Gastrointestinal problems- exam 2

ostomy- where to put it and healing

1. Wound ostomy continence nurse (WOCN) assess for location of ostomy 2. Location: rectus muscle and on a flat part of abdomen 3 Healing: Assessment of the stoma

change in bowel habits

1st indicator that something is wrong is ___

N/V Etiology ◦ Pregnancy, uterus ◦ Infection ◦ Postoperative ◦ Chemotherapy, Side effects meds ◦ GI disorders ◦ Cardiovascular problems ◦ Metabolic disorders

#1 GI problem

E. coli

#1 cause of bloody diarrhea in US

chronic ulcerative colitis

- combination of two procedures- performed 8-12 weeks apart -can be cured with surgery - can reconnect but may end with colostomy -Patient able to resume control of defecation at the anal sphincter -Major complication: acute or chronic pouchitis

acute/chronic gastritis- very common

- inflammation of stomach ◦ Results from breakdown in the normal gastric mucosal barrier ◦ HCL acid and pepsin backflow into the mucosa causing: >Edema >Disruption of the capillary walls Risk factors: ◦ Drugs ◦ Diet ◦ Diseases ◦ H. Pylori

barium swallow

-Can detect protrusion of gastric fundus - encourage fluids after test to flush out

esophageal cancer

-Cause is unknown -Incidence ↑ with age -↑ Incidence in non-Hispanic white men and Alaska Natives -Incidence higher in men than in women -DX: endoscopy and biopsy Poor prognosis • Risk factors >Barrett's esophagus >Smoking >Excessive alcohol intake >Obesity >History of achalasia- difficulty/impaired swallowing >Dysphagia: first sign with meats >Pain >Weight loss

hemorrhoids

-Dilated veins due to increased pressure on the support tissue -Due to increased weight of baby during pregnancy -With pushing during delivery, pushing of constipation Nursing care: -Anti-inflammatory agents, increased fluids, high fiber, stool softeners, baths -Surgery to remove, if needed -Monitor bleeding, and first BM

upper GI endoscopy

-Useful in assessing LES competence, degree of inflammation, scarring, strictures ◦ Monitor PH of secretions using nasogastric probe

inflammatory bowel disease

-autoimmune disease ◦ Involves an immune reaction to a person's own intestinal tract ◦ Some agent or combination of agents triggers an overactive, inappropriate, sustained immune response ◦ Results in widespread inflammation and tissue destruction On the basis of clinical manifestations, IBD is classified as either ◦ Ulcerative colitis Crohn's disease

constipation

-drug induced- pain meds - metabolic disorders - neurologic- post op - increase fiber, fluids, exercises, laxatives, enemas, schedule

chronic & inflammatory abdominal pain

-irritable bowel syndrome - appendicitis - abdominal trauma - peritonitis - gastroenteritis

irritable bowel syndrome

-men more susceptible - women get constipation -Chronic abdomen pain and rapid GI transit of stool -Diagnosed on symptoms only -TX: Diet changes, reduce stress, meds for stool management, EXERCISE -Men: more likely to have with diarrhea -Women: more likely to have with constipation -History: important to help DX

hiatal hernia

-treatment similar to GERD - top of stomach slides up through diaphragm - head of bed elevated - weight loss - surgery - occurs when supine - increased ABD (abdomen) pressure is factor

upper GI bleeding

1. Shock: tachycardia, weak pulse, hypotension, 2. URINE output is one of best measures of organ perfusion 3. Risk for perforation and peritonitis, monitor 4. First line TX is endoscopy, to determine need for surgical intervention, clips and bands to control bleeding 5. PPI and H2 and antacids

Diverticulosis/diverticulitis

Symptoms: pain, abdominal mass LLQ Erosion of the bowel wall with perforation: peritonitis (may need surgery) Nursing management: High fiber diet, fruit, veggies, exercise Allow colon to rest, antibiotics, NPO prn,

Ondansetron (Zofran)- anti-emetic

Used to treat: ◦ Chemotherapy-induced vomiting ◦ Migraine headache ◦ Anesthesia ◦ Postoperative nausea and vomiting

fistula

abnormal opening between two hollow organs 1. Monitor fluids, vitals, patient condition 2. Hygiene 3. NPO as needed 4. Rest the area: let it heal

-usually managed at home -fluids: slowly, room temp - resuming food: SLOWLY ◦ Begin with dry toast, crackers ◦ First: High-carbohydrate ◦ Second: low-fat foods, as easier to digest ◦ EX: Baked potato, rice, chicken

acute care nurse management of N/V

H. pylori

bacterial infection that can be treated with antibiotics

Rectal bleeding is most common ◦ Alternating constipation and diarrhea ◦ Change in stool size: Narrow, ribbon-like ◦ Sensation of incomplete evacuation ◦ Obstruction ◦ Change of bowel pattern, concerning

bowel symptoms

hemorrhage

bright red blood- upper GI coffee ground- mixed with HCl- lower GI Most common complication

cologuard

can check for cancer but can't remove a polyp -good for low risk family history of cancer

H pylori, alcoholism

chronic gastritis

◦ Sore throat and mouth sores, *Lower LIP* most common ◦ Voice Changes ◦ asymptomatic neck mass ◦ Nutritional intake ↓ ◦ Nursing care: Post-op ◦ -wound care, swallowing ◦ -maintain airway, nutrition ◦ -communication -pain control ◦ -appearance, feeding tube

clinical manifestations- cancer

◦ Anorexia◦ Nausea and Vomiting ◦ Feeling of fullness ◦ Complete healing is expected after a few days

clinical manifestations: nursing assessment acute/chronic gastritis

E. coli (Escherichia coli)

contaminated meats, fish, cookie dough 8hr-1 week

short bowel

crohn's disease -Bowel lost to surgery due to GI disease ◦ Too little bowel surface area to maintain normal nutrition and hydration ◦ Lifetime fluid issues and parenteral nutrition may be needed ◦ Special diet needed, support etc

◦ Strictures ◦ Obstructions ◦ Bleeding ◦ Fistula - most pt eventually require surgery - disease often recurs at anastomosis site

crohn's disease- surgical therapy

colonoscopy

detects polyps only when bowel has been adequately prepared

Barium swallow Upper GI endoscopy

diagnostic studies: GI

◦ Based on the patient's symptoms ◦ Endoscopy ◦ Urine, serum, stool, and gastric tissue to test for H. Pylori

diagnostic testing- acute/chronic gastritis

diverticulosis

dilations or outpouching of the mucosa

risk factor for stomach cancer

does h.pylori cause cancer?

Ondansetron (Zofran)- anti-emetic promethazine (phenergan)- anticholinergics? Antihistamines

drugs used to treat N/V

◦ After surgery, IV fluids only ◦ NG tube to suction ◦ feeding tube may be placed ◦ SEMI or FOWLERS position during recovery -When permitted, water (30-60 mL) is given hourly • Gradual progression to small, frequent, bland meals • Maintain upright position• Observe for intolerance of feeding

esophageal cancer- nursing care

◦ Physical exercise ◦ Diet high in fruits, vegetables, and grains ◦ Long-term use of NSAIDS

factors that decrease risk of colorectal cancer (CRC)

lactose intolerance high fat foods cold foods high fiber foods

food helps identify problems for individuals

kergel exercise

for urinary incontinence - tighten muscle so don't fart and pee -10 sets every hour

◦ Rest the bowel ◦ Control inflammation and infection ◦ Correct malnutrition◦ Alleviate stress ◦ Relieve symptoms ◦ Improve quality of life ◦ Drug therapy

goals of treatment of IBD

NURSING CARE Upper GI bleeding interventions: monitor NG secretions NG tube: monitor patency due to blood clots Vital signs: shock Assess blood loss and abdominal distension Will transfuse with whole blood if hemorrhage is massive Lactated Ringers

hemorrhage due to ulcers

with combination of drugs: antibiotics and GI meds

how is h.pylori treated?

1500-1800 mL per 24 hrs Observe for: ◦ Fluid and electrolyte imbalance ◦ Hemorrhage ◦ Abdominal abscess ◦ Small bowel obstruction ◦ Dehydration ◦ Initial drainage will be liquid ◦ Transient incontinence of mucus from manipulation of anal canal ◦ Kegel exercises ◦ Perianal skin care

ileostomy output ____

botulism

improperly canned or home-preserved foods 12-36 hrs

dusky blue stoma

indicates ischemia

brown-black stoma

indicates necrosis

rosey pink and red stoma

indicates proper healing and profusion of stoma

diverticulitis

inflammation of the diverticula

peritonitis

inflammation of the peritoneum -Occurs when organisms enter the peritoneal cavity, perforation, trauma -Intestinal content, feces, etc in peritoneum -Painful, illness, infection, fever, vitals change with infection -Obtain CBC, x-ray, ultrasound. Place NG tube, start antibiotics, IV fluids. Surgical repair, prn

perforation

inflammation starts up after...

colorectal cancer

inflammatory bowel disease- high risk for

abdominal pain vomiting distention constipation

intestinal obstruction- 4 classic signs

thick mucous layer

lining of stomach is protected by

regurgitation

liquid coming into throat or mouth

lactose intolerance IBD celiac disease tropical sprue cystic fibrosis

malabsorption: GI tissues

adenocarcinoma

most common type of CRC - about 85% from adenomatous polyps - tumors spread through walls of colon into musculature and into lymphatic and vascular systems - colonoscopy can be curative

edema- stoma

normal over first 6 weeks. Size will get smaller as healing progresses

1. hemorrhage- upper GI bleed 2. perforation: rigid abdomen as contents spill- firm, tender, hard when palpate 3. gastric outlet obstruction: distal stomach & duodenum due to edema

nursing assessment: major complications- PUD

Assess and monitor the following: Swallowing Nutrition Breathing Talking Vessels of the neck Acute Pain and body image Radiation

nursing care for cancers: head, neck, esophageal, stomach

relief of obstruction 1. Pt NPO with strict I and O 2. Insert NG tube, monitor emesis 3. IV fluids and pain rx

nursing care goal for intestinal obstruction

Mouth to anus 1. aspiration: airway 2. hemorrhage: bleeding 3. perforation/trauma: infection 4. obstruction: blockage, vomiting 5. intake and output: vomiting, diarrhea:→ NPO, NG tubes→ H20 balance 6. Diagnostics: Endoscopy, Colonoscopy, biopsy, xray scans, lab work 7. HCL: PH

nursing care of GI system: what a nurse must know for safe practice

1. Eliminate the cause 2. Begin interventions, same as nausea and vomiting 3. NPO and anti-nausea meds given, PPI and H2 receptor blockers 4. Monitor for blood in emesis 5. No smoking during TX, 6. H. pylori bacterial infection: Must use multi-drug TX , 3-4 drugs PPI + antibiotic = H. pylori treatment

nursing care of pt with gastritis

rest the stomach

nursing management for N/V

assess acute care- preop post op care ambulatory evaluate

nursing management: abd pain

1. Oral cavity Cancer 2. Oropharyngeal Cancer

oral cancer risk factors: ◦ Tobacco and alcohol use ◦ HPV ◦ Prolonged exposure to sun (lip) ◦ Syphilis

1.5-3.5

pH of HCl

anticholinergics

patch behind ear Scopolamine transdermal (Transderm-Scōp)

Sudden, dramatic onset Initial phase (0-2 hours after perforation) >Sudden, severe upper abdominal pain-radiates to back >Rigid, board like abdominal muscles Shallow, rapid respirations Tachycardia, weak pulse Bowel sounds absent Nausea/vomiting History of previous ulcer MASSIVE INFECTION, bacterial peritonitis

perforation clinical manifestations

meds Hospitalization • IV fluids and glucose replacement • NPO • Possible NG tube • Monitor V/S • Maintain an odor free environment

persistent vomiting nursing management

◦ Dumping syndrome: ◦Postprandial hypoglycemia ◦ Bile reflux gastritis ◦ NPO with nasogastric tube in place (review care of NG patient) ◦ Monitor Vitals◦ Monitor bleeding

postop problems and care

antihistamines

◦ Meclizine ◦ Hydroxyzine ◦ Diphenhydramine

Billroth 2: gastrojejunostomy

◦ Partial gastrectomy with removal of distal 2/3 of stomach and anastomosis of gastric stump to jejunum ◦ Vagotomy: decreases stomachs ability to secrete HCL

billroth 1: gastroduodenostomy

◦ Partial gastrectomy with removal of distal 2/3 of stomach and anastomosis of gastric stump to duodenum

esophagectomy

◦ Removal of part or all of esophagus ◦ Use of Dacron graft to replace resected part

drug therapy

◦ Sulfasalazine: Daily folic acid supplements ◦ Corticosteroids: Calcium supplements to prevent osteoporosis; Potassium supplements -Vitamin D deficiency is common

gastric outlet obstruction

Acute and chronic PUD can result in ________

diarrhea causing stoma

Alcohol Beer Cabbage Spinach Green beans Fresh raw fruits Coffee

celiac disease

Autoimmune damage to small intestine: ↑ risk GI CA 1. Genetics 2. gluten ingestion 3. immune response 1. Abdominal pain 2. malnutrition 3. lifelong

gas forming stoma

Beans Cabbage Onions Beer Soda Sprouts

abdominal trauma

Blunt trauma, stabbing, gunshot, motor vehicle accidents Assessment: 1. Guarding and splinting of abdomen with pain 2. Hard or distended abd with absent or decreased bowel sounds, ecchymosis around umbilicus 3. Bleeding, blood in emesis or urine 4. VS, hypotension, and shock, level of consciousness 5. Abdominal CT scan or ultrasound to DX, baseline CBC 6. Nursing management: apply O2, control external bleeding, start an IV 7. Do NOT remove the object (knife) cover with dressing 8. Monitor

GERD

Chronic reflux of stomach acids Risk factors: LES issues Obesity, chocolate, peppermint, alcohol Pregnancy Cigarette and cigar smoking Hiatal hernia

-edema -inflammation - Pain worsens toward end of day as stomach fills and dilates -Relief obtained by belching or vomiting-projectile

Distal stomach and duodenum obstruction is the result of

odor producing stoma

Eggs Garlic Onions Asparagus Cabbage Broccoli Alcohol

peptic ulcer disease (PUD)

Erosion of GI mucosa resulting from digestive action of HCL acid and pepsin r/f: h.pylori, smoking, NSAID use, genetics, aspirin

Elevate HOB 30 degrees, loose clothing around abdomen Decrease high-fat foods ◦ Weight loss (pressure on stomach), no tight clothes ◦ Take fluids between rather than with meals ◦ Avoid milk products and snacking at night ◦ Avoid chocolate, peppermint, caffeine, tomato products, orange juice ◦ Proton pump inhibitors (PPIs) Histamine-2 receptor (H2R) blockers, antacids

GERD nursing care

Hemorrhage Strictures Perforation (with possible peritonitis) Abscesses Fistulas

GI tract- local- complications - Inflammatory bowel disease

ulcerative colitis- lower GI

Inflammation and ulceration of colon and rectum - can be treated with surgery High vegetable intake associated with ↓ risk ◦ Colon◦ Removal of colon curative

crohn's disease

Inflammation of any segment of GI tract from mouth to anus ◦ High fiber and fruit intake associated with ↓ risk ◦ Oral contraceptives and NSAIDS exacerbate symptoms ◦ Mouth to anus...anywhere

appendicitis

LRQ - don't push bc don't want it to pop 1. Assess: Pain at McBurneys point (right lower quadrant) , fever, tender, rigid, rebound tenderness 2. DX studies: WBC, UA, CT scan, Ultrasound, or MRI 3. Surgical removal (laparotomy and tx with antibiotics) 4. Pt NPO if suspect appendicitis 5. IV fluids 6. Monitor, home if uncomplicated removal

determine underlying cause: ◦ Type of vomiting: projectile ? ◦ What do you do? ◦ Precipitating factors ◦ Contents of emesis: "coffee grounds", bright red blood ◦ Bowel obstruction: fecal odor, bile ◦ Fluid status ◦ Lab work: K, Na, urinalysis

N/V assessment

inflammation and infection of oral cavity

Neglected hygiene ◦ Antibiotics ◦ Decreased immune system ◦Trauma *Nursing care: assist and provide oral care, ↓ smoking** *Drugs: antivirial, antibiotics, antifungal.* Gingivitis Oral Candidiasis Herpes Simplex Stomatitis

dumping syndrome

Rapid emptying of gastric contents into small intestines. Client experience ab pain, nausea, vomiting, explosive diarrhea, weakness, dizziness, palpitations & tachycardia. who is at riske: if had certain gastric surgeries- most common in people who have had surgeries that remove or bypass large portions of stomach

incompetent LES (lower esophageal sphincter) heartburn- main complaint dyspepsia regurgitation dental erosion

symptoms of GERD

surgery

treatment for esophageal cancer-MONITOR: surgical site for bleeding and leaking of fluid into the chest

surgical removal of stomach, chemotherapy

treatment of stomach cancer

lower esophagus stomach duodenum

ulcer development can occur in:

clostridial

uncooked foods 8-24hrs

site of cancer

what dictates site of resection/colon removal - right or left hemicolectomy

ulcers of stomach lining

what does h.pylori place a pt at risk for?

perforation- b/c of infection

which complication is considered most lethal in PUD?

may resolve on own, infections will need TX

will h.pylori go away?

Past health history Medication usage Heartburn Weight loss Black, tarry stools - indicates blood Epigastric tenderness Nausea and vomiting Abnormal laboratory values: blood and H pylori *Pain generally high in epigastrium "Burning" or "gaseous"* *Food aggravates pain if ulcer has eroded through gastric mucosa*

PUD nursing assessment

◦ Adequate rest, monitor vitals ◦ Drug therapy◦ Smoking cessation ◦ Dietary modification, eliminate foods that irritate ◦ H. pylori drug treatment LAB: ◦ CBC - HCT/ Hgb, Liver enzyme studies ◦ Serum amylase determination◦ Stool examination for blood Treated: ambulatory/inpatient • Pain gone after 3-6 days • Ulcer healing requires many weeks of treatment, NG tube prn- obstruction • Endoscopy most accurate method to monitor healing • Meds:1. PPI 2. H2-blockers 3.antacids

PUD treatment- nursing care

dyspepsia

Pain or discomfort centered in upper abdomen (indigestion)

esophagogastrostomy

Resection of portion of esophagus and graft remaining part to stomach

salmonella

raw meats 8hr- several days

◦ Perforation ◦ Peritonitis ◦Hemodynamic instability ◦ Cancer

reasons for temporary colostomy

50-75 yo ◦Flexible sigmoidoscopy ◦ Colonoscopy ◦Cologuard -new ◦Blood testing for DNA-new

regular screening for polyps and cancer from ___

GERD

related chest/lung pain otolaryngology changes ◦ Described as burning, squeezing, or radiating to back, neck, jaw ◦ Respiratory: cough, bronchospasm ◦ Otolaryngology: hoarse voice, sore throat, choking

hemiglossectomy

removal of half the tongue #1 concern= pain! have pain, impaired nutrition, risk for aspiration, hurt to swallow, pain when swallowing and eating, can be hard to breathe (through mouth), tricky to talk

-No single risk factor accounts for most cases of CRC -Highest risk in those with first-degree relatives with CRC and people with IBD (30% cases) -Personal hx of breast, uterine, colon ca, IBS

risk factors (increase) - colorectal cancer

staphylococcal

skin & respiratory tract 30min-7hr

acute abdomen

sudden onset of abdominal pain - may signal life threatening problem - immediate assessment by RN

exacerbations are debilitating and frequent - massive bleeding - perforation - strictures and/or obstruction - tissues changes indicating dysplasia or carcinoma surgery if treatment fails

surgical therapy- interprofessional care