EliminationGINUR170 - Student (1) updated_standardized.pptx

Care of clients with gastrointestinal disorders NUR 170 ASSESSMENT OF GI SYSTEM  History  Nutrition  OTC meds/prescription meds  Current health- bowel pattern, blood in stool, weight  Physical assessment  Labs  Other diagnostics  Assessment and R...

Care of clients with gastrointestinal disorders NUR 170 ASSESSMENT OF GI SYSTEM  History  Nutrition  OTC meds/prescription meds  Current health- bowel pattern, blood in stool, weight  Physical assessment  Labs  Other diagnostics  Assessment and Risk Gastroesopha factors geal Reflux Disorder Gastric content into the (GERD) esophagus through the Lower Esophageal Sphincter Risk factors – Things that increase abdominal pressure and push contents from stomach back into esophagus Obesity Pregnancy Certain foods Caffeine, chocolate, acidic foods, fatty foods GERD Dyspepsia - Belching Regurgitation (into pharynx) “Metallic” taste in mouth Heartburn – due to reflux of acidic gastric contents into esophagus - Worse after eating Chest Pain Dysphagia Odynophagia Poor dentition Cough Hoarseness Wheezing *Extraesophageal symptoms GERD Most of the risk factors were lifestyle related. Teach patient about nutrition and lifestyle changes. Elevate HOB Diet modification: Avoid coffee, ETOH, fatty foods, smoking Weight loss No tight clothing Avoid eating 3 hrs before bedtime, esp if pt has night-time symptoms Sleep left lateral decubitus position: Moves stomach contents away from LES Diagnosis - Upper GI series, CT Drug therapy – Antacids, Histamine blockers, Proton pump inhibitors May need surgery - Nissen Fundoplication  Protrusion of stomach Hiatal hernia through esophageal hiatus in diaphragm Hiatal hernia S/S – similar to GERD If sliding hernia, patient can experience feelings of fullness, breathlessness after eating. Check pain, and it worsens when lying down Dx – barium swallow, EGD TX – PPI meds, diet similar to GERD Surgery – Nissen procedure Post-op considerations – watch for aspiration, client can often not belch  PUD- ulcerations in stomach Peptic Ulcer or duodenum Disease  PEPTIC ULCER DISEASE (PUD)  Due to focal ulceration of stomach or duodenal tissue  Very common cause of epigastric pain (AFTER eating)  Gastric: During/briefly after eating; a/w weight loss  Duodenal: A few hours after eating  Physiology:  Gastric Ulcer: Stomach secretes acid when you eat, irritates ulcer  Duodenal: Ulcer far off in duodenum; when acid comes into contact with duodenum they get pain  Causes:  NSAID use, H. Pylori  PEPTIC ULCER DISEASE  Symptoms:  Postprandial epigastric pain  Epigastric pain that awakens patient at night  “Heartburn” that doesn’t respond to antacids  Dx:  Test for H. Pylori: Serology, EGD with biopsy, stool antigen testing  Alarm symptoms? Scope (EGD)  Tx:  PPI’s  Stop NSAIDS (replace with COX-2 if necessary)  H.Pylori: Triple therapy  COMPLICATIONS OF PUD  Bleeding: Very deep ulcers can erode into arteries, leading to rapid blood loss and shock  Symptoms: Bright red or coffee ground emesis, dark tarry stool (melena); signs of hypovolemia: Tachycardia, pallor, hypotension, etc.  Perforation: Ulcer goes all the way through stomach or duodenum and GI contents get into normally sterile peritoneal space: PERITONITIS!!  Symptoms: Sudden, significantly worse abdominal pain. Very sensitive to touch, rebound tenderness, fever, shock. Abdomen will be ridged and boardlike, pt may curl into the fetal  COMPLICATIONS OF PUD: PERITONITIS  Pain is significantly worse (suddenly worsening),  Abdomen is sensitive to touch, ridged, and boardlike  Rebound tenderness over affected area (Blumberg’s sign)  Pt will exhibit guarding  Abdominal Distension/Bloating  Fever  Shock: Symptoms????  Diminished peristalsis  Passing few/no stools/gas COMPLICATIONS OF PUD PUD Post Surgery Nursing actions: 1.Keep head of bed (HOB) at high fowlers. 2.Never manipulate the nasogastric tube (NGT). 3.Monitor patient-controlled analgesia (PCA) pump. 4.Start patient on clear liquid diet as prescribed. 5. Monitor v/s and for post op complications like mechanical obstruction and bleeding.  Gastroenteritis Stomach or Ends in “itis” – Inflammation of small stomach or small bowel from virus or bacteria due to virus or intestine bacteria Viral: Norovirus, Rotavirus Bacterial: Campylobacter, e- coli Parasitic: Giardia Gastroenteritis Self limiting, N/V, then abd cramping and diarrhea If elderly, must assess further for hydration status Tx- fluids- Gatorade, Pedialyte, Powerade Gastroenteritis Diarrhea, abdominal pain/cramps, N/V, fever, anorexia, tenesmus, signs & symptoms of dehydration. Diagnosis: Stool studies, CBC, BMP (electrolytes, renal function) Treatment: Treat s/s of hypovolemia (dehydration) Rehydrate! Antibiotics if bacterial, typically NO antidiarrheals!  Gastrectomy Removal of stomach due to cancer – could be from ulcers that turn malignant Stomach NGT, TPN, reduced intrinsic factor -vit B12, iron, folic acid, calcium Dumping syndrome  Irritable Bowel Syndrome Spastic colon; chronic or recurrent diarrhea, Small and constipation, abd. pain Large and bloating Intestine Issues IRRITABLE BOWEL SYNDROME Caffeine/carbonation, dairy can be cause, raw foods Bacterial overgrowth Women more than men Stress or behavioral issues – depression and anxiety relate to IBS  IRRITABLE BOWEL SYNDROME Symptoms: May be primarily diarrhea (most common), primarily constipation, or both Abdominal pain (commonly LLQ); , discomfort, constipation and/or diarrhea, and abdominal bloating; pain is relieved by a BM. Typical scenario: Chronic diarrhea unamenable to tx; diarrhea is NEVER bloody or fatty; NEVER any weight loss or constitutional symptoms (fever, malaise, etc). Diarrhea will be urgent, especially post prandial.  IRRITABLE BOWEL SYNDROME DX: Must satisfy Rome Criteria Sx > 3 months: Abd pain > 3 days in past 3 months a/w at least 2 of the following Improvement with defecation Onset with change in stool frequency Onset with a change in stool form https://www.mdcalc.com/rome-iii-diagnostic-criteria-irritable-b owel-syndrome-ibs Must completely rule out other causes TX: High fiber diet for ALL patients, 30-40gm/day Avoid caffeine Diarrhea: Loperamide, Diphenoxylate, serotonin antagonist (Alosetron- last resort) Constipation: Bulking laxatives (methylcellulose, psyllium), Lubiprostone (take with food and water) Other tx: Peppermint oil capsules—relaxes intestinal muscles and relieves pain; TCA’s: IBS is also a pain and psychiatric disorder; Antispasmodics: Dicyclomine, Hyoscyamine  Inflammatory Bowel Disease Two main types: Crohn’s Bowel (CD), Ulcerative Colitis (UC)  INFLAMMATORY BOWEL DISEASE (IBD)  Idiopathic, inflammatory, autoimmune disease  Age of onset 20-30’s  Higher incidence in Caucasians than AA’s/Hispanics  Higher incidence in developed countries  Higher risk for colon cancer, decreased QOL from symptoms  Crohn’s Disease Large Inflammatory disease of small intestine (mainly) although it can Bowel be anywhere in GI tract Inflammation causes thickening- leads to fistulas and/or bowel obstruction Crohn’s Disease S/S- diarrhea, abd pain, fever, anorexia, visible peristalsis, anemia – with fistula, signs of poor nutrition such as brittle nails and hair (malabsorption) Crohn’s ileitis, Aphthous ulcers, weight loss Tx- meds – adalimumab (Humira), diet high in calories, protein, vitamin and low in fiber 70% require surgery Crohn’s Disease Dx: Abdominal CT, EGD/Colonoscopy, Labs, C-diff toxin Treat: dehydration (IVF) Pregnancy test in women of childbearing age Be vigilant for acute complications: Perforation, obstruction IV corticosteroids Diet as tolerated, unless a candidate for surgery After 2-3 days on IV steroids will transition to po Surgery: Surgical resection of affected area  Ulcerative Colitis Large Ends in “itis”. Inflammation of rectum which proceeds upward. Bowel Seen more in Jewish and whites  ULCERATIVE COLITIS  Continuous  Affects colon (ulcers)  Most cases only affect the rectum and sigmoid Ulcerative Colitis Remissions and exacerbations 10-20 bloody, liquid stools/day with mucus Urge comes on quickly Nutritional deficiencies Hemorrhage LLQ Abd pain Weight loss Tenesmus: Rectal fullness, unable to pass stools, straining during BM’s 1/3 require surgery: Curative in UC, not in Crohn’s Dx- barium enema, Barium enema: May help differentiate CD vs UC; Colonoscopy Sigmoidoscopy/Bx: Mucosal Inflammation Tx- meds such as antidiarrheal, corticosteroids (anti-inflammatory), nutrition, surgery  IBD DIAGNOSIS: BARIUM ENEMA  No solid foods day before exam  NPO after MN  Prep: Enema, Mg citrate, Dulcolax  Instill barium/air: Pt will feel crampy, urge to defecate  Barium will be expelled immediately after test, stools will be grey/white colored for a few days after  Drink plenty of fluids following exam  IBD: DIETARY TREATMENT  Low residue diet  Avoid seeds, beans, nuts, kernels  Avoid caffeine, alcohol  Increase omega-3’s: Salmon, mackerel, herring, sardines  Small, frequent meals  Nutritional supplements  Decrease concentrated sweets  Decrease fresh fruits and vegetables INFLAMMATORY BOWEL DISEASE – RX THERAPY  Aminosalicylates  Inhibits prostaglandins  decreased inflammation  Sulfasalazine (Azulfidine)  Mesalamine (Asacol)  Corticosteroids  Decreases inflammation. Assess for hyperglycemia. Taper.  Prednisone (Deltasone)  Immunomodulators  Alters a person’s immune response. Works better in combination with a steroid.  Mercaptopurine (6-MP)  Methotrexate (MTX)  Biological therapies  Reduces activity of tumor necrosis factor (TNF)  reduced inflammation. These agents decrease the immune system. Signs and symptoms of an illness should be reported promptly. Baseline TB Testing.  Infliximab (Remicade)  Adalimumab (Humira)  Small or large bowel obstruction Due to twisting of bowel or Small and paralytic ileus large Intestinal contents (food) intestine accumulates above the issues obstruction Distention Increased peristalsis above obstruction Dx – abdominal CT or MRI Tx- surgery or NGT  Obstruction The bowel is physically blocked Tumors: Large tumor leads to obstruction. Adhesions – Most common cause; scar tissue from previous surgeries causes Intestines fibrous bridges between segments of the intestine. Strictures (IBD) – narrowing Hernia: Protrusion of intestine through abdominal wall Volvulus – twisting of the intestine; cecum and sigmoid area Intussusception – telescoping of the intestine within itself; ileocecal valve INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION Non-mechanical obstruction  Theintestinal musculature cannot propel the contents along the bowel  Paralytic ileus  Common following surgery (hypokalemia, drugs)  Hypoactive to absent bowel sounds  Hiccups  N/V  Abdominal distention INTESTINAL OBSTRUCTION CLINICAL PRESENTATION  Small-bowel  Large-bowel  Abdominal  Intermittent lower abdominal discomfort or pain with visible peristaltic waves cramping  Lower abdominal distention  Upper or epigastric abdominal distention  Minimal/no vomiting  N/V – may contain fecal  Constipation or ribbon-like stools matter.  No major fluid and electrolyte  Obstipation imbalance  Severe fluid and electrolyte  Metabolic acidosis (not always disturbances present)  Metabolic alkalosis INTESTINAL OBSTRUCTION: LABS/PE  Labs: Elevated WBC if infection or inflammation  Electrolytes: Hypokalemia often seen in paralytic ileus  Metabolic alkalosis with SBO, possibly acidosis with large bowel obstruction  Elevated B/C in dehydration  PE:  Distension  Visible hernia?  Auscultation  Obstipation  Failure to pass flatus  Palpation: Tender or distended  INTESTINAL OBSTRUCTION  Imaging  AXR: Initial diagnostic test; reveals dilated loops  CT/MRI: More accurate  Non-surgical management  NPO  IV fluids – watch for electrolyte abnormalities  Pain medication  IV ABX – potentially  Oral care  Nasogastric (NG) tube – Decompression  Anti-emetics  Entereg  Surgical management  Exploratory laparotomy  Open  Laparoscopic  Lysisof adhesions  Colon resection  Diverticular Disease Instestine Sac like herniations in colon (usually sigmoid) Diverticula: Pouches in the wall of the colon Diverticulosis: The state of having diverticula (may or may not be symptomatic) Diverticulitis: Infection of a diverticulum, which occurs in patients with diverticulitis DIVERTICULAR DISEASE: ETIOLOGY AND PATHOPHYSIOLOGY Etiology and Risk Factors Pathophysiology  Aging  Diverticula form due to increased pressure in large intestine and  Low fiber diet weakness in the colon wall. Colon wall bulges out.  Constipation  Weakest point of colon is also where arterioles traverse the colon wall; this is why diverticular disease places patient at increased risk for bleeding  Diverticulitis: Undigested food or bacteria become trapped in diverticulum, leading to inflammation, infection, or perforation DIVERTICULAR DISEASE: S/S  Diverticulosis: No Symptoms unless pain or bleeding develop;  Diverticulitis  LLQ pain  Fever/chills/tachycardia  Distension/rebound tenderness  N/V, abdominal or pelvic mass  Leukocytosis  Bloody stools  Peritonitis, shock  Fistula formation: Pneumaturia/fecaluria o Workup – CBC, CMP, Blood Cultures, Beta-HCG Imaging: CT with contrast Absolutely NO contrast enema or colonoscopy during acute phase! Can cause a perforation. DIVERTICULITIS Diverticulitis Nursing Care  NPO  IVF  NGT Suction: For N/V, distension  Broad Spectrum antibiotics  High fiber diet after resolution Diverticulosis outpatient recommendations  Encourage a high-fiber diet  Adequate hydration (avoid constipation)  Bulk forming laxatives  Avoid foods with seeds (debatable)  Avoid alcohol DIVERTICULITIS: COMPLICATIONS  Bleeding  Intra-abdominal Abscess: Will Require CT- guided drainage  Sx: Fever, palpable mass  Purulent/Feculent Peritonitis: Patient will have guarding, rebound tenderness. Will need surgery: Laparotomy with resection, colostomy.  Fistula By definition a fistula is an Intestinal abnormal opening Fistula See systemic infections, malnutrition, F/E imbalance, skin problems Diet high calories, high protein High risk for sepsis  Peritonitis Lining of Ends in “itis” –Inflammation of Abdomen peritoneum What are s/s and treatments for inflammation? Paralytic ileus results with air and fluid in bowel Peritonitis Life threatening Causes – Usually from bacteria in the GI (i.e. perforated appendix, diverticulitis or peptic ulcer) and female reproductive system External trauma – i.e. penetrating wounds Abdominal procedures and peritoneal dialysis Peritonitis S/S – Based on location and extent – i.e. peptic ulcer perforation – sudden, sharp mid-epigastric pain; perforated appendix – abdominal pain worsen with activity & pain relief when hips are flexed. Symptoms of cause come first – i.e. fever, increase WBC, tachycardia, & hypotension. Abdominal distention, and bloating. Rigid, and board-like abdomen. N/V, and hypoactive to no bowel sounds. Peritonitis Monitor for signs and symptoms of shock. Monitor for signs and symptoms of sepsis. Monitor for intestinal obstruction. Fluid replacement. Insertion of nasogastric tube (NGT). Drug therapy – i.e. Famotidine, Acetaminophen. Monitor gastrointestinal functioning. Paracentesis or drains. Pain management. Surgery – i.e. exploratory laparotomy. Post-op care. Antibiotics NGT, surgery IVF  Appendicitis Accessory Ends in “itis” so you know it is an inflammation. organs Acute inflammation leads to blockage, mucosa secretes fluid increasing pressure, eventually will rupture Appendicitis RLQ pain – McBurney’s point Fever, increased WBC Cramping pain in abdomen, anorexia, followed by n/v Perforation of appendix is life threatening Dx- WBC, ultrasound, CT Tx- surgery - Appendectomy Pain that increases with movement and relieved when hip flexed indicates perforation and peritonitis  APPENDICITIS Obturator Sign Psoas Sign  Nursing interventions APPENDICITIS  Keep the client NPO. Occurs when the appendix is occluded by  Administer analgesics and feces, tumors or indigestible substances. IVF, antibiotics as prescribed.  Semi-fowlers Clinical Manifestations  No laxatives, enemas, or heat  Abdominal pain/tenderness, N/V, anorexia  Pre-operative teaching and  Starts as epigastric or periumbilical pain, obtaining consent. eventually radiates to RLQ  Pain in the RLQ (McBurney’s point)  Rebound pain when palpated  Leukocytosis: 10,000-18,000 with appendicitis; > 20,000 perforated appendix  Low grade fever  N/V Diagnostics: Obturator/Psoas sign  CT Scan or Ultrasound Treatment  Appendectomy and empirical ABX Complications: the appendix could rupture and cause peritonitis Notify the provider for abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees.  Gallbladder disease Accessory Cholelithiasis: Stones in Organs gallbladder Cholecystitis: Inflammation of gallbladder Choledocholithiasis: Stones in common bile duct Cholangitis:  CHOLELITHIASIS  Stones in the Gallbladder  Risk Factors: Five F’s  Female  Fat  > Forty  Fertile  Flatulent  Sx:  RUQ Pain: May radiate to back or right shoulder  Pain presents suddenly and is intense, may subside and become a dull ache  No fever GALLBLADDER DISEASE: CHOLECYSTITIS  Most common – Calculous cholecystitis (95% of the time)  Etiology & Pathophysiology  Calculous cholecystitis  Cholecystitis: Results from stone in the cystic duct, bile can’t flow out. Bile stasis triggers release of enzymes that cause inflammation in the gallbladder.  Sx:  Fever  RUQ pain  N/V  Dyspepsia  Flatulence  Rebound tenderness  Murphy’s Sign (Inspiratory arrest with palpation of RUQ)  Jaundice***  CHOLECYSTITIS: WORKUP AND TREATMENT  Diagnostic Tests: Elevated WBC, Alk phos, AST, Bilirubin  RUQ Ultrasound: Best initial Test; cheap and fast  Tx:  Immediate supportive care: IVF, antibiotics, pain meds  Cholecystectomy: Surgical Removal of GB (laparoscopic or open)  Medication: Ursodeoxycholic Acid—Dissolves tiny gallstones  ERCP: Endoscopic Retrograde Cholangiopancreatography  ERCP PATIENT EDUCATION PROCEDURE and NURSING CARE  Usually done d/t obstruction  NPO > 6 hours at level of CBD  No blood thinners  Looks like endoscope for  Local anesthetic to numb EGD, goes to second part of throat: Make sure gag reflex duodenum, additional tool returned before offering gets to ampulla of vater and food/fluids CBD. Dye injected into biliary  Sedation: Someone must drive tract. Stone retrieved. patient home Elective lap choley may follow.  Bloating/gas expected after,  Complication: Acute but not pain, N/V, or fever!! pancreatitis; dye injected into pancreatic duct ERCP GALLBLADDER DISEASE: CLINICAL VIGNETTE  A 46 y/o female presents to the ED with C/O N/V and pain in her abdomen for the past six hours. She denies any changes in bowel habits or blood in the stool. She has no surgical history. She is febrile at 103.6, BP 135/90, HR 103. PE reveals and overweight female in moderate pain. There is scleral icterus. Abdomen is tender to palpation in the RUQ but non-tender elsewhere. The abdomen is non-distended. BS are normal. She is admitted to the surgical floor and is awaiting a RUQ U/S. On the floor, she becomes increasingly somnolent, and her BP drops to 96/55. IVF are started and it rises to 115/90, but she remains somnolent. What would you do?  Hepatitis A, B, C, D, E Accessory Ends in “itis”. Inflammation of liver cells for different reasons Organs based upon its type Hepatitis A, B, C, D, E A – survives on hands, fecal-oral route, contaminated food, like a GI illness B – blood or open sores-direct contact, unprotected sex, needle stick, sharing razor. Flu like symptoms C – IV drug use (sharing needles), chronic infection leading to cirrhosis D – IV drugs, sex E – waterborne infection from fecal contamination, like hepatitis A Osteomalacia Interventions & Nutrition Therapy ◦Rest ◦High carbohydrate & calorie diet; moderate fat & low- moderate protein diet ◦Small frequent meals; likes/dislikes; avoid alcohol ◦Vitamin supplements Drug Therapy; use sparingly ◦Antiemetic ◦Antiviral & immunomodulating drugs for chronic hepatitis B and C.  Total Parenteral Nutrition Management of severe malnutrition Lab Values: Pre-albumin, blood glucose Interventions ◦Change the TPN bag and set Nutritional within 24 hours. Options ◦Monitor blood glucose level. ◦Monitor signs and symptoms of hyperglycemia – i.e. polyuria, polydipsia, polyphagia, & blurred vision. ◦Follow infusion rate and normal saline flush rate.  Nasogastric Tube; Gastric Tube and Jejunostomy Nutritional Feeding or food supplement Options Interventions Follow infusion rate and normal saline flush rate. Check for residuals. Position head of the bed (HOB) in high fowlers.  POST-OPERATIVE CARE OF THE PATIENT WITH AN ILEOSTOMY  Stoma should be pink to cherry red  Pt must wear pouch at all times  Skin care around stoma is a priority!  Skin protection:  Skin barrier to protect skin from stool  Watch for redness/irritation  https://www.youtube.com/watch?v=FbMNHX6sWO0  Pouch Care:  Empty when 1/3 to ½ full, change entire pouch Q3-7 days  Nutrition:  Chew food thoroughly, be cautious with high fiber foods  Drug Therapy:  No enteric coated meds, no laxatives or enemas  Symptoms to watch???