Care Of The Gastrointestinal Patient PDF

CARE OF THE GASTROINTESTINAL PATIENT  TODAY’S LEARNING OBJECTIVES Briefly review GI anatomy and physiology Assess digestion and GI system Discuss treatment modalities of the GI patient Describe management of patients with: Oral/Esophageal, Gastric/Duode...

CARE OF THE GASTROINTESTINAL PATIENT  TODAY’S LEARNING OBJECTIVES Briefly review GI anatomy and physiology Assess digestion and GI system Discuss treatment modalities of the GI patient Describe management of patients with: Oral/Esophageal, Gastric/Duodenal, and Intestinal/Rectal disorders GASTROINTESTINAL ANATOMY AND PHYSIOLOGY GASTROINTESTINAL ANATOMY AND PHYSIOLOGY WALL OF THE GI TRACT  ASSESSMENT OF DIGESTION AND GASTROINTESTINAL FUNCTION FOCUSED GI ASSESSMENT-INTERVIEW Chief complaint Present health status Change in appetite, Weight gain/loss, Dysphagia, Food intolerance, N/V, Change in bowel patterns, Abdominal pain (PQRST or OLDCART), dyspepsia, jaundice Past health history Current lifestyle Psychosocial status Family health history FOCUSED GI ASSESSMENT-INTERVIEW FOCUSED GI PHYSICAL ASSESSMENT Oral assessment Lips, gums, mucosal membranes, teeth, tongue Abdominal assessment: Inspection Auscultation Percussion Palpation Rectal inspection and palpation ABDOMINAL INSPECTION Right upper Left upper quadrant quadrant Color, Bulges, Masses, Right lower Left lower quadrant quadrant Hernias, Ascites, Spider/Enlarged veins, Pulsations or movements, Inability to lie flat AUSCULTATION Auscultate before percussion or palpation to prevent production of false bowel sounds PERCUSSION Used to assess size and density of organs and detect air-filled, fluid-filled, or solid masses Tympany vs. Dullness PALPATION Light: tenderness, muscular resistance Deep: to identify masses Note any areas where pain is reported ASSESSING AND INTERPRETING LABORATORY VALUES DIAGNOSTIC STUDIES Stool tests Endoscopic Procedures Abdominal EGD ultrasonography Colonoscopy Genetic testing Imaging studies: CT, PET, MRI, virtual colonoscopy GASTROINTESTINAL TREATMENT MODALITIES GI TREATMENT MODALITIES GI intubation Feedings Enteral and parenteral Endoscopic procedures Endoscopy and colonoscopy Surgery Ostomies GASTROINTESTINAL INTUBATION GASTROINTESTINAL INTUBATION Insertion of plastic tube into the stomach, duodenum, or intestine Indications Decompress the stomachà remove gas and fluid Lavage the stomachà remove ingested toxins Administer tube feedings, fluids, medications Compress a bleeding site Aspirate gastric contents for analysis  GASTROINTESTINAL INTUBATION Types of tubes 1. Lavage tubes a. Levin: decompression ONLY (single lumen with internment suction that creates suction and then stops to prevent damage to the mucosa) b. Gastric (Salem) sump: decompression OR feeding (Radio opaque tube that’s seen on x-rays and has double lumen) and can be used for continuous suctioning 2. Enteric tubes: feeding ONLY a. Nasoduodenal, nasojejunal b. Dobbhoff terminates in the duodenum; Tiger tube (self advancing) and radio opaque (Seen on x-rays) and they are used for short term feedings terminates in jejunum. (celia flaps that provide self advancing over 4 hours) NASOGASTRIC TUBE NASOGASTRIC TUBE BEFORE AND AFTER PLACEMENT TIGER TUBE INSERTION AND ADVANCEMENT https://www.medicalexpo.com/prod/cook-medical/product-78422-480504.html PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBE JEJUNOSTOMY TUBE NURSING CARE: PATIENTS UNDERGOING NG OR NASOENTERIC INTUBATION Instruct patient about purpose of skin care (very important because it’s tube and the procedure a foreign object) Describe the sensations to be Monitoring, preventing, and managing expected potential complications Assisting with tube insertion Removing the tube Confirming placement of the tube Monitoring the patient and maintaining tube function Providing oral and nasal hygiene and  NG/NE INTUBATIONS: POTENTIAL PROBLEMS AND COMPLICATIONS Fluid volume deficit (if placed for Irritation of the mucous membranes decompression there's a loss of fluid) Nostrils, oral mucosa, esophagus, Dry skin and mucous membranes, trachea (skin surrounding tube decreased urinary output, lethargy, should be documented) and decreased body temperature Pulmonary complications Inability to clear secretions Impaired coughing/deep breathing Tube dislodged NURSING PROCESS: PEG/PEJ-ASSESSMENT Patient knowledge and ability to learn Self-care ability and support Skin condition Nutrition and fluid status Inspection of the tube (Migration, Flow of output for decompression or input for feeding, kinks and secure it to the gown and assess surrounding mucous membranes) NURSING PROCESS: PEG/PEJ-NURSING DIAGNOSIS Imbalanced nutrition Disturbed body image Risk of infection Risk for impaired skin integrity NURSING PROCESS: PLANNING/IMPLEMENTATION Meet nutritional needs Prevent infection: Hand hygiene, skin care (peri insertion), dressings, manipulation of stabilizing disk to prevent skin breakdown) Enhance body image Monitor for potential complications Nursing Process: Evaluation Document PEG/PEJ-COMPLICATIONS Wound infection, cellulitis, leakage GI bleeding Premature dislodgment of tube  ENTERAL AND PARENTERAL FEEDING CONDITIONS THAT MAY REQUIRE ENTERAL THERAPY  Tubes Nasogastric or nasoenteric tubes Gastrostomy or jejunostomy tubes for long-term feeding Methods TUBE FEEDING Intermittent bolus feedings (single ADMINISTRATION dose of preparation all at once) METHODS Gravity infusion Continuous infusion (infusion pump is more accurate for recording purposes) Cyclic feeding (for patients being weened) and are administered at certain hours. BOLUS FEEDING BY GRAVITY VS. CONTINUOUS FEEDING VIA PUMP MEDICATION ADMINISTRATION VIA FEEDING TUBE NURSING PROCESS ENTERAL FEEDING- ASSESSMENT Tube placement (Verify Placement) Patient’s ability to tolerate formula and amount (Intolerance: Distention, Vomiting, Diarrhea, Pain Passing Flatulence) Clinical response Signs of dehydration Elevated blood glucose level (Check formulation for diabetic patients) Check gastric residual I & O, weekly weights, dietician consult NURSING PROCESS ENTERAL FEEDING- NURSING DIAGNOSIS Imbalanced nutrition Disturbed body image Risk of infection Risk for impaired skin integrity NURSING PROCESS ENTERAL FEEDING- PLANNING/IMPLEMENTATION Maintain nutrition balance and tube function Prevent complications Maintain normal bowel elimination Patient education Reduce risk for aspiration Nursing Process: Evaluation Maintain hydration (Order for free Patient education, tolerance water bolus) Document Promote coping NURSING PROCESS NG/ENTERAL FEEDING- COMPLICATIONS Diarrhea Tube displacement Nausea and vomiting Gas, bloating, cramping (can Tube obstruction occur due to tolerance) Nasopharyngeal irritation Dumping syndrome (When Hyperglycemia gastric contents move too quickly out of the stomach and Dehydration and azotemia into the intestines and cause intense cramping) Aspiration pneumonia  MAINTAINING NUTRITION BALANCE AND TUBE FUNCTION Use a 30-mL or larger syringe Administer feeding at prescribed rate and method, according to patient tolerance Measure GRV before intermittent feedings; every 4-8 hours during continuous feedings Administer H2O before and after each medication and each feeding, before and after checking residual, every 4-6 hours, and whenever the tube feeding is discontinued or interrupted Do not mix medications with feedings Do not hang more than 4 hours of feeding in an open system (in an open system there's an increase risk for bacteria build up) MAINTAINING NORMAL BOWEL ELIMINATION Selection of TF formula; consider fiber, osmolality, and fluid content Prevent contamination of TF: maintain closed system; do not hang more than 4 hours TF in an open system Maintain proper nutritional intake Assess for reason for diarrhea and obtain treatment as needed Avoid cold TF (Can cause discomfort) & administer TF slowly to prevent dumping syndrome REDUCE RISK FOR ASPIRATION Elevate head of bed at least 30-45 degrees during and for at least one hour after feedings Monitor GRV Maintain hydration by supplying additional water and assessing for signs of dehydration Promote coping by support and encouragement; encourage self- care and activities Patient education  PARENTERAL FEEDING Method of providing nutrients to the body via an IV route Composition is modified daily based on patients nutritional requirements Contains (Proteins, Fats, Carbs, Vitamins, Minerals and Sterile Water) Lipids can be given to buffer the PPN to reduce risk of irritation and are also a source of fat for the patient Indications 10% deficit in bodyweight compared to pre-illness weight; disinterest or inability to ingest food orally or by tube; major infection, fever, trauma, burns, major surgery; prolonged pre or post operative nutritional needs IV access PPN (peripheral): given because solution is less hypertonic vs. TPN (Not nutritionally compete) (central) Dextrose over 10% should not be administered via peripheral vein because they irritate small veins causing phlebitis which is why TPN is not given peripherally because of the dextrose concentration Parental Nutrition is monitored and increased gradually Nursing interventions Maintaining optimal nutrition, preventing infection, encouraging activity when the patient is physically capable, and patient education, Monitor blood glucose (this is extremely important) regardless of diabetic history on parental nutrition. Monitor Labs such as CBC, Magnesium, Phosphates INDICATIONS FOR PARENTERAL NUTRITION (ADULTS USUALLY NEED 2L)  TPN VS. PPN If TPN runs out administer 10% dextrose to prevent hypoglycemia.You also want to ween patient off TPN to prevent rebound hypoglycemia. NURSING PROCESS PARENTERAL NUTRITION- ASSESSMENT Assist in identifying patients who are Electrolytes candidates for PN Caloric intake Nutrition status; decreased oral intake Review medications >1 week Weight loss 10% or more of usual weight Assess respiratory status Muscle wasting, decreased tissue healing Persistent N&V Hydration status NURSING PROCESS PARENTERAL NUTRITION- NURSING DIAGNOSIS Imbalanced nutrition Risk for infection Risk for imbalanced fluid volume Risk for activity intolerance NURSING PROCESS PARENTERAL NUTRITION- PLANNING/IMPLEMENTATION 1 OF 2 Review medications (To verify route) Prevent infection Assess respiratory status Hand hygiene De-clog tube per protocol Sterile technique for dressing changes Wear mask for changing the dressing Maintain optimal nutrition Assess insertion site Daily weight at same time of day Assess for indicators of infection Accurate I&O Proper IV and tubing care Caloric count Trace elements included in solution NURSING PROCESS PARENTERAL NUTRITION- PLANNING/IMPLEMENTATION 2 OF 2 Maintain fluid balance Patient education Use infusion pump. Flow rate should not Goals and purpose be increased or decreased rapidly. If fluid Potential complications and actions runs out, hang 10% dextrose solution Nursing Process: Evaluation Monitor indicators of fluid balance and Patient education electrolyte levels Improved nutritional status I&O, daily weights Monitor blood glucose levels Document NURSING PROCESS PARENTERAL NUTRITION- COMPLICATIONS Pneumothorax (Air Enters Pleural Cavity and occurs with central venous access) Air embolism (Occurs with central venous access) Clotted catheter or displaced catheter (Central Venous Access) Line sepsis Hyperglycemia Rebound hypoglycemia Fluid overload