care of patients with gastrointestinal problems nursing 1930 brendalyn browner muriel mitchell
TRANSCRIPT
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Care of patients with Gastrointestinal Problems
Nursing 1930 Brendalyn Browner Muriel Mitchell
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GI Focused Assessment Health History Current GI Symptoms Previous GI Problems Family History of GI Problems Medication Use: prescription and OTC Diet and Nutrition (Food Allergies) Use of Alcohol, street drugs, Caffeine Bowel Elimination Pattern Social\Cultural Factors
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GI Focused Assessment Physical
Vital Signs Height and Weight Lab and diagnostic test results Emesis ,amount, color, consistency Stool,amount, color, consistency, odor. Oral Assessment Abdominal Assessment Rectal Assessment
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COMMON “GI OFFENDERS”
Caffeine (coffee, tea, cola)
Dairy products Chocolate Pepper (black and
green) Alcohol Spicy foods Tobacco Drugs
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Abdominal Assessment
Inspection Auscultation
Diaphragm (Bowel sounds)
Bell (Vascular sounds, bruits)
Percussion Palpation
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GI Charting Exercise
Document an assessment of the mouth in a person with normal findings.
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EFFECTS OF AGINGEFFECTS OF AGINGPhysiologic Changes in the GI Tract
Mouth Teeth loosen, reduced circulation to
gums, teeth darken and fracture Decreased output of salivary glands Decreased stimulation of taste buds
Stomach Atrophy of gastric mucosa Decreased secretion of hydrochloric
acid Decreased bile secretion
Decreased muscle tone and strength
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1. Anus
2. Rectum
3. Limit of digital-rectal exam
4. Colon
5. Limit of rigid procto exam
6. Limit of flexible procto (35 cm) exam
7. Limit of flexible procto (60 cm) exam
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Common Causes of Bleeding in the GI Tract Esophagus
Inflammation (esophagitis) Tear (Mallory-Weiss syndrome) Cancer
Stomach Ulcers Inflammation (gastritis) Cancer
Small Intestines Duodenal ulcer Inflammation (Crohn’s disease)
Large Intestines and Rectum Hemorrhoids, infections, inflammation (ulcerative colitis) Colorectal polyps, colorectal cancer Diverticular disease
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GastroesophagealREFLUX DISEASE (GERD)
Physiological Contributing Factors:
Incompetent lower esophageal sphincter Irritant effects of reflux Abnormal esophageal clearance Delayed gastric emptying
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GastroesophagealREFLUX DISEASE (GERD)
Common Signs and Symptoms:
Heartburn RegurgitationRetrosternal Burning Pain (epigastrium, neck, throat)
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GastroesophagealREFLUX DISEASE (GERD)
Management and Treatment:
Lifestyle modification measuresAntacids, H2 antagonists, proton-pump inhibitor, carafate, prokinetic agents (reglan)Surgical InterventionNissen Fundoplication
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GastroesophagealREFLUX DISEASE (GERD)
Pharmacology Antacids H2 Antagonist Proton Pump Inhibitors (Bid)
Prilosec Prevacid Protonix Nexium Aciphex
Pro-Motility Agents (Qid) Reglan
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GastroesophagealREFLUX DISEASE (GERD)
Lifestyle Modifications: Avoid fried and fatty foods, garlic and
onions Avoid chocolate, caffeine and alcohol Avoid citrus fruits and juices, tomato
products and pepper Reduce food portions, eat 2-3 hours before
bedtime Lose excess weight, avoid tight clothing Raise the head of your bed with 6-inch
blocks
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GastroesophagealREFLUX DISEASE (GERD)
Nursing Interventions and Patient Education:
Offer emotional support Reinforce lifestyle modifications Teach about prescribed medications Advise patient to sit or stand when taking pills, tablets or capsules and follow with at least 100mL of liquid
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PEPTIC ULCER DISEASE
DUODENAL (80%) Increased gastric secretion,
between meals, after meals, during night.
Twice as many parietal cells.
Pain 2-3 hours after meal. Relieved by food. Peak age 35-45 yrs May cause weight gain Hemorrhage, perforation,
outlet obstruction, intractability
GASTRIC Decreased gastric acid
secretion. 2/3 as many parietal cells. Pain 1/2-1 hour after
eating. Not relieved by food. More likely to be malignant Peak age 50-60 yrs May cause weight loss Hemorrhage, perforation,
obstruction
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CASE STUDY
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Peptic Ulcer Disease:DRUG THERAPY
Antacids ( Decrease gastric acidity) Histamine (H2 ) Receptor Antagonists (Inhibit
HCL secretion) Proton Pump Inhibitors (Suppress gastric
acid secretion) Cytoprotective Agent (carafate) GI Stimulant (Reglan) Triple Drug Therapy H. Pylori Therapy
Proton Pump Inhibitor (Prilosec) Antibiotic Pink Bismuth
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Peptic Ulcer Disease:COMPLICATIONS
HEMORRHAGE
PERFORATION
PYLORIC OBSTRUCTION
INTRACTABILITY
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Peptic Ulcer Disease Signs of Complications
Signs of Bleeding Dizziness Paleness Bloody, black or
tarry stools Coffee ground
vomitus Sweating and/or
chills Restlessness/anxiety
Signs of Perforation Severe pain in the
stomach, shoulders or both
A rigid, boardlike abdomen
A flushed sweaty sensation
Fever and dizziness
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GI JEOPARDY Clients with resection of the ileum
are susceptible to this vitamin deficiency
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Peptic Ulcer Disease: POST-OP COMPLICATIONS
Dumping Syndrome Vitamin B12
Deficiency Leaking from
suture line Shock and
Hemorrhage Dehiscence Evisceration
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Peptic Ulcer Disease: DUMPING SYNDROME SYMPTOMS: ( Weakness, faintness,
dizziness, flushing, palpitations, gastric fullness,nausea, cramping pains, diarrhea)
TREATMENT: (Teach the patient to eat meals low in simple carbohydrates, Hi in protein and moderate in fat, eat small frequent meals, lie down after eating, fluids only between meals. Sedatives, antispasmodics, surgery)
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Peptic Ulcer Disease:Nursing Interventions and Patient Teaching
Alleviate Pain Ensure Adequate Nutrition Avoid Fluid Volume Deficit
I&O Decrease diarrhea Monitor for bleeding (emesis, stool) Monitor hemoglobin, hematocrit and electrolytes Monitor NG tube drainage
Monitor for S&S of complications Hemorrhage, shock, perforation, gastric outlet obstruction
Implement measures to reduce stress Patient teaching related to disease, treatment
and procedures
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Peptic Ulcer Disease:Nursing Diagnoses:
Pain R/T Increased Secretion of Gastric Acid
Diarrhea R/T Gastrointestinal Bleeding Altered Nutrition: Less Than Body
Requirements R/T Nausea, Vomiting or Pain or more than body requirements R/T……..
Fluid Volume Deficit R/T Gastrointestinal Bleeding
Knowledge Deficit R/T Management and Treatment of Peptic Ulcer Disease
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Peptic Ulcer Disease: Outcome-Based Evaluation
Pain Free Vital Signs Stable Fluid Volume Maintained Enjoys Meals Without Pain Reports No Weight Loss Complies With Treatment Regimen Can Describe Peptic Ulcer Disease,
its Treatment and Complications
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INFLAMMATORY BOWEL DISEASE
CROHNS DISEASE Affects any part of
the GI tract, all parts of the bowel
Diarrhea, non-bloody,mucous and pus, less than 5/day
Not cured by surgery
ULCERATIVE COLITIS
Affects colon and rectum
Severe bloody diarrhea with mucus and pus 15-20 stools per day
Can be cured with surgery, colectomy and ileostomy
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INFLAMMATORY BOWEL DISEASE (Con’t)
CROHNS DISEASE Regional ileitis, Regional enteritis, Crohns Colitis Most often seen in
terminal ileum, jejunum, colon, but can occur anywhere in bowel
Complications of Crohns can occur outside the bowel, i.e.,arthritis, Inflammatory disorders of the eye, gallstones
ULCERATIVE COLITIS Usually begins in
rectum and sigmoid colon, involves mucosa and submucosa
Complications include hemorrhage, fistulas, obstruction, strictures perianal/perirectal abscesses, toxic megacolon, colon cancer
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GI JEOPARDY
Increased values of this laboratory test finding is normal during fetal life but may indicate colorectal cancer or inflammatory bowel disease in adults.
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AMINOSALICYLICS (contain 5-aminosalicyclic acid or 5-ASA) Sulfasalazine is an anti-inflammatory, olsalazine, mesalamine or balsalazide maybe used in patients allergic to sulfa
SULFASALAZINE (azulfadine) sulfa and aspirin like compound, anti-inflammatory, anti-bacterial
TOPICAL 5-ASA (Rowasa suppositories or enemas) distal colitis CORTICOSTEROIDS anti-inflammatory, (IV, PO or enema) Immunomodulators azathioprine and 6-mercapto-purine (6-MP) used
for patients who do not respond to 5-ASA or corticoids takes 6-months to see benefits METRONIDAZOLE (Flagyl) anti-bacterial LOPERAMIDE (Imodium) antidiarrheal BULK AGENTS(Metamucil) To absorb fluid from colon and add bulk INFIXIMAB (Remicade) ( New Drug) a monoclonal antibody with
serious side effects
INFLAMMATORY BOWEL DISEASE: DRUG THERAPY
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Inflammatory Bowel DiseaseNursing Diagnoses
Diarrhea R\T inflamed intestinal mucosa
Altered nutrition: Less than body requirements R\T diarrhea and malabsorption
Pain R\T inflamed bowel Risk for ineffective individual coping
R\T exacerbations of the disease
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INFLAMMATORY BOWEL DISEASE Nursing Dx = Diarrhea R/T ………
Nursing Interventions Administer medications Note # and appearance of stools Monitor I&O Monitor lab values Make sure pt is near restroom or has bedpan near Provide perianal care, wipes, topical anesthetics Empty bedpan immediately Use room deodorizer Diet as ordered or TPN Monitor for potential complications, i.e. F&E
imbalance,obstruction, abscess, etc.
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INFLAMMATORY BOWEL DISEASE Outcome-Based Evaluation
The Patient: Reports decrease in #
of stools Has less pain and
cramping Maintains fluid
balance Moves toward
optimum nutrition Copes successfully
with diagnosis Understands disease
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Intestinal obstruction
Fistula
Acute Chronic
Hemorrhage PerforationPericolic abscess
Stricture
General peritonitis
Local suppuration
Diverticulitis
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APPENDICITIS Signs and Symptoms may be
abrupt! Characterized by pain around the
umbilicus but may be generalized abdominal pain
Rebound tenderness Low grade temp,vomiting, nausea,
constipation Ruptured Appendix
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APPENDICITISTreatment and Nursing Intervention
No Medical Management Surgery ASAP to prevent rupture
Nursing Interventions NPO until surgery Bedrest Apply ice pack for comfort, NEVER HEAT! Never give an enema unless ordered by
MD Administer pain med only after diagnosis
is made
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APPENDICITISNursing Diagnosis, Outcome-Based Evaluation
NURSING DIAGNOSES: Pain R\T Inflammation
Outcomes = client describes decreased postoperative pain
Risk for fluid volume deficit R\T vomiting Outcomes = client maintains fluid and electrolyte
balance Risk for Infection
Outcomes = client will receive prompt treatment to prevent rupture, client will not develop infection
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PERITONITISInflammation of the peritoneal membrane
Caused by leakage of content from abdominal organs into the abdominal cavity
May be caused by appendicitis, perforated ulcer, diverticulitis, bowel perforations, acute salpingitis, trauma, CAPD
S&s= pain, rigid abdomen,rebound tenderness, paralytic ileus, increased temp, pulse, WBC
Massive doses of antibiotics initiated early to prevent death from Sepsis
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CLIENTCLIENT
Total parenteral nutrition
Nasogastric tube orGastrostomy
orPEG
Functional GI tract
Dietary consult Nonfunctional GI tract
Unable to eatAble to eat
Gastrostomyor
Jejunostomy tube
Intermittent enteral
feedings
Continuous enteral
feedings
No aspiration Aspiration
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GI JEOPARDY The single most important factor in
nutrient deficiencies in the United States
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STATISTICS:COLON AND RECTAL CANCER
The American Cancer Society Reports: Colorectal cancer is the third most common type of
cancer in both men and women. It predicts 57, 100 deaths from colon cancer in 2003. 105, 500 new cases of colon cancer and 42, 000 new
cases of rectal cancer will be diagnosed in 2003. The 5-year survival rate is 90% for people whose
cancer is treated in the early stages but only 37% are found in the early stage.
Spread to nearby organs or lymph nodes, survival rate is 65%
Spread to distant part of the body (liver, lungs), survival rate is only 9%.
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What is Colorectal Cancer?
Cancer develops when cells in a part of the body grow and divide out of control.
Colorectal cancer is a disease in which abnormal or malignant cells form in the tissues of the colon, rectum or anus.
Most colorectal cancers begin as polyps or adenomas.
These polyps may slowly change to cancer after 5-10 years
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Types of Colorectal Cancers
95% are Adenocarcinomas Less Common Types Are:
Carcinoid Tumors - develop from hormone producing cells of the intestines.
Gastrointestinal Stromal Tumors – develop in the connective tissue and muscle layers in the wall of the colon and rectum.
Lymphomas - are cancers of the immune system cells, usually develop in the lymph nodes but may start in the colon or rectum
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RISK FACTORS:Colorectal Cancer
Family History Familial adenomatous polyposis (FAP) Hereditary nonpolyposis colorectal cancer (HNPCC)
Ethnic Background Jews of Eastern European decent
Personal History of: Colorectal cancer Intestinal polyps Inflammatory bowel disease
Aging Diet Physical Inactivity Obesity Diabetes
30-40% increased chance of developing colon cancer
Smoking Alcohol
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Possible Signs/SymptomsColorectal Cancer Change in bowel habits Blood in stool Diarrhea, constipation Feeling of incomplete
evacuation of bowel Narrow stools General abdominal
discomfort Frequent gas, bloating, fullness,
cramps
Weight loss Constant tiredness Vomiting
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TREATMENT OPTIONS:Colorectal Cancer
SURGERY Resection/Anastomosis Ostomies
CHEMOTHERPY RADIATION THERAPY BIOLOGICAL THERAPY
Treatment to stimulate the immune system to fight cancer, also called immunotherapy
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Care of the patient/client with an Ostomy
Before surgery After surgery
Check the stoma and the skin around it daily during your assessment.
A healthy stoma should be shiny, moist and a deep rich red.
Monitor the output and stool consistency Pouching and skin care Patient Teaching:
Medications Diet modification Irrigations
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GI JEOPARDY
Ostomy clients may want to avoid this alcoholic beverage because of excessive odor
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GI VIDEOS ( In the Library, Non-Print Section)
“ Basics of ileostomy care” (N278)
“Basics of Colostomy Care” (N280)
“Enteral Feeding” (N279)
“Peptic Ulcers” (N277)