Nursing Management: Gastrointestinal Problems

George Ann Daniels, MS. RN

Oral Cancer• Involves the lip, tongue, or inside mouth• Predisposing Factors:

– Interferes with defense mechanisms• Alcohol• Tobacco• Poor oral hygiene• Trauma from jagged teeth• Poor fitting dentures• Malnutrition• syphilis• Cirrhosis• Sun exposure• Recurrent herpetic Lesions

• Squamous cell carcinoma

Assessment

• Leukoplakia– White nodular, patchy areas on

the mucosa– Smokers patch

• Erthroplasia– Red velvety patch

• Blister• Non-healing sore> 3 weeks

– Crusts and bleeds

• Painless hard fixed mass• ulcerations• Areas of constant irritation

• Mouth and tongue– White or yellowish ulcerated lesions

• Early stage- red or white and asymptomatic• Feels like rough area

– Pain • Hot/spicy foods

– Impaired speech• Slurred

– Difficulty swallowing– Increased salivation– Blood tinged sputum

Diagnostic test

• Oral exfoliative cytology– Scrapping from lesion

– Examined microscopically

• Surgery treatment– Small lesions

• Simple surgical excision with radiation

• Large tumors– Total glossectomy– Laryngectomy– Mandibulectomy– Hemiglassectomy– Radial Neck

• Most common

– Followed with radiation and chemotherapy

Pre-operative Nursing Care

• Assessment– Nutritional, fluid, and electrolyte status– Weight loss– Respiratory status

• Teach– Disfigurement– Impairment of speaking, swallowing, and eating

• Review– Oral suctioning

• Surgery Preparation– NPO– Cleanse mouth prior to surgery

Post Operative Nursing Care

• Removal or parotid gland– Assess for Cranial Nerve VI function

• Pain management• Nutritional

– IV for 24-48 hours R/t edema– May have NG or gastrostomy tube for tube feeding– Ability to handle food/fluids

• Psychologic– Withdraw from people– Non-adaptive response– Anxiety about resuming personal responsibilities

Nursing Process

• Risk for ineffective airway clearance R/T edema, difficulty swallowing, increased secretions

• Pain R/T surgical tissue trauma

• Altered nutrition: Less than body requirements R/t inability to ingest foods and fluids orally

• Impaired verbal communication R/T postoperative restriction on mouth movement

• Risk for body image disturbance R/T changes in appearance secondary to surgery.

• Risk for infection R/T location of surgical site

Mandibular Fraacture

• Fracture of the mandible from trauma to the face or jaws

• Surgery– Immobilization

• Wiring the jaws, cross wires, or rubber bands

• 4-6 weeks

Pre-operative Care

• Teach– Disfigurement– Will be able to breathe, speak, and swallow

liquids– May have N/G tube to prevent vomiting

• May also be used as feeding tube

Post-Operatively

• Focus on airway – Respiratory distress

emergency• Cut wires and bands• Tape wire cutter and

scissors to bed• Surgeon outlines which

wires to cut• Trach and/or endotrach

suction on hand

– Aspiration• Place on side• Elevate HOB• Suction

• Diet– Liquid diet

• Straw– Gas and fatigue

• Oral hygiene– Warm saline swishes after

meals and snacks– Keep corners of mouth moist

• Oral Communication• Discharged with wires• Patient concerns

– Oral care, handling secretions, diet, facing people

Nausea/Vomiting• Nausea is the feeling to vomit

– Diaphoresis, increased salivation, pallor, tachycardia, dizziness and faintness

• Vomiting is the expulsion of gastric contents– Reverse peristalsis and relaxation of the esophageal

sphincter– Types: Projectile, retching (dry heaves)

• Assessment of vomit– Condition associated with N/V– Amount, odor– Content- undigested food, mucus, parasites, foreign bodies– Color- Green, red, coffee ground, black, brown

• Hospital– NPO then IV’s with electrolyte replacement– NG tube

• Keeps stomach empty• Decreases the urge to vomit

– Bowel obstruction– Paralytic Illus

• Drugs– Antiemetic

• Prevention– Start with water first– Clear liquids, warm cola, increase in amounts if no vomiting– Dry toast, crackers, bland foods

• Avoid foods that stimulate peristalsis– High fat foods, orange juice, caffeine, high fiber

foods.extremely hot or cold fluids

Geriatric consideration

• Major problem with electrolyte imbalance– Decreased level of consciousness

• Increased risk of aspirations

• May need to alter doses of antimetics– Confusion– Reduce for fragile adults

Constipation– Passage of hard, dry

stool, less than the patient’s normal pattern

– Factors• Inadequate dietary

fiber, inadequate fluid intake, lack of exercise, irregular bowel habits, medications (iron).

Assessment

– Feeling of fullness, back pain, headache, anorexia, and malaise, absence of stool, abdominal distention, decreased frequency, rectal pressure, straining, tenesmus, increase flatus, nausea, palpable mass, stools with blood, dizzy, and urinary retention

• Time of day , events associated with defecation: smoking, coffee, eating, diet exercise medications

(laxatives), BS, percussion for abdominal distention, check for hemorrhoids, fissures, or irritation.

Long periods between movements

fecal impaction

Pediatric Considerations

• Newborn– 1st stool meconium

• 24-36 hours old

– No stool red flag• Meconium plug• Atresia• Hirschsprung• Hypothyroidism

• Infancy– Relates to diet– Usually no constipation seen

in Breastfed infant– Change to cow’s milk or

formula fed infants

• Childhood– Environmental

• Delaying urge– Playing

• School age– Embarassment

• Stress and change in toileting patterns

• Lack of privacy

• Busy schedule

Pharmacology

• Laxative types– Bulk formers- Metamucil

• Absorbs H20 and increases bulk

– Surfactants ( stool softeners) Colace, pericolace• Lubricates intestines and softens feces

– Contact Laxatives Dulcolax, Exlax• stimulates peristalsis

– Saline Laxatives- Milk of Mag• Retention of fluid causing an osmotic effect

Prevention

• Increase fluid 3 quarts/3000mL per day– Water, fruit juice– Avoid caffeine

• Stimulates fluid loss-hard stools

• Increase dietary fiber 20-20 grams– Softens stool, adds bulk,

promotes evacuation– Bran, fruits, grains– Infants- increase cereal, add

vegetables and fruits

• Increase exercise– Walking, swimming, bike– 3 times a week

• Promote normal environment– Regular times to defecate– Do not delay

• Avoid depending on laxatives or enemas– Can actually cause constipation– Normal motility of bowel is

interupted– BM slows or stops passage

Diarrhea

Passage of liquid stool more frequent than normal bowel habitAbdominal cramping, presence of mucus, blood, or fat, urgency, tenesmus, perianal discomfort, feeling not completely empty– Pharmacology

• Lomotil, Imodium

Nursing DXDiarrhea

Well ventilated room, easy access to bathroom or bedpan, Stress free environment, Antidirrahea medications, NPO for 4 hours, then weak tea, bouillon, Jell-O, thin cooked cereal then to low residue diet: tender beef, veal, chicken, boiled or steamed rice, hard boiled eggs. Avoid cold liquids, caffeine, and concentrated sweets

Risk for Impaired tissue integrityuse soft toilet paper, gently wash with gentle soap and warm h20, pat dry. Protective salve. Sitz baths for 10 minutes TID. Witch hazel soaked pads (Tucks)

• Fluid Volume deficit– IV, I & O, measure all liquid stool and count in

output. Weight daily, monitor lab values for electrolyte imbalance.

Pediatric Diarrhea• Most acute diarrhea is infectious

– Self limiting – Less than 14 days in duration

• Chronic diarrhea– Greater than 14 days

• Intractable diarrhea of infancy– Fist few months – Greater than 2 weeks

• Chronic nonspecific diarrhea (CNSD)– Irritable bowel of childhood and toddlers– Ages 6-54 months

• Assessment data– Mild diarrhea

• Few stools/day without evidence of illness

• Moderate diarrhea– Several loose or watery stools/day– Normal or elevated temperature– Vomiting– Fretful and irritable

• Severe diarrhea– Numerous to continuous stools

– Evident signs of dehydration

– Cry lacks vigor, often whining and high pitched

– Irritable

– Seeks comfort and attention

– Displays purposeless movements

– Inappropriate response to people/familiar things

– Lethargic, comatose, or moribund (near death)

Goals in Management of diarrhea

• Assessment of fluid and electrolyte imbalance

• Re-hydration

• Maintenance of fluid therapy

• Re-introduction of adequate diet

Oral Hydrating Solutions

• ORS’s• Mild to moderate diarrhea

– 60-80 mL/kg over 2 hours

• Older children– 1:1 replacement ( stool amount: replacement

fluids)– 10 mL/kg or ½ to 1 cup ORS for each diarrhea

stool

Pediatric Considerations

• Dehydration– Total output of fluid exceeds the total intake, regardless

of the underlying cause

• Fluid loss– Insensible loss

• Skin and respirations

– Renal excretions– GI tract– Diabetes Ketoacidosis– Extensive burns

Extent of Dehydration

• Know the moderate and severe signs and symptoms located in table 24-1 on page 882 of Wong

Pediatric Fluid Requirements

• Daily maintenance fluid requirements– Calculate weigh of child in kilograms

– Allow 100 mL per kilogram for first 10 kg

– Allow 50 mL per kilogram for second 10 kg

– Allow 20 mL for remainder of weight in kilograms

– Total the amounts

– Divide total amount by 24 hours to obtain rate in mL’s per hour

Nursing Management

• Monitor I & O• Assess change in condition

– Very rapid– VS, Skin, Mucous Membranes, Body Weight,

Fontanels, Sensory alterations

• Interventions are specialized to specific disorder– Diabetes, renal, etc.

• Manage diarrhea with ORS• AVOID Fruit juices, carbonated drinks and gelatin

– Avoid high carbohydrate content low electrolyte high osmolality

• AVOID Caffeinated soda high in caffeine=diuretic• AVOID BRAT diet

– No longer used r/t little nutritional value ( low in energy and protein) high in carbohydrate and low in electrolytes

Hiatal Hernia

Herniation of a portion of the stomach into the esophagus

S & S

Heartburn

Regurgitation

Chest pain

Dysphagia

Types

• Sliding– Most common

– Gastroesophageal sphincter is displaced into the thoracic cavity

• Paraesophgeal (rolling)Hiatal Hernia– Stomach fundus rolls

into the thorax

Complications

• Erosion

• Hemorrhage

• Stenosis

• Strangulation

• Regurgitation– Aspiration

Nursing Management

• Bland diet in small feedings• Semi-fowlers position after eating-promotes

movement of ingested foods• Pain management• Antacids

– Pyrosis

– Histimine- Blocking agents• Tagamet

• Pepcid

Surgical Treatment

• Fundoplication– Wrapping the fundus of the

stomach around the lower portion of the stomach

– Creates a one-way valve

• Post op

• NPO until peristalsis returns– IV until peristalsis returns

– Patent N/G tube• irrigate

Esophagitis/GERD

• Inflammation of the esophagus

• Most common– GERD

– Reflux of gastric secretions in the esophagus

• Incompetent LES

Triggers

• Smoking• Intake of alcohol or spicy

foods• Ingestion of caustic agents

– Lye/ammonia

• Reflux (GERD)• Friction movement of

sliding hiatal hernia• Prolonged gastric

intubations• Bacterial/viral invasion

Assessment

• Heartburn– Pyrosis

• Retrosternal

• Burning• Painful swallowing

– Radiate to arms, neck, back, jaw

• Regurgitation– belching

• Diet– Produces Heartburn

• Feels like lump in the throat

• Food stoppage• Dysphagia

– Solid foods

• Respiratory difficulty– Aspiration of gastric

content

Complications

• Local effects of gastric secretion irritation on the esophageal mucosa– Formation of fibrosis scar tissue– Ulcerations

• bleeding

Management of Mild Esophagitis

• Goal- eliminate cause and promote healing

• Nutritional– Bland diet

– Restrict spicy/acid foods

– Weight reduction

• Prevent reflux– Small frequent meals– Sleep with HOB elevated

• Blocks 4-6 inches

– Do not lie down 2-3 hours post eating

– Avoid tight fitting clothing around waist

– Avoid bending over after meals

• Diet– High protein, low fat

• Avoid – Alcohol

– Smoking

– Caffeine

– Late night eating

– Avoid fatty foods, chocolate, peppermint, spearmint, alcohol, tea, coffee

Medications

• Antacids– Coats stomach lining that

help decrease gastric secretions

– Between meals and HS• 1-3 hours

• Cholinergic drugs– Increases pressure at the

LES=increased gastric emptying

• Reglan

• Histamine Antagonist– Reduces gastric

secretions• Cimetidine (tagamet)

• Famotidine (Pepcid)

• Ranitidine (Zantac)

– Proton-pump inhibitors• Lanosprazole

( Prevacid)

• Omprazole (Prilosec

Pediatric Considerations

• Assessment:– Spitting up– Vomiting– Weight loss– Gagging– Chocking at the end of the

feeding– Respiratory problems– Hematemesis– Melena – Anemia– Heartburn– Irritability

• Medication– Tagment, Zantac,

Pepcid, Prilosec

• Nursing Care– 30 degree angle– Elevate head of crib

with extra bedding, wood, or metal frame, or wedge constructed from cardboard.

Gastritis

• Inflammation of the gastric mucosa

• Factors– Break down in the gastric

mucosa

– Chronic alcohol abuse

– Excessive ingestion of ASA/NSAIDS

– Reflux of duodenal contests post gastric surgery

• Radiation• Helicobacter pylori• Staph• Salmonella• Smoking• Stress• Renal failure• Spicy, irritating foods• Trauma

– NG suction– Hiatal hernia– Endoscopic procedures

Types

• Type A– Autoimmune disease

– Eats away the mucosa

• Type B– Presence of

Helicobacter pylori

Manifestations

• Anorexia

• N/V

• Epigastric tenderness

• Feeling of fullness

• Hemorrhage– Alcohol abuse

Management

• Bland diet

• Six small meals a day

• Antacid after meals

Achalasia

• Peristalsis of the lower 2/3 of the esophagus is absent

• Food and fluid accumulate in the lower esophagus

• Results in dilation of the lower esophagus

Assessment

• Dysphagia– More frequent with fluids

• Substernal pain– After meals

• Halitosis• Inability to erucate• Regurgiation of sour-tasting food and liquids

– Horisontal position

• Weight Loss

Treatment• Dilation

– Dilation of the esophagus– Pneumatic dilation of the LES – Balloon tipped dilator passed orally

• Surgery– Esophagomyotomy– Division of muscle fibers in the esophagus– Allows pouch to form– Swallowing with out obstruction

• Medications– Anticholinergics, calcium channel blockers, long acting

nitrates

Abdominal Trauma

• Blunt – MVA

• Penetrating– Gunshot wounds or stab

wounds

• Lacerated liver, ruptured spleen, pancreatic trauma, mesenteric artery tears, diaphragmatic rupture, urinary bladder rupture, great vessel tears, renal injury, and stomach or intestinal rupture

Manifestations

• Guarding and splinting of the abdominal wall• Hard, distended abdomen

– Intraabdominal bleeding

• Decreased or absent bowel sounds• Contusions, abrasions, or bruising• Abdominal pain• Pain over scapula• Hematemesis/hematuria• Hypovolemic shock• Cullen’s sign

Nursing management

Airway/breathing 02 Control bleeding

IV Blood T & C CBC

Remove clothing Stabilize impaled object

Cover any protruding organs

Foley/ if no blood UA NG

VS LOC 02 sat

Urinary output warmth

Hirschsprung Disease• Obstruction caused by

inadequate motility of parts of the large intestines

• Failure of ganglion cells to migrate along the GI tract during gestation– Aganglionic segments of the

proximal portion of the large intestines and rectum

• Absence of peristalsis in a segment of the large intestines– Accmulation of intestinal

contents– Megacolon

Diagnostic Evaluation

• Based on clinical manifestations

• Barium Enema

• Anorectal biopsy with histological examination for absence of ganglion cells

Clinical Manifestation

• Newborn Period– Failure to pass

meconium within 24-48 hours after birth

– Spitting up

– Poor feeding

– Visible bowel loops

– Bile-stained vomitus

– Abdominal distention

• Infancy– Failure to thrive

– Constipation

– Abdominal distention

– Diarrhea and vomiting

– Explosive watery stools

– Fever

– Severe prostration

• Childhood– Symptoms more

chronic

– Constipation

– Ribbon like foul smelling stools

– Abdominal distention

– Palpable fecal masses

– Poorly nourished

• Prognosis– Good with corrective

surgery• Temporary colostomy

Nursing Care• Pre-op

– Improving nutritional status• Low fiber, high calorie,

high protein• TPN• Enemas

– Sterilizing colon• Saline enemas with

antibiotic solutions• Oral antibiotics

– Psychological preparation for possible colostomyParent and child

• Stress colostomy is temporary

• Post-op– Stoma Care

– Diaper pinned below dressing to prevent contamination

– Possible foley

• Discharge teaching– Colostomy care

– High fiber diet