NCM 118 (Midterm-GIT) PDF

1 NCM 118 : MIDTERM (GI CONDITIONS) Lecture by: Cristine R. Al-Sundal, RN, MN Transes by: Dayang-Aiza A. Laja (BSN-4D) CARE OF CLIENTS WITH GI CONDITIONS GASTROINTESTINAL ASSESSEMENT (PHYSICAL ASSESSMENT) MOUTH  moist or dry  presence of gingivitis or inflammation...

1 NCM 118 : MIDTERM (GI CONDITIONS) Lecture by: Cristine R. Al-Sundal, RN, MN Transes by: Dayang-Aiza A. Laja (BSN-4D) CARE OF CLIENTS WITH GI CONDITIONS GASTROINTESTINAL ASSESSEMENT (PHYSICAL ASSESSMENT) MOUTH  moist or dry  presence of gingivitis or inflammation of tonsils  number of teeth (32)  presence of dentures,  (+) Gag reflex/ swallowing  taste sensation, odor, etc. ESOPHAGUS  sallowing difficulties  Gag reflex ABDOMEN  Inspection  Ausculation - it should precede percussion and palpation to not alter normal bowel sounds. Right lower quadrant should be auscultated first, just follow the anatomy of the colon (tract of the fecal matter).  Percussion - it is important to percuss to detect any presence of abnormality such as, if it is tympanic, it is filled with extra air. Patient’s abdomen could be distended because it is filled with flatulence or gases that are not supposed to be there.  Palpaption - the part where there is pain is the part to palpate last. Palpating the area where there is pain could bring discomfort to the patient because of the pressure exerted and the patient may not want you to touch the again. Ask which part of their abdomen is the pain located then palpate it last ANUS  Bleeding  hemorrhoids, fissures or cracks  abscesses, etc. ABDOMINAL REGIONS: ABDOMINAL EXAMINATION: (For PREGNANT CLIENT) The sequence to follow is: Inspection (note abnormalities, presence of linea negra, striae gravidarum, etc.) Palpation (Leopold’s maneuvers) Auscultation (fetal heart sounds) Avoid percussion LUMINARY 2025  2 ASSESSING BOWEL SOUNDS:  Place the diaphragm of the stethoscope lightly lover the right lower quadrant and listen for bowel sounds.  If there isn’t any, continue listening for 5 minutes within that quadrant. Then proceed to:  Right upper quadrant  Left upper quadrant  Left lower quadrant NORMAL BOWEL SOUNDS Clicks Gurgles Borborygmi BOWEL SOUNDS Normal - sound heard within 5-20 seconds in all four quadrants Hypoactive - 1 to 2 sounds in 2 minutes Hyperactive - 5-6 sounds in less than 30 seconds Absent - no sound heard in 3-5 minutes LABORATORY PROCEDURES FECALYSIS  Examination of stool consistency, color and the presence of occult blood.  Identify what is present physically in the stool (how is the status of the stool physically).  Special tests for fat, nitrogen, parasites, ova, pathogens and others. OCCULT BLOOD TESTING  Instruct the patient to adhere to a 3- day meatless diet.  No intake of NSAIDs, aspirin, and anticoagulant.  Screening test for colonic cancer. UPPER GI STUDY: BARIUM SWALLOW  Examines the upper GI tract  Barium sulfate is usually used as contrast  Pre-Test: NPO post-midnight, secure consent  Post-Test: Laxative is ordered, increase pt fluid intake, instruct that stools will turn white (the barium may cause changes in the stool), monitor for obstruction. LOWER GIT STUDY: BARIUM ENEMA  Examines the lower GI tract  Pre-Test: clear liquid diet and laxatives (evacuate the natural contents of the bowel), NPO post-midnight, cleansing enema prior to the test.  Post-Test: Laxative is ordered (to eliminate the barium), increase patient fluid intake, instruct that stools will turn white, monitor for obstruction. LUMINARY 2025  3 GASTRIC ANALYSIS  Aspiration of gastric juice to measure pH, appearance, volume, and contents.  Pre-test: NPO 8 hours, avoidance of stimulants, drugs, and smoking.  Post-test: avoid gas–forming foods and beverages ESOPHAGOGASTRODUODENOSCOPY (EGD)  Visualization of the upper GIT by endoscope  Pre-Test: Ensure consent; NPO 8hours, pre-medications like atropine and anxiolytics.  Intra-Test position: Left lateral to facilitate salivary drainage and easy access.  Post-Test: NPO until gag reflex returns; place patient in Sim’s position until he awakens; monitor for complications, saline gargles for mild oral discomfort COLONOSCOPY  Lower GI-Scopy  Use of endoscope to visualize the anus, rectum, sigmoid and colon.  Pre-Test: Consent; NPO 8 hours; cleansing enema until return is clear.  Intra-Test: position is LEFT lateral, right leg is bent and placed anteriorly  Post-Test: bed rest, monitor for complications like bleeding and perforation CHOLECYSTOGRAPHY  Examination of the gallbladder to detect stones, its ability to concetrate, store and release the bile.  Pre-Test: ensure consent; ask allergy to iodine, seafood and dyes; contrast medium is administered the night prior, NPO after contrast administration.  Post-Test: advice that dysuria is common as the dye is excreted in the urine; resume normal activities PARECENTESIS  Removal of peritoneal fluid for analysis or depression.  Pre-Test: ensure consent; instruct to void and empty bladder; measure abdominal girth  Intra-Test: upright on the edge of the bed, back supported and feet resting on a foot stool LIVER BIOPSY  Pre-Test: Consent; NPO, Check for the bleeding parameters (PT/PTT,etc)  Intra-Test: a semi fowler’s position left lateral to expose the right side abdomen  Post-Test : Position the patient on right lateral with pillow underneath, monitor VS and complications like bleeding, perforation.  Instruct to avoid lifting objects for 1 week ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)  Examines the gall bladder and the pancreas SPECIAL FEATURE:  NASOGASTRIC TUBES Purpose:  To feed the patient with fluid when oral intake is not possible.  To dilute and remove consumed poison  To instill ice cold solution to control gastric bleeding  To prevent stress on operated side by decompressing  To relieve vomiting and distension  To collect gastric juice for diagnostic purposes *GAVAGE = Feeding purposes *LAVAGE = “labas” to Wash out or flushing purposes Using X-ray: To confirm an NG tube is positioned safely, all of the following criteria should be met:  The chest X-ray viewing field should include the upper oesophagus and extend to below the diaphragm.  The NG tube should remain in the midline down to the level of the diaphragm  GASTROSTOMY TUBE  Gastrostomy - a procedure used to insert a tube, often referred to as a "G-tube", through the abdomen and into the stomach. LUMINARY 2025  4  CENTRAL LINES  For measurement of Central Venous Pressure  For administration of drugs, feeding, blood, etc.  For blood extraction  For medical tests *additional info (from prev discussion during NCM 112)  RECTAL ENEMA  Introducing liquid or gas into the rectum  to empty the bowels  Allow for an examination  Administer medication NOTE: an enema can be effective in treating certain medical conditions, but regular enema use can cause serious health problems. TYPES OF ENEMA 1. CLEANSING ENEMA  Water-based solution with a small concentration of stool softener, baking soda, or apple cider vinegar is used to stimulate the movement of the large intestine.  A cleansing enema should stimulate the bowels to quickly expel both the solution and any impacted fecal matte 2. RETENSION ENEMA  Is used to provide nourishment, medication, or anesthetic.  It should be made from fluids that will not stimulate peristalsis.  A small amount of solution (e.g., 100 to 250 mL) is typically used in adults 3. RETURN-FLOW ENEMA  or Harris flush  Is used to remove intestinal gas and stimulate peristalsis (used in distension). 1. A large volume fluid is used but the fluid is Instilled in 100-200 ml Increments. 2. The fluid is drawn out by lowering the container below the level of the bowel. LUMINARY 2025  5 3. Peristalsis is stimulated 4. The flatus is brought out with the fluid. 4. CARMINATIVE ENEMA  A small volume enema given to release flatus.  Traditionally the enema consisted of two ounces of glycerin,one ounce of magnesium sulfate (Epsom salts) and three ounces of water.  The combination of ingredients stimulate peristalsis resulting in a bowel movement in where feces and flatus are expelled 5. FLEET ENEMA (COMMERCIALLY PREPARED)  With steady pressure, gently insert enema tip into the rectum with a slight side-to-side movement, pointing the tip toward the navel.  Avoid forcing the enema tip into the rectum  Squeeze the bottle until the recommended amount of the drug is inside the rectum NOTE: Soap suds and saline used for cleansing enemas can cause irritation of the lining of the bowel, with repeated use or a solution that is too strong. Only white soap should be used; the bar should not have been previously used, to prevent infusing undesirable organisms into the individual receiving the enema. Common household detergents are considered too strong for the rectum and bowel. The commercially prepared soap is preferred, and should be used in concentration no greater than 5 cc soap to 1, 000 cc of water. COMMON GIT SYMPTOMS AND MANAGEMENT DUMPING SYNDROME  A condition emptying of contents into intestine usually of rapid the gastric the small after a gastric surgery  Symptoms occur 30 minutes after eating  Occurs as a complication of gastric surgery PATHOPHYSIOLOGY Foods high in CHO and electrolytes must be diluted in the jejunum before absorption takes place. The rapId influx of stomach contents will cause distention of the jejenum. Early Symptoms: 1. Nausea & vomitting 2. Abdominal fullness 3. Abdominal cramping 4. Palpitation 5. Diaphoresis The hypertonic food bolus Will draw fluid from the blood vessels to dilute the high concentrations of CHO and electrolytes in the food bolus Later, there is increased blood glucose (HYPERGLYCEMIA) Stimulating increased secretion of insulin HYPOGLYCEMIA Late symptoms: 6. Drowsiness 7. Weakness and Dizziness 8. Hypoglycemia MANAGEMENT: OCTREOTIDE (Sandostatin) - for severe cases  This drug changes how the digestive tract works, slowing down the emptying of the stomach into the intestine.  It also blocks the release of insulin. NURSING INTERVENTION: 1. LOW-carbohydrate 2. SMALL meals, frequent include MORE dry items. 3. Instruct to AVOID consuming FLUIDS with meals. LUMINARY 2025  6 4. Instruct to LIE DOWN after meals 5. Administer anti-spasmodic medications to delay gastric emptying PERNICIOUS ANEMIA  A condition in which the patient’s stomach gets damaged or is no longer functional.  Results from deficiency of vitamin B12 due to: 1. Autoimmune destruction of the parietal cells 2. Lack of Intrinsic Factor 3. Total destruction or removal of the stomach ASSESSMENT: 1. Severe Pallor 2. Fatigue 3. Weight Loss 4. Smooth Beefy-red tounge 5. Mild Jaundice 6. Paresthesia of extremities 7. Balance disturbances NURSING INTERVENTION: Lifetime injection of Vitamin B12 up to 12 x weekly initially, then monthly. MAJOR CONDITIONS AFFECTING THE GIT GASTRO - ESOPHAGEAL REFLUX DISEASE (GERD)  Backflow of gastric contents into the esophagus  Usually due to incompetent lower esophageal sphincter  Sometimes due to pyloric stenosis or motility disorder  Pain may mimic ANGINA or MI MANIFESTATION:  Regurgitation - nausea / vomiting  Heart burn - pain / discomfort  Dyspepsia - indigestion  Epigastric pain  Dysphagia - risk for aspiration  Ptyalism- hypersalivation DIAGNOSTIC TEST: 1. Endoscopy or barium swallow 2. Gastric ambulatory pH analysis -The machine registers the different pH of the refluxed material into the esophagus NURSING INTERVENTIONS: 1. Avoid any stimulus - that increases stomach pressure 2. Avoid spices, coffee, tobacco and carbonated drinks 3. LOW - FAT, HIGH - FIBER diet 4. No foods and drinks TWO (2) hours before bedtime 5. Elevate the head of the bed with an approximately 8 - inch block 6. Administer prescribed H2 - blockers, PPI and prokinetic meds like cisapride, metoclopramide 7. Advise proper weight reduction COMMON SURGERIES: FUNDOPLICATION (Gastric bonding) - the top part of your stomach called the fundus is folded and sewn around the lower esophageal sphincter  Nissen fundoplication - 360 degrees wrap  Hill's surgery - 180 degrees wrap  Betsey's repair - 280 ACUTE GI BLEEDING  Is a potentially life-threatening abdominal emergency that is characterized by bleeding in the Gatstrointestinal Tract  The most common cause is Peptic Ulcer Disease  PEPTIC ULCERATION - is a break in the continuity in the esophageal, gastric or duodenal mucosa. It may develop anywhere in the GIT that comes in contact with gastric juices. LUMINARY 2025  7  PUD occurs in approximately 10% of the population. Duodenal ulcers are more common in men during their 40-50s DUODENAL ULCER GASTRIC ULCER Pain occurs 90 min to 3 h after meals; wakes Commonly pain occurs within a short time of up patient midnight to 3 AM food intake Relieved by food, antacids, and H, blockers; is Commonly accompanied by nausea, vomiting not associated with vomiting (if atypical with food intake, and a variable response to features occur think of complications) medications *relieved by eating *Relieved by vomiting High gastric acid levels Low gastric acid levels H. pylori +++ H. pylori +++ Does not represent a malignancy Malignancy + Usually not accompanied by a high 25% of GUs will be accompanied by significant complication rate; when complications do bleeding: higher mortality and morbidity than occur it is usually pyloric stenosis or posterior DU penetration  ESOPHAGEAL VARICES - Dilation and turtuosity (twisted) of the submucosal veins in the distal esophagus  ETIOLOGY : commonly caused by Portal Hypertension secondary to liver cirrhosis  If bleeding, is an emergency condition! ACUTE GI BLEEDING ASSESSMENT FINDINGS  Tarry stool  Coffee-ground vomits  Dizziness  Hematemesis (vomit with blood)  Fatigue  Weakness  Adbominal cramps  Pallor  Melena  Shortness of breath Signs of Shock:  Tachycardia  Hypotension  Tacypnea  Cold clammy skin  Narrowed pulse pressure etc Video Capsule Endoscopy (VCE) A procedure where a small battery-powered capsule is swallowed. The capsule has a camera It allows examination of the internal position of the intestines. The capsule is removed by the doctor about 8 hours after it was swallowed The capsule should pass on its own within 5 to 7 days and may be safely flushed. X-ray can be confirm if it is still inside Clear fluids may be allowed after 2 hours and light meals after 4 hours unless otherwise ordered MANAGEMENT : PROBLEMS AFFECTING GIT 1. ACID SUPPRESSION  Patients admitted to the hospital with acute upper GI bleeding are typically treated with a proton pump inhibitor (PPI) or H2 blockers  IV PPI is usually given every 12 hours or starting a continuous infusion  Usual dosage is intravenous PPI 80mg bolus, followed by a continuous infusion of 8mg/hour for 72 hours 2. ENDOSCOPIC CLIPPING OR SEWING TECHNIQUES  Typically entails over sewing the bleeding vessel in the stomach or duodenum (usually preoperatively identified by endoscopy)  widely used for the treatment of no-variceal bleeding in the upper GIT  Clips are passed out with stools  Some clips are passed our 1-3weeks later 3. SENGSTAKEN - BLAKEMORE TUBE  A tube is inserted through the nose or mouth to control bleeding that is usually caused by esophageal varicosities  Usually remains in place for 24 hours LUMINARY 2025  8 NOTE:  It has 3 lumens i. One lumen to inflate gastric balloon ii. Second lumen to inflate esophageal balloon iii. Third lumen to aspirate gastric contents There is no esophageal suction port. This causes saliva to pool in the esophagus and this put patients at risk for aspiration. Gastric port – inflated initially with 50 ml (followed by x-ray) then add 200 ml more of air Esophageal port – using a manometer, inflate initially with 30 mmHg, if bleeding continues, inflate more until 45 mmHg in total Therefore, the gastric baloon is inflated first and placed on traction If bleeding is not controlled, the esophageal balloon is then inflated. Pressure in the balloon is released in 24 - 48 hours (ro prevent necrosis), during removal what was inflated first, will be deflated last NURSING MANAGEMENT: FOR BLEEDING 1. Maintain on NPO 2. Administer IVF and medications 3. Monitor hydration status, hematocrit and hemoglobin 4. Assist with saline lavage 5. Insert NGT fro decompression and lavage 6. Prepare to administer blood transfusion 7. Prepare to give VASOPRESSIN to induce vasoconstriction to reduce bleeding 8. Prepare patient for SURGERY if warranted  Total gastrectomy, vagotomy, gastric resection, bilroth I and II, pyloroplasty, antrectomy NURSING MANAGEMENT: AFTER SURGERY Post-operative: 1. Monitor VS 2. Post-op position : FOWLER’S 3. NPO until peristalsis returns 4. Monitor for bowel sounds 5. Monitor for complications of surgery 6. Monitor I & O, IVF 7. Maintain NGT 8. Diet progress: clear liquid > full liquid > six bland meal 9. Manage DUMPING SYNDROME As a SUMMARY: GASTRIC ULCER DUODENAL ULCER Oder Younger Normal acidity increased acidity Pain early after eating Pain late after eating (2-4hours) Worsens by food, relieved by vomiting Relieved by food Bleeding, weight loss and vomiting Less likely bleeding and vomiting (+) cancer (-) cancer MAJOR CONDITIONS AFFECTING THE LIVER What are the functions of the Liver?  or sphincter of ampulla, is a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the duodenum.  The sphincter of Oddi is relaxed by the hormone Cholecystokinin (CCK) via vasoactive intestinal polypeptide (VIP). LUMINARY 2025  9 COMMON MANIFESTATIONS OF LIVER DISEASES (GENERAL) 1. ELEVATED LIVER ENZYMES (LFT)  More than 70% of the parenchyma of the liver may be damaged before the LFT's become abnormal  Normal Values: AST (Aspartate aminotransferase) : 10 - 40 units ALT (Alanine aminotransferase) : 5 - 35 units GGT/ GGTP (y-glutamyl transpeptidase) : 10 - 40 IU/ L LDH : 100 - 200 units (for biliary cholestasis)  Other Studies (Normal Values) Total Serum Protein: 7. 0 - 7.5 g/dL Serum Albumin : 4. 0-5.5 g/dL Serum globulin : 1.7 - 3.3 g/dL Prothrombin time : 12 - 16 seconds (100%) Ammonia (plasma) : 15 - 45 g/dL 2. ASCITES  usually results from portal hypertension causing an increase in capillary pressure and obstruction of venous blood flow through the damaged liver. 3. JAUNDICE  a condition that develops when bilirubin concentration in the blood becomes elevated hence; all body tissues including the sclerae and the skin become tinged - yellow or greenish - yellow.  becomes clinically evident when serum bilirubin levels reach more than 2. 5 mg/dL. 3 TYPES OF JAUNDICE: Results from an increased destruction of RBC's, the effect of which is to flood the plasma with bilirubin so rapidly that the liver, Hemolytic although functioning normally, cannot excrete bilirubin as quickly Jaundice as it was formed. Common among those with hemolytic transfusion and other hemolytic disease. Results from inability of damaged liver cells to clear normal amounts of bilirubin from the blood. Hepatic damage may be caused by viral hepatitis infection, toxic medications, liver cirrhosis, alcoholism, etc. Hepatocellular Common hepatotoxic drugs: Jaundice  phenothiazines  antithyroid drugs  erythromycin  Amoxicillin  androgens, etc. Results from extra hepatic obstruction due to occlusion of the bile duct from gallstone, an inflammatory process, a tumor, or Obstructive pressure from an enlarged organ like the liver or the gallbladder Jaundice (during hepatomegaly or cholecystitis) LUMINARY 2025  10 FULMINANT HEPATIC FAILURE  Clinical syndrome of sudden and severely impaired liver function in a previously healthy person.  Failure develops within weeks  Common causes: Viral hepatitis, Toxic meds and chemicals, metabolic disturbances  First symptom: jaundice and progresses to encephalopathy 3 CATEGORIES OF LIVER FAILURE 1. HYPERACUTE - duration of jaundice before the onset of encephalopathy is 1 - 7 days 2. ACUTE - duration is 8 - 28 days 3. SUBACUTE - duration is 28 - 72 days CLINICAL MANIFESTATIONS:  Jaundice  Profound anorexia  Coagulation defects  Renal failure  Electrolyte imbalance  Infection  Hypoglycemia  Cerebral edema (encephalopathy) MANAGEMENT:  ELAD - Extracorporeal Liver Assist Device: this will assist patient until the liver transplant  BAL - Bioartificial Liver: are hybrid devices, removes toxic substances Intracranial monitoring and management  Barbiturates  Liver transplant LIVER TRANSPLANT COMPLICATIONS: 1. Bleeding - due to coagulopathy, portal hypertension and fibrinolysis 2. Infection - pulmonary and fungal infections common 3. Rejection - if the immune system perceives the transplanted liver as foreign antigen, T Lymphocytes are activated that attack the new liver. ACUTE PANCREATITIS PATHOPHYSIOLOGY:  Self-digestion of the pancreas by its own digestive enzymes principally TRYPSIN Spasm, edema or block in the Ampulla of Vater reflux of proteolytic enzymes auto digestion of the pancreas inflammation Inflammation, Hemorrhage, Necrosis ACTIVATION of KININ (induce vasodilation and contraction of smooth muscle) increased permeability (in portal vessels and pancreatic cells) Loss of Protein-rich fluid into the peritoneum HYPOVOLEMIA with ASCITES ASSESSMENT FINDINGS  Abdominal pain acute occurs after a heavy meal Worsens with alcohol intake  Abdominal guarding  Bruising – (+) Cullen’s sign  N/V, jaundice  Hypotension and hypovolemia  HYPERGLYCEMIA  HYPOCALCEMIA  Signs of shock LUMINARY 2025  11 DIAGNOSTIC TESTS: 1. Serum amylase and serum lipase – elevated 2. Ultrasound 3. WBC 4. Serum calcium 5. CT scan 6. Hemoglobin and hematocrit OVERALL MANAGEMENT:  NPO  NGT  TPN  IVF  Pain Management (Demerol) NURSING INTERVENTIONS: 1. Assist in pain management with Demerol, avoid Morphine 2. Restore volume 3. NPO to inhibit pancreatic stimulation 4. NGT for decompression and aspiration 5. Bed rest 6. Position patient in SEMI-FOWLER’s to decrease pressure on the diaphragm 7. Breathing and coughing exercises 8. Provide parenteral nutrition – when emesis is present 9. Introduce oral feedings gradually- HIGH carbo, LOW FAT 10. Maintain skin integrity 11. Treat shock and other complications LUMINARY 2025