Nursing Care of Clients with problems in nutrition and GI function
Gastric Acid Stimulation Test
- A test that measures the amount of gastric acid for 1 hour after subcutaneous injection of a drug that stimulates gastric acid secretion. - volume and pH of the specimen are measured - gastric specimens are collected after the injection every 15mins for 1 H
Nursing Interventions - Anoscopy, Proctoscopy, Sigmoidoscopy
- Anoscopy: rigid scope to examine anal canal. pt knee-chest or lt side - Proctoscopy and sigmoidoscopy: flexible scope to examine rectum and sigmoid colon. pt lt side c rt leg bent - Keep pt informed throughout the examination and to explain the sensations associated with it - Pre: enemas (@ risk for fluid and electrolyte imbalances) - limited bowel preparation - dietary restrictions are not necessary - Post: monitor for bleeding
Serum Laboratory Studies
- CBC - metabolic panel - prothrombin time - triglycerides - liver function tests - amylase - lipase - carcinoembryonic antigen - cancer antigen (CA) 19 - 9 - alpha - fetoprotein (AFP)
Antiemetics
- Dopamine antagonists: metaclopramide, domperidone - Serotonin 5HTs receptor antagonist: ondansetron - Antihistamines: promethazine
Anoscopy, Proctoscopy, Sigmoidoscopy
- Endoscopic evaluation of the anus, rectum, sigmoid, and descending colon to evaluate chronic diarrhea, fecal incontinence, ischemic colitis and lower GI hemorrhage - to observe for ulceration, fissures, abscesses, tumors, polyps or other pathological processes - Biopsies and polypectomies can be performed during this procedure
Breath tests
- Hydrogen Breath test - Urea breath test
Nursing Intervention: Abdominal Ultrasonography
- NPO about 8 - 12H before the utz - fat free meal in the evening before the procedure if gallbladder studies are being performed
Nursing Interventions - endoscopic procedures
- NPO about 8H prior to the examination 0 before the introduction of the endoscopy , pt is given a local anesthetic gargle/spray - Midazolam (Versed) a sedative which provides moderate sedation with loss of gag reflex and relieves anxiety during the procedure - Atropine to reduce secretions - Position: Left lateral ( to facilitate clearance of pulmonary secretions and provide smooth entry of scope) - Post procedure: assessment and gag reflex
Nursing Interventions - Barium Swallow
- NPO post midnight - No smoking/chewing gum during the NPO period - polythylene glycol (PEG) based solutions are considered the most effective bowel cleansing preparatory agent - post procedure, increase fluid intake to facilitate evacuation of stool and barium
Tube feeding
- Osmolality of normal body fluids is approximately 300 mOsm/kg. - Osmolality is an important consideration for pts receiving tube feedings through the duodenum or jejunum because feeding formulas with a high osmolality may lead to undesirable effects
Nursing Intervention - Esophageal manometry/esophageal motility studies
- Pre procedure: NPO 8 - 12H - medications that could have a direct effect on motility are withheld 24 - 48H - During procedure: pressure - sensitive catheter is inserted through the nose and is connected to a transducer and a video recorder - Pt swallows' small amounts of water while the resultant pressure changes are recorded
Cholinergic
- Salivation - Lacrimation - Urination - Diaphoresis - GI Distress - Emesis - pinpoint pupils - increased bowel - increased diaphoresis - pilocarpine, rivastigmine, galantamine, donepezil
Gastric Analysis
- Study of the stomach content to determine the acid content and to detect the presence of blood, bacteria, bile, and abnormal cells - gastric samples are collected every 15mins for the next hour Position: semi - reclining position
Sleeve Gastrectomy
- The stomach is incised vertically and up to 85% of the stomach is surgically removed, leaving a "sleeve" shaped tube that retains intact nervous innervation and does not obstruct or decrease the size of the gastric outlet
Roux-en-Y gastric bypass
- a horizontal row of staples creates a pouch with a capacity of 20 - 30Ml - jejunum is divided distal to the ligament of treitz, and the distal end is anastomosed to the jejunum
Proctoscopy
- a procedure used to diagnose problems with your rectum and anus. The rectum is the end of your large intestine (colon). - The rectum is the end of your large intestine (colon). The anus is the opening of the rectum. The device used to perform this procedure is a hollow tube called a proctoscope.
Anoscopy
- a simple medical procedure that can help your doctor identify an abnormality in your gastrointestinal tract, notably in your anus and rectum. - doctor will insert a device called an anoscope into your anus.
Nursing Intervention - CT Scan
- assess for any allergies to contrast agents (shellfish, iodine) - assess for the pt's serum creatinine level - hold metformin 48H prior to the procedure - assess for pregnancy
Nursing Intervention - MRI
- assess for pt's with metal implants - assess for claustrophobia - NPO 6 - 8H before the study - instruct pt there may be a knocking sound during the procedure
GI motility studies
- assess gastric emptying and colonic transit time
Parasympathetic System
- causes peristalsis and increases secretory activities, rest & digest - cholinergic agonist
Gastrostomy
- creation of an artificial opening into the stomach - for administration of nutrition/fluids/medications - gastric decompression for pts with gastroparesis, gastroesophageal reflux disease or intestinal obstruction - delivers enteral nutrition support longer than 4 weeks compared to the nasally inserted tube
Jejunostomy
- creation of an opening between the jejunum and the surface of the abdominal wall - indicated when gastric route is inaccessible, or to decrease aspiration risk when the stomach is not functioning adequately to process and empty food and fluids
General Nursing Diagnoses surgical procedures
- deficient knowledge - anxiety r/t impending surgery - acute pain r/t surgical procedure - risk for deficient fluid volume - risk for infection - disturbed body image r/t body changes - risk for constipation
PET Scan
- detect radiation emitted from radioactive substances - radioactive substances are injected into the body IV and are usually tagged with radioactive isotopes of oxygen,nitrogen, carbon, or fluorine - scanner captures where the radioactive substances are in the body which produces substances are in the body which produces "hot spot" for evaluation by the radiologist/oncologist
Urea breath test
- detect the presence of Helicobactor pylori (the bacteria that can live in the mucosal lining of the stomach which causes peptic ulcer disease) - pt ingests a capsule of carbon - labeled urea and a breath sample is obtained 10 - 20mins later
Laparoscopy (Peritoneoscopy)
- direct visualization of the organs and structures within the abdomen - injecting gas/CO2 into the peritoneal cavity to separate the intestines from the pelvic organs (pneumoperitoneum)
General adverse effects for these surgical procedures:
- dumping syndrome - feeling of fullness - diarrhea/constipation - gastritis - weight loss - pernicious anemia - malabsorption
Colonic transit studies
- evaluate colonic motility and obstructive defecation syndromes
Sympathetic System
- exert inhibitory effect on the GIT - adrenergic agonist
Biliopancreatic diversion with duodenal switch
- half of the stomach is removed, leaving a small area that holds about 60ml - entire jejunum is excluded from tehr est of the GIT - duodenum is disconnected and sealed off - ileum is divided above the ileocecal junction, and the distal end of the jejunum is anastomosed to the first portion of the duodenum - distal end of the biliopancreatic limb is anastomosed to the ileum
Goal for parenteral nutrition
- improve nutritional status - establish a positive nitrogen balance - maintain muscle mass - promote weight maintenance/gain - enhance the healing process
Indications for parenteral nutrition
- inability to ingest adequate oral food or fluid within a 7 - 10 day timeframe
anticholinergic
- increased HR, temp - dilated pupils - dry - blind - red - mad - atropine, scopolamine, oxybutynin, benztropine
Barium Swallow
- ingestion of radiopaque liquid (e.g. barium sulfate) - detect or exclude anatomic/functional disorders of the upper GI tract
Nursing Intervention - Colonoscopy: Bowel preparation
- laxative 2 nights before the exam - fleet/saline enema until the return is clear - Diet: clear liquid starting the noon before the procedure - PEG electrolyte lavage solutions
Gastric Emptying Studies
- liquid and solid components of a meal (typically scrambled eggs) are tagged with radionuclide markers; after ingestion of meal are tagged with radionuclide markers, which measures the rate of passage of the radioactive substance from the stomach; is useful for diagnosing disorders of gastric motility, diabetic gastroparesis and dumping syndrome
Manometry test
- measures changes in the intraluminal pressures and the coordination of muscle activity in the GI tract with the pressures transmitted to a computer analyzer
General Nursing Interventions for tube feedings
- meeting nutritional needs - preventing infection and providing skin care - enhancing body image - monitoring and managing potential complications - promoting home, community based and transitional care
Parenteral Nutrition
- method of providing nutrients to the body by the IV route - nutrients are complex admixture containing proteins, carbs, fats, electrolytes, vitamins, trace minerals, and sterile water in a single container
Nursing Intervention - Colonoscopy
- monitor continuously cardiac and respi function and oxygen saturation - C/I: suspected/documented colon perforation, acute severe diverticulitis, fulminant colitis - obtain informed consent - Postcolonoscopy: > monitor for signs of bleeding > assessment > must remain in bed until fully alert (sedated pts)
Capsule Endoscopy
- noninvasive visualization of the mucosa throughout the entire small intestine - evaluation of obscure GI bleeding
Radical partial (subtotal) gastrectomy
- performed for a resectable tumor in the middle and distal portions of the stomach
Proximal partial (subtotal) gastrectomy
- performed for a resectable tumor located in the proximal portion of the stomach or cardia
General Nursing Responsibilities for surgical procedures
- potential complications: hemorrhage, venous thromboembolism, bile reflux, dumping syndrome, dysphagia, bowel/gastric outlet obstruction - Post - op dietary instructions: > eat smaller but more frequent meals that contain protein and fiber; each meal size should not exceed 1 cup > eat slowly and chew thoroughly > ensure a low - carb intake; avoid concentrated sources of carbs > eat foods high in nutrients > assume a low fowler position during mealtime then remain in that position for 20 - 30mins after mealtime > don't drink fluid with meals instead consume fluids up to 30 mins before a meal and 30 - 60 mins after mealtime > follow - up with the physician for monthly injections of vitamin B12 and iron as prescribed
Nursing Intervention - Barium Enema
- pre - procedure: emptying and cleansing of the lower bowel - lower residue diet 1 - 2days before a test - laxative the evening before the procedure - NPO post midnight - ensure that barium enemas are scheduled first - post procedure: increase fluid intake, eat high fiber foods to expel barium from intestine
CT Scan
- provides cross sectional images of abdominal organs and structures - may be performed with or without oral/IV contrast
Barium Enema
- rectal installation of barium and x - ray images are obtained - detect the presence of polyps, tumors and other lesions of the large intestine and demonstrate any anatomic abnormalities or malfunctioning of the bowel - uses water - soluble iodinated contrast agent (ditrizoic acid)
Billroth I (gastroduodenostomy)
- removal of the lower portion of the antrum of the stomach (which contains the cells which secrete gastrin) and also a small portion of the duodenum and pylorus - remaining segment is anastomosed to the duodenum
Gastric Analysis, Gastric Acid Simulation Test and pH monitoring
- secretory activity of the gastric mucosa and the presence or degree of gastric retention in pt's thought to have pyloric or duodenal obstruction
Preventing Dumping Syndrome
- slow formula instillation rate - feedings at room temp - continuous drip feedings - semi fowlers for 1 hr post procedure - minimal amount of water needed post procedure
Nursing Intervention: Endoscopy through ostomy
- supine position and drape ostomy site - scope @ right angle to the abdominal wall to facilitate entry through the ostomy - maintain tight seal around the endoscope as it enters the stoma to achieve adequate insufflation - post procedure: observe for stomal bleeding, vomiting, change in VS, abdominal rigidity, severe/persistent abdominal pain
MRI
- supplement ultrasonography and CT - uses magnetic fields and radio waves to produce images of the area being studied
Pill Cam/Capsule endoscopy
- swallows a capsule that travels by peristalsis through the small intestines - capsule contains an oxide metal silicon chip video camera, which transmits digital images of the GI mucosa to a data recorded that is worn on the pt's waist - transit time from the time the capsule is swallowed until it is passed approximately 24H
Hydrogen Breath Test
- to evaluate CHO absorption - determines the amount of hydrogen expelled in the breath after it has been produced in teh colon
Total Gastrectomy
- total removal of stomach along with duodenum, the lower portion of the esophagus, supporting mesentery and lymph nodes - anastomosing the end of the jejunum to the end of the esophagus - perform for a resectable cancer in the midportion/body of the stomach
Fiberoptic Colonoscopy
- used as diagnostic aid and screening device - tissue biopsy can be obtained and polyps can be removed and evaluated with the use of a special snare and cautery - evaluation of pts with diarrhea of unknown cause, occult bleeding/anemia Patient position: left side with legs drawn up toward the chest initially - procedure take about 1 H - post procedure discomfort due to instillation of air to expand the colon
Esophageal manometry/esophageal motility studies
- used to detect motility disorders of the esophagus and the upper and lower esophageal sphincter
Endoscopy through an ostomy
- useful for visualizing a segment of the small/large intestine - indicated to evaluate the anastomosis for recurrent disease, visualize / treat bleeding in a segment of a bowel
Endoscopic Retrograde Cholangiopancreatography (ERCP)
- uses endoscope in combination with x - rays to view the bile ducts, pancreatic ducts and gallbladder - this procedure is helpful in evaluating jaundice, pancreatitis, pancreatic tumors, commo bile duct stones and biliary tract disease
Esophagogastroduodenoscopy
- visual examination of the esophagus, stomach, and duodenum - used when esophageal, gastric or duodenal disorders or inflammatory, neoplastic or infectious processes are suspected - used to evaluate esophageal and gastric motility and to collect secretions and tissue specimens for further analysis
Double balloon enteroscopy
- visualizes the mucosa of the entire small bowel as well as carry out diagnostic and therapeutic interventions - one balloon at the distal end of the scope and the other to the transparent overtube that slides over the endoscope - requires moderate sedation and takes about 1 - 3H
Nursing Intervention - parenteral nutrition
- weigh pt daily - monitor I & O - check blood glucose - check for signs of dehydration - monitor laboratory results (CBC, platelet count, serum electrolytes) - maintain optimal nutrition - prevent infection - encourage activity
Maltase
A digestive enzyme that breaks maltose into glucose.
Pepsin
An enzyme present in gastric juice that begins the hydrolysis of proteins
Anti - ulcer agents
Antacid: > aluminum/magnesium hydroxide, (Maalox) > calcium carbohydrate (tums) Proton pump inhibitors: > pantoprazole > rabeprazole > lansoprazole > omeprazole > esomeprazole Histamine - 2 (H-2) receptor antagonist/blocker > cimetidine > famotidine > ranitidine Gastric protectant > sucralfate
Laxatives
Bulk forming: > psyllium(Metamucil) > Wheat dextrin(Benefiber) > Methylcellulose(Citrucel) > Polycarbophil(Fibercon) Lubricant: > mineral oil > glycerin suppository Stimulants(irritants) > Bisacodyl(Dulcolax)po and supp > Senna extract(Senokot)PO > Aloe vera juice Fecal Softener: > docusate (Colace) Osmotics > Polyehylene glycol or PEG(Miralax) > Lactulose(Cephulac) > Saline laxatives > Mag Citrate >Mag hydroxide(Milk of Magnesia) > Mag Sulfate(Epsom salts) Chloride channel activators >Lubiprostone(Amitza)
Billroth II (gastrojejunostomy)
Removal of lower portion (antrum) of stomach with anastomosis to jejunum. Dotted lines show portion removed (antrectomy). A duodenal stump remains and is oversewn.
Sample of special test
Rovsing sign and McBurney's point rebound tenderness, psoas sign for acute appendicitis
Ptyalin
a digestive enzyme of the saliva that turns starch into maltose (salivary amylase)
Nasoduodenal tube
a hollow, flexible, cylindrical device, inserted through the nose and extending to the duodenum, that serves primarily as a conduit for delivering enteral feedings
Nasojejunal tube
a hollow, flexible, cylindrical device, inserted through the nose and extending to the jejunum, that serves primarily as a conduit for delivering enteral feedings
Gastric Binding
a silicone band is placed around the top of the stomach to greatly reduce its size - a small pouch of 10 - 15 ml is created
Trypsin
an enzyme from the pancreas that digests proteins in the small intestine
Lactase
breaks down lactose into glucose and galactose
Sucrase
breaks down sucrose into fructose and glucose
Complications - Fiberoptic Colonoscopy
cardiac dysrhythmias, respiratory depression resulting from the given medications, vasovagal reactions, circulatory overload or hypotension resulting from overhydration or underhydration during bowel preparation
Functions of the GIT
digestion, absorption, elimination
Cancer Antigen 19 -9
elevated for most patients with advanced pancreatic cancer also with colorectal, stomach, bile duct cancer
Amylase
enzyme that breaks down starch into maltose
Dumping Syndrome
fullness, nausea, cramping, dizziness, diaphoresis, and osmotic diarrhea
Carcinoembryonic antigen (CEA)
indicates that cancer is present particularly for colorectal cancer
Oroenteric tube
inserted from the mouth to the small intestine
Abdominal Assessment
inspection, auscultation, percussion, palpation supine with knees flexed slightly
Stool Test - FOBT (Fecal Occult Blood Test)
inspects the specimen for consistency, color, and occult
Biopsy forceps/cytology brush
may be passed through the scope to obtain specimens for histology and cytology examination
Scintigraphy
relies on the use of radioactive isotopes to reveal displaced anatomic structures, changes in organ size and the presence of neoplasms or other focal lesions such as cysts or abscesses
Abdominal Ultrasonography
sound waves beamed into the abdomen produce an image of abdominal viscera
Sigmoidoscopy
the endoscopic examination of the interior of the rectum, sigmoid colon, and possibly a portion of the descending colon
Orogastric tube
tube inserted through the mouth into the stomach
Nasogastric tube
tube inserted through the nose into the stomach
Nasoenteric tube
tube inserted through the nose into the stomach and beyond the pylorus into the small intestine
