Vomiting and Retching

Vomiting

• Vomiting involves the forceful expulsion of stomach and intestinal contents through the mouth.
• Causes includes ipecac in the duodenum, severe pain, distention of stomach or duodenum, trauma to reproductive or urinary organs, and activation of the chemoreceptor trigger zone in the medulla.
• Nausea normally precedes vomiting and is considered subjective.

Retching

• Retching starts with deep inspiration followed by vomiting
• The glottis closes
• Intrathoracic pressure falls as the esophagus becomes distended
• Abdominal muscles contract creating pressure
• The lower esophageal sphincter and the body of the stomach relax, yet the duodenum and antrum of the stomach go into spasm.
• Reverse peristalsis and a pressure gradient forces chyme up the esophagus from the stomach
• Chyme is prevented from entering the mouth by the closed upper esophageal sphincter.
• Abdominal muscles then relax, and the contents go back into the stomach.
• Retching might occur multiple times prior to vomiting.
• Projectile emesis isn't preceded by either nausea or retching.
• Metabolic consequences of this includes fluid, electrolyte, and acid-base disturbances.

Medications

• Anticholinergic medications include scopolamine (transdermal patch).
• Antihistamines include dimenhydrinate (Gravol) and diphenhydramine (Benadryl).
• Neuroleptics include prochlorperazine (Stemetil).
• Pro-Kinetic Agents include metoclopramide (Maxeran).
• Serotonin blockers include ondansetron (Zofran).
• Tetrahydrocannabinoids include POT (Dronabinol).
• Side effects vary based on the agent and the nonselective blockade of receptors.

Nursing Implications for Vomiting

• Assess the full history of nausea and vomiting, including precipitating variables.
• Assess current medications, contraindications, and possible drug interactions.
• Anti-emetics may cause severe drowsiness.
• Anti-emetics should be given 30 minutes to 3 hours before chemotherapy.
• Anti-emetics used with alcohol may cause severe CNS depression.

Constipation

• Constipation is difficult or infrequent defecation.
• It must be individually defined because of the diverse bowel habits in the population.
• Normal bowel movements can occur from 2-3 times a day to once a week.
• Causes may be from neurogenic disorders evident from birth, functional or mechanical disorders, weakness or pain.
• A low-residue diet may cause constipation, therefore you should increase intake of veggies, cereals, and fruits.
• Sedentary lifestyles, lack of exercise, depression, and anticholinergics can contribute to lack of motility.

Laxatives - Mechanism of Action

• Bulk forming involves high fibre, absorbs water to increase bulk, distends bowel to initiate reflex bowel activity, examples of which are psyllium, methylcellulose, and polycarbophil.
• Emollient stool softeners and lubricants, promote more water and fat in the stools, and lubricate the fecal material and intestinal walls, such as docusate salts (Colace) and mineral oil.
• Hyperosmotic increase fecal water content, cause bowel distention, increase peristalsis, and evacuation, such as polyethylene glycol, sorbitol, glycerin, and lactulose.
• Saline laxatives increase osmotic pressure within the intestinal tract, are use to cause more water to enter the intestines, resulting in bowel distention, increased peristalsis, and evacuation, such as magnesium sulfate, magnesium hydroxide, magnesium citrate, and sodium phosphate.
• Stimulant laxatives increase peristalsis via intestinal nerve stimulation, such as castor oil, senna (Senekot), cascara, bisacodyl (Dulcolax), and Ex-lax.

Laxatives - Side Effects

• Bulk forming may cause impaction and fluid overload.
• Emollient use can cause skin rashes and decreased vitamin absorption.
• Hyperosmotic laxatives can cause abdominal bloating and rectal irritation.
• Saline laxative use may cause magnesium toxicity (with renal insufficiency) and cramping.
• Stimulant use side effects can include diarrhea, increased thirst, nutrient malabsorption, skin rashes, gastric irritation, and rectal irritation.

Laxatives - Nursing Implications

• Electrolyte imbalances!
• Take a complete history detailing current symptoms, elimination habits, and any allergies.
• Evaluate fluid and electrolyte levels before treatment is initiated.
• A high-fiber, high-fluid diet should be advised.
• Long-term use could cause a decreased bowel tone which may cause dependency issues.
• Take all laxative pills with 180 to 240 mL of water.
• Take bulk-forming laxatives with at least 240 mL of water.
• if nausea, , vomiting, and/or abdominal pain occurs, clients shouldn't consume a laxative or cathartic

Diarrhea

• Diarrhea involves an increase in defecation frequency, with increased fluidity and volume of feces.
• Stool volume >200g/day in normal adults.
• Large volume diarrhea (increased feces volume) is usually from increased water or secretions.
• Small volume diarrhea is from excessive intestinal motility.
• Surgical resection or bypass may cause motility diarrhea.
• Diarrhea can be acute or chronic.
• Systemic effects: dehydration, electrolyte imbalance, metabolic acidosis, weight loss.
• Fever, cramping, pain, and bloody stools might signify inflammatory bowel disease.
• Steatorrhea (fat in stools) is more common with malabsorption syndromes.

Antidiarrheals - Mechanism of Action

• Adsorbents, which coat the GI tract walls, bind to bacteria or toxins. Examples of which are bismuth subsalicylate (Pepto-Bismol) and activated charcoal.
• Anticholinergics or antispasmodics decrease intestinal muscle tone and peristalsis, slowing movement, such as atropine.
• Intestinal flora modifiers are bacterial cultures of Lactobacillus which is the normal bacteria to create an unfavourable environment for fungi, an example of which is L. acidophilus.
• Opiates decrease bowel motility and relieve rectal spasms allowing more time to absorb water and electrolytes and shorten transit time. Examples include diphenoxylate (Lomotil) and *loperamide (Imodium).

Antidiarrheal Agents - Interactions

• Adsorbents decrease the absorption of many agents including digoxin, clindamycin, quinidine, and hypoglycemic agents.
• Adsorbents cause increased bleeding time when given with anticoagulants

Abdominal Pain

• A common symptom of GI disorders is abdominal pain
• Causes may be mechanical, inflammatory, or ischemic
• May be parietal (parietal peritoneum), visceral (organs themselves), and/or referred (such as Gall bladder pain)

GI Bleeding

• Upper GI bleeding from the esophagus, stomach, or duodenum often results in bleeding ulcers.
• Lower GI bleeding can be caused by polyps, inflammatory disease, cancer, or hemorrhoids in the jejunum, ileum, colon, or rectum.
• Acute severe bleeding is life threatening.
• Hematemisis is blood in vomitus.
• Hematochezia is bright blood from the rectum.
• Melena is dark, tarry stools.
• Chronic blood loss found in the stool is tested by a guiac test resulting in iron deficiency anemia.
• acute bleeds should be monitoring for changes in blood pressure and heart rate.

Ulcers

• Peptic ulcers can occur in the lower esophagus, duodenal, and gastric organs.
• Duodenal ulcers are more frequent than other types of peptic ulcers.
• Infections with H. pylori, hypersecretion of acid and pepsin, and inadequate secretion of bicarbonate are major causes
• The acid and pepsin can penetrate concentrations, penetrate the mucosal barrier and can cause ulceration.
• Epigastric area pain should be an area of concern The Pain often begins 30m-2h postprandial.
• The pain is relieved rapidly with use of antacids.
• In elderly clients, the first symptom may be perforation or bleed.
• There is a possible need to regulate secretion of acid.
• Gastric ulcers are ulcers of the stomach and adjacent to acid-secreting mucosa.
• An abnormality increases the mucosal barrier's permeability to hydrogen ions
• The acid production may be normal or decreased.
• Symptoms are similar to duodenal ulcers.
• Gastric ulcers tend to be chronic rather than intermittant causing more anorexia, vomiting and weight loss.

Acid Controlling Agents

• May include antacids, H2 antagonists and proton pump inhibitors (PPI).

Antacids - Mechanism of Action

• These promote gastric mucosal defense mechanisms
• This includes the secretion of:
  • Mucus: protective barrier against HCl
  • Bicarbonate: helps buffer acidic properties of HCl
  • Prostaglandins: prevent activation of proton pump

Antacids - Drug Effects

• Reduction of pain associated with acid-related disorders
• Raising gastric pH from 1.3 to 1.6 neutralizes 50% of the gastric acid, raising gastric pH 1 point (1.3 to 2.3) neutralizes 90% of the gastric acid.
• Reduces acidity decreasing pain.

Antacid Categories

• Aluminum salts: Constipating effects
• Magnesium salts: Commonly causes diarrhea
• Calcium salts: May cause constipation and kidney stones
• Sodium bicarbonate: Highly soluble

Antacids - Side Effects

• Side effects are minimal and depend on the compound used. -Aluminum & Calcium may cause constipation. -Magnesium may cause diarrhea. -Calcium carbonate produces gas and belching.

Antacids - Drug Interactions

• Adsorption of other drugs to antacids in the ability of the other drug to be absorbed into the body.
• Increased stomach pH: -Increased absorption of base drugs -Decreased absorption of acidic drugs
• Increased urinary pH: -Increased excretion of acidic drugs -Decreased excretion of basic drugs

Histamine (H2) Antagonists

• These reduce acid secretion for acid-related disorders such as:
  • Cimetidine (Tagamet)
  • Famotidine (Pepcid)
  • Ranitidine (Zantac). Block histamine (H2) at the receptors of acid-producing parietal cells Production of hydrogen ions is reduced, resulting in decreased production of HCl
• Suppressed acid secretion in the stomach.

H2 Antagonists - Indications

• GERD (Gastric esophageal reflux disease)
• PUD (Peptic Ulcer Disease)
• Erosive esophagitis
• Adjunct therapy in control of upper GI bleeding
• Pathological gastric hypersecretory conditions

H2 Antagonists - Side Effects

• Overall, less than 3% incidence of side effects
• Cimetidine may induce impotence and gynecomastia (the abnormal development of large mammary glands in males resulting in breast enlargement)
• Headaches, lethargy, confusion, diarrhea, urticaria, sweating, flushing, other effects

H2 Antagonists - Drug Interactions

• Cimetidine: Binds with P-450 microsomal oxidase system in the liver, resulting in inhibited oxidation of many drugs and increased drug levels.
• All H2 antagonists may inhibit the absorption of drugs that require an acidic GI environment for absorption.

Proton Pump

• The parietal cells release positive hydrogen ions (protons) during HCl production.
• This process is called the “proton pump”.
• Agents such as H2 blockers and antihistamines don't stop the action of this pump.

Proton Pump Inhibitors - Mechanism of Action

• Irreversibly bind to H+/K+ ATPase enzyme. This bond prevents the movement of hydrogen ions from the parietal cell into the stomach.
• Result: achlorhydria (ALL gastric acid secretion is blocked).

Proton Pump Inhibitors (PPI)

• In order to return to normal acid secretion, the parietal cell must synthesize new H+/K+ ATPase.
• Total inhibition of gastric acid secretion include lansoprazole (Prevacid) and omeprazole (Losec).

Proton Pump Inhibitors - Indications

• GERD maintenance therapy
• Erosive esophagitis
• Short-term treatment of active duodenal and benign gastric ulcers
• Treatment of H. pylori–induced ulcers

Proton Pump Inhibitors - Side Effects

• Proton Pump Inhibitors are safe for short-term therapy.
• They have a low incidence and are uncommon.

Proton Pump Inhibitors - Nursing Considerations

• Assess for allergies and history of liver disease.
• Pantoprazole is the only proton pump inhibitor available for parenteral administration.
• They may increase serum levels of diazepam and phenytoin.

Obstrucitons

• Pyloric obstruction involves narrowing or blocking of opening between stomach and duodenum
• Acquired obstruction can be caused by peptic ulcer disease (more often duodenal ulcers) or carcinoma
• A patient becomes more distressed postprandial hours after eating with anorexia and weight loss developing with copious vomiting.
• Intestinal obstruction involves anything that prevents normal flow of chyme through intestine with simple obstruction being a mechanical blockage and functional due to lack of motility.

Obstructions - Patho

• Consequences of obstrucitons are dependent on onset and location and length of intestinal tract proximal to obstruction.
• The presence of gas (either swallowed air or fermenting food) causes distention which may lead to failure of the intestines' ability to absorb water and electrolytes.
• Severe pressure from distension may cause ischemia, necrosis, perforation and peritonitis.

Small Bowel Obstruction (SBO)

• IBD is an inflammatory bowel disease usually expressed as ulcerative colitis.
• Ulcerative colitis is a chronic condition causing ulceration of colonic mucosa, usually in rectum and sigmoid colon.
• Usually occurs in people between the age of 20-40.
• Causes: dietary, infectious, genetic and immunologic with anticolon antibodies found and often accompanied by SLE and other autoimmune disorders. -Begins with inflammation most frequently in left colon, with neutrophil infiltration Inflammatory cytokines cause tissue damage with Abscesses and mucosal destruction
• Causes bleeding, cramping pain and urge to defecate. Frequent diarrhea with small amounts of blood and purulent mucus.

Ulcerative Colitis

• Intermittent periods of exacerbation & remission with symptoms varying with disease severity which can show up as dehydration, wt loss anemia and fever. Chronic blood loss: can precipitate hypotension and shock, perforation is rare
• Diagnosis: based on Hx, CM, and colonoscopy or sigmoidoscopy
• Treatment: use conservative tx

Crohn’s Disease

• There is a risk factors or causes the same as ulcerative colitis. It is an inflammatory disorder that can affect any part of the GI tract (mouth -> anus).
• Begins in intestinal submucosa and spreads to mucosa and serosa, most common site is ileocolon
• May skip areas or be limited to one side of colon. Inflammation may extend into lymphoid tissue.
• Fistulae may form in perianal area or extend into bladder

Crohn's Cont'

• Crohn's has no specific symptoms except irritable bowel for several years with diarrhea being the most common sign.
• Look for weight loss and lower abd pain. May be protein, vitamin B12, D, folic acid and calcium deficiencies
• Anal manifestations in 30%. At risk for carcinomas of small intestine
• Obstruction, fistulae, abscess formation and blood loss are complications due to the use of steroids
• DMARDS 5ASA Pentasa Methotrexate Hydroxychloroquine (Plaquenil) Azothioprine (Imuran)
• Biologics Infliximab (Remicade) Adalimumab (Humira) Antibiotics

Appendicitis

• May arise from obstruction: >bacterial infection Inflammation of vermiform appendix-projection of apex of cecum.
• The most common surgical emergency of the abdomen Can develop being hypoxic, ulcerates, gangrene may develop with epigastric or periumbilical pain increasing over 3-4 hours. -Right lower quadrant pain associated with extension or inflammation.
• N&V, anorexia, fever is common can lead to serious complications of perforation, peritonitis and abscess formation.
• Other signs Rebound tenderness, elevated WBC and C-reactive protein. Antibiotics and appendectomy are needed

Dysphagia

• Difficulty swallowing. Arise from mechanical obstruciton or impaired esophageal motility.
• The most common cause is tumor
• Dysphagia is caused by neural or muscular disorders - e.g. CVA, Parkinsons Look for pain following swallowing: if cause is tumor first will come dysphagia with solids progressing to liquids Dysphagia can lead to aspiration if esophageal contents, causing pneumonia Use barium swallow to visualize defects Taught to manage symptoms Mechanical dilation possible or surgery

Malabsorption Syndromes

• Inteversion with nutrient absorption in small intestine
• Maldigestion: failure of chemical, process of digestion to take place - often caused by deficiencies of enzymes necessary for the digestion
• Malabsorption: failure of intestinal mucosa to absorb digested nutrients - results from mucosal disruption caused by gastric or intestinal resection, vascular disorders or intestinal disease

Eating Disorders

• Obesity: body mass index that is >120% ideal body weight - associated with 3 leading causes of death with imbalance between energy intake and expenditure with exogenous and endogenous causes.

Anorexia Nervosa

• Anorexia Nervosa occurs among 1% women and asdolescent girls. The many risk factors include genetic, familial, biologic, psychologic, and social factors
• Associated with sexual assault, elderly with depression, anxiety with lack of desire to eat, also commonly associated with nausea, abd. pain & diarrhea
• Can be associated with: cancer, heart disease, and renal disease along with psychologic factors.

Anorexia

• Fear of becoming obese and there is a distorted body image
• The risk factors: genetic ,biologic, depression , anxiety, personality Disorders, social Factors and sexual assault
• Denial of having an eating disorder due to depletion making a person look like a skeleton along with other possible risks: Muscle and fat depletion of person with reproductive functioning is affected, Postural hypotension and Hypokalemia Hypothermia and Sleep Disturbances

Anorexia- Tx

• Aims to promote insight & knowledge about the disorder by setting goals, restore food habits, increase interaction with family Members and restore development to make eating safe Body weight is 15% less than normal for age and height because of refusal to eat absence of three consecutive menstrual periods Dec. WBC -> incre Risk of infection loss of 25 30% body weight leads to death caused by starvation induced cardiac failure

Bulimia Nervosa:

• Typically starts with and attempt to lose weight due to bing eating during which the person is unable to stop (2 binge eating episodes per week for at least 3 months) Bulimia is more common than anorexia with the risks being the similar Bulimia caused pitted teeth, pharyngeal and esophageal inflammation A vicious cycle of depression , overeating, vomiting and purging often worse in the winter months A patient may perform binges and purging nearly 20X/day, causing weight fluctuations and the person will often be isolated and have pitted teeth.

Viral Hepatitis

• A common Systemic disease that affect the liver(Six Strains known), HEP A (HAV) being the fecal oral rout and HEB B being transfusion from infected blood. Incubation period is 4-6 weeks( HAV HEPC) HEP B's is 6-8 Weeks -Abnormal liver function test Look for: marker for (HBV -HBsAg. , AntiHAV. For Hav and Hepc Low fat high carbohydrates diet if bile flow Obstructed

Cholilithiasis

• Affects to 20% of the population for over 40 plus more prevalent in women
• Sign's and Symptoms: Non localized abd discomfort, Eructation, Intolerance to particular foods Treatment: is cholecystectomy for clients with severe pain
• Diagnosis: Through an untrasound of the gallbladder. Treatment: Usually surgery

Cholecystitis

• Acute or chronic inflamed gallbladder - the causes are: alcohol , trauma, Infection , certain drugs , ETOH USE AND HEPATITIS C Acute: Caused by a gallstone that cannot pass through the cystic duct causing the symptoms : N&V/eructation/ RUQ pain/flaatuence

Pancreatitis

• Characterized by severe abd pain(epigastric) and may be acute or chronic leading to Anorexia N&V , Jaundice Chronic will show similar symptoms as the acute forms but will also have in alcohol abuse, scarring, abdominal pain,steatorrhea and diabetes
• Chronic patients have scarring of the pancreatic with decreased enzymatic function: abdominal pains , N and V, and steatorrhea