NEW Acute GI UPPER (2).pdf

https://www.toonzone.net/best-episode-ever-toonzone-talks-joe/ ACUTE GASTROINTESTINAL CONDITIONS – UPPER GI HLTENN043 Implement and monitor care for a person with acute health conditions By the end of this lesson, students should be able to: Discuss indications and contraindications for insertion of a nasogastric tube (NGT) Discuss steps and rationales for NGT insertion Discuss management of patients with a NGT Discuss steps for NGT removal Discuss indications for and management of a Percutaneous Endoscopic Gastrostomy (PEG) device Acute Abdomen Acute abdomen – emergency conditions  Bowel obstruction  Appendicitis  Peritonitis  Pancreatitis  Strangulated hernias  Abdominal trauma  Wound dehiscence / evisceration 3 https://www.mja.com.au/podcast/207/11/mja-podcasts-2017-episode-71-fast-tracking-acute-abdomen-dr-katherine-broughton S&S ACUTE ABDOMEN  Severe abdominal pain, tenderness at the site, temperature, nausea and vomiting  Can be caused by infections, trauma, rupture  Treatment depends on the condition  Analgesia may be required depends on the condition 4 GASTROSOCPY  The examination of the upper GIT (oesophagus, stomach and duodenum)  Performed using a ‘twilight’ anaesthetic in day surgery  NBM @ 6 hours prior to procedure  Cease medications such as warfarin, NSAID, 2- days prior to reduce chance of bleeding 5 GASTROSOCPY Ulcer Cancer 6 Polyps HIATUS HERNIA  Condition where the lower portion of the stomach and the oesophagus move up the hiatus of the diaphragm into the chest.  Sliding hiatus hernia is most common  Most common in women and those older than 60 years  Can also occur in obese people and during pregnancy 7 NISSEN FUNDOPLICATION  also known as laparoscopic fundoplication, is a surgical procedure to treat gastrooesophageal reflux disease (GORD) and hiatal hernia. 8 MANAGEMENT  Small frequent meals  Remain sitting up for 1-hour after eating  Elevate head of bed 15-30 degrees  Avoid spicy foods, alcohol, caffeine, smoking and eating before bed  Surgery 9 CONDITIONS AFFECTING THE GALL BLADDER  Cholecystitis   inflammation of the gall bladder  Acute  Chronic Cholelithiasis  presence of stones in the gall bladder May result in gangrene and perforation if untreated  Choledocholithiasis  presence of stones in the bile duct 10 CHOLOELITHIASIS Aetiology  More common in fair, 40 year, overweight women  High cholesterol  Alcoholic cirrhosis S&S:  ? Asymptomatic  Severe, sudden RUQ or epigastric pain – usually following a fatty meal  N&V  Jaundice develops as bile backs up into the liver 11 CHOLELITHIASIS Management  Non-surgical - lithotripsy  Surgical - Cholecystectomy – laproscopic / open (higher risk of respiratory complications) http://www.laserstonesurgery.org/project/laparoscopic-cholecystectomy/ 12 CHOLECYSTECTOMY Post op care  Routine post anaesthetic observations  Wound – bleeding around insertion site  Pain assessment  IVT and FBC  N&V  Antibiotic therapy 13 CONDITIONS AFFECTING THE PANCREAS Acute Pancreatitis  Inflammation of the pancreas, may be acute or chronic resulting in autodigestion.  Acute: considered a medical emergency  S&S:  Severe pain  Shock  Abdominal distension  Treatment:  All oral intake is stopped  Analgesics and IV therapy  Mortality Rate – about 20% 14 ABDOMINAL TRAUMA  Penetrating or blunt force trauma  Causes?  The liver and spleen seem to be the most frequently injured organs  Management:  Splenectomy  ? Removal of part of the liver  ? Kidney removal  Colectomy 15 INTESTINAL OBSTRUCTION  large or small intestine  Mechanical  Adhesions, twisting of the bowel, strangulated hernia  Paralytic ileus https://www.stepwards.com/?page_id=3291  Peristalsis is impaired  after surgery, mesenteric ischaemia, trauma or infection 16 INTESTINAL OBSTRUCTION  Nursing Management:  Auscultate for bowel sounds (each quadrant)  Palpate for distension, firmness and tenderness (document and report)  Pain assessment – including characteristics of pain  NGT – to decompress and remove contents   Monitor amount, colour and characteristic of drainage Vital signs  Assess for infection or shock 17 WHAT IS AN ENTERAL TUBE?  Enteral tubes are inserted into the gastrointestinal tract for diagnostic and therapeutic purposes. 6/29/2021 INDICATIONS FOR INSERTION OF A NASOGASTRIC TUBE To administer hydration, nutrition and medication  i.e. for patients with swallowing difficulty – i.e. dysphagia Aspiration of gastric content  i.e to evaluate an upper gastrointestinal (GI) bleed or remove ingested toxic substances - eg. drug overdose 29/06/2021 INDICATIONS FOR INSERTION OF AN ENTERAL TUBE For bowel decompression i.e. maintenance of a decompressed state in patients with a paralytic ileus To perform gastric lavage i.e. prior to an endoscopy for a patient with a bleeding peptic ulcer http://alfa.saddleback.edu/N170/tubes.aspx Possible alternative: Orogastric tube http://www.impactednurse.com/?p=2235 CONTRAINDICATIONS FOR NGTS Severe mid-face trauma Recent nasal surgery Base of skull fracture Nasopharyngeal obstruction Deviated septum 29/06/2021 http://www.ispub.com/journal/the-internet-journal-of-anesthesiology/volume-30-number-2/technique-to-convert-an-orogastrictube-to-a-nasogastric-tube.html#sthash.Fw7oSkb8.dpbs SHORT-TERM NGTS PVC Single lumen – wider bore Various sizes – colour coded connector Varied lengths Left in situ for 24 hours - 7 days For enteral feeds and/or aspiration of gastric secretions Example: Ryles tubes, Levin tube 29/06/2021 http://purewondermed.com/ryle.html http://www.kendallpatientcare.com/Patientcare/pageBuilder.aspx?topicID=69726&breadcru 81040:0,69725:0 LONG-TERM NGTS  Polyurethane – very flexible  Radiopaque  +/- Stylet to guide insertion – removed after insertion  Can be left in situ 4 - 6 weeks  weighted polyurethane feeding tube  designed for nasogastric and nasoduodenal feeding http://www.kendallpatientcare.com/Patientcare/pageBuilder.aspx?topicID=72902&brea 81038:0,72587:0 SALEM SUMP NGTS  Dual lumen Smaller blue lumen:Vent attaches. Allows room air in, preventing distal end adhering to stomach. Larger clear lumen: Gastric suctioning, decompression, irrigation & delivery of medication Not for feeding 29/06/2021 http://www.phoenixmed2u.com/index.php?crn=302&rn=1508&action=show_detail http://www.jafarimedicalsupply.com/enteral-nutrition-feed.html http://www.kendallhealthcare.com/kendallhealthcare/pageBuilder.aspx?topicID=69667&breadcrumbs=0:121623,81040:0,69605:0 SAFETY MEASURE BEFORE NGT INSERTION  The length of the NGT is measured before insertion by: 1. Placing the distal end of the tube at the nose tip 2. Extend the tube to the ear lobe 3. Then extend towards the xyphoid process. NEX: Nose Earlobe Xyphoid 29/06/2021 MEASURING THE NGT BEFORE INSERTION: ‘NEX’ MEASUREMENT Xiphoid Process: 29/06/2021 http://www.yourgicenter.com/images/peptic_ulcer.jpg http://en.wikipedia.org/wiki/File:Xiphoid_process_animation.gif SAFETY MEASURES DURING NGT INSERTION  Patient positioning: Tilting the head in slight extension or forward can facilitate insertion of tube.  Unconscious patient  Left lateral position  Head turned to downward side  Gag and cough reflexes absent or suppressed  NG tube easily misplaced (lung)  Inability to swallow 29/06/2021 http://vimeo.com/10728253 SAFETY MEASURE AFTER NGT INSERTION Measurement of tube length after: Initial insertion Prior to feed or medication At least once per shift Radiological imaging i.e. chest X-ray is the gold standard for confirming NGT placement after insertion. SAFETY MEASURES AFTER NGT INSERTION Aspiration of gastric contents with pH testing as well as X-ray confirmation is more effective for determining tube placement (Hadwen 2010) Litmus paper not reliable 29/06/2021 http://www.studyblue.com/notes/note/n/ch-39-patient-with-hepatic-disorders/deck/3557376 WHEN TO RE-CONFIRM CORRECT TUBE POSITION  After episodes of vomiting or coughing Unexplained respiratory distress If excessive tube length noted externally (compared to length previously documented) If excessive salivation or gagging is noted 29/06/2021 REMOVAL OF A NGT 1. Check placement – pH 2. Flush the tube with 20mls of water so that gastric content does not drain back into the oesophagus 3. Insert a bolus of air to free tube from stomach lining 4. When withdrawing the tube, instruct patient to hold their breath to ensure that the glottis closes this prevents aspiration. 29/06/2021 PERCUTANEOUS ENDOSCOPIC GASTROSTOMY - PEG http://www.myprimeyears.com/hnc/feedingtube.shtml http://fatfrogess.blogspot.com.au/2008/01/gross-out-photos.html Gastrostomy is a surgical procedure for inserting a tube through the abdomen wall and into the stomach, used for feeding or drainage. PEG  Examples of gastrostomy tubes: Percutaneous Endoscopic Gastrostomy (PEG) Mickey button 29/06/2021 GASTROSTOMY TUBE PEG – Percutaneous endoscopic gastrostomy PEJ – Percutaneous endoscopic jejunostomy May be indicated for: Surgery to the upper digestive tract Obstruction to the upper digestive tract Long term treatment for feeding difficulties Tube is a hollow tube made of silicone, inserted through the abdomen into the stomach. 29/06/2021 29 June 2021 34 INDICATIONS FOR A PEG The need for long-term feeding, plus… Difficulties with oral intake - obstruction to the upper airway or gastrointestinal tract makes passing a NGT difficult. Oesophageal malfunction Patients at high-risk of aspiration Dysphagia Head and neck cancers Malabsorption diseases (Crohns_ 29/06/2021 NURSING CARE OF A GASTROSTOMY TUBE 1. Ensure stoma is cleaned daily +/- dressing 2. Determine tube position prior to feeding by: testing aspirate for pH 3. Ensure tube is flushed after feeding and administration of medication to avoid blockage. 4. Assess for complications – including tube dislodgement or leakage around stoma 29/06/2021 http://shrimplate.blogspot.com.au/2007_09_01_archive.html Minor complications include:  oozing from the wound  formation of granulation tissue  tube blockage  localised redness  bleeding or infection of the stoma http://www.articles.complexchild.com/feb2010/00182.html 29/06/2021 ALTERNATIVE METHODS OF NUTRITION Indicated when a client is unable to consume food or fluid orally. Methods include:  Total parenteral nutrition (TPN)  Intravenous therapy  Tube feeding http://pharmrx.yolasite.com/tpnspecial-edition.php 29 June 2021 29/06/2021 http://en.wikipedia.org/wiki/Intr avenous_therapy http://www.cartoonstock.com/direct ory/f/feeding_tube.asp 38 REASONS FOR ENTERAL FEEDING Malabsorption (inflammatory bowel disease) Surgery (oral or throat surgery) Central nervous system disorders (paraplegia, unconsciousness) Metabolic disorders (hypoglycaemia) Malnutrition (related to disease or surgery) Dysphagia Food refusal 29 June 2021 https://sydney.edu.au/science/molecular_bioscience/NUTR4001/enf/Nutrition_Support_Enteral_RNSH.pdf 39 PREPARED FEEDS ARE ADMINISTERED BY: https://www.youtube.com/watch?v=hAazHARwDLA BOLUS FEEDS - feed is administered at regular intervals - given to clients who are able to tolerate volumes at a rate they would normally drink orally 29 June 2021 40 https://sydney.edu.au/science/molecular_bioscience/NUTR4001/enf/Nutrition_Support_Enteral_ RNSH.pdf BY: CONTINUOUS OR INTERMITTENT FEEDS - gravity infusion set or mechanical pump is used to deliver the fluid at a regulated rate over time - given to clients unable to tolerate bolus feeds or overnight 29/06/2021 29 June 2021 https://sydney.edu.au/science/molecular_bioscience/NUTR4001/enf/Nutrition_Support_Enteral_ RNSH.pdf 41 Image from Creative Commons 29/06/2021 https://www.youtube.com/watch?v=v36FoLyiDpQ  Enteral feeding tubes should be flushed regularly with water (or sterile water if appropriate): Prior to and after feeding Prior to, in-between and after medications Regularly in between tube use  Between 5 – 20mls of water depending on the viscosity of the feed/medication & fluid status.  Feeds in the closed system bottle can hang (at room temperature) for 24 hours. https://sydney.edu.au/science/molecular_bioscience/NU TR4001/enf/Nutrition_Support_Enteral_RNSH.pdf 29/06/2021 https://www.leadingnutrition.com.au/artificial-feeding-and-aged-care/  Diarrhoea = from medications / osmolarity  Constipation = from medications / lack of fibre / water  Stomach Upset = from total volume / temperature of formula  Aspiration = from positioning / large gastric residuals / infusion rate / reflux SIDE EFFECTS 6/29/2021 MEDICATIONS VIA A FEEDING TUBE  Use liquid preparations whenever available.  Beware of crushing any medication with an enteric coating  Flush the feeding tube with water before and after each medication. 29/06/2021 FROM ALFRED HEALTH https://www.alfredhealth.org.au/contents/resources/clinicalresources/MedicationAdministrationAndDrugInteractions.pdf UNBLOCKING THE ENTERAL TUBE  If tube appears to be blocked use the smallest syringe available that fits onto tube, suck out as much of tube content as possible, using slow and gentle pressure, then fill the syringe with very warm water (tea/coffee temperature) and flush into the tube using moderate pressure.  NB Check facility policies & procedures  http://cedd.org.au/wordpress/wp-content/uploads/2015/04/Enteral-feeding.pdf http://www.shieldhealthcare.com/community/nutrition/2015/12/03/tube-feeding-how-to-unclog-yourfeeding-tube/ REINTRODUCING FLUIDS https://meded.ucsd.edu/clinicalmed/abdomen.htm Postoperative Ileus (POI) = temporary impairment of bowel motility after abdominal surgery. POI usually 48-72 hours post surgery Presents as intolerance of oral feeding, distended abdomen, absent bowel sounds, N&V, failure of passage of flatus &/or bowel movement. FESHARAKIZADEH, M. ET AL. (2013) POSTOPERATIVE ILEUS IN COLORECTAL SURGERY: IS THERE ANY DIFFERENCE BETWEEN LAPAROSCOPIC AND OPEN SURGERY? HTTPS://WWW.NCBI.NLM.NIH.GOV/PMC/ARTICLES/PMC3938009/ 48 REINTRODUCING FLUIDS UNTIL S&S of bowel motility return, patient NBM! Then slow introduction of … Water Clear fluids Light diet Full diet As tolerated 49 CENTRAL VENOUS ACCESS DEVICE AND TPN largeUsed fluidfor volumes patients needing: infusion of vein-irritating medications multiple infusions , infusion of fluids with a high osmolarity (TPN) long term therapy 29/06/2021 TOTAL PARENTERAL NUTRITION  Intravenous nutritional support  Supplies glucose, protein, vitamins, electrolytes, trace elements and sometimes fats  Maintains the body’s growth, development and tissue repair http://www.derby.ac.uk/images/dr_3005f3362df90854cefe213be0bcf0a6.jpg 29/06/2021 REFERENCES  Khair , J 2005, ‘Guidelines for testing the placing of nasogastric tubes’, Nursing times. Net, vol.101, no.20, p.26  Koutoukidis. G, Stainton. K, Hughson. J (2013) Tabbners Nursing Care;Theory and Practice 6th Ed; Elsevier  Lemone, P et al. 2011, Medical-Surgical Nursing: Critical Thinking in Client Care (First Australian Edition), Pearson Australia, Frenchs Forest.  Marieb. E, (2012) Essentials of Human Anatomy and Physiology; 10th Ed, Pearson Benjamin Cummings  Memmler’s The Human Body in Health & Disease; (2012) 10th Ed ;Lippincott Williams & Wilkins  https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Enteral_feeding_and_medication_administration/  https://www.crohnsandcolitis.com.au/about-crohns-colitis/ accessed 07/09/18 1401  Wimpenny, P & Royal District Nursing Society, 2011, Nasogastric/Nasoenteric Tube care and Management, accessed March 8th, 2013 from Joanna Briggs Institute http://connect.jbiconnectplus.org.ezproxy.holmesglen.vic.edu.au/ViewPdf.aspx?0=3520&1=2

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