Gastrointestinal System

• OVERVIEW OF ANATOMY AND PHYSIOLOGY

Gastrointestinal System

• Alimentary canal (GI tract)

• Length: 23-26 Ff

• Accessory digestive organs

Gastrointestinal (GI) System

• Muscular tube that extends from the mouth to the anus.

• Oral cavity (mouth).

• Throat (pharynx).

• Esophagus.

• Stomach.

• Small intestine,

• Large intestine.

• Rectum.

• Anus.
Gastrointestinal (GI) System

• Accessory organs of digestion:

• Liver.

• Gallbladder.

• Pancreas.
Gastrointestinal System

• Functions:

• Aids ingestion, mastication, and salivation of food

• Transports and digests food

• Absorbs nutrients

• Reabsorbs water from digested food

• Eliminates indigestible material in the rectum

Gastrointestinal System

• The accessory organs:

• The liver produces bile

• The gallbladder stores bile

• The pancreas produces digestive enzymes.

Oral Cavity
 Chewing:
 Tongue, teeth
 Salivary glands (Ptyalin, salivary amylase)

 Swallowing:
 Voluntary (Medulla oblongata)
 Epiglottis
 LES
Esophagus

• Transfer of food from mouth to stomach

• Epiglottis: blocks trachea

• LES/cardiac sphincter:
• Anterior to the spine, posterior to trachea

Layers:
Stomach

• Location: LUQ, under diaphragm

• Divisions:

• Sphincters: LES,PS

• Stores and mixes food

• Hormone: Gastrin (HCL)

• Gastric secretion

 pepsin, IF

 Mucus

Small Intestine Functions

• Secretions:

• Hormones:

• Cholecystokinin: GB (bile), pancreas (Enzymes: trypsin, amylase, lipase)

• Secretin: pancreas (Pancreatic juice- bicarbonate)

• Mucus, electrolytes

• Final breakdown of foods

• Absorption: Villi
Small Intestine Function
Large Intestines
Colonic Functions
• Ileocecal valve

• Secretions:

• Electrolytes, mucus

• Bacteria

• Slow peristaltic activity

Waste Products of Digestion

• Feces:

• undigested foodstuff, water, bacteria

• Color: bile

• Elimination: 12 hrs after

• Distention rectum

• Internal anal sphincter: involuntary (ANS)

• External anal sphincter: voluntary

Blood Supply

• Oxygen and nutrients: gastric artery and mesenteric arteries (intestines)

• The portal venous system:

• superior mesenteric, inferior mesenteric, gastric, splenic

Sympathetic Nervous System

• Fight-or-flight response

• Generally INHIBITORY!

• Decreased gastric secretions

• Decreased GIT motility

• Sphincters and blood vessels constrict

Parasympathetic Nevous System

• Generally EXCITATORY!

• Increased gastric secretions

• Increased gastric motility

• Sphincters relax

• ASSESSMENT
ASSESSMENT

• Health history

• Physical Assessment

• Laboratory/Diagnostic tests
Health History

• Anorexia: No desire to eat

• Dysphagia: difficulty swallowing

• Odynophagia: painful swallowing

• Nausea: sensation of needing to vomit

Health History:

• Regurgitation: spitting of stomach contents w/o forceful abdomen contractions

• Vomiting: forceful contraction of the stomach, propels abd contents out

Health History:

• Dyspepsia (indigestion),
• Heartburn (pyrosis)

• Pain: character, frequency, location, duration, aggravating factors

Referred Abdominal Pain Sites

Health History:

• Bowel habits:

• Constipation

• Diarrhea

• Bleeding

• Hematemesis, Melena, hematochezia

Health History

• Hematemesis: vomit of blood

• Bright red, Coffee ground

• Melena: tarry stools

• Esophagus, stomach, small intestine

• Hematochezia: bright red blood

• Large intestine

Constipation

• Infrequent,hard,dry, difficult to pass stool

• Causes:

• Laxative, advanced age, sedentary

• Inadequate fiber, fluid, immobilization

• Assessment:

• bloating, cramping, straining on defecation

Diarrhea

• Increased number of loose, liquid stools

• Causes:

• Gastroenteritis, IBD

• Antibiotics

• Assessment:

• Loose stools, cramping, Dehydration

Health History:

• Hepatic/Biliary problems:

• Jaundice

• Pruritus

• Urine color

• Clay-colored stools

• Physical Exam
Physical Exam:

• Mouth:

• Lips: color, moisture

• Buccal mucosa: color, lesions, ulcerations

• Teeth:

• Palates: color

Physical Exam:
 Abdomen
 Supine, knees flexed
 Inspection:
 Skin: color, scars, lesions
 Architecture:
 Movement:

Physical exam
 Auscultation: BS (RLQ)
 Normal: Q 5 – 20 sec
 Hypoactive: 1-2 sounds in 2 min
 Hyperactive: 5 – 6 in < than 30 sec
 Absent: No sound in 3- 5 min
 Percussion:
 Palpation: tenderness
 No palpation tumor: liver, kidney

LABORATORY
DIAGNOSTIC PROCEDURES
Stool Exams

• Collect in clean bedpan

• Use tongue depressor to transfer to container (walnut, 30 ml)

• Types of testing:
• For blood: occult (Guiaac, Hematest)

• C/S: sterile container

• Ova and parasite: warm (lab)

Stool Exams
Fecal Occult Blood Test (FOBT)

• NO red meat, raw, Vit C, iron, steroids, NSAIDS ( 3 d)

• Hematest: hematest tablet, 2-3 gtts water

GI Series

• X-rays in various positions after barium

• Barium or Gastrografin Swallow, Upper GI Series

• NPO 6-8 hrs, NO smoking

• No jewelry, metal before test

• Lower GI Series (Barium Enema)

• NPO 6-8 hrs, laxative, enema

GI Series

• Post-procedure:

• Increase fluids, enemas, laxatives

• Stool color

GI Series
Imaging Exams
Endoscopic Procedures

• Esophagogastroduodenoscopy (EGD)

• Sigmoidoscopy

• Colonoscopy
Endoscopy

• Scope procedure:

• Flexible tube into cavity or orifice

• Direct visualization, biopsy,surgery

Esophagogastroduodenoscopy (EGD)

• Nursing Interventions:

• NPO

• Remove dentures, eyeglasses, jewelry

• Anesthesia: topical, conscious sedation (IV)

• Position: sitting, supine, head elevated

Esophagogastroduodenoscopy (EGD)

• Post-Op:

• gargles, lozenges, gag reflex

• Monitor: bleeding, abd/chest pain, infection

Sigmoidoscopy, Colonoscopy

• Nursing Interventions:

• Clear liquid, NPO

• Bowel prep: dulcolax, Golytely

• Anesthesia: conscious

• Position: left side, knees to chest

Sigmoidoscopy, Colonoscopy

• Post-procedure:

• Monitor rectal bleed, inc fluids

• Increased flatulence
Colonoscopy, Sigmoidoscopy
Complications

• Hemorrhage

• Bleeding, cold clammy skin

• Hypotension, tachycardia, tachypnea

• Over-sedation

• Difficulty arousing, poor resp effort

• Maintain open airway, O2, antidote, VS

• Perforation:

• Chest or abd pain

• Fever, nausea, vomiting, abdominal distention

• Aspiration:

• NPO until return gag

• Dyspnea, tachypnea, tachycardia, fever

Endoscopy

• ANALYSIS
Nursing Diagnoses

• Risk for deficient fluid volume

• Imbalanced nutrition: less than body requirement

• Diarrhea

• Constipation
• Pain

• Impaired skin integrity

• INTERVENTIONS

• GASTROINTESTINAL FEEDING

• GASTROINTESTINAL INTUBATION (LAVAGE)

Tubes:

• Short-term: NGT

• Levin: single (low-intermittent)

• Salem-Sump: double (low continuous)

Tubes

• Long-term:

• PEG: Percutaneous endoscopic gastrostomy

• PEJ: Percutaneous endoscopic jejunostomy

Nasogastric Tube insertion

• High Fowler’s position

• Measure: Tip of nose→earlobe→sternum

• Lubricate:

• Hyperextend neck, tilt head forward (oropharnyx), sip water with a straw

• Stop: gag, withdraw slightly

Nasogastric tube insertion

• Tube placement:

• pH (≤ 4 - ≥ 6), 5-10 ml air, X-ray:

• Secure: bridge of nose, gown

Tube Feeding Administration

• Nsg considerations:

• Room temp, shake well, check expiry

• Flush:

• Assess BS

• Aspirate residual, return, hold >100

• Position: HF, right side (comatose)

• Patency: Q 4 hours: 30 mL of saline

 Frequent oral care, hard candy, ice chips
 Documentation: feeding, skin

Tube Feeding Administration

• Bolus

• Resembles normal meal pattern

• Large amt: 300-400 ml, 10 min, Q 3-6 h

• Cyclical (infusion pump)

• Administered day/nighttime for 8-16h

• Continuous (Infusion pump)

• Continually for 24 hrs, change cont daily

• Solution: 4hr-period, flush Q 4 hrs

Gastrointestinal intubation

• NGT, Intestinal tubes

• Insertion:

• Recording:

• Suction setting:

• Recording: color, consistency, amount

• Monitoring: skin breakdown

Nasoenteric (Intestinal) Tubes

• Intestinal Tubes: intestinal obstruction

• Cantor, Harris: Single lumen, tungsten

• Miller-Abbott: Double lumen:

Intestinal Tube

• Removal:

• Remove weight with 5 ml syringe

• Exhale: remove 1-2 in Q hour→ smooth pull

Total Parenteral Nutrition

• Nutrients are infused into a vein

• Total Parenteral Nutrition (TPN):

• Hypertonic glucose 20 – 70%

• Peripheral Vein Parenteral Nutrition (PPN)

• Glucose < 20%

Central Venous Access

• Tunneled caths (Hickman/Groshong cath):

• PICC: antecubital fossa to SVC

• Porta Caths: injection port

Complications

• Phlebitis/Thrombophlebitis:

• Mechanical or chemical trauma

• Assessment:

• Redness, pain, warmth, swelling

• Interventions:

• Stop IV, warm moist compress

• Change IV site (Q 48 – 72 hrs)

• Never irrigate
Complications

• Air Embolism: 5 ml or more

• Dyspnea, cyanosis, tachycardia, hypotension

• Interventions:

• Prevention: Prime, do not allow to dry

• Stop, Left side with head down

• O2, Call MD

Complications

• Circulatory Overload (Hypervolemia)

• SOB, frothy sputum, cough, crackles, engorged neck veins, inc BP

• Interventions:

• Slow, elevate HOB

• VS, Call MD

• PHARMACOLOGY
Antacid

• Neutralize gastric acid secretions; nonsystemic

• Aluminum Hydroxide (Amphogel)

• Aluminum Hydroxide and Magnesium salt (Maalox, Gaviscon)

• Sodium Bicarbonate (Rolaids, Tums)

• Nsg Interventions:

• Avoid within 1-2 hrs of other meds

Histamine (H2) Receptor Antagonists
• Reduce gastric acid secretion

• Cimetidine (Tagamet),

• Ranitidine (Zantac)

• Nizatidine (Axid), Famotidine (Pepcid)

• Nsg Interventions:

• Take with or after meals

• Do not take with antacids

Proton Pump Inhibitors (PPI)

• Inhibit enzyme that produces gastric acid

• Omeprazole (Prilosec)

• Lansoprazole (Prevacid)

• Nsg Interventions:

• Before meals

• Do not crush, do not open

Cytoprotective Agent

• Provides protective barrier to acid

• Sucralfate (Carafate)

• Nsg Interventions:

• Avoid antacids
Prostaglandin Analogue

• Suppress gastric acid secretion

• Increases protective mucus and mucosal blood flow

• Misoprostol (Cytotec)
• Nsg Interventions:

• Contraindicated in pregnancy
Cholinergic Blocker (Antispasmodic)

• Inhibit GI motility and gastric secretions

• Dicyclomine hydrochloride (Bentyl)

• Hyoscyamine (Levsin)

• Propantheline (Pro-Banthine)

• Nsg Interventions:

• Do not administer with antacid

• Use in caution with glaucoma

Intestinal Antibiotics

• Decrease bacteria (GIT), sterilize bowel before surgery

• Kanamycin Sulfate (Kantrex)

• Neomycin Sulfate (Mycifradin Sulfate)

• Gastrointestinal Disorders
Location of GI diseases
Stomatitis
Stomatitis

• Inflammation of mouth mucous membrane

Stomatitis

• Causes:

• Trauma to mucous membranes

• Irritation

• Vitamin C deficiency (scurvy):

• Fungal infection: Candida albicans (Candidiasis)

Stomatitis

• Causes:

• Herpes simplex: Cold sore

• HIV and AIDS:

• Gonorrhea:

• Measles

• Leukemia:

Stomatitis

• Assessment:

• Pain

• Ulcerations

• Swollen lymph nodes

Stomatitis

• Dx Tests:

• CBC

• Culture of scraping
Stomatitis

• Nursing Interventions:

• Good oral hygiene

• Avoid Irritating foods and beverages, spicy foods, Hot foods and drinks

• Cool liquids, easily be swallowed

• Topical anesthetics: Benzocaine anesthetics (Anbesol), 2% viscous lidocaine mouthwash
Stomatitis

• Nursing Interventions:

• Acyclovir: herpes simplex

• Tetracycline, corticosteroid:

• Nystatin oral suspension (Swish and swallow): fungal infections

Achalasia

• Ineffective or absent peristalsis of the distal esophagus

• Lack of sphincter relaxation during swallowing

• Cause:

• Denervation of muscle layers of esophagus

Achalasia

• Assessment:

• Difficulty swallowing

• Feeling of food sticking in LE

• Chest pain

• Weight loss

• Regurgitation of undigested food (non acidic)

• Halitosis

Achalasia

• Diagnostic tests:

• Barium swallow

• Esophagoscopy
• Biopsy

Achalasia

• Nursing Interventions:

• Eat slowly and chew food completely

• Warm foods and drinks

• Drink fluids with meals

• Elevate HOB: 6-12 in

• Medications:

– Nitrates

– CCB: Nifedipine (Procardia)

Achalasia

• Nursing Interventions:

• Balloon dilation

• Botulinum toxin (Botox) injection

• Esophagomyotomy)

Gastroesophageal Reflux Disease (GERD)

• Reflux of gastric contents into the esophagus.

Gastroesophageal Reflux Disease (GERD)

• Causes:

• Insufficient closure of lower esophageal sphincter (LES)

• Gastric distention

• Hiatal Hernia

• Lifestyle
• Medications: NSAIDs, nitrates, CCB
Gastroesophageal Reflux Disease (GERD)

• Assessment:

• Dyspepsia (heartburn)

• Regurgitation (bitter or sour tasting)

• Hypersalivation

• Nausea

• Pain: 30 min after meal

• Hoarseness, sore throat

• Dysphagia, odynophagia

• Coughing

Gastroesophageal Reflux Disease (GERD)

• Dx Tests:

• Barium swallow

• Endoscopy

Gastroesophageal Reflux Disease (GERD)

• Nursing Interventions:

• Losing weight if obese.

• Low-fat, high-protein diet

• Avoid chocolate, fatty, carbonated, spicy, high-acid foods

• Small frequent meals (4 to 6 a day)

• Increase fluids
Gastroesophageal Reflux Disease (GERD)

• Nursing Interventions:
• Avoid meals (3 h) before bedtime

• Discontinuing of NSAIDs, as ordered

• Elevating HOB (6-12 in)

• Stop smoking

• Avoid constrictive clothing

Gastroesophageal Reflux Disease (GERD)

• Medications:

• PPI:

• Omeprazole (Prilosec), Lansoprazole (Prevacid), Esomeprazole (Nexium), Pantoprazole

(Protonix)

• H2 blocker:

• Nizatidine (Axid), ranitidine (Zantac)

• Famotidine (Pepcid)
Gastroesophageal Reflux Disease (GERD)

• Antacid:

• Aluminum magnesium combinations (Mylanta,Maalox)

• Mucosal barrier fortifiers:

• Sucralfate (Carafate)

• Laparoscopic Nissen fundoplication (LNF)

GERD

• Therapeutic Procedures:

• Surgery (Fundoplication): laparoscopy

• In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around

the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower
esophageal sphincter:

• Whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach
acids into it.

• This prevents the reflux of gastric acid (in GERD).

• The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal
hernia, in which the fundus slides up through the enlarged esophageal hiatus of the diaphragm.

• In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped all the
way 360 degrees around the esophagus. In contrast, surgery for achalasia is generally accompanied by
either a Dor or Toupet partial fundoplication, which is less likely than a Nissen wrap to aggravate
thedysphagia that characterizes achalasia. In a Dor (anterior) fundoplication, the fundus is laid over the
top of the esophagus; while in a Toupet (posterior) fundoplication, the fundus is wrapped around the back
of the esophagus.

• The procedure is now routinely performed laparoscopically. When used to alleviate

gastroesophageal reflux symptoms in patients with delayed gastric emptying, it is frequently combined
with modification of the pylorus via pyloromyotomy or pyloroplasty.

Hiatal Hernia

• Part of the stomach protrudes through the esophageal hiatus

• Types:

• Sliding: portion of stomach slip into thoracic cavity

• Paraesophageal: fundus rolls out of stomach and forms a pocket

Hiatal Hernia

• Causes:

• Malformation

• Muscle weakness of esophageal hiatus

• Esophageal shortening

• Obesity
Hiatal Hernia

• Assessment:

• Feeling of fullness, suffocation after meal

• Anemia
Hiatal Hernia

• Dx Tests:

• Fluoroscopy.

• X-ray studies
Hiatal Hernia

• Nursing Interventions:

• Dietary and Medical Mx (GERD)

• AVOID: HIATAL

• Hot and spicy, Ingestion of large meals, Apparel that constrictive, Twisting/bending/lifting,
Alcohol, Limit carbonated beverages

• Monitor for strangulation

• Laparoscopic Nissen fundoplication

Gastritis

• Inflammation of the stomach lining

• Acute (few days)

• Chronic.

Gastritis

• Causes:

• Infection

• Irritation from medications, alcohol, foods, corrosive substances

• Stress
• Radiation

• Gastrectomy
Gastritis

• Assessment:

• Pain or discomfort

• Dyspepsia (heartburn)

• Gnawing or burning aches in upper abdomen

• Nausea and vomiting

Gastritis

• Assessment:

• Loss of appetite (anorexia)

• Bloating, belching

• Weight loss

• Bleeding: hematemesis, melena→anemia

Gastritis

• Dx tests:

• EGD

• Blood tests

• Urea breath

• Stool tests
Gastritis

• Nursing Interventions:

• Proton-pump inhibitors

• H2-receptor blockers

• Antacids
• Mucosal barrier fortifiers

• Lifestyle changes

• Avoid aspirin and NSAIDs

Gastritis

• Nursing Interventions:

• H. pylori: 2-week course

• Bismuth subsalicylate (Pepto-Bismol) or

• PPI and metronidazole (Flagyl) and tetracycline (Achromycin) or

• Clarithromycin (Biaxin) and amoxicillin (Amoxil).

Gastroenteritis (Stomach Flu)

• Inflammation of the GI tract.

• Causes:

• Parasitic organisms (Entamoeba histolytica and Cryptosporidium and Giardia species)

• Bacterial organisms (Escherichia coli, Vibrio cholerae, and Campylobacter, Salmonella, and
Shigella species)
Gastroenteritis (Stomach Flu)

• Causes:

• Viral organisms (astroviruses, Norwalk virus, rotaviruses)

• Chemical toxins (lead, arsenic, mercury, poisonous mushroom, seafood, water)

Gastroenteritis (Stomach Flu)

• Assessment:

• Diarrhea

• Abdominal cramps
• Nausea and vomiting

• Loss of appetite

• Fever and chills

• Dehydration

• Weakness, fatigue
Gastroenteritis (Stomach Flu)

• Dx Tests:

• Stool culture

• Blood tests

• Potassium, sodium, and other electrolyte levels.

Gastroenteritis (Stomach Flu)

• Nursing Inteventions:

• Avoid carbonated, caffeinated, and high-sugar drinks, spicy, dairy

• Clear liquids with electrolytes (Pedialyte, Resol)

• IV fluid with potassium

• bland foods (cream soups, crackers, toast, rice, yogurt, custards)

Gastroenteritis (Stomach Flu)

• Nursing interventions:

• Antibiotics: if bacteria.

• Antiparasitics

• Antidiarrheals (avoided)

• Perineal irritation: cleansing, pat dry, barrier creams, witch hazel (Tucks)

Helicobacter pylori (HP)

• Gram-negative
 Causes ulcers and chronic gastritis

• Dx tests:

• Cultures from ulcer craters.

• Blood test or breath test

H. Pylori

• Nursing Interventions:

• Clarithromycin, amoxicillin, tetracycline, or metronidazole (Flagyl)

• Combined with PPI

Peptic Ulcer Disease
Peptic Ulcer Disease (PUD)

• Erosion of the lining of the stomach, pylorus, duodenum, or esophagus

Peptic Ulcer Disease (PUD)

• Causes:

• H. Pylori

• Medications:

• Aspirin, NSAIDs

• Theophylline, caffeine, Prednisone

• Smoking

• Stress
Peptic Ulcer Disease

• Assessment:

• Pain: burning, gnawing

• Gastric: 1-2 hrs; left epigastric area

• Duodenal: 2-4 hrs or at night, food relief, right epigastric area

• Weight loss, weight gain
Peptic Ulcer Disease

• Dx tests:

• Urea breath test

• Serum IgG antibody screening

• Upper GI (barium swallow)

• EGD

• Stool for occult blood

Peptic Ulcer Disease
Nursing Interventions:

• A bland diet, no spicy, high-acid food

• Lifestyle changes

• Avoid alcohol, and smoking

• Meditation.

• Herbs and vitamins

• No bedtime snacks

• No NSAIDs, aspirin
Peptic Ulcer Disease

• Nursing Interventions:

• PPI, H2 block, antacids

• Mucosal barrier fortifiers

• Helicobacter pylori therapy

Peptic Ulcer Disease

• Complications:

• Bleeding
• Interventions:

• NPO, IV, saline lavage

• Endoscopy, Surgery

• H2 blockers, PPI
Peptic Ulcer Disease (PUD)

• Complications:

• Perforation

• Interventions:

• Fluids, electrolytes IV

• NG suction

• IV antibiotics

• Surgery

Gastric Surgery

• Gastrectomy

• Partial gastrectomy

• Gastroduodenostomy (Billroth 1)

• Gastrojejunostomy (Billroth 11)

• Vagotomy: cut vagus nerve

• Pyloroplasty
Gastric Surgery

• Nsg Interventions:

• Semi-Fowler’s,

• NPO: 3 days, IV fluids: no peristalsis

• NGT: Do not irrigate,

• Bright red (24 h),yellow-green (36-48 h)

• Monitor dressing: bleed, infection

• Turn, cough, deep breath

Gastric Surgery Complications

• Pernicious anemia

• Pallor, glossitis (sore tongue), fatigue, paresthesias

• Lifelong B12 inj (Once a month)

Dumping Syndrome

• Occurs when large bolus of chyme enter the intestine

Dumping Syndrome

• Dizziness

• Diaphoresis

• Diarrhea

• Tachycardia

• Lie down after meal

• Small frequent meals

• high protein, high fat, avoid simple carbohydrates (juice, honey, syrup, jelly)

• NO fluid with meal and for 1 hr prior and after meal

• Med: Bentyl (antispasmodic)

Hernias

• Abnormal protrusion of a loop of bowel through the thin muscular wall of the abdomen.
Hernias

• Classifications:

• Reducible

• Irreducible (incarcerated)

• Strangulated

Hernias

• Hernia type:

• Inguinal : direct, indirect

• Femoral

• Umbilical

• Incisional (ventral)
Hernias

• Causes

• Congenital

• Increased abdominal pressure

• Abdominal surgery

• Assessment:

• Bulging in abdominal

• Pain
Hernias

• Nursing Interventions:
• Avoid lifting, constipation

• Deep-breathing

• Stop smoking

• S/S strangulation.

• Truss (elastic belt)

• Herniorrhaphy, Hernioplasty

• Post-op: Urinary retention

Hernias

• Complications:

• Incarceration

• Gangrene
Appendicitis
Appendicitis
Appendicitis

• Acute inflammation of the appendix

• Cause:

• Obstruction

Appendicitis

• Assessment:

• Pain:

• Peri-umbilical→Mc Burney’s

• Rebound tenderness

• Abdominal rigidity

• Nausea and vomiting

• Loss of appetite
Appendicitis

• Dx tests:

• CBC: WBC > 10,000/mL

• CT scan

• Urinalysis
Appendicitis

• Nursing Interventions:

• NPO, IV fluids

• Pain: avoid heat

• Elevate HOB: perforation

• Appendectomy

• Avoid laxative, enema

• Antibiotics: post-surgery
Appendicitis
Peritonitis

• Acute inflammatory disorder of the peritoneum

• Causes:

• Rupture of organs.

• Infection

• Wound

Peritonitis

• Assessment:

• Pain

• Generalized, rebound tenderness

• Abdominal rigidity

• Dec peristalsis, BS

• N/V

• F/E imbalances, dec urine

• Increased pulse

Peritonitis

• Nursing Interventions:

• NPO, F/E

• Nasogastric tube

• O2, Semi-fowler’s

• Pain management

• Antibiotics

• Surgery, Temporary colostomy

Types of Ostomy

• Colostomy: colon through abd wall

• Semi-soft stool

• Ileostomy: ileum through abd wall

• Kock’s ileostomy: continent ileostomy; internal reservoir

Ostomy Care:

• Nursing Interventions:

• Low-residue diet

• Select appropriate sized appliance

• Keep skin around stoma clean, dry and free of intestinal juices
Colostomy
Crohn’s disease

• Chronic inflammatory bowel disease (IBD)

• Causes:

• Smoking

• Genetic predisposition

Crohn’s Disease

• Assessment:

• Pain: crampy, abd pain (RLQ)

• Chronic diarrhea

• Weight loss, malnutrition

• Elevated temperature

• Fluid and electrolyte imbalances

Crohn’s Disease

• Dx tests:

• Upper GI Series, barium enema

• Colonoscopy
Crohn’s disease

• Nursing Interventions:

• NPO, TPN

• I and O, weight

• Low-fiber, low-fat diet, high calories, protein; supplements

• Corticosteroids, sulfasalazine, Antidiarrheal, antibiotics, opiod

• Surgery
Ulcerative Colitis

• Chronic inflammatory bowel disease that affects large intestine

• Rectum→cecum

• Causes:

• Autoimmunity

• Genetic predisposition
Ulcerative Colitis:

• Assessment:

• Pain: crampy, LLQ

• Diarrhea: 20 times

• Rectal bleed

• Anorexia, weight loss

Ulcerative Colitis

• Dx tests:

• Sigmoidoscopy or colonoscopy

• Barium enema

• Stool sample: infectious

Ulcerative Colitis

• Nursing Interventions:

• NPO or clear liquids; TPN

• Avoid high-bulk foods, milk products, alcohol, caffeinated

• Bed rest.

• Sulfasalazine

Ulcerative Colitis

• Surgery:
• 1. Removing the colon, rectum, and anus and placing an ileostomy

• 2. Removing the colon, rectum, and anus and forming a pouch

• 3. Removing the colon and rectum, suturing the ileum to the anal canal and a temporary
ileostomy
Diverticulitis

• Acute inflammatory bowel disease characterized by inflammation of diverticula in the bowel

mucosa.

• Causes:

• Low fiber diet

• Decreased colon motility

Diverticulitis

• Assessment:

• Pain: LLQ

• Fever

• Weakness and fatigue

• Constipation alternating diarrhea

• Anemia

• Rectal bleeding

Diverticulitis

• Dx Tests:

• CT scan or ultrasound

• Abdominal X-rays

• CBC

• Colonoscopy

• Barium enema
Diverticulitis

• Nursing Interventions:

• Liquid diet, soft diet, low-fiber

• Stool softeners

• After healing: High-fiber, inc fluid

• IV, oral antibiotics

• Pain control

• Colon resection

Polyps

• Polyps are small growths along the lining of the intestinal tract.

Polyps

• Assessment:

• Bleeding

• Abdominal pain and cramping

• Diarrhea or any change bladder habit

Polyps

• Diagnostic tests:

• DRE

• Sigmoidoscopy

• Colonoscopy

• Fecal occult blood

• Barium Enema
Polyps

• Nursing Interventions:
• Polypectomy

• Colectomy

• Increase calcium intake

• NSAIDs/ASA

• Exercise, stop smoking, ↓alcohol, low-fat/high-fiber diet.

• Routine colorectal screenings.

Colorectal Cancer

• Starts as a noncancerous polyp

• Adenomas are the types of polyps that have the potential to become cancerous.

• Develop slowly over a period of several years

• Aspirin may decrease the risk

Colorectal Cancer
Colorectal Cancer

• Risks:

• Excess saturated red meats

• Age older than 50 years

• Low-fiber, high-carbohydrate

• Chronic constipation

• Diverticulosis

• Ulcerative colitis

Colorectal Cancer

• Assessment:

• Constipation and diarrhea

• Change shape of stool

• Rectal bleed, pallor, weakness

• Rectal pressure

• Anorexia, weight loss

• Screening:

Colorectal Cancer

• Diagnostic tests:

• FOBT

• DRE

• Sigmoidoscopy, Colonoscopy: biopsy

• Barium enema: after colonoscopy

Colorectal Cancer

• Interventions:

• Radiation.

• Chemotherapy.

• Doxorubicin (Adriamycin)

• 5-fluorouracil (Adrucil):

• A/R: cerebellar dysfunction, phototoxicity, stomatitis, diarrhea

• Antiemetics

Colorectal Cancer

• Interventions:

• Surgery

• Colectomy
• Abdominoperineal resection (sigmoid, rectum, anus) with permanent colostomy

Colorectal Cancer

• Interventions:

• Surgery

• Colectomy

• Abdominoperineal resection (sigmoid, rectum, anus) with permanent colostomy

Colostomy
Colostomy Irrigation
Colostomy Irrigation
Hemorrhoids

• Are varicose/distended veins of the anal canal.

• External hemorrhoids

• internal hemorrhoids
Hemorrhoids
Hemorrhoids

• Causes:

• Chronic constipation

• Pregnancy

• Obesity

• Heavy lifting, straining, standing for long periods

Hemorrhoids

• Assessment:

• Bleeding

• Itching

• Pain
Hemorrhoids
• Diagnostic Tests:

• Digital examination

• Anoscopy and flexible sigmoidoscopy

Hemorrhoids

• Nursing Interventions:

– Sitz bath

– Dibucaine (Nupercainal)

– Witch hazel (Tucks)

– Cleaning anal area by blotting

– High-fiber diet, fluids, docusate sodium (Colace)

– Sclerotherapy, Band ligation hemorrhoidectomy

Sitz bath
Hemorrhoids

• ACCESSORY ORGANS

Health History:

• Hepatic/Biliary problems:

• Jaundice

• Pruritus

• Urine color

• Clay-colored stools

Pathophysiology of Jaundice
Types of Jaundice
Serum Laboratory Tests
Imaging Tests
• Oral Cholecystogram (GB Series)

• X-ray visualization of GB

• Low fat or fat-free meal: dinner

• 6 telepaque tabs (5 min) after dinner, then NPO

• Post:

• Assess slight dysuria: excretion dye

Imaging tests

• Percutaneous Transhepatic cholangiography

• Radiopaque dye into a bile duct, then X-rays

• Operative Cholangiography

• Injection of dye directly into the biliary duct during GB surgery, then X-rays

Imaging Test

• ERCP: Endoscopic Retrograde Cholagiopancreatography

Liver Biopsy
Paracentesis

Esophageal Tamponade Balloon

Cirrhosis

• Cirrhosis is severe, potentially fatal scarring and fibrosis of liver tissue.

Cirrhosis

• Causes:

• Chronic alcoholism

• Viral or autoimmune hepatitis

• Bile duct obstruction

• Right-sided heart failure

• Drugs and toxins

Cirrhosis

• Assessment:

• Jaundice

• Ascites, SOB

• Hepatomegaly

• Nausea, anorexia, abd discomfort

• Malnutrition

Cirrhosis

• Assessment:

• Spider angiomas

• Increased medication sensitivity

• Splenomegaly

• Esophageal varices

• Confusion, mood changes, behavioral changes

• Hepatic encephalopathy, Asterixis

Cirrhosis

• Dx Tests:

• Ultrasound or CT scan

• Laboratory studies—bilirubin, albumin, alanine transaminase (ALT),

• aspartate transaminase (AST), prothrombin

• Liver biopsy

• Esophagoscopy
Laboratory Studies

• ↑Alkaline phosphatase:

• 4.5 – 13 King-Armstrong units/dl

• ↑ PT: 10-12 sec

• ↑Ammonia: 35-65 mg/dl

• ↑ Cholesterol:

• 140 – 199 mg/dl

• ↓Albumin: 3.4 to 5 g/dl

• ↑ Amylase: 2 –151 units/L

• ↑ lipase: 10-140 units/L):

• ↑ Bilirubin: liver, biliary obs

• Direct (con/water sol):

• 0 to 0.3 mg/dl

• Indirect (uncon):

• 0.1- 1.0 mg/dl

• Total: <1.5 mg/dl

Cirrhosis

• Nursing Interventions:

• Stop alcohol

• Take vitamins (thiamin, folate) and nutritional supplements

• Decrease sodium intake (less than 2 g/day) to control fluid accumulation

• Restrict fluid intake to 1000 to 1500 mL daily

• Use frequent rest periods

• Diuretics

Cirrhosis

• Nursing Interventions:

• Paracentesis

• Albumin administration

• Pain management if indicated.

• Liver transplant
Cirrhosis

• Nursing Interventions:

• Monitor medications that are usually metabolized in the liver.

• Give diuretics to rid the body of excess fluid.

• Elevate the head of the bed at least 30 degrees

• Implement bleeding precautions

Cirrhosis

• Depending on the client’s condition, the following may be required:

• Paracentesis

• Esophagogastric intubation or endoscopic sclerotherapy or endoscopic banding

• Blood transfusions for significant bleeding

• HAV vaccine and HBV vaccine

Esophageal Varices
Nursing Interventions:
1. Assessment of bleeding (onset and volume).
2. Assessment of blood pressure, pulse, and respirations.
3. Insertion of IV line for fluid infusion
Esophageal Varices

• Interventions:
• Saline lavage, esophagogastric balloon tamponade, BT, ligation and sclerotherapy

• Drugs: propranolol, vasopressin, Vit K

• Monitor VS and Hgb

• Mouth care
Esophageal Varices
Nursing Interventions:
4. Management of the airway
5. Insertion of nasogastric tube
6. Preparation for esophagogastric intubation, endoscopic sclerotherapy, or endoscopic banding
7. Procedure for blood administration
Cirrhosis

• Assessment:

• Early:

• Anorexia, weight loss, fatigue

• Hepatomegaly

• Pain: dull RUQ

Paracentesis
1. Obtaining consent for the procedure.
2. Positioning the client (supine or semi-Fowler’s position; or sitting up,if tolerated).
3. Educating client
4.Monitoring and reporting complications
5. Vital signs prior to procedure and frequent vital signs thereafter.
Hepatitis A (HAV)

• Incubation is about 30 days, and the virus is excreted in the stool for about 2 weeks

Hepatitis A

• Assessment:

• Jaundice, clay stools

• Dark urine

• Pruritus

• RUQ abdominal pain

• Fever

• Fatigue

• Loss of appetite, nausea, GI symptoms

• Bleeding tendencies

• Anemia
Hepatitis A

• Dx tests:

• A blood test: detects antibody IgM.

• No specific treatment
Hepatitis A

• Prevention:

• Hand hygiene

• Properly cleaning eating utensils.

• Exclusion of food handlers from work.

• Providing vaccination.

• Exposure to HAV, immune globulin (within 2 weeks of exposure)

Hepatitis A

• INFECTION CONTROL

• Hand hygiene to prevent the spread of HAV.

• Vaccine before traveling to places where HAV is endemic.

• Standard precautions, when caring for this client.

• Contact precautions, for incontinent clients (cannot control bladder/bowel).

Hepatitis B

• This virus has a complex structure capable of attacking and destroying liver cells
• architectural changes of the normal structure, of the liver which leads to

• disruption in the flow of blood and bile. Illness can range from
Hepatitis B

• Causes:

• Exposure to infected blood and body fluids

• Transfusion of blood and blood products

• Hemodialysis

• Assessment:

• Fatigue

• Fever

• Nausea and vomiting

• Anorexia

• Steatorrhea

• Jaundice, pruritus

• Dark urine, dark-colored stools

• Abdominal pain, ascites

• Hepatitis panel

• Liver profile:

• (AST, SGOT), alanine transaminase (ALT, SGPT), alkaline phosphatase

• (alk phos), gamma-glutamyltransferase (GGT), and bilirubin.

Hepatitis B

• Nursing Interventions:

• Antivirals.
• Interferon

• Supportive care and symptom relief.

• HBV immune globulin for infants

• Liver transplantation.

• Pregnant women: NO antivirals or interferon

Hepatitis B

• Prevention: HBV vaccine (health care workers, hemodialysis clients)

• Avoid razors, nail clippers, and toothbrushes

• Avoid tattoo parlors

• Practice abstinence or use condom

What can harm my client?

• Alcohol

• Acetaminophen

• Sedatives.

• Any hepatotoxic (toxic to the liver) drug.

• Strenuous activities.
Hepatitis C (HCV)

• One of the five hepatitis viruses that infect the

• 80% of those with HCV have no signs or symptoms.

• Causes:

• Exposure to infected blood and body fluids

• Transfusion of blood and blood products

• Hemodialysis
• Organ transplantation
Hepatitis C

• Assessment:

• Fatigue

• Myalgia

• Jaundice, pruritus

• Dark urine

• Abdominal pain

• Anorexia

• Nausea and vomiting

Hepatitis C

• Dx tests:

• Hepatitis profile, Liver enzymes

• Nursing Interventions:

• Interferon

• Symptomatic treatment for myalgia, nausea, vomiting, and pruritus.

• Unlike HBV, HCV does not have a vaccine.

Hepatitis C

• Prevention includes:

• Not sharing personal items, such as toothbrushes, razors, or nail clippers.

• Avoiding tattoos.

• Practicing abstinence or using a condom

Cholecystitis and Cholelithiasis

• Cholecystitis

• Inflammation of GB

• Associated with cholelithiasis (gall stone)

Cholecystitis and Cholelithiasis

Cholecytitis

• Inflammation of the gallbladder. About 90% of cases result from gallstones obstructing the cystic
duct.

• If cholecystitis occurs without gallstones, it is usually after a major illness or injury (acalculous
cholecystitis).

• Acute or chronic
Cholecystitis

• Acute cholecystitis: edema, inflammation, and impaction of bile in gallbladder

• Chronic cholecystitis: fibrotic thickening of gallbladder wall and incomplete emptying

Cholecystitis

• Assessment:

• Severe acute RUQ and epigastric pain radiating to shoulder and right scapula

• Nausea and vomiting

• Fever

• Indigestion

• Steatorrhea

Cholecystitis

• Dx Tests:

• Complete blood count (CBC)

• Serum amylase levels

• Ultrasound to check for gallstones

• X-ray to identify gallstones

• ERCP (endoscopic retrograde cholangiopancreatography)

Cholecystitis

• Nursing Interventions:

• NPO (nothing by mouth)

• (IV) fluids and electrolytes

• Pain control (opioids

• Antispasmodics or anticholinergics

• Laparoscopic cholecystectomy
Exercise:

• Which of the following food choices might trigger a cholecystitis attack?

• __Ice cream

• __Chocolate cake

• __Fresh noodle with vegetables

• __Baked fish

• __broccoli with cheese sauce

• __Rice and Pork BBQ

• __Sweetened strawberries

• __Fried eggs and bacon

Exercise

• The client who undergone abdominal cholecystectomy had fully recovered from anesthesia.
Which position is best for the client?

• A. Side lying position, to prevent aspiration

• B. Semi-Fowler’s position, to facilitate breathing

• C. Supine, to decrease strain on the incision line

• D. Prone, to reduce nausea

Pancreatitis

• Acute or chronic inflammation of the pancreas

• Acute pancreatitis results when pancreatic enzymes are activated while still in the pancreas

• Chronic pancreatitis results when progressive, recurring episodes cause structural changes, and
function
Pancreatitis

• Causes:

• Toxic metabolic processes

• Biliary obstruction

• Trauma

• Viral infections

• Cancer

• Unknown origin
Pancreatitis

• Assessment:

• Pain

• Nausea and persistent vomiting

• Decreased or absent BS

• Respiratory distress

• Fluctuation in BP

Pancreatitis

• Assessment:
• Fever

• Malaise and decreased level of consciousness

• Steatorrhea

• Cullen’s, Turner’s, Ascites

Pancreatitis

• Increased serum amylase and lipase (enzymes produced in the pancreas).

• Amylase may be normal in chronic pancreatitis. Lipase usually elevates

Pancreatitis