Lower Gastrointestinal (LGI) - Constipation

Lower Gastrointestinal (LGI) - Constipation

• Passing fewer than 3 stools a week may indicate constipation
• Other signs of constipation include lumpy or hard stools and straining during bowel movements
• A sensation of a blockage, feeling of incomplete emptying, abdominal pressure, or needing to manually remove stool can also occur
• Causes consist of blockage, nerve issues, muscle difficulties, hormone problems, dehydration, limited activity, older age, medications, and being female
• Possible complications include decreased cardiac output, fecal impaction, hemorrhoids, fissures, rectal prolapse, or megacolon
• Straining can lead to a Valsalva maneuver, causing orthostasis, dizziness, syncope, or a drop in blood pressure
• Management involves gradually increasing fiber intake (14g/1,000cal), exercising, and establishing a routine
• Additional interventions: add bran, strengthen core muscles, assume a proper toilet position, ambulate, and avoid ignoring urges
• Laxatives can be used, such as: bulk forming agents (Metamucil), saline agents (milk of magnesia or magnesium hydroxide), lubricants (mineral oil), stimulant agents (Dulcolax), stool softeners (Colace), and osmotic agents (GoLYTELY)
• Enemas and suppositories are considered if other treatments fail

Lower Gastrointestinal (LGI) - Diarrhea

• Having more than 3 bowel movements a day with altered consistency suggests diarrhea
• Other signs and symptoms consist of urgency, nausea, incontinence, abdominal cramps, distention, borborygmus, anorexia, thirst, spasmodic anal contractions, and tenesmus
• Viruses, milk of magnesia, antibiotics, diabetes mellitus, Addison's disease, celiac disease, AIDS, and Clostridium difficile are all potential causes
• Malabsorption can cause voluminous/greasy stools
• Blood, mucus, or pus points to inflammatory enteritis or colitis
• Oil droplets can indicate pancreatic insufficiency
• Dehydration, low potassium, metabolic acidosis, muscle weakness, dysrhythmias, decreased peristaltic motility, and paralytic ileus are potential complications
• Skin integrity should be monitored, especially in older adults
• Diagnostic tests include: complete blood count, serum chemistries, urinalysis, stool exam, and endoscopy or barium enema
• Management goals are to control symptoms, prevent complications and transmission (for C. diff), and address causative factors
• Antidiarrheals (Lomotil or Imodium) can be used with caution
• Monitor urine output (report if medications are causing less than 30ml for 2-3 hours)
• Assess and report muscle weakness, hypotension, paresthesia, anorexia, or drowsiness
• Report potassium levels less than 3.5 immediately
• Check skin, administer IV fluids, and assess the abdomen

Lower Gastrointestinal: Fecal Incontinence

• Fecal incontinence is characterized as experiencing at least 3 months of bowel control issues related to sphincter weakness from trauma, surgery, neuropathies and other disorders
• Sphincter Weakness from trauma
• Past surgery
• Neuropathies
• Rectal prolapse
• Medication side effects of radiation
• CNS disorders
• Fecal Incontinence can present itself as minor soiling, urgency, loss of control, or complete fecal incontinence

Upper Gastrointestinal (UGI) - Esophagogastroduodenoscopy (EGD)

• Moderate sedation is administered via IV and the patient should be NPO for 6-8 hours, and remove dentures before the procedure
• Monitor vital signs, maintain an open airway, check the gag reflex, and withhold fluids until the gag reflex returns and check AO status.
• Notify a healthcare provider if chest/abdominal pain or signs/symptoms of infection occur
• Avoid driving for 12-18 hours post-procedure and use lozenges for a sore throat

Upper Gastrointestinal (UGI) - Hiatal Hernia

• This condition occurs when the upper part of the stomach bulges through the diaphragm into the chest cavity and can be sliding or paraesophageal
• Sliding hernias exhibit pyrosis, regurgitation, dysphagia, and no symptoms
• Larger hernias can cause food intolerance, nausea/vomiting, and anorexia
• Complications: hemorrhage, obstruction, volvulus (bowel obstruction caused by a twist in the intestines and supporting mesentery) and strangulation
• Diagnostics: confirmed by X-ray, barium swallow, and EGD
• Risk factor: women
• Management: frequent small feedings, no reclining 1 hour after eating, elevate the head of the bed on 4-8 inch blockers
• Interventions: relax, avoid heavy lifting/smoking/tight clothing around the waist and increase fiber
• Surgical intervention may be indicated for symptomatic patients with GERD through a laparoscopic procedure
• Post-operative care: dysphagia, advance diet slowly from liquids to solids, manage nausea/vomiting, track nutritional intake, monitor weight and avoid significant weight loss

Upper Gastrointestinal (UGI) - Gastroesophageal Reflux Disease (GERD)

• A chronic digestive disease occurring when stomach acid or contents flow back into the esophagus, irritating its lining and causing heartburn or acid regurgitation
• Diagnose: heartburn occurring two or more times a week can indicate GERD. Seek treatment if heartburn worsens, occurs at night, persists for several years, causes difficulty/pain when swallowing, and interferes with activities of daily living
• Signs and symptoms: belching, difficulty/painful swallowing, waterbrash (excess saliva), dysphagia, chronic sore throat, laryngitis, inflammation of the gums, erosion of tooth enamel, chronic throat irritation, hoarseness in the morning, sour taste, bad breath, and mid-sternal chest pain
• Complications: Barrett’s esophagus or stricture
• Treatment: avoid lying down within 2-3 hours of eating, eat six small meals a day, avoid eating 3 hours before bed, eat slowly, chew thoroughly, and avoid trigger foods/drinks (varies by person); weight loss is encouraged
• Medications: Increase risk of developing C. diff
• H2 blockers (-tidine, pepcid): reduce amount of acid produced in the stomach
  • Side effect: monitor QT interval prolongations, caution with kidney injury
• PPIs (-prazole, protonix): limited acid secretion in the stomach allows rapid resolution of symptoms
  • Side effect: interact with diuretics and clopidogrel, increase risk of hip fracture, and interfere with B12, iron, and magnesium absorption
• Antacids (Tums)
• Prokinetics: metoclopramide
  • Side effect: tardive dyskinesia (TDK)
• Reflux inhibitors: avoid with possible GI obstruction or peptic ulcer
• Surface agents: give on an empty stomach and separate from antacid by 30 minutes
• Surgery: Nissen fundoplication, a laparoscopic or open procedure that wraps a portion of the stomach around the lower esophageal sphincter (LES) to increase pressure
• The procedure may be too tight post-op, leading to discomfort and an inability to eat

Upper Gastrointestinal (UGI) - Peptic Ulcer Disease (PUD)

• PUD can be gastric, duodenal, or esophageal, with duodenal ulcers being the most common
• Gastric ulcer occurs immediately after eating
• Duodenal ulcer occurs 2-3 hours after eating
• Risk Factors: being between 30-60 years old, using NSAIDs, Helicobacter pylori (H. pylori) infection, smoking, alcohol consumption, family history, and having blood type O
• Signs and Symptoms: last a few days to weeks, come and go, or no symptoms (dull, gnawing, burning gastric pain-mid epigastric or back, heartburn, vomiting)
• Diagnostics: endoscopy, H. pylori testing via complete blood count, stool test for blood, or gastric secretions
• Assessment: patient history, diet history/diary, abdominal assessment, vital signs, NSAID usage, and signs and symptoms of anemia or bleeding
• Management:
  • Medications: antibiotics to treat H. pylori (Flagyl, amoxicillin, clindamycin) plus a proton pump inhibitor (PPI), and sometimes bismuth salts
    • Histamine-2 Receptor Blockers and PPIs are used for ulcers not associated with H. pylori
      • H2 maintenance dosage is 1 year
    • Strict adherence to and completion of the medication regimen is crucial
  • Diet: avoid extreme temperatures in food/beverages, alcohol/caffeine, and have small, frequent meals
  • Nursing interventions: relieve pain, reduce anxiety (using coping techniques and relaxation methods), monitor nutritional status, and manage potential complications
• Complications:
  • Hemorrhage: hematemesis, melena. Assess for faintness/dizziness/nausea, monitor VS (tachycardia, hypotension, tachypnea), test stool for gross or occult blood, and measure intake/output (oliguria or anuria)
    • Hemorrhagic shock: requires IV line insertion for fluid resuscitation and blood component therapy
  • Perforation: erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning, more common in duodenal ulcers, very serious—can result in sepsis or multiorgan failure
    • Signs and Symptoms: sudden/severe abdominal pain (persisting and increasing in intensity), pain referred to the shoulders (right shoulder), vomiting, collapse, extremely tender/rigid abdomen, hypotension, and tachycardia (shock)
  • Penetration: erosion of the ulcer through gastric serosa into adjacent structures (pancreas, biliary tract, gastrohepatic omentum)
    • Signs and Symptoms: back and epigastric pain
  • Interventions: monitor fluid and electrolyte balance, assess for infection or peritonitis (increased temperature, abdominal pain, paralytic ileus, altered bowel sounds, abdominal distension)
• Ulcer Education:
  • Treat with two antibiotics and a PPI for 10-14 days, avoid NSAIDs, aspirin, alcohol, tobacco, caffeine, lose weight, and reduce stress
    • PPIs should be used for 4-8 weeks to allow complete peptic ulcer healing and may need a maintenance dose for 1 year

Upper Gastrointestinal (UGI) - Gastric Cancer

• Often diagnosed late
• Symptoms are often relieved by antacids early on
• Progressive weight loss, indigestion, abdominal pain above the umbilicus, bloating after meals, and nausea/vomiting are common symptoms
• Liver enlargement (hepatomegaly) and ascites, as well as a palpable lump node around the umbilicus (Sister Mary Joseph nodes), indicate early metastasis
• Diagnostics: EGD, barium enema, UGI series, CT scan
• Risk factors: age around 68, male, non-Caucasian ethnicity, chronic inflammation of the stomach, H. pylori infection, pernicious anemia, smoking, achlorhydria, gastric ulcers, previous subtotal gastrectomy, genetics (GERD-like)
• Management: TPN, J-tube
• Surgery: Billroth
  • Encourage early ambulation and leg exercises
  • Irrigate NG tube
  • Encourage coughing and deep breathing
  • Provide pain control
  • Be aware of the increased risk of atelectasis

Upper Gastrointestinal (UGI) - Dumping Syndrome

• Occurs after procedures involving removal of a significant portion of the stomach or resection of the pylorus, typically persisting for a few months but can be long-term
• Signs and Symptoms: occur 10-30 minutes after a meal (early satiety, cramping/abdominal pain, nausea, vomiting, diarrhea); early symptoms resolve within 1 hour or with bowel evacuation
  • Vasomotor symptoms: headache, flushing and feelings of warmth, diaphoresis, dizziness, palpitations, drowsiness, fairness, syncope
• Management: limit fluids taken with meals

Irritable Bowel Syndrome (IBS), Crohn's Disease, and Ulcerative Colitis

• Crohn's Disease:
  • Crohn’s and Ulcerative Colitis separated
  • Risk Factor: Diagnosed in ages 20-30 -Cause: Unknown, possible genetic, environment triggers, with high fat diet, stress, bacterial or viral infections, smoking
  • Manifestations: Diarrhea, RLQ abdominal pain, pain with eating, crampy
  • Chronic: Diarrhea, abnormalities on abdominal assessment, steatorrhea, anorexia, weight loss, nutrition deficiency (transmural thickening)
  • Diagnostic: Barium swallow that can detect discontinuous skip, narrowing of colon, thickening of bowel wall, mucosal edema, stenosis, or sigmoidoscopy
  • Treatment: Corticosteroids, immunomodulators, conocolonal antibodies, parenteral nutrition

Irritable Bowel Syndrome (IBS), Crohn's Disease, and Ulcerative Colitis - Treatment/Interventions

• SBO (small bowel obstruction), right-sided hydronephrosis, nephrolithiasis, colon cancer, cholelithiasis (gall stone)
• Provide the correct education for medicating the patient
• Avoid high fiber content, limit dairy, spicy and fatty food as well as wheat/fish while encouraging low fiber and high protein content
• Preventing inflammation calls for smoking cessation along with strict I&Os, daily weights, and frequent gastrointestinal assessment
• Can incorporate structureplasty, bowel resection, ileostomy, and ostomy.

Irritable Bowel Syndrome (IBS), Crohn's Disease, and Ulcerative Colitis

• Ulcerative Colitis is an autoimmune inflammation of the inner colon and rectum with unknown cause that is usually diagnosed with a colonoscopy
• Risk Factors such as family history, being Jewish with NSAID use and consuming dairy products, and can be triggered by stress, illness, NSAID use, and smoking
• Inflammation decreases electrolyte imbalance, dehydration, a sense of urgency with diarrhea, loss of RBCs (anemia), and weight loss
• The location for pain is the rectum, which can cause discomfort dependent on which area is affected in the colon, urgent/frequent bowel movements and loss of weight due to low red blood cell count and electrolyte imbalance
• Severe symptoms to monitor: VS for peritonitis and toxic megacolon.
• With low hematocrit, high WBCs, low albumin, and an electrolyte imbalance, diagnosis should be made with colonoscopy
• Treatment: decrease inflammation can be aided with nutrition and may need TPN if the infection is severe as well as steroid treatments like sedatives or corticosteroids
• Risk: Steroid use and Colon Cancer
• Surgery such as proctocolectomy with ileostomy

Crohn's vs Ulcerative Colitis

• Rupture due to small hole from retreated ulceration, and leakage of contents in the abdomen, and in return may cause septic shock or death
• Manage with medications such as sulfasalazine, which is the first line
• Sulfa-free salicylates are geared towards preventing or treating any occurrences
• Steroids will decrease inflammation and can increase the risk of infection, osteoporosis, and thin skin
• Remember that doses of steroids must be tapered off*
• Nutrition: Ensure there is correct dehydration, high protein and calorie intake
• Crohn's occurs most often on the right side of the body
• Electryolyte imbalance and cardiac dysrhythmias must be observed for
• A big difference with Chron´s and UC; UC is in the inner lining and Crohn´s is full thickness

Medical Procedures- Colonoscopy & Total Parenteral Nutrition (TPN)

• Colonoscopy will monitor your airway, will encourage patient preoperation to have an empty GI System, along with TPN which will encourage: hydration, electrolytes, and caloric intake with precautions such as monitoring your body for CRI/CHF along with keeping both the central line and filter needed in mind and discontinuing gradually to avoid rebound hypoglycemia
• With colonoscopy, there is normal flatuence, so assess before exam
• With TPN assess patient for any decreased oral intake, weight loss, and muscle wasting

Colorectal Cancer

• The 3rd most common cancer in the United States with risk factors such as being older in age; along with family history, smoking, increased alcohol. intake, or previous colon cancer
• Warning Factors: High fat, high protein, low fiber
• High history: genital cancer
• DM2: High presence in this population
• Jewish/AA/obese population
• Changes in bowel movements with possible Right dull abdomen pain and melena or left-sided narrowing/distention/crampig
• Prevention includes cessation, more activity, modification in your diet with high fibre, and weight control along with a colonoscopy roughly after the age of 45

Acute Pancreatitis

• Exocrine: Cell digestive tract and Endocrine: hormones
• Elevated serums: Amylase/Lipase

Pancreatitis Manifestations and Nursing Interventions

• Gallstones are the TOP cause of pancreatitis
• #2 cause is: Alcohol
• S/S: Pain, Abrupt onset, Mid epigastric, Absent bowels. Systemic includes a low function in the heart due to third space losses
• Test: Elevated levels in Amylase/Lipase Medical: No pain

Gallbladder

• The most common cause of cholecystistis is obstruction from stones or sludge
• Key Signs: upper quadrant pain that affects the right side, radiates to scapula. and murphy´s sign
• Diagnostics: abdominal ultrasound (primary), oral cholecystography, X-Ray, ERCP through endoscopy
• Test levels that are elevated includes: AST, ALT
• Pt with gallbladder should be on: cooperative sedation (NPO) 8-12 hours
• Surgical: Removal the stones before, gallbladder lithotripsy

Musculoskeletal: Injuries and Care

• Contusions (soft tissue) are injured by a blunt force as the skin ruptures and starts to bleed
• Strains occur because of injury to the muscle due to stress that can commonly occur in. the leg and back!
• Sprain can be graded that will cause more inflammation or mild tenderness or edema
• Main Goal: Rest and Ice with elevation
• Neurovascular- Assess, Check

Musculoskeletal Fractures

• A Fracture is simply having a break in your bone that can be classified as a compound fracture or a complex fracture
• Risk for osteomyelitis and the management. of these scenarios include adequate splinting/reduction and stability
• Management includes evaluating the 5´P´s (Pain, Parethesia, Paralysis, Pallor, Pulselessness
• Traction: Skin traction-Buck, Assess circulation with proper alignment. External; Pin must be clean

Cervical Complications and Syndrome

• Look for hypovolemia which is trauma related and DVT
• Top Focus: Preventing skin breakdown and negative pressure
• Syndrome: Elevation of pressure which can be a emergency that leads to many long term issues. Be aware of the 5 P´s
• The embolism will cause a rapid onset and is commonly found with fractures and the first red flag is HYPOEXMA

Osteonecrosis and Prevention of Fractures

• Prevent: Infection must use aseptic technique while dealing with dressings
• Osteonecrosis: is where a bone dies because. of blood supply
• Be aware that delayed union and fracture usually recover within a period of six weeks
• Remember : Immobilize is key to reduce infection and ensure proper alignment along with reduction with stability
• Hemiarthroplasty

Kidney and Urinary Manifestations: Causes & Assessment

• Classification in the Urinary Area is known as: (Upper, Lower, Middle Urethra/cystitis
• Assessment in the urine will be determined based on bacteria that is presence
• Monitor Hygiene, pattern, discontinue diagram, and applying local heat

Pyelonephritis Characteristics and Care

• Bacterial Infections of the renal
• Can be Kidney related; one or both
• Can lead to ESKD with HTN and Inflammation
• Asses vitals every 44 Q4 +monitor kidney function

Incontinence vs Kidney Stones

• Incontinence: Loss that has lack of control that can often be treated with bladder controlling mechanisms
• Kidney Stones: When what can occur with increase volume of uric acid, calcium oxalate, or calcium phosphate with a lack of dietary restriction, be away. Pain and ensure their is a balanced pH