care of the patient with a gastrointestinal · pdf filecare of the patient with a...
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 11
Care of the Patient with aGastrointestinal DisorderCare of the Patient with aGastrointestinal Disorder
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 2
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 3
Quick overview of A&P
• Digestive tract
– a muscular tube: mouth – anus
– Mouth‐pharynx – esophagus – stomach – small intestine – large intestine – rectum – anus
Accessory organs assist in digestion
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 4
Location of digestive organs.
(From Thibodeau, G.A., Patton, K.T. [1987]. Anatomy and physiology. St. Louis: Mosby.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 5
• Which is the largest and heaviest GI organ?
• Liver – weighs 3 ‐ 4 lbs.
• Small intestine – 20 feet long
• Stomach ‐@ size of a football
• Pancreas – 6‐9 inches long
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 6
Overview of the Digestive System aka Alimentary canal
• Digestive system• Tongue & teeth break down food
• Salivary glands –amylase –enzyme / starch
• Mouth: digestion starts here
• Stomach: churn and mix contents with gastric juices producing CHYME
• Digestion of PROTEIN begins here
• Small intestine: (@20’ long)most digestion occurs here
• Up to 90% of digestion occurs here
• villi
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 7
villi
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 8
A&P overview
• Large intestine:
• 5‐6’ long
• 80% of water absorbed, forms and expels feces
• Main function is reabsorption of water
• Rectum: @ 8 “ ‐ stores and expels feces
• Anus is a sphincter
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 9
Accessory Organs and their functions
Liver
• Produces bile; necessary to digest fat • Stores it in the gallbladder
• Manages blood coagulation
• Metabolizes PRO, fats, CHO
• Manufactures cholesterol & albumin
• Detoxifies poisons (alcohol, nicotine, drugs)
• Converts ammonia to ure
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 10
Gall bladder & Pancreas• GB: connected to underside of liver
• Stores bile –ejects bile into duodenum
• emulsification
• Pancreas: produces pancreatic enzymes to aid digestion of CHO, PRO & fats
• Secretes sodium bicarbonate to neutralize stomach acid
• Exocrine function
• Endocrine function – blood glucose regulation
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 11
A&P review
• Regulation of food intake
–Hypothalamus
• One center stimulates eating and another signals to stop eating
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 12
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 13
Disorders of the GI system
• There are some visually disturbing photos.
• Please remember your professionalism while viewing
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 14
Disorders of the Mouth• Candidiasis
• Infection caused by Candida albicans
• Fungus normally present in the mouth, intestine, vagina, and on the skin
• Also referred to as thrush
• Clinical manifestations/assessment
• Small (painful) white patches on the mucous membrane of the mouth
• Nursing Dx: Impaired Oral Mucus Membrane
• TX: antifungal meds
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 15
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 16
Carcinoma of oral cavity
HX: ETOH, tobacco, HPV s/s: difficulty chewing, swallowing, speaking, earache, facial pain, toothache
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 17
Disorders of the Esophagus• Gastroesophageal reflux disease: GERD
• Backward flow of stomach acid into the esophagus
– Clinical manifestations/assessment
• Heartburn 20 min – 2 hrs after eating
• Regurgitation
• Dysphagia
• Eructation
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 18
Disorders of the Esophagus
• GERD disease: Gastroesophageal reflux
• Medical management/nursing interventions
• Histamine H2 receptor blockers – acid blockers
– ranitidine ‐ Zantac
– famotidine ‐ Pepcid
• Proton Pump Inhibitor
– omeprazole – Prilosec
– lansoprazole – Prevacid
– Decrease Ca++ absorp on,↑ risk of C.diff,
– ↑risk of pneumonia in elders/immune compromised
• metoclopromide – Reglan ↑mo lity stomach, duodenum, jejunum (↑risk Tardive dyskinesia)
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 19
GERD
• Diet: 4‐6 small meals/day, low fat, adequate protein, remain upright for 1‐2 hours after eating
• Lifestyle: eliminate smoking, avoid constrictive clothing, HOB up at least 6‐8 inches for sleep
• Risk factor for Barrett’s Esophagus ‐ CA
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 20
Esophageal varices
• Secondary to liver failure
• Alcoholics
• Bulemics
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 21
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 22
Disorders of the Stomach• Gastric ulcers and duodenal ulcers
– Most commonly occur in the stomach and duodenum
– Result of acid and pepsin imbalances
–H. pylori
• Bacterium found in 70% of patients with gastric ulcers and 95% of patients with duodenal ulcers
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 23
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 24
Disorders of the Stomach• Gastric and duodenal ulcers
• Clinical manifestations/assessment• Pain: Dull, burning, boring, or gnawing, epigastric
• Dyspepsia
• Hematemesis
– Diagnostic tests
• Esophagogastroduodenoscopy (EGD)
• Breath test for H. pylori
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 25
Figure 45‐5
Fiberoptic endoscopy of the stomach.
(From Phipps, W.J., Monahan, F.D., Sands, J.K., Marek, J.F., Neighbors, M. [2003]. Medical-surgical nursing: health and illness perspectives. [7th ed.]. St. Louis: Mosby.)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 26
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 27
Disorders of the Stomach
• Gastric and duodenal ulcers
• Medical management/nursing interventions
• Antibiotics
• Diet: high in fat and carbohydrates; low in protein and milk products; small frequent meals; limit coffee, tobacco, alcohol, and aspirin use
• Gastrectomy? At risk for what dietary deficiencies?
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 28
Disorders of the Intestines
• Infection
– Etiology/pathophysiology
• Invasion of the alimentary canal by pathogenic microorganisms
• Most commonly enters through the mouth in food or water
• Person‐to‐person contact
• Fecal‐oral transmission
• Long‐term antibiotic therapy can cause an overgrowth of the normal intestinal flora (C. difficile)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 29
Disorders of the Intestines
• Infections• Clinical manifestations/assessment
• Diarrhea• Nausea and vomiting
• Abdominal cramping
• Fever
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 30
Disorders of the Intestines
• Diagnostic tests• Stool culture : deliver specimen to lab within 30 minutes
– Medical management/nursing interventions
• Antibiotics
• Fluid and electrolyte replacement– Coca‐Cola ‐ sodium Pepsi ‐ potassium
• Kaopectate ‐ loperimide
• Pepto‐Bismol – bismuth subsalycilate – black tongue, stool
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 31
Ulcerative Colitis
• Etiology/pathophysiology
• Ulceration of the mucosa and submucosa of the colon• Tiny abscesses form which produce purulent drainage, slough the mucosa, and ulcerations occur
– Clinical manifestations/assessment
• Diarrhea—pus and blood; 15‐20 stools per day
• Abdominal cramping
• Involuntary leakage of stool
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 32
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 33
Ulcerative Colitis
• Diagnostic tests• Barium studies, colonoscopy, stool for occult blood
– Medical management/nursing interventions
• Medications– Azulfidine, Dipentum, Rowasa, corticosteroids, Imodium
• Diet: No milk products or spicy foods; high‐protein, high‐calorie; total parenteral nutrition
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 34
Disorders of the Intestines
• Ulcerative colitis
• Medical management/nursing interventions• Surgical interventions
–Colon resection
– Ileostomy
• Increased risk for Colon CA
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 35
Disorders of the Intestines
• Crohn’s disease
– Etiology/pathophysiology
• Inflammation, fibrosis, scarring, and thickening of the bowel wall
• Segments – cobblestone appearance
• Malabsorption is a major issue
– Clinical manifestations/assessment
• Weakness; loss of appetite
• Diarrhea: 3‐4 daily; contain mucus and pus
• Right lower abdominal pain
• Steatorrhea
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 36
Crohn’s disease
Medical management/nursing interventions• Diet
– Avoid lactose‐containing foods, brassica vegetables, caffeine, beer, monosodium glutamate, highly seasoned foods, carbonated beverages, fatty foods
–High‐protein–Hyperalimentation:
»artificial supply of nutrients
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 37
Crohn’s disease
• Medical management/nursing interventions• Medications
– Corticosteroids
– Antibiotics
– Anti‐diarrheal; antispasmodics
– Enteric‐coated fish oil capsules
– B12 replacement
• Surgery
– Segmental resection of diseased bowel
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 38
Surgical resection
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 39
Disorders of the Intestines• Appendicitis
– Etiology/pathophysiology
• Inflammation of the vermiform appendix
• Lumen of the appendix becomes obstructed E. colimultiplies, and an infection develops
– Clinical manifestations/assessment
• Rebound tenderness over the right lower quadrant of the abdomen (McBurney’s point)
• Vomiting
• Low‐grade fever
• Elevated WBC
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 40
Right lower Quadrant Pain –McBurney’s point
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 41
Disorders of the Intestines
• Appendicitis
–Diagnostic tests• WBC
• x‐ray
• Ultrasound
• Laparoscopy
– Medical management/nursing interventions
• Appendectomy
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.Slide 42
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 43
Disorders of the Intestines
• Diverticular disease
– Etiology/pathophysiology
• Diverticulosis
–Pouch‐like herniations through the muscular layer of the colon
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 44
Figure 45‐11
Diverticulosis.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 45
Diverticular disease
• Clinical manifestations/assessment• Diverticulosis
– May have few, if any, symptoms
– Constipation, diarrhea, and/or flatulence
– Pain in the left lower quadrant
• Diverticulitis– Mild to severe pain in the left lower quadrant
– Elevated WBC; low‐grade fever
– Abdominal distention
– Vomiting
– Blood in stool
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 46
Diverticular disease
• Medical management/nursing interventions
•Diverticulosis with muscular atrophy, narrowing or sclerosing of the colon wall
–Low‐residue diet;» designed to reduce the frequency and volume of stools while prolonging intestinal transit time
–stool softeners
–Bedrest
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 47
Low residue * High fiber
• Residue refers to undigested food including fiber that make up stool
• Crackers vs. whole grain bread
• No seeds or nuts
• Cooked vegetables vs raw
• Avoid some vegetables broccoli, cabbage, corn, onions, cauliflower and baked beans
• Avoid or limit caffeine
• Avoid dried fruits, popcorn, tough meats
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 48
Surgical interventions
• Diverticular disease
• Medical management/nursing interventions Surgery
–Hartmann’s pouch
–Double‐barrel transverse colostomy
–Transverse loop colostomy
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 49
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 50
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 51
Stoma care
• Pink/red
• Slightly edematous
• Skin barrier / pouch
• Documentation “Stoma pink and viable”
• Promote independence and self care
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 52
Psych Nursing Interventions
• The patient complains that he will never adjust to his colostomy. What should the PT do?
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 53
Peritonitis
– Etiology/pathophysiology
• Inflammation of the abdominal peritoneum
• Perforation, abscess, hemorrhage
• Bacterial contamination of the peritoneal cavity from fecal matter or chemical irritation
– Clinical manifestations/assessment
• Severe abdominal pain; nausea and vomiting
• Abdomen is tympanic; absence of bowel sounds
• Chills; weakness
• Weak rapid pulse; fever; hypotension
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 54
Peritonitis• Diagnostic tests
• Flat plate Xray of the abdomen
• CBC with differential
– Medical management/nursing interventions
• Position patient in semi‐Fowler’s position
• Surgery
– Repair cause of fecal contamination
– Removal of chemical irritant
• Parenteral antibiotics
• NG tube to prevent GI distention
• IV fluids
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 55
Hernias
– Etiology/pathophysiology
• Congenital or acquired weakness of the abdominal wall or postoperative defect
–Abdominal
–Femoral or inguinal
–Umbilical
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 56
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 57
Hernias
• Clinical manifestations/assessment
• Protruding viscus mass or bulge around the
umbilicus, in the inguinal area, or near an incision
• Reducible or irreducible
• Incarceration: trapped ‐ obstruct intestinal flow
• Strangulation: occludes blood supply & intestinal flow
– Diagnostic tests
• Radiographs
• Palpation
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.Slide 58
Hernias
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 59
Hernias
• Medical management/nursing interventions
• If no discomfort, hernia is left unrepaired, unless it becomes strangulated or obstruction occurs
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 60
Hiatal hernia
– Etiology/pathophysiology
• Protrusion of the stomach and other abdominal viscera through an opening in the membrane or tissue of the diaphragm
• Contributing factors: obesity, trauma, aging
– Clinical manifestations/assessment
• Most people display few, if any, symptoms
• Gastroesophageal reflux
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 61
Figure 5‐12
Hiatal hernia. A, Sliding hernia. B, Rolling hernia.
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.Slide 62
What is a transthoracic fundoplication?
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 63
fundoplication
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 64
Hiatal hernia
• Medical management/nursing interventions
• Head of bed should be slightly elevated when lying down
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 65
Intestinal obstruction
– Etiology/pathophysiology
• Intestinal contents cannot pass through the GI tract
• Partial or complete
– Clinical manifestations/assessment
• Vomiting feces ‐ dehydration
• Abdominal tenderness and distention
• Constipation and diarrhea – oozing diarrhea
• Potential death
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 66
General GI nursing interventions
–Assess / auscultate for return of bowel sounds
–Ambulation to enhance peristalsis
• This is what students look like when they see this on the test!!!
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 67
Nursing interventions
• GoLYTELY bowel prep
• Physician order prior to surgery
• Time frame
• Bedside commode?
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 68
Nursing interventions
• If a patient had a Barium enema study, what teaching should the nurse/PT provide?
• Laxatives?
• Fluids?
• Monitor BMs?
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 69
Hemorrhoids– Etiology/pathophysiology
• Varicosities (dilated veins)
– External or internal
• Contributing factors– Straining with defecation, diarrhea, pregnancy, CHF, portal hypertension, prolonged sitting and standing
– Clinical manifestations/assessment
• Varicosities in rectal area
• Bright red bleeding with defecation
• Pruritus
• Severe pain when thrombosed
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 70
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 71
Hemorrhoids
Medical management/nursing interventions• Bulk stool softeners; hydrocortisone cream
• Analgesic ointment
• Sitz baths
• Ligation
• Sclerotherapy; cryotherapy
• Infrared photocoagulation
• Laser excision
• Hemorrhoidectomy
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 72
Vocabulary
• Achalasia
• Perforation
• Gastric gavage
• Gastric lavage
• Anastomosis
• Evisceration
• Dehiscence
• Celiac Sprue
• Stoma
• Dumping Syndrome
• Guiac test
• Bolus
• Cachexia
• Hematemesis
• Melena
• leukoplakia