Care of patients with Gastrointestinal Problems

Nursing 1930 Brendalyn Browner Muriel Mitchell

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

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

COMMON “GI OFFENDERS”

Caffeine (coffee, tea, cola)

Dairy products Chocolate Pepper (black and

green) Alcohol Spicy foods Tobacco Drugs

Abdominal Assessment

Inspection Auscultation

Diaphragm (Bowel sounds)

Bell (Vascular sounds, bruits)

Percussion Palpation

GI Charting Exercise

Document an assessment of the mouth in a person with normal findings.

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

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

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

GastroesophagealREFLUX DISEASE (GERD)

Physiological Contributing Factors:

Incompetent lower esophageal sphincter Irritant effects of reflux Abnormal esophageal clearance Delayed gastric emptying

GastroesophagealREFLUX DISEASE (GERD)

Common Signs and Symptoms:

Heartburn RegurgitationRetrosternal Burning Pain (epigastrium, neck, throat)

GastroesophagealREFLUX DISEASE (GERD)

Management and Treatment:

Lifestyle modification measuresAntacids, H2 antagonists, proton-pump inhibitor, carafate, prokinetic agents (reglan)Surgical InterventionNissen Fundoplication

GastroesophagealREFLUX DISEASE (GERD)

Pharmacology Antacids H2 Antagonist Proton Pump Inhibitors (Bid)

Prilosec Prevacid Protonix Nexium Aciphex

Pro-Motility Agents (Qid) Reglan

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

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

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

CASE STUDY

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

Peptic Ulcer Disease:COMPLICATIONS

HEMORRHAGE

PERFORATION

PYLORIC OBSTRUCTION

INTRACTABILITY

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

GI JEOPARDY Clients with resection of the ileum

are susceptible to this vitamin deficiency

Peptic Ulcer Disease: POST-OP COMPLICATIONS

Dumping Syndrome Vitamin B12

Deficiency Leaking from

suture line Shock and

Hemorrhage Dehiscence Evisceration

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)

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

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

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

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

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

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.

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

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

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.

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

Intestinal obstruction

Fistula

Acute Chronic

Hemorrhage PerforationPericolic abscess

Stricture

General peritonitis

Local suppuration

Diverticulitis

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

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

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

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

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

GI JEOPARDY The single most important factor in

nutrient deficiencies in the United States

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%.

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

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

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

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

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

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

GI JEOPARDY

Ostomy clients may want to avoid this alcoholic beverage because of excessive odor

GI VIDEOS ( In the Library, Non-Print Section)

“ Basics of ileostomy care” (N278)

“Basics of Colostomy Care” (N280)

“Enteral Feeding” (N279)

“Peptic Ulcers” (N277)