GI Adult health 1

Diagnostic Procedures

• Flat and Erect Radiographic Study: Identifies obstructions, paralytic ileus, perforated organs, and abdominal abscesses.
• Ultrasound: Employs sound waves to examine various parts of the GI tract.
• CAT Scan (Computed Tomography): Can be performed with or without contrast; follow-up is essential.
• MRI (Magnetic Resonance Imaging).
• Upper GI Series: X-ray of the lower esophagus, stomach, and duodenum using barium.
  • Post-procedure: Increase fluids to facilitate barium passage, monitor stools until they are no longer white.
• Barium Enema (Lower GI Series): Detects polyps, tumors, and diverticula; barium is used.
  • Can be used for reduction of intussusception.
  • Pre-procedure: Bowel cleanse the night before.
  • Post-procedure: Force fluids and administer a post-barium laxative.

Endoscopic Procedures and Other Tests

• EGD (Esophagogastroduodenoscopy): Scope of the esophagus, stomach, and duodenum.
  • Detects tumors, mucosal inflammation, hiatal hernias, polyps, ulcers, H. pylori, strictures, and obstructions.
  • Can remove polyps, coagulate GI bleeders, and perform sclerotherapy for esophageal varices.
  • Can obtain biopsies and cultures.
  • Pre-procedure: NPO past midnight, signed consent form.
  • Post-procedure: NPO until gag reflex returns and swallowing is effective, assess for perforation.
  • Perforation signs: Abdominal pain, guarding, oral bleeding, melena, hypovolemia.
• Capsule Endoscopy: A swallowable capsule with a camera.
  • Used for diagnosing Crohn's disease, celiac disease, malabsorption syndromes, and GI bleeds.
  • Pre-procedure: NPO for 12 hours prior, no smoking for 24 hours.
• Sigmoidoscopy: Scope of the sigmoid colon.
  • Detects tumors, polyps, and ulcerations of the anus, rectum, and sigmoid colon.
  • Can obtain tissue specimens.
  • Requires NPO status, a consent form, and bowel preparation.
• H. pylori Blood Test: Can also be detected via stool antigen or stomach biopsy.
• Barium Swallow: Outlines the esophagus to identify tumors, strictures, esophageal varices, swallowing difficulties, hiatal hernias, GERD, and ulcers.
  • Requires NPO past midnight, standard barium protocol, and increased fluids post-procedure.

Laboratory Tests

• Stool for Occult Blood: Tests for hidden blood in stool (e.g., Hemoccult test, guaiac test).
  • Ensure stool sample is free of urine and toilet paper, avoid organ meat for 24-48 hours before the test (guaiac test).
• Stool Analysis: Detects bacteria, ova, and parasites.
  • For bacteria, send the collected sample to the lab immediately.
  • For ova and parasites, collect three stool specimens on consecutive days.
  • If an enema is necessary, use only normal saline or tap water.
  • Avoid urine contamination, and deliver the sample to the lab within 30 minutes of collection.
• CEA (Carcinoembryonic Antigen): Detects the protein CEA; elevated levels may indicate cancer.
  • Not used for diagnosis but assesses treatment effectiveness and cancer recurrence.
• Albumin (Serum Albumin): Assesses liver function.
  • Decreased levels may indicate nephrotic syndrome, liver disease, or third spacing (e.g., ascites).
• Nitrogen Balance: Determines protein loss and intake, crucial for assessing nutritional status.
• BUN (Blood Urea Nitrogen): Waste product of the liver's protein breakdown, relevant in GI assessment.
• Urine Urea Nitrogen: Assesses urea levels in urine; checks for adequate protein intake.
• Transferrin: Assesses the body's ability to transport iron in the blood.
  • Used to diagnose iron deficiency or overload.
• Iron Level: Important for GI assessment since iron is found in red meats and fortified cereals and is needed for red blood cell production and hemoglobin.

Preoperative Care for GI Surgical Procedures

• Consent Form: Required for any surgical procedure.
• Lab Work and X-Ray Reports: Confirm all necessary labs and reports are on the chart.
• Bowel Preparation: Cleansing enemas or bowel preps are essential.
• Pre-Surgical Checklist: Ensures all pre-operative tasks are completed.
• Dietary Modifications: Low-residue diet pre-op.
  • Avoid high-fiber foods like whole wheat, nuts, cereals, seeds, raw/dried fruits, and vegetables.
• Antibiotics: May use erythromycin or neomycin to kill bacteria in the colon.
• Post-op Exercises: Teach wound splinting, range of motion, early ambulation, turning, coughing, deep breathing, and incentive spirometry.
• Wound Care: Discuss stoma site choice.
• Pain Control: Explain pain management options.
• Post-op Expectations: Inform patients about IV lines, NG tubes for drainage, and catheters.

Postoperative Care for GI Surgical Procedures

• Peristalsis Assessment: Monitor for the return of peristalsis, which may be absent for the first 12-36 hours.
• NPO Status: Patients are NPO until passing gas.
• NG Tube Management: Usually inserted post-op for decompression or suction.
• Abdominal Assessment: Monitor for abdominal distension; measure and record abdominal girth at consistent locations.
• Bowel Sounds: High-pitched bowel sounds in one quadrant with absent sounds elsewhere may indicate obstruction.
• Accurate I&O: Track all fluid intake and output from tubes and bodily functions.
• Paralytic Ileus: A common complication where peristalsis stops completely.
  • Symptoms: Nausea, vomiting, abdominal distension, and absence of bowel sounds.

Oral Cavity Disorders: Stomatitis

• Stomatitis: Inflammation of the oral mucosa due to various causes (e.g., chemotherapy).
  • Symptoms: Burning sensation, pain, mouth ulcers, tender mouth, bleeding gums, odor, and fever.
  • Treatment: Identify and treat the cause, avoid commercial mouthwashes with alcohol, maintain good oral hygiene preventatively.
• Antifungal Prophylaxis: Example includes Nystatin swish and swallow for yeast infections.
• Diet: Soft, bland, or liquid diet is recommended.
• Oral Hygiene: Use a soft-bristled toothbrush.

Oral Cavity Disorders: Candida Albicans (Thrush)

• Candida Albicans (Thrush): A fungal organism that can overgrow, especially after antibiotic use.
  • Symptoms: Small white patches that scrape off easily.
  • Treatments: Nystatin swish and swallow, buccal tablets, or fluconazole.
• Prevention: Careful hand washing and care of breastfeeding mothers' nipples and feeding equipment.
• Risk Factors: Antibiotic use, leukemia, diabetes, alcoholism, steroid inhalers, immunosuppression (chemo, radiation, HIV/AIDS).
• Symptoms: Difficulty swallowing due to pain, angular cheilitis (wounds at the corners of the mouth), indicates nutritional deficit
• Management: One-third strength hydrogen peroxide or saline mouth rinses, unsweetened yogurt (with active cultures), or acidophilus capsules.
• Oral Care: Soft-bristled toothbrush, avoid hot/spicy, cold, fried, or citrus foods.
• Pain Relief: Lidocaine or benzocaine oral solutions to numb the mouth before eating.

Oral Cavity Disorders: Oral Cancer

• Oral Cancer: Occurs in the oral cavity and lips; the most common malignancy is in the mouth and pharynx.
  • Risk Factors: Smoking, smokeless tobacco, alcohol, and human papillomavirus (HPV).
• Kaposi Sarcoma: A type of oral cancer seen in clients with AIDS.
  • Lesions are purple and non-ulcerated; treated with radiation.
• Squamous Cell: Most oral cancers are squamous cell, grow rapidly and metastasize quickly.
• Symptoms: Asymptomatic early on; a roughened area in the mouth, leukoplakia (white patches that do not wipe off).
• Advanced: Lymph node enlargement, difficulty chewing/swallowing/speaking, edema, numbness, earache, facial pain, or toothache.
• Lip Cancer: Non-healing lesion, raised or ulcerated.
• Tongue Cancer: Slight dysphagia, sore throat, excess salivation.
• Diagnosis: Biopsy.
• Treatment: Radiation, surgery, chemo, or a combination, depending on stage.
• Stage 1: Surgery or radiation (internal/external).
• Stages 2 and 3: Surgery and radiation (internal/external).
• Stage 4: A combination of treatments.
• Communication: Alternate forms of communication may be needed.
• Prevention: Avoid excess sun and wind, no smoking/chewing tobacco, dental care to remove plaque and cavities, decrease alcohol, monitor HPV.
• Intervention: Lesions that don't heal in 2-3 weeks should be evaluated by a healthcare provider.
• Nutrition: Alternate forms of intake may be needed (NG tube feeding or enteral tube feeding).

Inflammatory Disorders: Gastroesophageal Reflux Disease (GERD)

• Gastroesophageal Reflux Disease (GERD): Lower esophageal sphincter does not function properly, allowing backflow of acidic stomach contents into the esophagus.
  • Symptoms: Heartburn, burning, pressure behind the sternum (worse after eating, may extend to jaw/neck/back), regurgitation, dry cough (worse at night). lump in throat, dysphagia, odynophagia, hoarseness, wheezing, sore throat, eructation.
• Chronic GERD: Can lead to esophageal ulcers or hemorrhage, chronic nighttime reflux can lead to aspiration, adenocarcinoma.
• Treatment: Avoid irritating foods, lose weight, avoid smoking.
• Medications: H2 receptor antagonists and antacids, proton pump inhibitors (PPIs), sucralfate, metoclopramide.
• Procedures: Nissan fundoplication (strengthens the LES), barrier placement to prevent backflow.
• Nursing Interventions:
  • Diet: Six to eight small meals a day, low-fat, adequate protein, decreased chocolate/tea/caffeine, limit/eliminate alcohol.
  • Eating Habits: Eat slowly, chew thoroughly, avoid evening snacking, and do not eat within 2-3 hours of bedtime.
  • Lifestyle: Remain upright for 1-2 hours after meals, avoid eating in bed, avoid foods that cause heartburn, reduce body weight, stop smoking.
  • Clothing: Avoid constrictive clothing over the abdomen, no straining or heavy lifting, avoid working in a bent-over position, elevate the head six to eight inches while sleeping.

Inflammatory Disorders: Esophageal Cancer

• Esophageal Cancer: More common in men; risk factors include alcohol, tobacco, acid reflux, obesity, and Barrett's esophagus.
  • Outcomes: Typically poor.
• Symptoms: Progressive dysphagia (starts with meat, progresses to soft foods, then fluids), weight loss, odynophagia, chest pain/pressure, heartburn, fatigue.
• Diagnosis: Barium swallow with biopsy.
• Treatment:
  • Upper 1/3: Typically radiation, which may be palliative or curative, risk of fistulas and burns, aspiration from fistulas.
  • Lower 1/3: Surgery if not advanced; esophagectomy (removal of the esophagus) if advanced.
  • Esophagogastrectomy: Removal of part of the esophagus with portion of the stomach.
  • Esophagoesophagostomy: Reception of esophagus and small intestine.
  • Gastrostomy: Insertion of a catheter into the stomach for nutrition.
• Chemotherapy: Taxol or 5-FU are typically used and may be combined with radiation before and after surgery.

Inflammatory Disorders: Gastritis

• Gastritis: Inflammation of the lining of the stomach.
  • Causes: Alcoholism, smoking, stressful physical events, irritating drugs, uremia, liver disease.
• Types: Acute or chronic; chronic if H. pylori is present.
• Acute Symptoms: Fever, nausea/vomiting, headache, coated tongue, anorexia, epigastric pain, hematemesis, and melena.
• Treatment: Anti-emetics for nausea/vomiting, antacids, antibiotics (if bacterial), IV fluids for imbalance.
• Nursing Interventions: Strict I&O, withhold oral foods/fluids until it subsides (as determined by provider), monitor tolerance of IV or oral feedings, and teach about stress effects and avoidance of irritants.

Inflammatory Disorders: Peptic Ulcer Disease (PUD)

• Peptic Ulcer Disease (PUD): Acid in the digestive tract erodes the mucosal lining of the stomach, esophagus, or duodenum.
  • Risk Factors: H. pylori, regular NSAID use, stress (physical/physiological), burns, sepsis, lengthy hospital stay.
• Stress Ulcers: Develop due to transient ischemia from severe physiological issues; high-risk clients are prophylactically treated with H2 receptor blockers or proton pump inhibitors.
• Aggravators: Aspirin, alcohol, smoking, chewing tobacco.
• Clinical Manifestations: Occur 1-2 hours after meals, postprandial nausea, weight loss, eructation, abdominal distension, dyspepsia, hematemesis, and melena.
• Hemorrhage: Can cause hypovolemic shock.
• Perforation: Penetration of the stomach or intestinal wall, increases the risk of peritonitis and death.
• Obstruction: Vomiting undigested food, requiring an NG tube for aspiration.
• Diagnosis: Endoscopy and EGD (esophagogastroduodenoscopy) to obtain specimens for H. pylori or biopsies.
• Breath Test: Alternative to diagnose H. pylori.
• Intervention: NPO

Nursing and Medical Treatment for Peptic Ulcer Disease (PUD)

• NG tube Management: Insertion, irrigation, and intermittent suction for blood or gastric contents.
• Diet: NPO
• Suctioning: Maintained at 100-125 mmHg.
• Surgeries: Indicated by perforation and obstructions
• Diet modifications: caffeine free
• Avoidance: Avoid caffeinated and decaffeinated coffee, tobacco, alcohol, and aspirin.
• Small frequent feedings
• Reminders of NG tubes: decompressions, compression, lavage
• Decreasing Gastric Acidity: An antacids and antiacids
• Antibiotics: For H Pylori such as amoxicillin
• Patient teaching for wound care: Wound care if applicable
• Eating habits: Small frequent and chewing completely.
• Monitor weight: And daily weights

Inflammatory Disorders: Gastric Cancer

• Gastric Cancer: Adenocarcinoma is most common, typically in the pyloric area.
  • Metastasis: To lymph nodes, liver, spleen, pancreas, or esophagus.
• Risk Factors: Diet (smoked, salted, pickled foods, carbs, low fresh fruits/vegetables).
• Clinical Manifestations: May be asymptomatic early, then pain, pallor, lethargy, weight loss, anorexia, indigestion, early satiety, postprandial fullness, melena, hematemesis, pernicious anemia (lack of B12), ascites.
• Diagnostic Tests: Endoscopy with biopsy, CT/PET scans, stool exam for occult/gross bleeding, elevated CEA levels.
• Treatments:
  • Chemotherapy: More effective than radiation, typically used for palliative care.
  • Targeted Drug Therapy: Prevents cancer cell multiplication and induces cell death.
  • Surgical: Total or partial gastric resection; esophagectomy/gastrectomy based on severity.
• Postsurgical Complications:
  • 7 days postop: Abdominal pain, increase pulse, dropping blood pressure
  • Anemia
  • diarrhea or dieantal infection
  • malnutrition
  • Vitamin deficiency

Complications and Nursing Interventions for Gastric Cancer

• Monitor: I fluid intake, tube placement and site for infection
• Intervention for site: dressing changes
• Treatment for site: good pain management
• Care: may have gastronomy tube for treatment
• Dumping Syndrome: Results from the surgical removal of a large portion of the stomach or pyloric sphincter.
  • Mechanism: Rapid gastric emptying of undigested food into the small intestine, causing distention of the duodenum and jejunum, leading to increased peristalsis.
  • Symptoms: Diaphoresis, N/V, epigastric pain, explosive diarrhea, borborygmi, and dyspepsia.
  • Treatment: Six small meals daily, high in protein and fat, low in carbohydrates, eat slowly, avoid fluids during meals.
• Medications: Anticholinergics.
• Lifestyle: Recline one hour after meals. Resolution usually occurs within months to a year after surgery.

Disorders of the Intestines: Celiac Disease

• Celiac Disease: A genetic, autoimmune disorder primarily affecting the small intestine.
  • Mechanism: Consumption of gluten (protein in wheat, rye, barley) triggers an immune response that damages the lining of the small intestine, destroying the villi.
• Diagnosis: Blood test for autoantibodies and intestinal biopsy during endoscopy.
• Gluten-free eating: Eating rice and soy, and plain meat with rice is okay
• Management: Lifelong gluten-free diet, referral to a dietitian, vitamin and supplement replacement.
• Nursing Interventions: Advise clients to avoid wheat, rye, and barley, replacing them with alternatives like potatoes, rice, soy, amaranth, quinoa, buckwheat, or bean flour. Plain meat, fish, fruits, vegetables, and rice can be safely consumed.

Disorders of the Intestines: Irritable Bowel Syndrome (IBS)

• Irritable Bowel Syndrome (IBS): Characterized by altered bowel function and recurrent abdominal discomfort/pain.
  • Subtypes: IBS-C (constipation), IBS-D (diarrhea), or a combination of both.
  • Cause: May be unknown, but triggers can include stress, chocolate, milk, alcohol, and caffeine.
• Symptoms: Cramping and abdominal pain relieved with bowel movements, increased bowel movement frequency with pain onset, incomplete evacuation, flatulence, constipation, diarrhea.
• Medications: Anti-cholinergic meds

Disorder of the Intestines/Inflammatory: Inflammatory Bowel Disease (IBD) and Ulcerative Colitis

• Inflammatory Bowel Disease (IBD): Both ulcerative colitis and Crohn's disease.
  • Characteristics: Unknown causes, exacerbations, and remissions.
• Ulcerative Colitis: Affects the mucosa and sub-mucosa, starting in the rectum and moving toward the cecum from distal end.
  • The process can cause 15-20 bloody and puss filled movements.
  • Pathophysiology: Inflammation and ulcerations in the mucosal layer cause capillary bleeding, leading to diarrhea with pus and blood; pseudopolyps are common and may become cancerous; scar tissue forms, reducing colon elasticity and absorption.
• Diagnostics steps for Ulcerative disease: Barium Enema
• Sigmoidoscopy scope
• Nursing interventions for:
  • Medication use: Non-sulfa drugs
  • Nutrition Therapy: Balance diet with calories and proteing
  • Managing: Stress and inflammation is key