GI Notes PDF - Nursing, Gastritis, and Digestive Disorders

Current Health - Last bowel movement (first question is that normal for you) - Has anything changed - Color, consistency, frequency - Last period for women (10-65 years old) Patient History - Surgical hx - Skin changes (itching, color, bruising, tendency to bleed) Nutriti...

Current Health - Last bowel movement (first question is that normal for you) - Has anything changed - Color, consistency, frequency - Last period for women (10-65 years old) Patient History - Surgical hx - Skin changes (itching, color, bruising, tendency to bleed) Nutrition History - Normal eating habits - Have they stopped eating foods due to stomach issues - Cultural preference (spicy food, fasting, etc) - Lactose intolerance (African American, Asian American) - Health problems that affect nutrition (decreased appetite, change in taste, loss of taste, anorexia) - Difficulty or pain with swallowing/chewing - Dentures (untaken care of, ill fit) - Unintentional weight loss or gain - Large amounts of caffeine/ETOH - Smoking - Balanced diet (can they afford it, limited income) - No access to fresh fruit/veggies (food desert) - Over the counter meds or herbal remedies for abdominal issues Family History - Colon cancer hx (first degree relatives can inherent) Physical Assessment - Empty bladder and lie supine with arms relaxed by side and knees slightly flexed - Inspection - Movement, color, symmetry, distention - If bulge that is pulsating do NOT palpate - Auscultation - High pitched q 5-15 seconds - Decreased or absent (listen for full 5 minutes) - Bruit: whooshing sound - Borborygmus: loud high-pitched gurgling - Indicative of increased motility (hunger) - Percussion (provider to perform) - Used to determine size of solid organs - Detect masses/fluid/air - Tympanic and dull sounds - Palpation - Tenderness or mass Labs - CBC - Anemia, infection - Decreased calcium, potassium, sodium - AST and ALT (liver function) - Amylase and lipase - Acute pancreatitis (elevate within 24 hrs and can last up to 5 days) - Ammonia - Alcohol pts, pancreatitis, cholecystitis - CA 19-9/CEA - Oncofetal antigen test (effectiveness of cancer therapies/recurrency of cancer) - Bilirubin - Coagulation studies (PT) - Stool tests - FOBT - Ova and parasites - Fecal fats - Malabsorption (fatty stools) - Clostridium difficile Diagnostic Assessment (purpose, description, any special pre/post procedure care) - Abdominal ultrasound - Abdominal X-ray - Abdominal MRI - Abdominal CT - Assess for allergies (shellfish and iodine) - Hold metformin (diabetics) 24 hrs prior and 48 hrs after - Can cause contrast induced renal failure - Small bowel endoscopy - Esophagogastroduodenoscopy (EGD) - Endoscopic Retrograde Cholangiopancreatography (ERCP) - Virtual colonoscopy (CT colonography) - Colonoscopy (45 or older; every 10 years) - Bowel prep (liquid or pill form; enema) - Hold anticoagulants and asprin 5 days prior - Drink electrolyte replacements (on clear liquid diet) - No red, orange or purple dye in the fluid - Biopsy can expect small amount of blood (still report larger amounts due to perforation risk) - No fluids until flatus occurs after surgery - Sigmoidoscopy (45 or older; every 5 years) - Liver-Spleen Scan - Radioactive chemical through IV - Check pregnant/breastfeeding (cant have) - Use careful, diligent hand hygiene following scan (residual chemical will be excreted) Effects of Aging of GI Tract - Atrophy of gastric mucosa - Disorder/problem: risk for decreased breakdown of food, decreased protein absorption, decreased vitamin B12 and iron absorption, increase in bacteria growth - Interventions: diet changes, foods easier to digest, supplemental vitamins/minerals (calcium, zinc, iron, vitamin b12) - Peristalsis decreases - Disorder/problem: decrease sensation on urge to defecate, constipation, fecal impaction - Interventions: dietary changes, possible laxative, schedule bowel routine - Calcification of pancreatic vessels - Disorder/problem: distention/dilation of pancreatic duct, inability to absorb fat solute vitamins (A, E, D, K), inability to digest and store fat, fatty stools, decrease lipase levels - Interventions: pancreatic enzymes, vitamin supplements - Decrease in number and size of hepatic cells - Disorder/problem: decrease ability to metabolize certain drugs, drugs can accumulate and lead to toxicity - Intervention: adjust medication dose - Decrease in aerobic and anaerobic flora in GI system - Problem: impact disease response, obesity, inflammatory disease - Intervention: prebiotic and probiotic Function of the stomach - Digestive organ - Endocrine organ - Reservoir Gastritis - Inflammation or break down of gastric mucosa (stomach lining) - Typically, not treated in hospital unless there is GI bleed or fluid/electrolyte imbalance - 2 types - Acute gastritis: sudden onset with short duration - Exposure of gastric mucosa to a local irritant - Causes: exposure to local irritant - H. pylori (contaminated food/water) - Changes to stomach and duodenum - Long term NSAID use - ETOH, caffeine, steroids, smoking - Stress - Reflux of bile salts (valves that keep the bile from back washing into your stomach and esophagus are not working properly) - Contaminated foods/water (Montezuma's revenge) - Check if they have traveled anywhere - Visual on colonoscopy: acute will have redness and irritation of gastric mucosa - Recognizing Cues - Epigastric pain (rapid onset) - Increase or decrease with eating - Hiccupping (several hours or several days) - N/V - Anorexia - Intolerance of spicy or fatty foods - Cramping - Dyspepsia - Hematemesis (vomiting blood/coffee grounds) or melena (bloody stool) - Resolution/healing of gastric mucosa during an acute attack can occur within a few days of onset - Chronic gastritis: often related to autoimmune disorder - Persistent inflammation extends deep into mucosa - Inflammation more widespread - Gastric walls thin and atrophy - Causes - Pernicious anemia - H. pylori - Age (declining stomach lining) - GERD - Visual appearance on colonoscopy: very dep erosions that are coving almost the entire gastric mucosa - Recognizing cues: - N/V - Epigastric discomfort after eating - Key difference between acute/chronic - Abdominal pain (deep, persistent and widespread) - Diagnosis of Gastritis - EGD with biopsy (gold standard of diagnosis) - NPO 6-8 hours prior to procedure - Outpatient basis but need driver due to IV sedation - May experience sore throat due to scope; lidocaine spray can be prescribed to less sore throat - Monitor for manifestations of perforation - Chest pain, abdominal pain, fever, nausea, vomiting, abdominal distention - Blood samples - Test for the presence or elevation of IgG and/or IgM (anti-H pylori antibodies) - Proteins produced by immune system in response to H. pylori infection - CBC to test for anemia - Less than 12 in females and less than 14 in males - Treatment of Gastritis - Hospital for treatment only if fluid and electrolyte problems or GI bleeding occurs - **Determine cause then treat the symptoms** - Fluid replacement (fluid and electrolyte imbalances)/blood transfusion (anemia) - Limit intake of foods that cause the irritation and flare up - Spicy food, alcohol, caffeine - Avoid drugs that can contribute to episodes of gastritis - Steroids and NSAIDs - Surgical treatment in rare cases - NPO, NGT - Medications - H2-receptor antagonist: decrease gastric acid secretions by blocking histamine receptors in parietal cells - Famotidine (can also be given IV to prevent surgical stress ulcers) - Given as single dose at bedtime - Bedtime administration suppresses nocturnal acid production in the stomach - Mucosal Barrier Fortifiers: protect stomach mucosa - Sucralfate (Carafate) - Give one hour before or two hours after meals, at bedtime - Food interferes with the drug's adherence to mucosa - Do not give within 30 minutes of giving antacid or other drugs - Antacids may interfere with effect - Bismuth subsalicylate - Refrain from taking aspirin since it is a salicylic acid and can lead to overdose - Antacids: increase the pH of gastric contents by deactivating pepsin - Magnesium Hydroxide with aluminum hydroxide - Give 2 hrs after meals and at bedtime for higher hydrogen ion load - Use liquid rather than tablets (more effective) - Do not give other drugs within 1-2 hours of antacids - Antacids interfere with other drug absorption - Assess patients for hx of CKD due to risk of hypermagnesemia and toxicity - Assess for hx of HF which decreases kidney ability to excrete - Monitor for diarrhea (s/s of hypermagnesemia) - Aluminum Hydroxide - Give 1 hr after meals and at bedtime for higher hydrogen ion load - Use liquid rather than tablets (more effective) - Do not give other drugs within 1-2 hours of antacids - Antacids interfere with absorption - Monitor for constipation - If constipation occurs, consider antacid containing magnesium (laxative effect) - Use for CKD patients since it does not contain magnesium - Proton pump inhibitor: suppress HK-ATPase enzyme system of gastric acid secretion to suppress acid - Omeprazole - Do not crush due to it being a capsule - Give 30 min before the main meals of day (proton pump activated by food presence) - Lansoprazole - Give 30 min before the main meals of day (proton pump activated by food presence) - Rabeprazole: promotes healing and symptom relief of duodenal ulcers - Take after morning meal - Do not crush capsule - Pantoprazole - Do not crush (enteric coated) - IV form must be given on pump with a filter and in a separate line (precipitates easily) - Do not give IV with other IV drugs - Monitor for adverse drug interactions if patient on other medications - IV form not compatible with most other drugs - Alter how other drugs are metabolized, either increasing or decreasing effectiveness - Esomeprazole - Assess for hepatic impairment (need lower dose) - Do not give Nexium IV with other IV drugs (not compatible) - Monitor for adverse drug interactions - Alter how other drugs are metabolized, either increasing or decreasing effectiveness - Antimicrobial: treat H. pylori infection - Metronidazole - Take with food (cause nausea) - Avoid alcohol during drug therapy and for at least 3 days after therapy is completed - Can cause severe dug-alcohol reaction (N/V, HA) - Clarithromycin - Give with caution to renal impaired patients and monitor BUN level - Amoxicillin - Take drug with food or immediately after - Can cause N/V/D - Tetracycline - Take drug 1 hr before meals or 2 hrs after meals - Dairy products and other foods may interfere with drug absorption - Avoid direct sunlight and wear sunscreen when outdoors (cause photosensitivity) - Prostaglandin Analogs: stimulate mucosal protection and decrease gastric acid secretions - Misoprostol - Used for clients receiving NSAIDs (protect stomach mucosa) - Avoid meagnesium0containg antacids (cause diarrhea) - Do not administer to pregnant women - Can cause abortion, premature birth, or birth defects Gastric Cancer - Adenocarcinoma that begins in the glands and cells of the stomach mucosa - Was once the 2^nd^ largest cancer in US but rates are declining - Usually asymptomatic in early stages ® advanced disease when detected - Highly curable for many if diagnosed early - 5-year survival rate of adults with stomach cancer in US Is poor due to lack of symptoms until disease advances - High chance of metastasis - Causes - Age (50+; increasing number of adults under 45 being diagnosed) - H. pylori infection, HPV, Streptococcus bovis - Chronic gastritis - **Gastric polyps** - Gastric surgery - Smoking - Heavy alcohol use - Obesity - Diet - Pickled foods - Low intake of fruits and vegetables - Highly smoked and salted foods - Processed foods - High fat (red meats) - Genetic link - 3-4 times the risk for those with first degree relative diagnosed with CRC - Recognizing cues - Early: most often ignored or change in diet or use of antacids relieves them; as tumor grows, these symptoms become more severe and do not respond to nutrition changes or drug therapy - Asymptomatic - Indigestion - Abdominal discomfort - Changes in bowel elimination habits - Advanced - N/V - Weakness - Fatigue - Anemia (iron deficiency, B12 of Folate deficiency) - Progressive, unintentional weight loss - Occult blood - Enlarged lymph nodes (supraclavicular chain, umbilicus) - Hepatomegaly (enlarged liver) - Diagnostic - EGD with biopsy - Endoscopic ultrasound - Preop: NPO 6-8 hours prior - Postop: sore throat (lidocaine spray can be prescribed), monitor for chest and abdominal pain, fever, N/V, abdominal distention, s/s of perforation - Adverse effects: - Perforation - S/S: bleeding, distention, sudden severe pain onset, chest pain - CT chest/abdomen/pelvis - MRI - POBT - CEA (carcinoembryonic antigen) - Elevated in people with CRC (normal: \