ch 47 GI therapeutic procedures

NG tube indications

Any disorder that causes a mechanical or functional intestinal obstruction (e.g., surgery, trauma, GI tract infections, and conditions in which peristalsis is absent)

bariatric surgery presentation

BMI greater than 40, or BMI greater than 35 with comorbidities

NG tube complications

Fluid/electrolyte imbalance NURSING ACTIONS ● Monitor for fluid and electrolyte imbalance (metabolic acidosis: low obstruction; alkalosis: high obstruction). ● Monitor I&O, observing for discrepancies. Skin breakdown NURSING ACTIONS: Assess nasal skin for irritation

paracentesis diagnoses

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.

TPN indications

Any condition that ● Affects the ability to absorb nutrition. ● Has a prolonged recovery. ● Creates a hypermetabolic state. ● Creates a chronic malnutrition.

bariatric surgery

Bariatric surgeries are a treatment for morbid obesity when other weight control methods have failed

NG decompression

Clients who have an intestinal obstruction require NG decompression. An NG tube is inserted, then suction is applied to relieve abdominal distention. Treatment continues until the obstruction resolves or is removed. The obstruction can be mechanical (tumors, adhesions, fecal impaction) or functional (paralytic ileus).

paracentesis presentation

Compromised lung expansion, increased abdominal girth, rapid weight gain

bariatric surgery cx

Dehydration ● Warn the client that excessive thirst or concentrated urine can be an indication of dehydration and the surgeon should be notified. ● Work with the client to establish goals and schedule for adequate daily fluid intake. Malabsorption/malnutrition Because bariatric surgeries reduce the size of the stomach or bypass portions of the intestinal tract, fewer nutrients are ingested and absorbed. NURSING ACTIONS ● Monitor the client's tolerance of increasing amounts of food and fluids. ● Refer the client for dietary management. ● Encourage the client to consume meals in a low-Fowler's position and to remain in this position for 30 min after eating to delay stomach emptying and minimize dumping syndrome. CLIENT EDUCATION ● Instruct the client to eat two servings of protein a day. ● Instruct the client to eat only nutrition-dense foods. Avoid empty calories, such as colas and fruit juice drinks.

enteral feedings

Enteral feedings are instituted when a client is unable take adequate nutrition orally.

bariatric surgery indication

History of morbid obesity with unsuccessful attempts at nonsurgical weight loss

paracentesis complications

Hypovolemia Albumin levels can drop dangerously low because the peritoneal fluid removed contains a large amount of protein. The removal of this protein-rich fluid can cause shifting of intravascular volume, resulting in hypovolemia. NURSING ACTIONS ● Preventive measures include slow drainage of fluid and administration of plasma expanders, such as albumin, to counter albumin losses. ● Monitor for evidence of hypovolemia, such as tachycardia, hypotension, pallor, diaphoresis, and dizziness. ● Report unexpected findings the provider. Bladder perforation Bladder perforation is a rare but possible complication. Manifestations include hematuria, low or no urine output, suprapubic pain 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 of bladder perforation. Peritonitis 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

ostomies diagnoses

Ileostomy: when the entire colon must be removed due to disease (Crohn's disease, ulcerative colitis). Colostomy: when a portion of the bowel must be removed (cancer, ischemic injury) or requires rest for healing (diverticulitis, traum

TPN complications

Metabolic complications Metabolic complications include hyperglycemia, hypoglycemia, and vitamin deficiencies. NURSING ACTIONS ● Daily laboratory tests are prescribed and results obtained before a new solution is prepared. ● Fluid needs are typically replaced with a separate IV bolus to prevent fluid volume excess. ● Monitor for hyperglycemia. Air embolism A pressure change during tubing changes can lead to an air embolism. NURSING ACTIONS ● Monitor for manifestations of an air embolism (sudden onset of dyspnea, chest pain, anxiety, hypoxia). ● Clamp the catheter immediately and place the client on his left side in Trendelenburg position to trap air. Administer oxygen and notify the provider so trapped air can be aspirated. Infection Concentrated glucose is a medium for bacteria. NURSING ACTIONS ● Observe the central line insertion site for local infection (erythema, tenderness, exudate). ● Change the sterile dressing on a central line per protocol (typically every 48 to 72 hr). ● Change IV tubing per protocol (typically every 24 hr). ● Observe the client for manifestations of systemic infection (fever, increased WBC, chills, malaise). ! Do not use TPN line for other IV bolus fluids and medications (repeated access increases the risk for infection). Fluid Imbalance TPN is a hyperosmotic solution (three to six times the osmolarity of blood), which poses a risk for fluid shifts, placing client at increased risk of fluid volume excess. OLDER ADULT CLIENTS are more vulnerable to fluid and electrolyte imbalances. NURSING ACTIONS ● Assess lungs for crackles and monitor for respiratory distress. ● Monitor daily weight and I&O. ● Use a controlled infusion pump to administer TPN at the prescribed rate. ● Do not speed up the infusion to catch up. ● Gradually increase the flow rate until the prescribed infusion rate is achieved.

ostomies postop

NURSING ACTIONS ● Assess 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 ● Assess peristomal skin integrity and appearance of the stoma. 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 one-fourth to one-half full of drainage. ● Assess for fluid and electrolyte imbalances, particularly with a new ileostomy. ● Evaluate ability of the client or support person to perform ostomy care.

ostomies prep

NURSING ACTIONS ● Determine the client's readiness for the procedure. Assess visual acuity, manual dexterity, cognitive status, cultural influences, and support systems. ● Initiate a referral to the wound ostomy care nurse (WOCN) for ostomy placement marking and client teaching. ● Work collaboratively with the WOCN to begin teaching the client and support person about ostomy care and management. CLIENT EDUCATION: Instruct the client and a support person regarding care and management of an ostomy.

bariatric surgery prep

NURSING ACTIONS ● Encourage the client to express emotions about eating behaviors, weight, and weight loss to identify psychosocial factors related to obesity. ● Ensure that the client understands needed diet and lifestyle changes. ● Prepare the client for postoperative course and potential complications. ● Arrange for availability of a bariatric bed and mechanical lifting devices to prevent client/staff injury. Assess pertinent lab results (CBC, electrolytes, BUN, creatinine, HbA1C, iron, vitamin B12, thiamine, and folate). ● Apply sequential compression stockings to help prevent deep vein thrombosis.

paracentesis intraprocedure

NURSING ACTIONS ● Monitor vital signs. ● Adhere to standard precautions. ● Label laboratory specimens and send to the laboratory. ● Between 4 and 6 L 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.

enteral feedings complications

Overfeeding Overfeeding results from infusion of a greater quantity of feeding than can be readily digested, resulting in abdominal distention, nausea, and vomiting. NURSING ACTIONS ● Check residual every 4 to 6 hr. ● Follow protocol for slowing or withholding feedings for excess residual volumes. Many facilities hold for residual volumes of 100 to 200 mL and then restart at a lower rate after a period of rest. ● Check pump for proper operation and ensure feeding infused at correct rate. Diarrhea Diarrhea occurs secondary to concentration of feeding or its constituents. NURSING ACTIONS ● Slow the rate of feeding and notify the provider. ● Confer with a dietitian. ● Provide skin care and protection. ● Evaluate for Clostridium difficile if diarrhea continues, especially if it has a very foul odor. Aspiration pneumonia Pneumonia can occur secondary to aspiration of feeding, and can be a life-threatening complication. Tube displacement is the primary cause of 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 and diminishing breath sounds. ● Notify the provider and obtain a chest x-ray if prescribed. Refeeding syndrome Refeeding syndrome is a potentially life-threatening condition that occurs when enteral feeding is started in a client who is in a starvation state and whose body has begun to catabolize protein and fat for energy. NURSING ACTIONS ● Monitor for new onset of confusion or seizures. ● Assess for shallow respirations. ● Monitor for increased muscular weakness. ● Notify the provider and obtain serum electrolytes if needed.

ostomies complications

Stomal ischemia/necrosis Stomal appearance should normally be pink or red and moist. ● Signs of stomal ischemia 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: Teach the client to watch for indications of stomal ischemia/necrosis. Intestinal obstruction Intestinal obstruction can occur for a variety of reasons. NURSING ACTIONS ● Monitor and record output from the stoma. ● Assess 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

TPN

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, such as a tunneled triple lumen catheter or a single- or double-lumen peripherally inserted central (PICC) line. ● TPN contains complete nutrition, including calories in a high concentration (10% to 50%) of dextrose, lipids/ essential fatty acids, protein, electrolytes, vitamins, and trace elements. Standard IV bolus therapy is typically no more than 700 calories/day. ● Partial parenteral nutrition or peripheral parenteral nutrition (PPN) is less hypertonic, intended for short-term use, and administered in a large peripheral vein. Usual dextrose concentration is 10% or less. Risks include phlebitis

ostomies

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. (47.4) ● Main types of ostomies performed in the abdominal area ◯ Ileostomy: A surgical opening into the ileum to drain stool, which is typically frequent and liquid since large intestine is bypassed ◯ Colostomy: A surgical opening into the large intestine to drain stool, with the ascending colon producing more liquid stools, the transverse colon producing more formed stools, and the sigmoid colon producing near-normal stool

paracentesis

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, radiology department, or acute care setting at the bed side. ● Usually preformed with ultrasound as a safety precaution. ● Once drained, ascitic fluid can be sent for laboratory culture.

GI therapeutic procedures

performed for maintenance of nutritional intake, and treatment of gastrointestinal obstructions, obesity, and other disorders

NG tube postop

● Assess and maintain proper function of the NG tube and suction equipment. ● Maintain accurate I&O. ● Assess bowel sounds and abdominal girth; return of flatus. ● Encourage repositioning and ambulation to help increase peristalsis. ● Monitor tube for displacement (decrease in drainage, increased nausea, vomiting, distention). ● Assess pertinent lab results (electrolytes, hematocrit). ● Provide frequent oral and nares care. CLIENT EDUCATION: Instruct the client to maintain NPO status.

TPN interventions

● Check capillary glucose every 4 to 6 hr for at least the first 24 hr. ● Clients receiving TPN frequently need supplemental regular insulin until the pancreas can increase its endogenous production of insulin. ● Keep dextrose 10% in water at the bedside in case the solution is unexpectedly ruined or the next bag is not available. This will minimize the risk of hypoglycemia with abrupt changes in dextrose concentrations. ● If a bag is unavailable and administered late, do not attempt to catch up by increasing the infusion rate because the client can develop hyperglycemia. ● OLDER ADULT CLIENTS have an increased incidence of glucose intolerance.

TPN diagnoses

● Chronic pancreatitis ● Diffuse peritonitis ● Short bowel syndrome ● Gastric paresis from diabetes mellitus ● Severe burns

TPN prep

● Determine the client's readiness for TPN. ● Obtain daily laboratory values, including electrolytes. Solutions are customized for each client according to daily laboratory results.

paracentesis prep

● Determine the client's readiness for the procedure. Variables such as the age of the client and chronic and acute diseases can influence ability to tolerate and recover from this procedure. ● Assess 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 in an upright position, either on the edge of the bed with feet supported or a high-Fowler's position in the bed. Clients who have ascites are typically more comfortable sitting up. ● Review baseline vital signs, record weight, and measure abdominal girth. ● Administer sedation as prescribed. ● Administer 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. ● Assess the client's knowledge of the procedure

ostomies 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. Buttermilk, cranberry juice, parsley and yogurt help to decrease odor. ◯ Foods that can cause gas include dark green leafy vegetables, beer, carbonated beverages, dairy products, and corn. Chewing gum, skipping meals, and smoking can also cause gas. Yogurt, crackers, and toast can be ingested to decrease gas. ◯ After an ostomy involving the small intestine is placed, instruct the client 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 to the diet. ◯ Proper appliance fit and maintenance prevent odor when pouch is not open. Filters, deodorizers, or a breath mint can be placed in the pouch to 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. ● Refer the client to a local ostomy support group

enteral feedings diagnoses

● Inability to eat due to a medical condition (comatose, intubated) ● Pathologies that cause difficulty swallowing or increase risk of aspiration (stroke, advanced Parkinson's disease, multiple sclerosis) ● Inability to maintain adequate oral nutritional intake and need for supplementation due to increased metabolic demands (cancer therapy, burns, sepsis)

paracentesis postop

● 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. Fever can indicate a bowel perforation ● Assess I&O every 4 hr. ● Administer medication. ◯ Diuretics such as spironolactone and furosemide can be prescribed to control fluid volume. ◯ Potassium supplements can be necessary when a loop diuretic such as furosemide has been administrated. ● Administer IV bolus fluids or albumin as prescribed. ● 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, electrolytes, BUN, and creatinine levels. CLIENT EDUCATION ● Avoid alcohol, maintain a low-sodium diet, take prescribed medications, and monitor the puncture site for bleeding or leakage of fluid. ● Report changes in mental and cognitive status due to change in fluid and electrolyte balance. ● Change positions slowly to decrease the risk of falls, which can be related to hypovolemia from the removal of ascites fluid.

enteral feedings presentation

● Malnutrition (decreased prealbumin, decreased transferrin or total iron-binding capacity) ● Aspiration pneumonia

bariatric surgery postop

● Monitor for leak of anastomosis (increasing back, shoulder, abdominal pain; restlessness; tachycardia; oliguria) and notify the provider immediately. This is a life-threatening emergency. ● Notify the provider for suspected nasogastric (NG) tube displacement. The NG tube is typically sutured in place following stomach surgery; do not attempt to manipulate the tube. ● Provide postoperative care and prevent postoperative complications. ● Monitor for the development of postoperative complications that are at increased risk due to obesity (atelectasis, thromboemboli, skin fold breakdown, incisional hernia, peritonitis). ● Assess the airway and oxygen saturation per facility protocol. Maintain the client in a semi-Fowler's position for lung expansion. ● Monitor bowel sounds. ● Apply an abdominal binder as prescribed to prevent dehiscence if there is an abdominal incision. ● 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). ● Collaborate with case management and mental health resources to assist with long-term behavior modification. 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). ● Instruct the client 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

bariatric surgeries

● Restrictive surgeries, such as laparoscopic adjustable gastric band (LAGB) or laparoscopic sleeve gastrectomy (LSG), limit the amount of food eaten at one time due to decreased volume capacity. Weight loss is often regained after a period of time unless the client adheres to stringent weight loss protocols and lifestyle modifications. (47.1) ◯ LAGB involves the placement of an adjustable band at the proximal portion of the stomach to restrict stomach volume to 10 to 15 mL. ◯ LSG involves removal of the portion of the stomach that secretes ghrelin, a hormone that stimulates feelings of hunger. Up to 85% of the stomach is removed. ● Vertical-banded gastroplasty involves the creation of a new, smaller stomach pouch using staples to decrease its functional size. (47.2) ● Malabsorption surgeries, such as Roux-en-Y gastric bypass (RNYGB) or simply gastric bypass, interfere with the absorption of food and nutrients from the GI tract. Most clients maintain 60% to 70% of weight loss even 20 years postprocedure. ◯ RNYGB involves restricting the volume of the stomach to 20 to 30 mL, bypassing the majority of the stomach and the duodenum. A section of the jejunum is anastomosed to the smaller section of the stomach, bypassing the majority of the stomach. (47.3) ● Some procedures combine more than one of these approaches

TPN ongoing care

● The flow rate is gradually increased and gradually decreased to allow body adjustment (usually no more than a 10% hourly increase in rate). ! Never abruptly stop TPN. Speeding up/slowing down the rate is contraindicated. An abrupt rate change can alter blood glucose levels significantly. ● Assess vital signs every 4 to 8 hr. ● Follow sterile procedures to minimize the risk of sepsis. ◯ TPN solution is prepared by the pharmacy using aseptic technique with a laminar flow hood. ◯ Change tubing and solution bag (even if not empty) every 24 hr. ◯ A filter is added to the tubing to collect particles from the solution. ◯ Do not use the line for other IV bolus solutions (prevents contamination and interruption of the flow rate). ◯ Do not add anything to the solution due to risks of contamination and incompatibility. ◯ Use sterile procedures, including a mask, when changing the central line dressing (per facility procedure).

NG tube presentation

● Vomiting (begins with stomach contents and continues until fecal material is also being regurgitated) ● Bowel sounds absent (paralytic ileus) or hyperactive and high-pitched (obstruction) ● Intermittent, colicky abdominal pain and distention ● Hiccups ● Abdominal distention

TPn diagnoses presentation

● Weight loss greater than 10% of body weight and NPO or unable to eat or drink for more than 5 days ● Hypermetabolic state ● Muscle wasting, poor tissue healing, burns, bowel disease disorders, acute kidney failure