GASTROINTESTINAL DISORDERS

C Washington RN, MSNEd

Relationship of GI System to Other SystemsNeurological Parasympathetic

nervous system increases peristalasis

Sympathetic nervous system decreases peristalsis

Many cranial nerves are essential for eating

Spinal cord probems may affect bowel & bladder control

Relationship of GI System to Other System

Endocrine Thyroid regulates

metabolism

Pancreas is an endocrine organ producing insulin, glucagons, and digestive enzymes

Relationship of GI System to Other System

Respiratory A distended

abdomen can impringe on respiratory structures

Chronic lung disease with

overinflation of lungs can

push diaphragm farther

into abdomen

Relationship of GI System to Other System

Cardiovascular CV system

transports nutrients and wastes

Abdominal aorta is located in the abdominal cavity

Right sided heart problem can result in fluid accumulation in abdomen (ascites)

Relationship of GI System to Other Systems

Muscular Abdominal

muscles protect and support abdominal contents

Skeletal Osteoporesis and

arthritis are complications of ulcerative colitis

Relationship of GI System to Other Systems

Integumentary Skin-color changes

such as jaundice may indicate liver disease

Nutritional deficits or

malabsorption problems

can affect growth of skin,

hair & nails

Relationship of GI System to Other Systems

Digestive Digestive system

is found in adominal cavity

Problems with digestive system may affect other abdominal structures

Relationship of GI System to Other Systems

Urinary Urinary structures

are located in the abdomen

Problems with the urinary system may affect other abdominal structures

Lymphatic The spleen is a

lymphatic structureReproductive Pregnancy displaces

abdominal contents

GI AssessmentAsk about Weight changes Diet Fevers Dizziness

Inspect: Orientation, facial

expression Posture Nutritional statusMeasure: Ht, wt, vital signs

GI Assessment Integumentary: Ask about Changes in skin,

hair, & nails Rashes, itching,

lesions

Inspect Skin, hair & nails

for changes in color & texture, lesions, and edema/ascites

Palpate: Skin turgor

GI Assessment Head & Neck: Ask

about Thyroid disease, neck

masses, recent infections

Eyes: Ask about Vision changes

Inspect: Neck massesPalpate: Thyroid

gland, lymph nodes

Inspect eyes: edema,color of sclera, retinalchanges

GI Assessment Assessment Ear, Nose, & Throat: Ask about Trouble swallowing Sore throat Dizziness Last dental exam

Inspect: mouth, throat,

teethTest:Cranial nerves 1, 7,

9, 10, 12

GI Assessment Respiratory: Ask

about Breathing

problems SOB History of COPD

Measure: Respiratory rate &

depth

Auscultate: Breath sounds

GI Assessment Cardiovascular:Ask about history of CVD HTN CHF

Palpate: Pulses: check for

thrills, edema

Auscultate: Heart sounds

GI Assessment Genitourinary:Ask about Color of urine Urinary burning,

frequency, hesitancy

Inspect: Color of urine,

external genitalia for lesions or discharge

Palpate: Bladder for

distention, kidneys, prostate

CVA tenderness

GI AssessmentReproductive:

Ask about History of STDs Women: LMP, vaginal

discharge Men: Prostate

problems, Penile discharge

Women Pelvic examMen Rectal exam

GI Assessment Musculoskeletal:Ask about History of

fractures Joint pain Weakness

Inspect Spinal curves,

joints, ROM

Palpate Muscle strength

GI Assessment Neurological:Ask about Alcohol use Numbness Back problems Loss of

bowel/bladder control

Test: Sensation DTR

GI AssessmentEndocrine:Ask about History of diabetes Thyroid problems

Lymphatic/HematologicAsk about Food Allergies Infection Sickle Cell AnemiaPalpate: Lymph nodes, spleen

GI: Key Terms Borborygmus Dumping

symdrome Dyspepsia Gastroparesis

Hematemesis Helicobacter pylori Intussusception leukoplakia

GI: Key Terms McBurney’s point Melena Peritonitis Pyrosis

Rebound tenderness

Steatorrhea Volvulus

obstruction Lavage/gavage

GI System Assessment: Health History

Description of presentillness or chief

complaint Onset, course,

duration Location Alleviating or

precipitating factors

GI System Assessment: Health History

Risk Factors Low fiber diet Smoking Alcohol

consumption

Inactivity Stress Familial

predisposition to Gi disorders

Assessment of GI System

Pain Location, quality,duration Abdomen, epigastric, indigestion Before or after meals Alleviated by position changes, OTC

med, home remedies

Assesment of GI SystemExamination of

abdomen Color, contour,

distention, previous scars

Bowel sounds Tympany or dullness Tenderness or masses

Elimination pattern Constipation Diarrhea rectal bleeding laxative use

Assessment of GI SystemNutritional issues Loss of appetite Anorexia Intake and output Difficulty

swallowing Nausea & vomiting

Assessment of GI System

Associatedmanifestations orcomplaints Flatus Bleching

Heartburn Dark urine Jaundice Excessive wt gain

or loss

Critical Thinking Challenge 50 yr old female c/o RUQ abd

pain/cramping x 2 days Travels extensively with job Eats at restaurants several times weekly Symptoms began 1-2 hrs after eating

dinner of fried or spicy foods.

Critical Thinking Challenge About what specific areas of the history

should you seek further information or clarification?

What physical assessment findings would you be most likely to find during the abdominal examination

Physical Exam Imperative that the nurse takes a

systematic approach to the examination Order is inspection, auscultation,

percussion and palpation

Inspection Watch the patient first

Guarding of abdomen, posture, movement, scars

Inspect oral mucosa, tongue, pharynx, soft palate, uvula, tonsils and anterior and posterior pillars

Inspect abdomen, ask about any scars

Auscultation Listen in all 4 quadrants for 2-5 minutes

each Assess aorta and renal arteries

Palpation Should start with the mouth and throat

area Palpate abdomen in a systematic

pattern, from light palpation to deeper palpation

Palpate the liver, spleen, kidneys, and aorta

Physical Assessment Work with the client prior to starting to

find a comfortable position

Physical Assessment Have the patient tilt their head back

slightly and then have the patient say “ahhh.” Allows for inspection of the uvula, tonsils,

soft palate and anterior and posterior pillars

Physical Assessment While inspecting the abdomen

Look at the contour of the abdomen both obliquely and straight on prior to touching

Look for masses, fluid waves or changed in contour

Look for scars and readdress any questions from the history to assist the patient in recalling further information

Auscultation A ticklish patient may not tolerate the

touch of the stethoscope Have the patient place the stethoscope

where the nurse directs Check bowel sounds in all 4 quadrants

for 2-5 minutes

Auscultation

Figure 44.6 Sites for vascular sounds.

Palpation Palpate the abdomen in a systematic

pattern Move from light palpation to deeper

palpation

Palpation In patients who are sensitive, even light

palpation will cause muscle resistance. In this case attempt to assist the patient to relax by having them bend their knees, or have the patient place their hand under the nurses and then press down

Palpation In clients with a complaint of abdominal

pain, palpation of the area the patient has identified as painful should be done last

Palpate the liver edge, spleen, right and left kidneys

Palpation

Figure 44.9 Palpation of kidneys. Source: Cheryl Wraa

Physical Examination Findings Rebound tenderness: greater when

pressure is released than applied A reliable sign of peritoneal inflammation

Gently press into the abdomen and then release pressure

Start away from painful area and work it

Physical Examination Findings Murphy’s sign: positive with inflammation of

the gallbladder Stand on the right side of the bed Place a hand flat on the abdomen, fingertips just

below right costal margin Have the patient gently inhale As the liver and gallbladder descend into the

fingertips, pain will be present where there is inflammation

Diagnostic Blood & Urine Test

Stomach Helicobacter pyloriBiliary system Total bilirubin Alkaline

phosphatase

Pancreas Amylase Lipase Calcium

Diagnostic Blood & Urine Test

Urine Bilirubin Amylase Urobilinogen

Intestine Total protein Lactose tolerance

test

Radiologic Tests UGI series Barium enema Ultrasonography Computed

Tomography Radionuclide imaging Cholecystography Cholangiography

Gastric analysis Schilling test EGD ERCP Colonscopy

Barium Swallow SeriesDetects abnormalities

ofthe esophagus,

stomach,and/or small intestines NPO MN No smoking, chewing,

or eating before procedure

Post-procedure Increase fluids Laxative Monitor stools for

chalky-white appearance as barium is eliminated

Barium Enema StudyExamines large

intestine Rectal insertion of

barium enema Cl liq diet Laxative NPO MN Cleansing enema in

am

Post-Procedure Increase fluids Laxative Monitor stools for

barium Notify MD if no BM

in 48 hrs

Critical Thinking Challenge A patient underwent an UGI series 2

days ago and is scheduled for a barium enema today.

What assessment data does the nurse need to obtain before sending the patient to radiology?

Endoscopic Studies: Lower GI

Colonscopy Visualize lining of

small intestine Biopsies PolypectomiesAnoscopy Examine anal canal

Sigmoidoscopy Examine rectum Sigmoid colon Biopsies polypectomies

Endoscopic Studies: Lower GI Nursing Interventions

Preparation Clear liquid diet Osmotic laxative

(fleets phospho soda/Golytely)

NPO MN Versed IV for

conscious sedation

Post-procedure Bedrest until alert Monitor for

perforation, bleeding

Critical Thinking Challenge 55 yr old male scheduled for a

colonoscopy “My aunt died of colon cancer 5 yrs ago He is very worried about the procedure States he is not sure his wife will be able

to leave work to pick him up after the test.

Critical Thinking Challenge What should you respond to his

comments about his worries and his aunt’s death?

What would you tell him about what he can expect during the procedure?

What discharge instructions will he need after the procedure is finished?

Critical Thinking Challenge When can you discharge him? Will he be able to drive home alone? Why or why not

Endoscopic Studies: Upper GI

EGD Visualize gastric

wall, spincters, doudenum

Tissue biopsies NPO MN Versed conscious

sedation

Post-Procedure Bedrest until alert Monitor for

perforation NPO until gag reflex

returns Observe for

dysphagia

Analysis of GI SecretionsStool analysis fecal urobilinogen, nitrates, bacteria,

parasites Inspect stool for color, consistency, occult

blood Do not refrigerate Send specimen promptly to lab

Analysis of GI SecretionsGastric Analysis NGT to aspirate gastric contents Measures amt of acid secreted in stomach NPO MN Antacids & H2-receptor antagonist stopped

24-48 hrs prior Avoid smoking/chewing tobacco 6 hrs before

Analysis of GI SecretionsGastric Analysis: Used to diagnose Pernicious anemia-lack of stomach acid Zollinger-Ellison Syndrome-high levels

of gastrin produced, excess hydrochloric acid

Pre/post acid suppressing therapy to eval adequacy of drug dose

Evaluation of the Gallbladder Cholecystogram Examines gallbladder Dx liver, gallbladder disorders (gallstones &

tumors) Check for allergy High-fat diet lunch, low fat dinner 12 hrs prior take contrast medium tablets NPO

Evaluation of the LiverPercutaneous Transhepatic Cholangiogram X-rays bile ducts inside & outside liver Contrast medium injected into bowel ducts Dx blockage causing juandice and

pancreatitis Check for allergy

Evaluation of the Liver

Percutaneous Transhepatic Cholangiogram

Post-procedure: monitor Bleeding Infection (sepsis) Inflammation of the bile ducts

Diagnostic ProceduresAbdominal X-ray KUB Flat plate Assess urinary

system Blockage of

intestines

Assist in diagnosis of:

abd pain Distention unexplained

nausea

Liver Biopsy Supine or left lateral

position Performed under

fluoroscopy Informed consent Check PT, PTT, INR,

platelet count NPO MN

Post-procedure Right side 1-2 hrs Monitor bleeding,

pneumothorax, infection

ParacentesisRemoval of abdominal fluid in peritoneum Treat new onset ascites/ascites unknown

reason Ascites: c/o fever, painful abd distension,

peritoneal irritation, hypotension, encephalopathy, sepsis, difficulty breathing

Malignant ascites Peritoneal dialysis with suspected peritonitis

ParacentesisPrep Informed consent Void prior to

procedure Measure weight Measure abd girth

Post Measure weight Measure abd girth Supine 2-4 hours Observe for

hypovolemia, shock, infection

Liver Function Test Alkaline phosphatase: tumor marker Prothrombin time: prolonged Blood ammonia: assess protein by products Elevated in liver disease (SGOT, SGPT, LDH,

AST, ALT) Cholesterol: increase with liver

damage/decreased with liver damage Bilirubin: monitor jaundice

Gastrointestinal Intubation NGT=decompress stomach Salem sump=continous or intermittent

suction-prevents trauma to stomach lining Miller-Abbot=intestinal suction-reposition

hourly for movement in intestines Sengstaken-Blakemore=treatment of

esophageal varices (ICU-rebleeding, pneumonia, respiratory obstruction)

NGT Feeding/Suction

Feeding Assess placement before feeding & q 4 hrs

with continous feeding Semi-fowler’s Check residual: hold feeding if over 100ml Nose & mouth care

NGT Feeding/Suction

Suction Drain stomach contents Should see a decrease in volume of

drainage

Feeding TubesGastrostomt/

Jejunostomytube Sutured in place Skin care

important Long term feeding

Percutaneous Endoscopic

Gastrostomy (PEG) No need to check

placement Long term feeding Preferred over GT

because of ease of insertion and care

Total Parental Nutrition (TPN) IV administration hyperosmotic solution 3-6 times osmolarity of blood Glucose Nitrogen Lipids Electrolytes Other nutrients

Total Parental Nutrition (TPN) Used when nutrition can’t be met by

enteral route Central line (for rapid dilution & blood flow) GI disorders Disorders that impair absorption of

nutrients GI tract dysfunction

Total Parental Nutrition CXR immediately after central line insertion Assess wt, electrolytes, blood glucose Maintain sterile technique during dressing

changes Maintain infusion rate-don’t increase or

decrease without order (hyper/hypoglycemia

Total Parental Nutrition Weight daily Change all tubings/filter daily Follow protocol for discontinuing TPN Turn off TPN 1 full minute before drawing

all labs Ensure safe medication administration with

regard to compatibility

Total Parental Nutrition

Monitor for complications Infection-change filter/tubing every bottle Hypoglycemia or hyperglycemia-BS q 4 hrs If behind admin rate don’t attempt to catch

up Fluid overload

Total Parental Nutrition Air embolism-never open subclavian

central line to air (less change with PICC line and multi lumen setups

Pneumothorax during insertion of central line

GI Health Problems Gastroesophageal

reflux disease (GERD)

Peptic ulcer disease Hiatal hernia Crohn’s disease Ulcerative colitis Diverticular disease

Intestional obstruction

Appendicitis Peritonitis Neoplasms of GI

tract