“air-fluid levels” seen in small bowel obstruction part i
TRANSCRIPT
The Gastrointestinal System:
Digestive Disorders
“Air-Fluid Levels” seen in small bowel obstructionJ. Carley MSN, MA, RN, CNE
Part I
The G-I System Supplemental
Learning Objects:
Flash Cards (Terminology) See the email I sent you yesterday
G-I System Games Meds for the Gastro Intestinal System
http://www.quia.com/rr/612817.html
G-I System Part Ihttp://www.quia.com/rr/612592.html
GI System Part 2http://www.quia.com/rr/612897.html
G-I System Part 3http://www.quia.com/rr/612899.html
1. Describe the mechanism of action, signs and symptoms, complications, treatments and nursing interventions for gastrointestinal disorders
2. Compare and describe the pathophysiology for Crohn’s Disease and ulcerative colitis
3. Explain pathophysiology, types, risk factors, and treatment for gastritis
LEARNING OUTCOMESAt the conclusion of this learning activity, the nurse will be able to:
4. Explain the use of radiography in diagnosis of GI health problems
5. Discuss the physical assessment findings in a client with digestion, nutrition, and elimination health problems
6. Describe procedures, risk factors, potential complications, nursing monitoring, and interventions for scope procedures
LEARNING OUTCOMESAt the conclusion of this learning activity, the nurse will be able to:
7. Describe preparation, post-op interventions, and teaching needs for a patient with a new colostomy
8. Analyze medications, usage, precautions, side effects, and mechanism of action
9. Apply the nursing process to medication administration and usage
LEARNING OUTCOMESAt the conclusion of this learning activity, the nurse will be able to:
10. Explain causes, sign/ symptoms, nursing interventions, treatments, and complications of a bowel obstruction
11. Explain pathophysiology, risk factors, and medical management of gastrointestinal disorders
12. Explain causes of bowel obstruction
LEARNING OUTCOMESAt the conclusion of this learning activity, the nurse will be able to:
A Rough Outline:For the Left Hemispheric Dominant Learners
Terminology A&P GI Disorders GERD Hiatal Hernias PUD
G-I Pharmacology
Antacids Prokinetic Agents H 2 Receptor
Antagonists Proton Pump Inhibitors Mucosal Barriers
G-I Diagnostic Testing
Key Terms & word roots* -algia -dynia volvulus dyspepsia regurgitation hypersalivation pyrosis eructation dysphagia odynophagia -enter/o -col/o -gastr/o -esophag/o
ulceration aspiration ischemia diverticula diverticulitis colostomy illeostomy tenesmus steatorrhea diarrhea fistula defecation --rrhea steato-
Anatomy and Pathophysiology
Length = 27-30 feet(9-10 meters)
GI Tract Functions Secretion Digestion Absorption Motility Elimination
CN X: Vagus Nerve Involves: esophagus, stomach, small
intestines, gallbladder, and large intestines
Parasympathetic: stimulates motor and secretory activity, relaxes sphincters
Oral Cavity Teeth: chewing Mucin and amylase: breaks down
food Tongue Pharynx Esophagus: 2 sphincters
Esophagus
Stomach
Function of Stomach Ingestion of food Food reservoir Digestive process: -movement -gastrin secretion: hydrochloric acid
and pepsin -chyme
GI Disorders
PHARMACOLOGY
ASSESSMENT
Physical Assessment Inspection Palpation Percussion AuscultationKEY ASSESSMENTSLab Monitoring
Care PlanningPlan for client adl’s, Monitoring, med admin.,Patient education, more…basedOn Nursing Process: A_D_O_P_I_E***Preparing for Diagnostic Tests
Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary
Pathophysiology
Upper GI Lower GI
Inflammatory Inflammatory
Non-Inflammatory
G.E.R.D.Peptic Ulcers Gastric Ulcers Duodenal UlcersGastritis
G.E.R.D.Hiatus Hernias
Acute AppendicitisPeritonitisUlcerative colitisCrohn’s DiseaseDiverticulitis
Non-Inflammatory
Constipation & DiarrheaIrritable Bowel SyndromeDumping SyndromeIntestinal ObstructionHemorrhoids & PolypsMalabsorption
Concept Map: Selected Topics in Gastro-Intestinal Nursing
***Diagnostic Testing
Anti-Acids (Antacids)Prototype: aluminum hydroxide gel (Amphojel)
Prokinetic Agents:Prototype: metoclopramide (Reglan)
Histamine 2 Receptor AgonistsPrototype: ranitidine hydrochloride (Zantac)
Proton Pump Inhibitors)Prototype: omeprazole (Prilosec)
Mucosal BarriersPrototype: sucralfate (Carafate)
Disease Specific Medications:
Nursing Skills: NG Tube Insertion Enteral Feedings
GI DisordersINFLAMMATORY NON-INFLAMMATORY
Upper GI Gastroesphageal Reflux
Disease Ulcers Gastritis
Upper GI Gastroesphageal Reflux
Disease Hiatus Hernia/hernias
GI DisordersINFLAMMATORY NON-INFLAMMATORY
Lower GI Acute Appendicitis Peritonitis Ulcerative colitis Crohn’s Disease Diverticulitis
Lower GI Constipation & Diarrhea Irritable bowel syndrome Dumping syndrome Intestinal Obstruction Hemorrhoids and polyps Malabsorption syndrome
The Inflammatory Process Acute local inflammation: -edema, pain, heat, and redness -exudates may or may not be
present
Acute systemic inflammation: -fever -leukocytosis (increased WBC) -plasma protein synthesis
Inflammatory Process Chronic Inflammation: -increased duration>2 weeks -proceeds after unsuccessful acute inflammatory response -may occur without distinct
inflammation
Overview:
Gastroesophageal Reflux Disease (GERD)
GERD : common condition (affects 14% of Americans) characterized by gastric content and enzyme leakage into the esophagus.
These corrosive fluids irritate the esophageal tissue and limit its ability to clear the esophagus.
Causes are related to the weakness or transient relaxation of the lower esophageal sphincter (LES) at the base of the esophagus, or delayed gastric emptying.
The chief symptom of GERD is frequent and prolonged retrosternal heartburn (dyspepsia) and regurgitation (acid reflux) in relationship to eating or activities.
Other symptoms can include chronic cough, dysphagia, belching (eructation), flatulence (gas), atypical chest pain, and asthma exacerbations.
Gastroesophageal Reflux Disease(GERD)
Backward flow of gastrointestinal contents into esophagus
Cause of GERD Inappropriate relaxation of lower
esophageal sphincter (food, medication, etc)
GERD: Etiology ETIOLOGY:
Any factor that relaxes the LES, such as smoking, caffeine, alcohol, or drugs.
Any factor that increases the abdominal pressure, such as obesity, tight clothing at the waist, ascites, or pregnancy.
Older age and/or a debilitating condition that weakens the LES tone.
CONTIBUTING FACTORS:
Excessive ingestion of foods that relax LES, e.g., fatty / fried foods, chocolate, tomatoes, alcohol
Distended abdomen from overeating or delayed emptying
Increased abdominal pressure resulting from obesity, pregnancy, bending at the waist, ascites or tight clothing at the waist
Drugs that relax the LES, such as theophylline, nitrates, calcium channel blockers, anticholinergics, and diazepam (Valium)
Drugs, such as NSAIDs, or events (stress) that increase gastric acid
Debilitation or age-related conditions resulting in weakened LES tone
Hiatal hernia (LES displacement into the thorax with delayed esophageal clearance)
Lying flat
Signs & Symptoms of GERD
Classic symptoms:
Dyspepsia, especially after eating an offending food / fluid, and regurgitation.
Other symptoms:
Symptoms from throat irritation (chronic cough, laryngitis), hypersalivation, eructation, flatulence, or atypical chest pain from esophageal spasm.
Chronic GERD can lead to dysphagia (difficulty swallowing).
Complications of GERD Irritation to esophagus and mucosal
injury Aspiration Barrett’s esophagus Esophageal erosions, ulcerations, or
tears Chronic bronchitis Asthma (adult onset)
Barrett’s Esophagus
Diagnostic Testing History and Physical Dietary monitoring 24 hour ambulatory pH monitoring Esophageal manometry Endoscopy
Diagnostic Interventions : GERD
Barium Upper GI:
Prepare the client for the procedure.
Post procedure: Assess
for bowel sounds and potential constipation.
Endoscopy :
Conscious sedation to observe for tissue damage
Post procedure: Verify gag response prior to providing oral fluids or food.
Barium Sulfate (Ba SO4)
Medical Management for GERDNon-surgical
Goals: relief of symptoms and prevent complications
Life style changes: -Diet: smaller meals more frequent, limit or
avoid carbonated beverages, coffee, chocolate, fats, mints, spicy or acidic food
Medical Management Continued
Life Style Changes: -Elevate HOB, sleep on LEFT side -AVOID smoking and ETOH -Avoid tight or restrictive clothing -Lose weight
Medical Management Antacids, E.g., aluminum hydroxide (Mylanta),
neutralize excess acid. -- should be administered when the acid secretion is highest (1 to 3 hr after eating and at bedtime). --Antacids should be separated from other medications by at least 1 hr.
Histamine 2 (H2) receptor antagonists
E.g., ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid), and cimetidine (Tagamet), reduce the secretion of acid.
The onset is longer than antacids, but the effect has a longer duration.
Proton Pump inhibitors (PPI)
E.g., pantoprazole (Protonix),omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid) reduce gastric acid by inhibiting the cellular pump necessary to secrete it.
Studies show that PPI are more effective than H2 antagonists.
Other Medications E.g., metoclopramide
hydrochloride (Reglan), increase the motility of the esophagus and stomach.
Invasive Interventions for GERD
Endosopic therapy: BESS (Bard EndoCinch Suturing System), Stretta, and Enteryx procedures
Surgery: Laparoscopic Nissen Fundoplication (The”Gold Standard”)
Nursing Interventions Post operative or procedure
management: - Monitor vital signs -Monitor swallow/gag reflex -Assess for abdominal pain -Monitor for bleeding -Assess incision sites -Assess and monitor NG tube
Nursing Diagnosis Altered Nutrition Acute or Chronic pain Risk for aspiration Alteration in sleep patterns Knowledge Deficit Impaired Swallowing Potential for complications
Nursing Interventions EDUCATION: -Medication Compliance -Dietary changes -Lifestyle changes
Post operative or procedure management
Normal Esophagus
GERD
Barrett’s Esophagitis
Hiatal Hernia Involve protrusion of the stomach
wall through the esophageal hiatus of the diaphragm
Types of Hiatal Hernias Sliding: (Most Common)
esophagogastric junction and portion of the fundus slide upward through the esophageal hiatas
Rolling: the fundus and portions of the stomach rolls through the esophageal hiatas
Causes of Hernias Muscle weakness Anatomic defects Congenital weakness Prolonged increased abdominal
pressure Surgery Trauma Obesity
Symptoms of HerniasSLIDING ROLLING
Adult onset asthma Symptoms worse
after meals Symptoms worse in
recumbent position
Feeling full after eating
Breathlessness or feeling of not be able to breath
Chest pain like angina
feeling of suffocation Symptoms worse in
recumbent position
Diagnostic Testing Barium Swallow Study
Medical Management Diet Medications (GERD) Weight Loss Avoid late night food Avoid straining/vigorous exercise No restrictive or binding clothes Surgical repair: Laparoscopic Nissen
Fundoplication
Nursing Interventions Education: -Medication compliance -Dietary changes and monitoring -Lifestyle changes and monitoring Post-op management Assess coping mechanisms
Peptic Ulcer Disease (PUD) A mucosal lesion of the stomach or
duodenum
PUD Causes Results when gastric mucosal
defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin
Types of PUD Gastric Ulcers: -a break in mucosal barrier, hydrochloric
acid injures epithelium -back diffusion of acid or dysfunction of
the pyloric sphincter -Mucosal Inflammation
Duodenal Ulcers: -increase acid content dumped into
duodenum
Types of PUD “Stress Ulcers:” -Unknown etiology, presence of
increased levels of hydrochloric acid, ischemia, and erosive gastritis seen
-Trauma, head injuries, respiratory failure, shock sepsis
Signs and Symptoms Intermittent sharp, burning, or
gnawing pain Gastric pain occurs to the left and
may be relieved by food A change in appetite with or weight
loss (gastric) Nausea or vomiting Bloody stools
Signs and Symptoms Frequent burping or bloating
Duodenal pain is usually to the right of the epigastruim and pain occurs 90 min-3 hours after eating.
Pain often awakes patient’s up at night
A change in appetite with weight gain (duodenal)
Diagnostic Tests History and Physical (family history) Endoscopy (EGD) Stool for occult blood H-pylori test (carbon ureas breath
test) Gastric secretion studies Biopsy
Medical Management Drug Therapy Diet Therapy Lifestyle Changes Surgical Intervention
Nursing Diagnosis Actual pain Anxiety/Fear Ineffective individual coping Potential fluid volume deficit Knowledge deficit Disturbed sleep pattern Nutrition deficit
Nursing Interventions Assessment of symptoms and family
history Assess for complications Medication and diet education Monitor pain management Monitor nutritional status Encourage smoking and alcohol
cessation
Complications Gastrointestinal bleeding Gastric Perforation Pyloric obstruction
Treatment of Complications
GI bleed Perforation Pyloric obstruction
Surgical Interventions Vagotomy & Pyloroplasty Gastroenterostomy
pyloroplasty
Post Operative Management
Assess patient Assess vital signs Monitor gastric decompression and
output Monitor labs Monitor continued ileus Monitor for gastric delay emptying
and recurrent ulcerations
End of Part IGastrointestinal System
The Appendix follows on this Power Point (Medication Information, etc…)
Pharmacology:
Anti-Acids (Antacids)Prototype: aluminum hydroxide gel ( Amphojel )
Pharmacological Action Neutralize gastric acid and inactivate pepsin.
Mucosal protection may occur by the antacid’s ability to stimulate the production of prostaglandins.
Therapeutic Uses Treat peptic ulcer disease (PUD) by promoting
healing and relieving pain. Symptomatic relief for clients with GERD.
Nursing Interventions and Client Education
Clients taking tablets should be instructed to chew the tablets thoroughly and then drink at least 8 oz of water or milk.
Teach the client to shake liquid formulations to ensure even dispersion of the medication.
Compliance is difficult for clients because of the frequency of administration.
Administered seven times a day: 1 hr before and 3 hr after meals, and again at bedtime.
Teach clients to take all medications at least 1 hr before or after taking an antacid.
Evaluation of Medication Effectiveness
Depending on therapeutic intent, effectiveness may be evidenced by:
Healing of gastric and duodenal ulcers.
Reduced frequency or absence of GERD symptoms.
No signs or symptoms of GI bleeding.
Back to Concept Map
Pharmacology:
Prokinetic AgentsPrototype : metoclopramide ( Reglan )
Pharmacological Action
Block dopamine and serotonin receptors in the chemoreceptor trigger zone (CTZ), and thereby suppress emesis.
Prokinetic agents augment action of acetylcholine which causes an ↑ in upper GI motility.
Therapeutic Uses
Control postoperative and chemotherapy-induced nausea and vomiting.
Prokinetic agents are used to treat GERD.
Prokinetic agents are used to treat diabetic gastroparesis.
Side Effects / Adverse Effects
Extra Pyramidal Symptoms (EPS) Sedation Diarrhea
Contraindications / Precautions
Contraindicated in clients with GI perforation, GI bleeding, bowel obstruction, and hemorrhage
Contraindicated in clients with a seizure disorder due to ↑ risk of seizures
Use cautiously in children and older adults due to the ↑ risk for EPS.
Nursing Interventions and Client Education
Monitor clients for CNS depression and EPS. Can be given orally or intravenously. If dose is <
10 mg, it may be administered undiluted over 2 min. If the dose is > 10 mg, it should be diluted and
infused over 15 min. Dilute medication in at least 50 mL of D5W or lactated Ringer’s solution.
Evaluation of Medication Effectiveness
Control of nausea and vomiting
Back to Concept Map
Pharmacology:
Histamine 2 (H2) Receptor AgonistsPrototype : ranitidine hydrochloride (Zantac)
Pharmacological Action
Suppress the secretion of gastric acid by selectively blocking H2 receptors in parietal cells lining the stomach.
Therapeutic Uses
Gastric and peptic ulcers, gastroesophageal reflux disease (GERD), and hypersecretory conditions, such as Zollinger-Ellison syndrome.
Used in conjunction with antibiotics to treat ulcers caused by H. pylori.
Therapeutic Nursing Interventions and Client Education
Encourage client to avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).
Ranitidine can be taken with or without food.
Treatment of peptic ulcer disease is usually started as an oral dose twice a day until he ulcer is healed, followed by a maintenance dose, which is usually taken once a day at bedtime.
Evaluation of Medication Effectiveness
Depending on therapeutic intent, effectiveness may be evidenced by:
Reduced frequency or absence of GERD symptoms (e.g., heartburn, bloating, belching).
No signs or symptoms of GI bleeding.
Healing of gastric and duodenal ulcers.
Back to Concept Map
Pharmacology:
Proton Pump InhibitorsPrototype : omeprazole (Prilosec)
Pharmacological Action
Reduce gastric acid secretion by irreversibly inhibiting the enzyme that produces gastric acid.
Reduce basal and stimulated acid production.
Therapeutic Uses
Prescribed for gastric and peptic ulcers, GERD, and hypersecretory conditions (e.g., Zollinger-Ellison syndrome).
Precaution:
Increases the risk for pneumonia. Omeprazole ↓ gastric acid pH, which promotes bacterial colonization of the stomach and the respiratory tract.
Use cautiously in clients at high risk for pneumonia (e.g., clients with COPD).
Nursing Interventions and Client Education
Do not crush, chew, or break sustained-release capsules.
The client may sprinkle the contents of the capsule over food to facilitate swallowing.
The client should take omeprazole once a day prior to eating.
Encourage the client to avoid irritating medications (e.g., ibuprofen and alcohol).
Active ulcers should be treated for 4 to 6 weeks.
Pantoprazole (Protonix) can be administered to the client intravenously.
Monitor the client’s IV site for signs of inflammation (e.g., redness, swelling, local pain) and change the IV site if indicated.
Teach clients to notify the primary care provider for any sign of obvious or occult GI bleeding (e.g., coffee ground emesis).
Evaluation of Medication Effectiveness Depending on therapeutic intent, effectiveness
may be evidenced by:
Healing of gastric and duodenal ulcers. Reduced frequency or absence of GERD
symptoms (e.g., heartburn, sour stomach). No signs or symptoms of GI bleeding.
Back to Concept Map
Pharmacology:
Mucosal BarriersPrototype: sucralfate ( Carafate )
Pharmacological Action
Changes into a viscous substance that adheres to an ulcer; protects ulcer from further injury by acid and pepsin.
Viscous substance adheres to the ulcer for up to 6 hr.
Sucralfate has no systemic effects.
Therapeutic Uses
Acute duodenal ulcers and maintenance therapy.
Investigational use in gastric ulcers and gastroesophageal reflux disease. (GERD)
Nursing Interventions and Client Education
Assist the client with the medication regimen. Instruct the client that the medication should
be taken on an empty stomach. Instruct the client that sucralfate should be
taken four times a day, 1 hr before meals, and again at bedtime.
The client can break or dissolve the medication in water, but should not crush or chew the tablet.
Encourage the client to complete the course of treatment.
Evaluation of Medication Effectiveness
Depending on therapeutic intent, effectiveness may be evidenced by:
Healing of gastric and duodenal ulcers. No signs or symptoms of GI bleeding.
Back to Concept Map
***Diagnostic Tests Blood Tests Complete Blood Count (CBC c
Diff)
Stool Tests: Stool for occult blood; (Guiac)
Stool for ova & parasites (O&P);
Stool for Clostridium difficile (C-Diff)
Stool Culture & Sensitivity (C&S)
Radiology:
Upper GI Series (UGI) Upper GI Series with Small
Bowel Follow-Through (UGI-SBFT)
Barium Enema Endoscopy
Endoscopy:
Return toConcept Map
Clostridium difficile