GI PresentationBy: Katie Dowdy, Adrianne Fejes, Kristy McKune, and Suzie Yoell

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NSG 132 GI Unit Case Study Your patient is a 35 y/o mentally challenged Caucasian female. She comes in with her guardian. She is a non-smoker, non-drinker and lives in a group home.

Chief complaint: Upper abdominal pain with vomiting. The patient is able to point to and clearly verbalize the location and severity of her pain.

Medical History: severe osteoporosis with multiple thoracic compression fractures, Surgical History: tubal ligation-remote, recent debridement leg.

Medications: Fosamax 10mg po q a.m., nortriptyline 25mg po q h.s., Flexeril 10 mg po tid prn, Darvocet prn, Naprosyn 375mg 2 po bid prn and a variety of supplements.

Vital Signs: 136/85-88-20, 98.8

HEENT- unremarkable

LUNGS- scattered rhonchi otherwise good air flow

HRT- RRR with a soft systolic murmur

ABDOMEN- tender epigastrum, voluntary guarding, BS x 4 quads and normoactive, no masses or organomegaly.

CXR neg., abdominal US neg.Upper GI – “irritability at the GE junction” with no hiatal hernia or reflux.

Lab Values for this patient:

WBC 3.7 lowRBC 5.25 high

HGB 10.3 low HCT 24.8 low

Urine Amylase 42 highESR 122 high

Cl 92 low

MCV 89.9 MCH 29.9

BUN 16 Cr 1.2

MCHC 33.2 PLT 329

Tot Pro 7.1 Ca 9.7

Na 135 K 3.9

globulin 3.5Alb 3.6 Tot Bili 0.7

ALT 32 AST 22

Mean PLT vol 8.4 Alk phos 82 Glucose 91

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Elevated RBC - 5.25• Signifies: Dehydration can cause an increase in

RBC

Elevated Urine Amylase - 42• Signifies: May be elevated due to a peptic ulcer,

a perforated bowel, or pancreatitis.

Low White Blood Cells - 3.7Signifies: White blood cells (Leukocytes) help fight off infection in the body. When WBC's are low it means your body's ability to fight off infection is compromised.

Lab results analysis:

Elevated ESR: -122 Signifies: can be caused by a bacterial infection.

Low HGB - 10.3Signifies: dehydration from vomiting.

Low HCT - 24.8Signifies: dehydration from vomiting.

Low Chloride – 91Signifies: prolonged vomiting

Overview: It appears that dehydration is causing some abnormal lab values with the possibility of an infected peptic ulcer or perforated bowel .

Lab results analysis:

DIAGNOSTIC TESTING: Upper GI endoscopy with

biopsy and cytologic analysis: Examines the lining of the upper

part of the gastrointestinal tract, including the esophagus, stomach and duodenum. 

More accurate than x-ray films to detect inflammation, ulcers, and tumors of the esophagus, stomach and duodenum. 

A biopsy helps distinguish between benign and malignant tissues.

A cytologic analysis is an examination of individual cells.

http://www.disease-picture.com/upper-gastrointestinal-endoscopy/

http://www.ageofautism.com/2010/01/new-papers-on-autism-and-gi-disorders.html

Barium swallow:

Fluoroscopic x-ray study using contrast medium. 

Used to diagnose structural abnormalities of esophagus, stomach, and duodenum.

Esophageal Motility (manometry) studies (EMS): A test to assess motor function of the upper esophageal sphincter (UES), esophageal body and lower esophageal sphincter (LES).

DIAGNOSTIC TESTING: (CONT.)

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DIAGNOSTIC TESTING: (CONT.)

pH monitoring (laboratory or 24 hour ambulatory): 

Method of recording the amount and degree of acidic stomach contents in the esophagus. 

A small probe is placed in the esophagus and carried for 24 hours. 

Using a microprocessor, this device is able to record the pH for 24 hours.

Endoscopic Ultrasound (EUS):

Small ultrasound transducer is installed on the tip of an endoscope. 

Detects and stages esophageal, gastric, rectal, biliary, and pancreatic tumors and abnormalities. 

Fine-needle aspiration can be used to diagnose cancer or dysplasia.

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Nausea & vomiting

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Path

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Nausea is related to the

slowing of gastric motility and emptying.

Causes of Vomiting:

Pregnancy, infection, central nervous system

disorders, cardiovascular

problems, metabolic

disorders, side effects from

drugs or psychological

factors.

Vomiting is a protective

mechanism in the body to get rid of spoiled or irritating foods

and liquids.

Neural impulses reach the vomiting center in the

brainstem from receptor s in the GI tract,

kidneys, heart and uterus.

Chemoreceptor trigger zone responds to

chemical stimuli of drugs

and toxins.

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Gastritis

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Path

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Gastritis is one of the most common problems with the stomach.

When the mucosal barrier is broken Hydrochloric Acid, (HCl) acid and pepsin can diffuse back into the

mucosa resulting in tissue edema, disruption of capillary walls, and possible hemorrhage.

Deterioration of the stomach lining can lead to the loss of the function of the parietal cells and the source of intrinsic factor is lost; resulting in the

inability to absorb vitamin B12.

Causes of Gastritis: Drug related:

NSAIDS: Aspirin, digitalis (digoxin) and alondronate (fosamax)

CorticosteroidsMicroorganisms:

H. PyloriSalmonella

Staphylococcus organisms

Environmental Factors:

RadiationSmoking

Pathophysiologic Conditions:Burns SepsisLarge hiatal hernia Shock

Physiologic stressRenal Failure

Reflux of bile and pancreatic secretionsDiet:

AlcoholSpicy

Irritating Foods

Other Factors:Endoscopi

c Procedure

sNG Tube

Psychologic stress

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Focused assessment for the abdomen and associated pain

Assessm

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Subjective Health Information: Objective Health Information:

Ask caregiver about medications - When did she start Fosamax for her osteoporosis? When were the last doses of Darvocet and Naprosyn?

Location of abdominal tenderness or pain

Is or has anyone else been sick in the group home?

Frequency, character and color of vomitus

When did the pain start?When did vomiting start?

Urinary output

What is the amount, frequency, character and color, dry heaves, anorexia or weight loss?

Lab results

Any weakness or fatigue?

Nursing Diagnoses to consider:• Risk for deficient fluid volume: Risk factors include: excessive loss from

gastrointestinal tract as a result of vomiting and decreased intake. 

 • Acute pain r/t irritated mucosa from acid

secretion AEB patient guarding abdominal region, nausea and vomiting .

• Imbalanced Nutrition: less than body requirements r/t vomiting, inability to absorb nutrients, and a restricted dietary regimen AEB abdominal pain.

• Nausea r/t abdominal pain AEB report of nausea

Nursing Interventions:

• Assess pain level and perform a focused assessment• Document history of pain - frequency, onset, duration

and precipitating  factors, (see if it correlates with medication intake, etc.)

• Routinely assess the client for the presence of pain• Discuss with client and caregiver medication regimen –

compliance and when medications were last taken.• Assess vital signs, monitor I/Os• Discuss with both client and caregiver nutritional

habits.• Encourage client and caregiver to particpate in creating

the health care management plan (i.e. nutrition, lifestyle, and hand hygiene to prevent the spread of bacteria).

• Develop a contract to create and maintain motivation for client to modify behavior.

• Reassure client in hopes to ease anxiety.           • HOB elevated                                                  

Means to Prevent Further Complications of gastritis

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-Avoid eating spicy or irritating foods- Eat six small frequent meals as opposed to larger meals-Antacids following meals may help- Don’t eat close to bedtime and stay elevated after eating-No smoking or quit-Limit alcohol use-Pay special attention to drug side effects and interactions-Follow-up medical attention is important because gastritis can be a precursor for stomach cancer

A Learning Exercise

Gastritis Clinical Manifestations

Anorexia

Nausea

Vomiting

Epigastric tenderness

A feeling of fullness

Name five clinical manifestations of Gastritis.

Anorexia

Nausea

Vomiting

Epigastric tenderness

A feeling of fullness

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that this client is at risk for which

vitamin deficiency?A. Vitamin AB. Vitamin B12C. Vitamin CD. Vitamin E

The answer: Vitamin B12

References

Ackley, B., & Ladwig, G. (2011). Nursing diagnosis handbook. (9th ed.). St. Louis: MosbyElsevier.

Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (2011). Medical-surgical nursing assessment and management of clinical problems. (8th ed., Vol. 2). St. Louis: Elsevier Mosby.

Pagana, K., & Pagana, T. (2011). Nursing diagnosis handbook. (4th ed.). St. Louis: MosbyElsevier.

Silvestri, L. (2011). Saunders comprehensive review for the nclex-rn examination. (5th ed.). St. Louis: Elsevier Saunders.