐ Type and location of the ostomy ☐ Visual acuity and manual dexterity of the client ■ Observe peristomal (The peristomal skin is the skin right around the stoma. It's the skin that the ostomy wafer adheres to. In adults, the are of peristomal skin is approximately 4 x 4 inches around the stoma) skin integrity and appearance of the stoma (should appear pink and moist). ■ Apply skin barriers and creams (adhesive paste) to peristomal skin and allow to dry before applying a new appliance. ■ Evaluate stoma output. Output should be more liquid and more acidic the closer the ostomy is to the proximal small intestine. ■ Empty the ostomy bag when it is 1⁄4 to 1⁄2 full of drainage. ■ Monitor for fluid and electrolyte imbalances, particularly with a new ileostomy.

Ostomies - Postprocedure: Client Education

■ Educate the client regarding dietary changes and ostomy appliances that can help manage flatus and odor: ☐ Foods that can cause odor include fish, eggs, asparagus, garlic, beans, and dark green leafy vegetables. ☐ Foods that can cause gas include dark green leafy vegetables, beer, carbonated beverages, dairy products, and corn. Yogurt can be eaten to decrease gas. ☐ After an ostomy involving the small intestine is placed, the client should be instructed to avoid high-fiber foods for the first 2 months after surgery, chew food well, increase fluid intake, and evaluate for evidence of blockage when slowly adding high-fiber foods tothe diet. ☐ Proper appliance fit and maintenance prevent odor when pouch is not open. Filters, deodorizers, or placement of a breath mint in the pouch can minimize odor while the pouch is open. ■ Provide opportunities for the client to discuss feelings about the ostomy and concerns about its effect on the client's life. Encourage the client to look at and touch the stoma. ■ Request a referral to a local ostomy support group.

Ostomies - Indications: Diagnoses for Ileostomy & Colostomy

■ Ileostomy is performed when the entire colon must be removed due to disease (inflammatory bowel disease). ■ Colostomy is performed when a portion of the bowel must be removed (cancer, ischemic injury) or requires rest for healing (diverticulitis, trauma).

Ostomies - Complications: Intestinal obstruction - Nursing Actions & Client Education

■ Nursing Actions ☐ Monitor and record output from the stoma. ☐ Monitor for manifestations of obstruction, including abdominal pain, hypoactive or absent bowel sounds, distention, nausea, and vomiting. Notify the surgeon of unexpected findings. ■ Client Education - Note indications of an intestinal obstruction following discharge.

Paracentesis - Complications/Peritonitis. Nursing Action & Client Education

■ Peritonitis can occur as a result of injury to the intestines during needle insertion. ■ Manifestations include sharp, constant abdominal pain, fever, nausea, vomiting, and diminished or absent bowel sounds. ■ Nursing Actions - Notify the provider immediately. ■ Client Education - Inform the client to report findings listed above. *DEFINITION: Inflammation of the membrane lining the abdominal wall and covering the abdominal organs. Peritonitis is usually infectious and often life-threatening. It's caused by leakage or a hole in the intestines, such as from a burst appendix.

Bariatric Surgeries - Post-procedure/Nursing Actions

■ Provide postoperative care and prevent postoperative complications. ■ Monitor oxygen saturation per facility protocol. ■ Maintain the client in a semi-Fowler's position for lung expansion. ■ Monitor bowel sounds. ■ Apply an abdominal binder to prevent dehiscence. ■ Ambulate the client as soon as possible. ■ Resume fluids as prescribed. The first fluids can be restricted to 30 mL and increased in frequency and volume. ■ Provide six small meals a day when the client can resume oral nutrients. Observe for indications of dumping syndrome (cramps, diarrhea, tachycardia, dizziness, fatigue).

Paracentesis - Indications: Abdominal ascites/Client Presentation

◯ Abdominal ascites: +Ascites is an abnormal accumulation of protein-rich fluid in the abdominal cavity most often caused by cirrhosis of the liver. The result is increased abdominal girth and distention. +Respiratory distress is the determining factor in the use of a paracentesis to treat ascites, and in the evaluation of treatment effectiveness. ◯ Client Presentation - compromised lung expansion

Bariatric Surgeries - Complication: Malabsorption/malnutrition & Education

◯ Client Education: ☐ Tell the client to eat two servings of protein a day. ☐ Tell the client to eat only nutrition-dense foods. Avoid empty calories, such as colas and fruit juice drinks.

Nasogastric Decompression - Indications: Diagnoses/Client Presentation

◯ Diagnoses - Any disorder that causes a mechanical or functional intestinal obstruction ◯ Client Presentation: ■ Vomiting (begins with stomach contents and continues until fecal material also is being regurgitated). ■ Bowel sounds can be absent (paralytic ileus) or hyperactive and high-pitched (obstruction). ■ Intermittent, colicky abdominal pain and distention; hiccups.

Total Parenteral Nutrition - Indication: The Diagnoses/Client Presentation

◯ Diagnoses: +Chronic pancreatitis +Diffuse peritonitis +Short bowel syndrome +Gastric paresis from diabetes mellitus +Severe burns ◯ Client Presentation: +Basic guidelines regarding when to initiate TPN: ☐ Weight loss of 7% body weight and NPO for 5 days or more ☐ Hyper-metabolic state

Enteral Feedings - Indication: The Diagnoses/Client Presentation

◯ Diagnoses: +Clients who are intubated +Pathologies that cause difficulty swallowing and/or increase risk of aspiration (stroke, advanced Parkinson's disease, and multiple sclerosis) +Clients who cannot maintain adequate oral nutritional intake and need supplementation ◯ Client Presentation: +Malnutrition +Aspiration pneumonia

Bariatric Surgeries - Indications: Diagnosis/Client Presentation

◯ Diagnosis - History of morbid obesity ◯ Client Presentation - BMI greater than 40, or greater than 35 with comorbidities *Definition: Comorbidity simply means more than one illness or disease occurring in one person at the same time//Multimorbidity means more than two illnesses or diseases occurring in the same person at the same time

Nasogastric Decompression - Complications

◯ Fluid/electrolyte imbalance ◯ Skin breakdown ■ Nursing Actions: ☐ Monitor I&O, observing for discrepancies. ☐ Observe nasal skin for irritation.

Paracentesis - Postprocedure/Nursing Actions

◯ Nursing Actions Maintain pressure at the insertion site for several minutes. Apply a dressing to the site. If the insertion site continues to leak after holding pressure for several minutes, dry sterile gauze dressings should be applied and changed as often as necessary. Check vital signs, record weight, and measure abdominal girth. Document and compare to preprocedure measurements. Continue to monitor vital signs and insertion site per facility protocol. Monitor temperature every 4 hr for a minimum of 48 hr. Monitor I&O every 4 hr. Administer medication, as prescribed. ☐ Diuretics such as spironolactone (Aldactone) and furosemide (Lasix) can be prescribed to control fluid volume. ☐ Potassium supplements can be necessary when a loop diuretic such as furosemide has been administrated. Assist the client into a position of comfort with the head of the bed elevated to promote lung expansion. Document color, odor, consistency, and amount of fluid removed; location of insertion site; evidence of leakage at the insertion site; manifestations of hypovolemia; and changes in mental status. Continue monitoring of serum albumin, protein, glucose, amylase, BUN, and creatinine levels.

Nasogastric Decompression - Preprocedure: Nursing Actions/Client Education

◯ Nursing Actions - Gather necessary equipment and supplies. ◯ Client Education - Instruct the client on the purpose of the NG tube and the client's role in its placement.

Paracentesis - Intraprocedure/Nursing Actions

◯ Nursing Actions: ■ Monitor vital signs. ■ Adhere to standard precautions. ■ Label laboratory specimens and send to the laboratory. ■ Between 4 and 6 L of fluid is slowly drained from the abdomen by gravity. The nurse is responsible for monitoring the amount of drainage and notifying the provider of any evidence of complications.

Nasogastric Decompression - Postprocedure: Nursing Actions/Client Education

◯ Nursing Actions: ■ Check and maintain proper function of the NG tube and suction equipment. ■ Maintain accurate I&O. ■ Monitor bowel sounds, abdominal girth, and return of flatus. ■ Monitor tube for displacement (decrease in drainage, increased nausea, vomiting, distention). ◯ Client Education - Instruct the client to maintain NPO status.

Paracentesis - Pre-procedure/Nursing Actions & Client Education

◯ Nursing Actions: ■ Determine the client's readiness for the procedure. ☐ Variables such as the age of the client and chronic and acute diseases can influence the client's ability to tolerate and recover from this procedure. ■ Review pertinent lab results (serum albumin, protein, glucose, amylase, BUN, and creatinine). ■ Verify that the client has signed the informed consent form. ■ Gather equipment for the procedure. ■ Have the client void, or insert an indwelling urinary catheter. ■ Position the client as tolerated. Clients with ascites are typically more comfortable sitting up. ■ Review baseline vital signs, record weight, and measure abdominal girth. ■ Administer sedation as prescribed. ■ Administer prescribed IV bolus fluids or albumin, prior to or after a paracentesis, to restore fluid balance. ◯ Client Education: ■ Explain the procedure and its purpose to the client. ■ Instruct the client that local anesthetics will be used at the insertion site. ■ Explain that there can be pressure or pain with needle insertion. ■ Check the client's knowledge of the procedure.