Download - Nursing of Adult Patients with Medical & Surgical Conditions Gastrointestinal Disorders Part I
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Nursing of Adult Patients with
Medical & Surgical Conditions
Gastrointestinal
Disorders
Part I
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Laboratory & Diagnostic Examinations
• Upper GI Series– Rationale
• Series of radiographs of the lower esophagus, stomach, and duodenum using barium sulfate as the medium contrast
– Nursing Interventions• NPO after midnight• Ensure pt. Expels barium
– increase fluid intake– Milk of Magnesia
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• Gastric Analysis– Rationale
• Aspiration of stomach contents to determine the amount of acid produced gy the parietal cells in the stomach, estimate acid secretory capacity for intrinsic factor
– Nursing Interventions• No anticholinergic medications for 24 hours before the test
• NPO after midnight
• No smoking
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• Esophagogastroduodenoscopy (EGD)– Rationale
• Direct visualization of the upper GI tract by means of a long, fiberoptic, flexible scope
• Assess for disease, remove abnormalities, dilate strictures
– Nursing Interventions• NPO after midnight• Informed consent• IV sedative as ordered• Do not allow pt. to eat or drink until
gag reflex returns (2-4 hrs)• Assess for s/s of perforation (pain,
bleeding)
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• Barium Swallow– Rationale
• Through study of the esophagus using barium contrast
• Assess for anatomical abnormalities
• Use Gastrografin if perforation is suspected– water soluble and easily absorbed
– Nursing Interventions• NPO after midnight
• Ensure pt. expels barium– increase fluids
– Milk of Magnesia
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• Bernstein Test– Rationale
• Reproduces the symptoms of gastroesophageal reflux
• Differentiates esophageal pain from angina
• Tube is inserted to the lower esophagus and hydrochloric acid is inserted
– Nursing Interventions• NPO for 8 hours prior to test
• Hold any antacids and analgesics
• No sedation (pt must describe the pain)
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• Stool for Occult Blood– Rationale
• Detect hidden blood in the stool
• May be caused from tumors, ulcerations, and inflammation
– Nursing Interventions• Stool should be free of urine, toilet paper, etc.
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• Sigmoidoscopy– Rationale
• Visualization of the anus, rectum, and sigmoid colon
• May obtain biopsies, remove polyps, or specimens of ulcerations
– Nursing Interventions• Informed consent
• Enemas the evening before and/or the morning of the exam
• Observe for s/s of perforation (pain, bleeding)
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• Barium Enema– Rationale
• Series of radiographs of the colon using barium contrast
• Assess for presence of polyps, tumors, and diverticula
– Nursing Interventions• Administer cathartics
– Magnesium citrate
• Cleansing enema the evening before and/or the morning of the exam
• Ensure pt. expels barium– Increase fluids
– Milk of Magnesia
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• Colonoscopy– Rationale
• Visualization of the colon from anus to cecum• Detection of neoplasms, inflammations, ulcerations,
and bleeding• Biopsies can be obtained and small tumors removed
– Nursing Interventions• Informed consent• Clear liquid diet 1-3 days prior to exam• NPO 8 hours before exam• Administer cathartic
– GoLYTELY
• Enemas as ordered• IV sedative as ordered
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• Stool Culture and Sensitivity; Stool for Ova and Parasites– Rationale
• Stool examined for bacteria, ova, and parasites
– Nursing Interventions• Use only normal saline enemas if required to obtain
specimen
• Take to lab within 30 minutes
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• Flat Plate of the Abdomen– Rationale
• Group of radiographic studies on the abdomen of pts. suspected of bowel obstruction, paralytic ileus, perforation, or abcess
– Nursing Interventions• Schedule before any barium studies
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Dental Plaque and Caries
• Etiology/Pathophysiology– Erosive process that results from the action of
bacteria on carbohydrates in the mouth, which produces acids that dissolve tooth enamel
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Dental Plaque and Caries
• Cause– Presence of plaque– Strength of acids and ability of saliva to
neutralize them– Length of time acids are in contact with the
teeth– Susceptibility of tooth to decay
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Dental Plaque and Caries
• Treatment– Removal of affected area and replace with
dental material
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Candidiasis
• Etiology/Pathophysiology– Infection caused by a species of Candida,
usually Candida albicans– Fungus normally present in the mouth,
intestine, vagina, and on the skin– Also refered to as thrush and moniliasis
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Candidiasis• Signs and Symptoms
– Small white patches on the mucous membrane of the mouth
– Thick white discharge from the vagina
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Candidiasis
• Treatment– Nystatin
• oral suspension
• vaginal tablets
– Half strength hydrogen peroxide/saline mouth wash
– Ketoconazole oral tablets– Meticulous handwashing
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Carcinoma of the Oral Cavity
• Etiology/Pathophysiology– Malignant lesions on the lips, oral cavity, tongue, or
the pharynx– Usually squamous cell epitheliomas
• grow rapidly and metastasize quickly
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Carcinoma of the Oral Cavity
• Signs and Symptoms– Leukoplakia
• white, firmly attached patch
on the mouth or tongue
mucosa
– Roughened area on the tongue– Difficulty chewing, swallowing, or speaking– Edema, numbness, or loss of feeling in the
mouth– Earache, faceache, and toothache become
constant
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Carcinoma of the Oral Cavity
• Treatment– Stage I
• Surgery or radiaiton
– Stage II & III• Both surgery and radiation
– Stage IV• palative
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Carcinoma of the Esophagus
• Etiology/pathophysiology– Malignant epithelial neoplasm that has invaded
the esophagus• 90% are squamous cell carcinoma associated with
alcohol intake and tobacco use• 6% are adenocarcinomas associated with reflux
esophagitis• Other causes are environmental carcinogens,
nutritional deficiencies, chronic irritation, and mucosal damage
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Carcinoma of the Esophagus
• Signs & Symptoms– Progressive dysphagia over a six month period– Sensation of food sticking in throat
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Carcinoma of the Esophagus• Treatment
– Radiation• May be curative or pallative• Complication
– Fistula formation may cause aspiration
– Surgery• may be palliative, increase longevity, or curative• Types of Surgical Procedures
– Esophagogastrectomy: remove a portion of the esophagus and stomach
– Esophagogastrostomy: remove a portion of the esophagus with anastomosis to the stomach
– Esophagoenterostomy: remove the esophagus with anastomosis to the colon
– Gastrostomy: insertion of a feeding tube into the stomach through the abdominal wall
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Esophagoenterostomy
Esophagogastrostomy
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Achalasia
• Etiology/Pathophysiology– Inability of the cardiac sphincter of the stomach to relax– Also called cardiospasm– Possible causes: nerve degeneration, esophageal dilation,
and hypertrophy
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Achalasia
• Signs and Symptoms– Dysphagia– Regurgitaion of food– Substernal chest pain– Loss of weight– Poor skin turgor– Weakness
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Achalasia
• Treatment– Medications
• Anticholinergics, nitrates, and calcium channel blockers
– Dilation of cardiac sphincter• Balloon is inflated and remains in place for 1 minute; 1-2
times
– Surgery• Cardiomyectomy
– Incision of the muscular layer
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Acute Gastritis
• Etiology/Pathophysiology– Inflammation of the lining of the stomach– May be associated to alcoholism, smoking, and
stressful physical problems– Usually a single occurance, resolving when
offending agent is removed
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Acute Gastritis
• Signs and Symptoms– Fever– Epigastric pain– Nausea– Vomiting– Headache– Coating of the tongue– Loss of appetite
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Acute Gastritis
• Treatment– Antiemetics
• Compazine
• Tigan
– Antacids & Tagamet or Zantac
– Antibiotics
– IV fluids
– NG tube and administration of blood, if bleeding
– NPO until s/s subside
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Peptic Ulcers
• Gastric Ulcers & Duodenal Ulcers– Ulcerations of the mucous membrane or
deeperstructures of the GI tract– Most commonly occur in the stomach and
duodenum– Result of acid and pepsin imbalances
• Excess of gastric acid or
• Decrease in protection from acid and pepsin
– H.pylori• Bacterium found in 70% of pts. with gastric ulcers
and 95% of pts. with duodenal ulcers
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Peptic Ulcers (Gastric)
• Etiology/Pathophysiology– Most common site is the distal half of the
stomach– Risk factors:
• Irregular diet
• Genetic predisposition
• Excessive use of salicylates
• Use of tobacco
• H.pylori
– Gastric mucosa is damaged, acid is secreted, mucosa errosion occurs, and an ulcer develops
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Peptic Ulcers (Duodenal)
• Etiology/Pathophysiolosy– Excessive production or release of gastrin– Increased sensitivity to gastrin– Decreased ability to buffer the acid secretions– Risk factors:
• H.pylori• NSAID’s• Smoking• Coffee
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Peptic Ulcers (Gastric & Duodenal)
• Signs & Symptoms– Pain
• Dull, burning, boring, or gnawing
• Epigastric
• Occurs between meals with gastric ulcers
• Duodenal ulcer pain may awaken pt. at night
– Dyspepsia• Nausea, eructation, and distention
– Hematemesis
– Melena
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Peptic Ulcers (Gastric & Duodenal)
• Treatment– Antacids
• Neutralize or reduce the acidity of the stomach– Maalox, Gaviscon, Rolaids, Tums, Mylanta, Riopan
– Histamine H2 Receptor Blockers • Decrease acid secretion by blocking the histamine H2 receptors
– Tagamet, Zantac, Pepcid, and Axid
– Proton Pump Inhibitor• Antisecretory agent ot inhibit secrtion of gastrin by the parietal
cells of the stomach– Prilosec, Losec, and Prevacid
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Peptic Ulcers (Gastric & Duodenal)
– Mucosal Healing Agents• Heal ulcers without antisecretory properties
• Adhere to the proteins in the ulcer base– Carafate and Cytotec
– Antibiotics• Eradicates H.Pylori
– Flagyl, tetracycline, amoxicillin, and Biaxin
– Usually combined with some of the other medications
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Peptic Ulcers (Gastric & Duodenal)
• Diet– High in fat and carbohydrates– Low in protein and milk products– Small frequent meals– Limit coffee, tobacco, alcohol, and aspirin use
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Peptic Ulcers (Gastric & Duodenal)
• Surgery– Antrectomy
• Removal of entire antrum(gastric producing portion of the lower stomach)
– Gastrodudodenostomy (Billroth I)• Fundus of the stomach is directly anastomosed to the
duodenum
– Gastrojejunostomy (Billroth II)• Duodenum is closed, and the fundus of the stomach is
anastomosed into the jejunum
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Billroth Procedures
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Peptic Ulcers (Gastric & Duodenal)
– Total Gastrectomy• Removal of the entire stomach
– Vagotomy• Removal of the vagal
innervation to the fundus
• Decreases acid production
– Pyloroplasty• Surgical enlargement of the
pylorus to provide drainage of the gastric contents
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Peptic Ulcers (Gastric & Duodenal)
• Complications– Dumping Syndrome
• Rapid gastric emptying causing distention of the duodenum or jejunum produced by a bolus of hypertonic food
• Increased intestinal motility and peristalsis and changes in blood glucose levels
• Diaphoresis, nausea, vomiting, epigastric pain, explosive diarrhea, borborygmi (noises from gas), and dyspepsia
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Peptic Ulcers (Gastric & Duodenal)
– Dumping Syndrome• Treatment
– Six small meals a day
– Diet high in protein and fat, low in carbohydrates
– No fluids during meals
– Anticholenergics
– Lying down for approximately 1 hour after meals
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Peptic Ulcers (Gastric & Duodenal)
– Pernicious Anemia• Caused by a deficiency of the intrinisic factor
– Aids in absorption of Vitamin B12
• Treatment
• Vitamin B12 Injections
– Iron Deficiency Anemia• Caused by impaired absorption in the duodenum and jejunum
as a result of rapid gastric emptying
• Treatment– Oral iron replacement
» Ferrous sulfate
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Cancer of the Stomach• Etiology/Pathophysiology
– Most commonly adenocarcinoma– Primary location is the pyloric area– Risk Factors:
• History of polyps• Pernicious anemia• Hypochlorhydria• Gastrectomy• Chronic gastritis• Gastric ulcer• Diet high in salt, perservatives, and carbohydrates• Diet low in fresh fruits and vegetables
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Cancer of the Stomach• Signs & Symptoms
– Early stages may be asymptomatic
– Vague epigastric discomfort or indigestion
– Postparandial fullness
– Ulcer-like pain that does not respond to therapy
– Anorexia
– Weakness
– Weight loss
– Blood in stools
– Hematemesis
– Vomiting after fluids and meals
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Cancer of the Stomach• Treatment
– Surgery• Partial or total gastric resection• Post-Op Complications
– Dehiscence» Separation of wound edges
– Evisceration» Viscera protrudes through the wound» Caused by coughing, straining, malnutrition, obesity,
and infection» Nursing Interventions: Pt. should remain quite and
calm, position with knees bent and semi-fowlers postion, cover eviseration with a warm sterile saline soaked dressing
– Chemotherapy– Chemotherapy and radiation
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Infection of the Intestines• Etiology/Pathophysiology
– Invasion of the alimentary canal by pathogenic microorganisms
– Most commonly enters through the mouth on food or water
– Person to person contact– Fecal-Oral transmission
• due to poor handwashing
– Long-term antibiotic therapy can cause an overgrowth of the normal intestinal flora (c.difficile)
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Infection of the Intestines
• Signs & Symptoms– Diarrhea
• May contain blood and mucus
– Rectal urgency
– Tenesmus• Ineffective and painful straining with defecation
– Nausea & vomiting
– Abdominal cramping
– Fever
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Infection of the Intestines
• Treatment– Antibiotics
• Stool postive for leukocytes
– Fluid and electrolyte replacement• Oral or IV
– Kaopectate• Increase stool consistency
– Pepto-Bismol• Decrease intestinal secretions and decrease diarrhea
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Irritable Bowel Syndrome• Etiology/Pathophysiology
– Episodes of alteration in bowel function– Low pain threshold to intestinal distention
caused by abnormal intestinal sensory neural circuitry
– May be associated with psychological problems– Spastic and uncoordinated muscle contractions
of the colon, usually due to excessively course or highly seasoned foods
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Irritable Bowel Syndrome
• Signs & Symptoms– Abdominal pain
• Relieved after bowel movement
– Frequent bowel movements– Sense of incomplete evacuation– Flatulance– Constipation and/or diarrhea
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Irritable Bowel Syndrome• Treatment
– Diet and Bulking Agents• Increase dietary fiber
• Administer fiber agents
• Avoid food which cause exacerbation
– Medications• Anticholinergics
– Relieve abdominal cramps
• Milk of Magnesia, fiber, or mineral oil for constipation
• Opioids for diarrhea
• Antianxiety drugs for panic attacks