Nursing Care 2 - Gastrointestinal Problems PDF

NURS20009 Nursing Care 2 Unit 2 Nursing Care of Clients Experiencing Gastrointestinal (Stomach and Intestines) Problems Unit 2 Topical Outcomes • Define Gastric and Duodenal Disorders, Intestinal and Rectal Disorders, Colorectal Cancer (Ileostomy and Colostomy Care), Gastrointestinal Disorders...

NURS20009 Nursing Care 2 Unit 2 Nursing Care of Clients Experiencing Gastrointestinal (Stomach and Intestines) Problems Unit 2 Topical Outcomes • Define Gastric and Duodenal Disorders, Intestinal and Rectal Disorders, Colorectal Cancer (Ileostomy and Colostomy Care), Gastrointestinal Disorders • Discuss Pathophysiology/ Causes • Examine Risk Factors • Identify Manifestations • Examine Diagnostic Tests • Explain Treatment • Discuss Nursing Interventions • Examine Complications • Discuss The Nursing Process • Apply learning to a Case Study and Critical Thinking Gastric and Duodenal Disorders Gastric and Duodenal Disorders Gastritis Peptic Ulcers Gastric Cancer Gastric and Duodenal Disorders Gastritis: • An inflammation of the lining of the stomach • May be acute(lasting several hours to few days) or chronic (prolong inflammation). • Pathophysiology: • Result of a breakdown in gastric mucosal barrier • Stomach tissue unprotected from autodigestion by HCl acid and pepsin • Tissue edema results. • Disruption of capillary walls – With loss of plasma into gastric lumen – Possible hemorrhage © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. Gastric and Duodenal Disorders • Gastritis: Risk Factors - Drugs: Aspirin, NSAIDs, digitalis & corticosteroids – Diet: Alcohol, spicy food – Microorganisms: Helicobacter pylori – cause of chronic gastritis & promotes breakdown of gastric mucosal barrier – Environmental factors: Radiation, smoking – Pathophysiological conditions • Burns, physiological stress, reflux of bile/pancreatic secretions – Other factors: Psychological stress, NG tube. Endoscopic procedures, autoimmune gastritis © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. Gastric and Duodenal Disorders Clinical Manifestation: • Acute Gastritis: Rapid onset of abdominal discomfort, nausea, anorexia, vomiting, feeling of fullness, possible hemorrhage • Symptoms can last from a few hours to a few days • Chronic Gastritis: anorexia, heartburn after eating, belching, a sour taste in the mouth, nausea & vomiting • Evidence of Vitamin B12 malabsorption Gastric and Duodenal Disorders Diagnostic tests: • Health history & physical exams; upper GI x-ray series, endoscopy, histologic exams of tissue specimen obtained by biopsy, serum H-Pylori test Treatment: • Acute gastritis: Refrain from alcohol & food until symptoms subside; Nonirritating diet; IV fluids if symptoms persist. NPO if vomiting. • Chronic gastritis: Modify diet; promoting rest; reducing stress; avoid alcohol & NSAIDs; medication(to treat H-Pylori) Gastric and Duodenal Disorders Peptic Ulcer: • May be referred to as duodenal, or esophageal ulcer depending on it location. • More likely to occur in the duodenum • They occur in multiples • Occurs frequently in people between Syears of age Gastric Cancer: Most gastric cancers are adenocarcinomas; they can occur anywhere in the stomach Types of Peptic Ulcer Disease © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 11 Gastric and Duodenal Disorders • Risk Factors – Peptic Ulcers - Bacteria (Helicobacter pylori), alcohol, drugs (NSAIDS) and toxins (smoking & tobacco), spicy foods, excessive secretion of HCL in stomach, stress, lifestyle factors, gastric ulcers, duodenal ulcers – Gastric Cancer - Exact cause unknown. Predisposing conditions are chronic gastric ulcers and gastritis Gastric and Duodenal Disorders • Pathophysiology – Lining of stomach and small intestines is protected against irritating acids produced in stomach – If the lining breaks down it results in inflammation or an ulcer – Perforation occurs if it affects the stomach or duodenum (medical emergency) Peptic Ulcers Perforated Peptic Ulcer Gastric and Duodenal Disorders • Manifestations – Peptic Ulcers and Gastric Cancer - Includes all symptoms below and burning pain (1-2 0r 2-4 hours after meals), fatty food intolerance, melena (dark, tarry stools), anemia, hematemesis – Nausea and vomiting, anorexia, epigastric tenderness, feeling of fullness, heartburn after eating, belching, cramping, diarrhea, abdominal discomfort, headache, hiccupping, Gastric and Duodenal Disorders • Diagnostic Tests – Patient history and physical exam – Lab studies (↓Hgb & serum gastrin level) – Stool culture (occult blood or h-pylori seen) – FOBT – H. pylori test – Barium swallow (esophagography) – EGD - Esophagogastroduodenoscopy (Endoscopy with biopsy) Peptic Ulcer & Gastric Cancer Endoscopy Gastric and Duodenal Disorders peptic ulcer Barium Studies Gastric and Duodenal Disorders • Treatment – Bed rest – NPO if nausea or vomiting is severe – Hydration with IV fluids – Drug therapy (antiemetic, antacids, H-Pac) – Progressive diet when acute symptoms subside (bland diet/ small frequent meals) – Elimination of smoking – Perforation - NG suction, IV fluids, antibiotics – Surgery - Removal of tumor, gastrectomy, radiation, chemotherapy Gastric and Duodenal Disorders Surgical Interventions Pyloroplasty and Vagotomy Partial Resection of the Stomach Gastrectomy) Quick Check 1 1. What are the nursing interventions appropriate for a patient with gastritis or peptic ulcers? 2. What is the postoperative care for a patient who has undergone subtotal gastrectomy? 3. What are the possible complications of peptic ulcer disease? Intestinal and Rectal Disorders Intestinal and Rectal Disorders Diverticulitis Irritable Bowel Disorder Bowel Obstruction Intestinal and Rectal Disorders • Inflammatory Bowel Disease (IBD): Refers to two chronic inflammatory GI disorders: Crohn’s disease & ulcerative colitis. Both disorders have similarities and several differences (See table on pg. 1155 in your text book). Intestinal and Rectal Disorders • Crohn’s disease: a subacute & chronic inflammation of the GI tract wall that extends through all layers(transmural). • Ulcerative Colitis: A recurrent ulcerative & inflammatory disease of the mucosal & submucosal layers of the colon & rectum IBD © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 26 Intestinal and Rectal Disorders • Irritable Bowel Syndrome(IBS)- Results from a functional disorder of intestinal motility. leads to abdominal pain and cramping and changes in bowel movements (diarrhea or constipation or both). IBS is not same as IBD • Diverticulitis - An inflammation of the diverticulum (an outpouching of the mucosa of the colon—large intestine) • Bowel Obstruction - Partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through Intestinal and Rectal Disorders • Causes/Risk Factors – Diverticulitis - Congenital weakness of the colon, colon distension, constipation and inadequate dietary fiber – Diverticulosis: Pouch in the colon/intestine – Irritable Bowel Disorder - Infection of the intestines – Bowel Obstruction - Tumor, paralytic ileus, volvulus (twisting of the bowel) Intestinal and Rectal Disorders • Manifestations – Abdominal cramps – Bloating or gas – Lower-quadrant tenderness – Altered bowel habit (constipation/diarrhea) – Nausea and vomiting – Occult bleeding – Fever Intestinal and Rectal Disorders • Diagnostic Tests – Patient history and physical exam – Lab studies (↑ WBC count, ↓ Hgb) – Stool culture (to detect any microorganisms) – FOBT-(for occult blood) – Barium studies – Sigmoidoscopy or Colonoscopy – Abdominal ultrasound, abdominal x-ray and CT scan (detect obstruction) Intestinal and Rectal Disorders Diverticulitis Diverticulitis Intestinal and Rectal Disorders Barium Study Intestinal Obstruction Intestinal and Rectal Disorders • Treatment – Rest in bed – Dietary changes - High residue diet, – IBD: Low-residue, high-protein, high-caloric diet with supplement vitamin & iron replacement – Drugs - Bulk laxatives, antibiotics, stool softeners, anticholinergics – NG tube (relieve abdominal distension and vomiting) – NPO and IV therapy (severe cases) – Surgery - Colon resection( total colectomy with ileostomy; proctocolectomy) for obstruction and hemorrhage Intestinal and Rectal Disorders • Gastrointestinal Intubation – Insertion of a flexible tube into the stomach beyond the pylorus into the duodenum or the jejunum. – The tube may be inserted through the mouth, the nose, or mouth. Intestinal and Rectal Disorders • Reasons for Intubations: – To decompress the stomach & remove gas & fluid – To lavage the stomach & remove ingested toxins; – To diagnose disorders of GI motility & other disorders – To administer medications & feedings – To treat an obstruction – To compress a bleeding site – To aspirate gastric contents for analysis Intestinal and Rectal Disorders • Nasogastric Tubes (NG tubes): – An NG tube is introduced through the nose into the stomach before or during surgery. – Primarily used in adults to remove fluid & gas (decompression) from the upper GI tract – Occasionally used for short-term (3-4 weeks) to administer medications or feedings. – Commonly used types: – Levin Tube – Gastric Sump Intestinal and Rectal Disorders • Enteric Tubes: – Used for feeding – Feeding tubes placed in the duodenum are 160cm long (called nasoduodenal tubes) – Feeding tubes placed in the jejunum are 175cm long – They are inserted before or during surgery by interventional radiologist assisted by fluoroscopy. – Placement is verified by x-ray study Intestinal and Rectal Disorders • Nursing Management of intubation: – Explain to pt. the purpose of the tube & procedure – Describe the sensations to be expected during tube insertion – Assisting with the insertion of the nasoenteric tube – Confirming the placement of the NG tube – Monitoring pt. & maintaining tube function – Providing oral & nasal hygiene and care – Monitoring for potential complications – Removing tube Intestinal and Rectal Disorders • Assessing Tube Feeding Regimens: – Assess tube placement, patient’s position (head of bed elevated 30-45 degrees), & formula flow rate – Determine patient’s ability to tolerate the formula (observe s&s for fullness, bloating, distention, urticarial, n&v, stool pattern & character – Observe for signs of dehydration, aspiration – Change tube feeding container & tubing q2472hrs – Monitor I&O, Weigh Pt. twice weekly, consult with dietician regularly Intestinal and Rectal Disorders Potential Complications of Chronic IBD: • Electrolyte imbalance • Cardiac dysrhythmias related to electrolyte imbalances • GI bleeding with fluid volume loss • Perforation of the bowel Nursing Interventions for Intestinal and Rectal Disorders – – – – – – – – – Maintaining normal elimination patterns Relieving pain Maintaining fluid intake Maintaining Optimal Nutrition Promoting Rest Reducing anxiety Enhancing coping measures Preventing skin breakdown. Monitoring & managing potential complications – Promoting Home and community-based care. Quick Check 2 1. What is the difference between diverticulosis and diverticulitis? 2. Do people with diverticulosis have symptoms? Colorectal Cancer Colorectal Cancer • Colorectal cancer starts in the large intestine or the rectum • Causes - Unknown. Most colorectal cancers begin as benign polyps which slowly develop into cancer • Higher risk - Older than 50 years, eat diet high in red or processed meats, have cancer elsewhere in the body, colorectal polyps, family history, low fiber diet, inflammatory intestinal conditions, smoking, alcohol, obesity Colorectal Cancer (Cont.) © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 45 Colorectal Cancer • Manifestations - Changes in bowel pattern, rectal bleeding, changes in shape of stool, weakness and fatigue, weight loss, rectal pain, abdominal pain, anemia • Diagnostic tests - Patient history and physical exam(abdominal & rectal), lab studies, fecal occult blood test(FOBT)barium studies, sigmoidoscopy or colonoscopy Colorectal Cancer • Treatment - Surgical resection of the affected area, creation of colostomy, chemotherapy or radiation therapy, supportive therapy Colorectal Cancer Possible surgical procedures: • Segmental resection with anastomosis(removal of the tumor & portion of the bowel on either side of the growth, plus blood vessels & lymphatic nodes • Abdominoperineal resection with permanent sigmoid colostomy(removal of the tumor & a portion of the sigmoid, all the rectum & anal sphincter • Temporary colostomy followed by segmental resection & anastomosis • Permanent colostomy or ileostomy: for palliation of unrespectable obstructing lesions Colorectal Cancer Surgical Resection of Colon Ostomy Surgery © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 50 Colorectal Cancer • Ileostomy and Colostomy Care – Remove the pouch – Gently clean the skin around stoma (mild soap and water; pat skin dry) – Use pouch with right size opening (pouch that has an opening that 1/8 of an inch larger than the stoma) – Use skin products to help reduce irritation – Use slight pressure to place pouch – Dispose of the used pouch correctly (double bag and throw it in the trash) Colorectal Cancer • Patient Teaching – Stoma and skin care, wound care – Appliances: Removing & applying the colostomy appliance; provide a list of the supplies needed – Irrigating the Colostomy- Occasionally irrigate stoma with water –Stoma therapist will advise – Supporting a Positive Body Image- Pt. is encouraged to verbalize feelings, support group, counseling – Discussing Sexuality Issues- encourage pt. to discuss feelings about sexuality & sexual functions, alternative sexual positions, alternative methods of stimulation to satisfy sexual drives, consult with sex counselor/therapist Colorectal Cancer • Patient Teaching – – – – Avoid tight clothing - Direct pressure over stoma Avoid foods that cause excess gas or odor Maintain fluid intake at least 2000 ml daily Avoid heavy lifting/strenuous activities for first 3 months – Monitoring and Managing Complications- Contact doctor/NP if : Skin breakdown, prolapse or obstruction Quick Check 3 1. List 2 nursing diagnoses and related nursing interventions for each nursing diagnoses for colorectal cancer. 2. Do patients become sexually dysfunctional (impotent) after a colostomy surgery? Give rational for your answer. Gastrointestinal Disorders Gastrointestinal Disorders • Rotavirus – Causes inflammation of the stomach and intestines, sometimes called gastroenteritis – Leading causes of severe diarrhea in infants and children - at least once by age 5 – Infects adults who are exposed to children with the virus, people in nursing homes • Transmission - (fecal-oral route) contact with contaminated hands, surfaces and objects, ingestion Gastrointestinal Disorders Manifestations Pathophysiology Gastrointestinal Disorders • Manifestations - Fever, vomiting (3-8 days), watery diarrhea (3-8 days), abdominal pain, dehydration • Diagnostic Tests - Stool & urine culture, blood test, look for signs of dehydration • Treatment - Replace fluid and electrolytes, encourage fluids, medications (anti-diarrheal), symptomatic relieve. Prevention (Frequent hand wash, vaccination for infants) Quick Check 4 1. What signs will indicate that a patient is dehydrated? 2. How would you advise a patient to prevent the recurrence of rotavirus infection? Gastrointestinal Disorders • Food Poisoning – Caused by ingesting contaminated food: bacteria, parasites, virus or toxins • Most common: – Clostridium botulinum (botulism) – improperly preserved home-processed or canned foods (causes paralysis and can be fatal) – E.coli – contaminated food and water – Salmonella - Contaminated food; undercooked meat, eggs Gastrointestinal Disorders Gastrointestinal Disorders • Manifestations - Nausea and vomiting, abdominal pain and cramping, diarrhea, fever – Botulism includes double and blurred vision, droopy eyelids, slurred speech, difficulty swallowing, dry mouth, muscle weakness • Diagnostic tests - Stool and blood culture, CBC, signs of dehydration • Treatment - IV fluids, oral fluids, medications (antiemetic, antidiarrheals, antitoxin - only for botulism) Quick Check 5 1. Which kind of food poisoning can cause paralysis and be fatal? 2. How would you advise a patient to prevent food poisoning? Gastrointestinal Disorders Case Study Case Study A 47-year-old man working as a truck driver has recently been diagnosed as having duodenal ulcers. He has a history of burning pain 2 to 3 hours after meals. The pain is located just beneath the xyphoid process and is relieved by antacid agents. Information Subjective Data • • • • • Symptoms include nausea and vomiting Stools have been darker than usual this week Health is good but is being treated for hypertension Rarely drinks alcoholic beverages but smokes 1½ packs of cigarettes daily Usually eats only 2 meals each day at irregular hours Objective Data • • • • • B/P 136/82 mm Hg; pulse 76 b/min; resp 16 b/min; oral temp 97.6°F (36.4°C) Weight 210 lb Alert and oriented Abdomen soft Bowel sounds present in all 4 quadrants Critical Thinking 1. What are the contributing factors to his duodenal ulcers? 2. Why might antibiotics be prescribed for the patient with peptic ulcer disease? 3. List 3 nursing diagnoses and appropriate nursing interventions based on the case study. References References Day, R.A., Paul, P., Williams, B., Smeltzer, S.C., Bare, B.. Brunner and Suddarth's Textbook of Canadian Medical-Surgical Nursing (Current Edition). Philadelphia: Lippincott Williams & Wilkins Kwong, J., Reinisch, C., Tyerman, J., Cobbett, S., Hagler, D., Harding, M., & Dott (2023). Lewis's Medical-Surgical Nursing in Canada (5th Edition). Elsevier Health Sciences (US). Lewis, S.L., Bucher, L., Heitkemper, M.M., Harding, M.M., Barry, M.A., Lok, J., Tyerman, J., Goldsworthy, S. (2019). Medical-Surgical Nursing in Canada (4th ed.). CA: Elsevier