NCM 202 GIT

8/4/2019 NCM 202 GIT

1/24

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN

110

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption

Nanette V. Velasco, RN MN

Evaluation

50-40-10

Update (something we did not know yet) with Reaction 5%

Summary and Reaction with Source

Clarity of thought 40%

Relevance 40%

Sentence Construction 20%

Anatomy and Physiology

1. Mouth- Teeth, cheek, tongue, pharynx; chewing, mastication, break down food- 2-3 Liters of saliva if properly hydrated- produced by glands

a. Parotidb. Submaxillaryc. Sublingual

- Contains amylase for breaking down of starchy substances- Saliva contains antibodies responsible in minimizing the level of bacteria in the mouth

2. Esophagus- Made of muscle, capable of peristalsis-wavelike motion, responsible for the movement of bolus (semi

digested food) from the mouth to the stomach

- 2-3 seconds to travel the entire length of the esophagus- 10inches or 25cm- Esophagectomy removal of the esophagus

3.

Stomach- Cardioesophageal sphincter- Bolus will turn to chyme almost digested with mixture of gastric secretions- Pouch like organ that is covered with muscle- Responsible for storing food and mixing it with gastric juices (hydrochloric acid, water, pepsin for

breaking down protein; mucus has mucin to coat the inner lining of the stomach to prevent

ulceration)

- pH is 2-3- 3 parts

a. Fundusb. Bodyc. Antrum most common site of ulceration, site commonly removed (antrectomy or partial

gastrectomy), acid pools in this area

- Food stays for 2-4 hours before transported to the duodenum- Further digestion of starches and protein (pepsin)- Pyloric sphincter, between stomach and small intestine

8/4/2019 NCM 202 GIT

2/24


111

2 Phases of Digestion

1. Cephalic Phase of Digestiono Digestion is stimulated by the smell, sight and thought food

2. GastricPhaseo Stimulated by the presence of food in the stomacho Actual phase of digestion

4. SmallIntestine- For absorption and to further digest food- Approximately 20ft long- 3 Parts

a. Duodenumo no absorption, just digestiono has Sphincter of Oddi connected to pancreas (produces lipase), liver, and gall bladder (stores

the bile); Cholecystokinin produced by the duodenum that stimulates the gall bladder to

release bile to emulsify the fat content of the food; pancreozymin stimulates the pancreas to

release the pancreatic lipase, to breakdown fat to release fatty acid for absorption

o Most sterile partb. Jejunum

o Also for absorptionc. Ileum

o Highly active for absorption5. Largeintestine

- For absorption of water and formation of stool- 4 Divisions

a. Cecum (Ascending Colon)

oStool is watery

b. Transverse Colono Mushy

c. Descendingo Semi formed

d. Sigmoido Formed

- Colectomy removal of the colon- Total Proctocolectomy client will excrete through ileostomy

6. Rectum- Reservoir or storage of stool

7. Anus- Passageways of stool- Has anal sphincter

Accessory Organs

1. Liver- The largest organ internal organ of the human body- Produces bile

8/4/2019 NCM 202 GIT

3/24


112

- Metabolic processes of Vit A, B, D and Iron, and other fat soluble vitamins (ADEK)- Storage of glucose in the form of glycogen- Production of coagulants low platelet count if having kidney trouble thrombocytopenia- Liver transplant is possible

2. GallBladder- Storage of Bile- Maximum of 60mL of bile- Cholecystectomy removal of gall bladder- Cholelithiasis gall stones

3. Pancreas- Just beneath the stomach- 2 Functions

a. Endocrine produces insulin

b. Exocrine produces pancreatic lipase (break down fats), amylase, trypsin (for protein substances)

- Can be entirely removed4. Appendix

- No known function but highly linked to the immune systemGastrointestinal Tract or Alimentary Canal

Function:

1. Absorption2. Digestion3. Secretion4. Motility

NGT landmarks NEX; Nose to Ears to the Xiphoid Process

History

-

To determine the direction and focus of the physical examination and the required diagnostic1. Family History

- Question related to history of GI- Vomiting diarrhea, constipation, reflux

2. Past abdominal history and current problems3. EatingHabits most GI problems are linked to GI pattern

- Recall previous 24 hours, unusual eating requirementa. Appetiteb. Food intolerancec. Bowel habits number of times defecate per week, less than 3 times a week constipation;

normal is everyday4. Nutritional Assessment

a. Basis is the food pyramid5. Dysphagia or Heartburn (substernal chest pain d/t reflux of acid usually after meals)6. Nausea and Vomiting HCl is high every morning7. Abdominal Pain using the pain scale; pinpoint precise area of pain8. Medications Aspirin, antibiotics, NSAIDS, Anti-Psychotic Drugs are gastric irritants

8/4/2019 NCM 202 GIT

4/24


113

GI Symptom Assessment

1. Pyrosis substernal pain, may be due to hot food2. Odynophagia3. Dysphagia4. Dyspepsia indigestion, common for those veracious eaters5. Queasiness (the stomach feels ill), nausea, regurgitation (common in those with esophageal CA), and

vomiting (involuntary passing of gastric contents)

6. Hiccups (Hicoughs) involuntary contraction of the diaphragm can be stimulated by suddenly drinkingcold, especially carbonated liquids; self limiting

7. GI Gas eating gas forming food and bacteria in the stomach8. Diarrhea watery, loose stool 3 or more times per day9. Constipation passing of stool less than 3 times in a week10.Abdominal Pain mild, moderate to severe abdominal pain; Buscopan is given, anticholinergic, relaxes

muscles

Physical Assessment: GI System

Body Mass Index good indicator of taking food normally based on the height and weight

Formula: ((weight in lbs/height in inches)/height in inches)x703 = BMI

Examples: 120lbs, Height is 60 inches BMI is 24.43

Interpretation

Less than is 18.5 = underweight

19-24.9 = normal

25-30 = overweight

30 or greater = obese

Abdomen

IAPP inspection, Auscultation, Percussion, Palpation

I. Inspectiona. Condition of the skin and contourb. Distention or irregular contourc. Rashes, discoloration ,scars, petechiae (small red spots), striae and dilated veins (usually with those

with cirrhosis)

II. Auscultationa. Beginning from the lower quadrant. Continue in clockwise fashion.b. Normal bowel sounds 5-35 sounds per minutesc. Borborygmi hyperactivity; loud high pitched sound d/t hyperactivity of the bowel; heard if

hungry, or if having diarrhea

III. Percussiona. Size and location of abdominal organs and to detect fluids, air, or massesb. Tympanic loud high pitch sound heard over gaseous area.c. Thud-like or dull sounds mass like organ such as the liver

8/4/2019 NCM 202 GIT

5/24


114

IV. Palpation exert pressure, best method for presence of paina. Palpate quadrant to quadrantb. Involuntary abdominal rigidity or guarding

Diagnostic Tests/ Laboratory Test:

1. Gastric Analysis- Measure secretion of HCl and pepsin the stomach- For gastritis and peptic ulcer diseases- Through NGT lavageNursing Care: Pretest

a. NPO 12 hours to get the acidity of HCl on an empty stomach; may sip waterb. Insert NGTc. Do not administer drugs that interfere with gastric acid levels (anticholinergic, antacids, antispasmodic)Nursing Care: Post-test

a. Record amount and color of drainage (usually greenish in color)b. Assess for signs of bowel perforation (fresh blood may mean bleeding in the ulcer or perfoaration)

2. Fecalysis- Form, consistency, color are notes- Mucus, blood, pus, parasites, and fat content- Guaiac test, Hemocult, Hematest for occult blood in the stool (melena)- No special preparation

3. Endoscopy- Direct visualization of the GI system by means of lighted, flexible tube- Can reach up to the duodenum3.1 Gastroscopy an instrument passed through the mouth and used to examine the stomach

3.2 Esophagogastroduodenoscopy direct visualization of the esophagus, stomach, and duodenum, nyy

insertion of a lighted fiber scope.Nursing Care: Pretest

a. NPO for 6-8 hoursb. Consent signed (this is an invasive procedure)c. Explain that local anesthetic will be used lidocaine sprayd. Speaking during the procedure will not be possible may cause spasms or displace the tube.

Discomfort will be felt. Provide piece of paper and a pen.

Nursing Care: Post-test

a. NPO until gag reflex will return get a padded tongue depressor and place at the back of the tongueb. Assess V/S, pain, dysphagia (give a glass of water) and bleedingc. Administer warn NSS gargles

4. Colonoscopy- The visual examination of the lining of the entire colon with a flexible fiberoptic endoscope; client is

sedated part of the info given to the client prior to the test

- May be performed OPDNursing Care: Pre-test

a. NPO for 8 hours and sedatedb. Position patient on the left side; left side lying with the legs flexed toward the chest

8/4/2019 NCM 202 GIT

6/24


115

c. Administer laxatives for 1-3 days before the exam; or enema until return flow is cleard. Consent signede. Explain a feeling of pressure might be experienced into the rectumNursing Care: Post-test

a. Observe for signs of perforation and rectal bleeding5. Acid Perfusion Test (Bernsteins Test)

- Used for client with CA of esophagus- To determined whether the clients chest pain is related to acid perfusion across the esophageal

mucosa.

- Uses PNSS or HCl6. Proctosigmoidoscopy (Rectosigmoidoscopy)

- Examination of the lining if the distal sigmoid colon, the rectum, and the anal canal- Diverticula sac like outpouching portion of the large intestine- Client is not sedatedNursing Resp

i. Enema giving before ad morning of the procedureii. Clear liquids

iii. Knee chest position fetal positioniv. Deep breathing during insertion of the scope, facilitates insertion of the tube and relaxes the

sphincter, and prevents unnecessary entrance of air

7. Liver Biopsy (closed needle)- Needle is inserted into the liver to remove a small piece of tissue for study- Percutaneous puncturing the abdomen- Liver has a tendency to bleedNursing Care: Pre-test

a.

Refrain from ingesting ASA, NSAIDS or anticoagulants 2 weeks pre-testb. NPO for 6h pretestc. Hold breath during the biopsyd. Blood clotting test ( PT prothrombin time, PTT partial thromboplastin time, bleeding time, platelet,

Hct)

e. Left side lyingNursing Care: Post-test

a. Assess V/Sb. Right side for 1-2 hours with a pillow against the abdomenc. Obs for hemorrhaged. Assess for complication of shock and pneumothorax (may compress the lung producing DOB)e. Bed rest for 24 hours

8. Nasogastric and Nasointestinal Intubation9. Ultrasonography

- High frequency sound waves over an abdominal organ to obtain an image of the structure- Generally no preparation unless prescribed by MDNursing Care:

8/4/2019 NCM 202 GIT

7/24


116

1. Special diet (High fat for gall bladder visualization), laxative or other medication to cleanse the boweland decrease gas.

2. NPO for 8-12 h10.Computed Tomography Scan (CT Scan)

- An x-ray technique that provide excellent anatomic definition and is used to detect tumors, cyst, andabscesses

- 30-35 minutes- Advise client to remove jewelry- Contraindication: pregnant and obeseNursing Care:

1. NPO for 6-12 hours2. Check of pregnant3. Supine position

11.Upper GI Series (Ba Swallow)- Fluoroscopic examination of upper GI tract to determine structural problems and gastric emptying time- Ba looks like flour and should be mixed with a little water, can be mixed with spriteNursing Care: Pre-test

a. NPO 6-8 hoursb. Expla9in that Ba will taste chalkyc. Avoid smoking smoke will create cloudy appearance; chewing gum is not advisedNursing Care: Post Test

a. Administer laxative and force fluids:b. Assess abdomen for distention Ba will clump together and clump together if not removed

immediately

c. Instruct patient that within 72 hours, stool will be whitish in colord.

No food restriction after the procedure

12.Lower GI Series (Ba Enema)- Ba is instill in to the colon by enemaNursing Care: Pre-test

a. NPO for 8hb. Give enemas until clear in AM of the testc. Administer laxative or suppositoryd. Explain that cramping may be experienced during the procedureNursing Care: Post-test

a. Administer laxatives and fluids to eliminate the Ba; maximum of 3 days that the stool may be white13.Oral Cholecystogram

- An x-ray test for gall bladder or cystic duct disease- Viewing of gall bladder emptying capacityNursing Care: Pre-test

a. Radiopaque dye 6 tablets will be giveni. Iopodate Na

ii. Iopanoic Acid best given if dinner is high fat if not prepared

b. Feed client high fat diet the day before (egg, cheese); 2 hours before the test, low fat meal

8/4/2019 NCM 202 GIT

8/24


117

Nursing Care: Post-test

a. Obs for S/E of the dye: allergies, report if symptoms are foundBenadryl for allergy

Pharmacologic Management

1. Antacid neutralizes the acidic environment of the stomach; ideally given after mealE.g. Na Bicarbonate; Calcium containing meds; Mg(OH)2or Gaviscon, Maalox; Al(OH)3 or Alu-cap, Gaviscon

2. Antispasmodicstops muscular contraction3. H2 Blocker (Cemitidine, Famotidine, Ranitidine) block histamine that stimulates parietal cells to produce

HCl; decreases HCl production

4. Anticholinergics (Antispasmodic) directly act is the ANS (involuntary) by blocking the effect of involuntarycontractions

E.g. Buscopan (relaxes the cervix cervical dilatation, 3 doses every 2 hours)

Bentyl

Pro-Banthene

5. CytoprotectiveAgent coats the inner lining of the stomach esp if with ulcer to cover it to prevent furtherdamage

E.g. Sucralfate/Carafate

6. Anti-inflammatory7. Antimicrobials8. Antidiarrheals9. Antiemetics10.Laxatives

Surgical Interventions

1. PartialGastrectomy certain portion of the stomach is surgically removedBariatric Surgery

2. Gastrostomy surgical opening of the stomacha. Billroth I (Gastroduodenostomy) portion of the stomach is anastomosed to the duodenum

b. Billroth II (Gastrojejunostomy)

c. Roux-en-y gastric bypass; portion of the stomach will not be used

Dumping syndrome food is dumped from the stomach to the small intestine

3. Vagotomy surgical cutting of the cranial (vagus) nerves; responsible for production of HCl; to decsecretions

4. Appendectomysurgical removal of the appendix; McBurneys point; if ruptured, ExLap 5. TotalProctocolectomywith permanent Ileostomy (In RLQ) removal of the colon, rectum, and anus with

the closure of the anus; Stoma6. TotalProctocolectomywithcontinentIleostomy Kock pouch is the continent ileostomy; no external

pouch

Problem is nutrition soft or low residue diet

7. TotalColectomyandIlealReservoir total removal of colon and ileoanal anastomosis with the formationof ileal reservoir.

8. Cholecystectomy and Choledocholithotomy- removal of the gall bladder

8/4/2019 NCM 202 GIT

9/24


118

- incision into common bile duct for removal of ductNissen Fundoplication (Gastric Wrap Around) stomach is sutured around the esophagus in cases of hiatal hernia

NCM of Patents with Digestive System Diseases

The Nursing Process Approach

1. Infections of the MouthA. Stomatitis (no scar formation)

- Inflammation of the Buccal mucosaa. Primary

i. Aphthous Stomatitiso canker soreo caused by biting cheeks and caused by virus that infiltrateo stress releases cortisol which balances hormones and immune systemo virus can remain active for yearso may last for 2-3 weeksCauses

o Herpes Simpleso Allergieso Stresso Trauma (Chemical or Mechanical Trauma)o Vitamin deficiencyTreatment

o Topical anesthetic (EMLA)o Topical or systemic steroid if problem is due to allergy (under strict prescription)o Tetracycline for severe pain

ii. Herpes Simplexo Inflammation of the mouth with vesicle formationo Cold soreso Vesicle formationo Around the lips or upper part of noseTreatment

a. Oral and topical analgesicsb. Acyclovir

Zovirax (IVTT) Denavir (Caplet)

iii. Vincents Anginao Aka oral thrusho Acute bacterial infection of the paino Painful swallowing that might be mistaken as chest paino Bacterial infection

8/4/2019 NCM 202 GIT

10/24


119

Treatment

o Removal of devitalized tissueso Improve oral hygieneo Bland dieto Vitaminso Analgesicso Saline mouth rinses (mouth wash should be mix with water)

b. Secondary Stomatitis1. Allergies2. Bone marrow disorders3. Nutritional disorders4. Chemotherapy, radiation, immunosuppressive therapy5. Immunodeficiency disorders

Precipitating Factors

Poor hygiene Increased age (increased bacteria in mouth) Malnutrition Lack of rest and sleep Debilitating disease Local tissue damage

B. Parotitis- Inflammation of the parotid glands- May cause sterility in males if not immune after puberty (has affinity to testacles)- May be prevented by MMRCauses:

a. Inactivity of the gland causes caused by medication (anticholinergic drugs)b. Prolonged NG intubation (client cannot taste food)c. Lack of oral intaked. DHN (when you feel that you are not producing saliva)

Nursing Intervention

a. Sialogogues any substance that can trigger salivation (E.g. Candy)b. Keep client well hydratedc. Warm compress (because it is swollen)

Medical Management

a. Antibioticb. Stop taking anticholinergic medications (stop it momentarily! For healing purposes)c. Analgesics

C. Candidiasis- Caused by C. albicans- Secondary infection by an overgrowth of an organism Candida albicans

8/4/2019 NCM 202 GIT

11/24


120

- Yeast infectionS/S:

a. milk curd appearanceb. Dry and hot lesionsc. Frequent sore throatd. Difficulty in swallowing

Precipitating Factors

Immunosuppressed clients GM Pregnant (caused by GDM) Stress Long term or high does antibiotic or steroid-based therapy Smoking may predispose

Management Monitor client closely Antifungal agents Analgesics Cotrimoxazole, Miconazole nitrate, Haloprogin creams for denture wearers

2. Cancer of the Mouth- Primarily in clients who smoke and drink alcoholic beverages in large quantities

Signs and Symptoms (Progressive)

Pain (localized pain in the mouth) Alteration in taste sensation Leukoplakia (pre-cancerous yellow or white patch in the mouth, any part of Buccal lining) Ulcerated area (burrowing of affected area) Difficulty chewing/speaking, dysphagia

Treatment

Reconstructive surgery Radiation then Chemotherapy

Nursing Care

Fluid and electrolyte balance Provide a means of communication (piece of paper and a pen) Relieve dryness of the mouth (cotton balls with water)

3. Cancer of the Esophagus- Cause: Smoking and Drinking alcohol- Predisposing Factors:

Habitual ingestion of alcohol Heavy smoking Nutritional deficiencies

8/4/2019 NCM 202 GIT

12/24


121

Poor oral hygiene Spicy foods Obesity (fat deposits may result to mutation process)

Signs and Symptoms (Progressive)

Progressive Dysphagia Odynophagia Substernal pain Substernal burning after drinking hot liquids Regurgitation Irregularities in the lumen of the esophagus Hoarseness of voice, choking sensation Weight loss

Management surgical removal of the esophagus

a. Esophagogastrostomy (Gastrostomy feeding)b. Esophagectomyc. Gastrostomyd. Radiation and/or chemotherapy

Nursing Care

Emotional support (Emotional Support therapeutic silence or providing the need of the client) Observe for respiratory distress caused by pressures on the trachea Semi-fowlers or high fowlers position Monitor V/S esp. RR Maintain nutritional status Client teaching (avoid drinking alcoholic beverages and stopping smoking) NDx: Imbalanced nutrition: less than body requirements

4. Gastritis- Inflammation of the gastric mucosa (the stomach lining)

a. Acute Gastritis- Produces mucosal reddening (tissue is inflamed), edema, hemorrhage (ruptured blood vessels), and

erosion uppermost layer is stripped off (ulceration is burrowing)

b. Chronic Gastritis- Common among elderly people- Present as chronic atrophic gastritis (decrease in the size of the cell), all stomach mucosal layers are

inflamed.

- Layers of the stomach are mucosal, sub-mucosal, musclesPossible Causes

Acute Gastritis

Irritating foods, spicy foods Drugs (ASA, NSAIDS, antibiotics, antipsychotics)

8/4/2019 NCM 202 GIT

13/24


122

Poisons and corrosive substances Endotoxins (substance released by an infecting bacteria)

Pathophysiology

Causative agent

Penetrates mucosal barrier

Results to injury to the mucosa

Injury to small vessels with edema, hemorrhage, ulceration

HCl comes in contract with injured mucosa

Chronic Gastritis

1. Alcohol ingestion2.

Cigarette smoking

3. Environmental irritants (CO)4. Peptic Ulcer Disease (PUD)

Assessment Findings

1. Abdominal discomfort (Queasiness)- Cramping, reflux

2. Epigastric discomfort- Burning or aching

3. Hematemesis- Blood together with the vomitus

4. Indigestion5. Belching (caused by acid and bacteria)6. N and V

Diagnosis

- CBC, SE, Gastric analysis, Ba swallow, EndoscopyTreatment

1. Blood transfusion PRBC2. IVF Therapy3. NG Lavage drain out stomach irritants4. O2 therapy low Hgb count; max of 6lpm via nasal cath5. Partial or total gastrectomy6. Vagotomy and pyloroplasty (mucin is produced somewhere in the pylorus)

Nursing Management

Implementation

1. Give antiemetics and IV Fluids to prevent DHN and electrolyte imbalance.2. MIO and electrolyte levels (through blood chemistry, Se Na, Se K, as often as 6h).3. Bland diet

8/4/2019 NCM 202 GIT

14/24


123

4. If surgery is necessary, prepare the client preop and provide appropriate postop care.5. Administer antacids and other prescribed medications6. Take prophylactic medications as prescribed7. Provide emotional support.

NDx: Ineffective tissue perfusion, Alteration in comfort: pain, Anxiety, Knowledge deficit

5. Peptic Ulcer Disease- Ulceration of the mucosal wall, pylorus, duodenum, esophagus- H. pylori one of the causative agent of PUD- 90% of PUD are caused by H. pylori- Helivax vaccination for H. pylori

a. Gastric ulcers- Extends to the submucosal layer of the stomach- Incompetent pylorus produces less mucus (mucin)Predisposing Factors

Stress (cortisol) Smoking (can increase HCl and poor O2 supply) Drugs (NSAIDS, ASA, Antibiotics, Antipsychotics) Hx of gastritis

b. Duodenal Ulcer- Mucosa of the duodenum- High acid secretionRisk factors

o Alcohol intake, smokingo Stress, caffeineo Drugs

Gastric Ulcer Duodenal Ulcer

1. Weight loss (foods stimulates pain)2. Left Epigastric pain3. N and V

1. Weight gain (pain 2-4 hours after mealeating decreases pain)

2. Mid epigastric pain (burning andcramping), Epigastric pain at HS

3. N and VDiagnostic Tests

- Gastric acid analysis, UTZ, UGI series, LGI series, SE (for presence of H. pylori),Complications

1. Hemorrhage (ruptured capillaries) anemia (pallor conjunctiva and Buccal mucosa), peripheralpulses, dizziness, cold clammy skin, orthostatic hypotension (dizziness upon sudden change of position)

2. Perforation submucosal layers become ulcerated/GIT contents empty into the peritoneum (may leadto peritonitis)

S/Sx: Sever sharp abdominal pain, vomiting/collapse, signs of shock, and boardlike abdomen

8/4/2019 NCM 202 GIT

15/24


124

3. Pyloric ObstructionS/Sx: epigastric fullness, anorexia, nausea, projectile vomiting

4. Intractability you can no longer manipulate the abdomen; most common indication for surgeryManagement (Goal: provide stomach rest)

A. Pharmacology1. Antacid

o Al containing antacidso Mg containing antacid (milk of magnesia)

2. H2 Receptor Blocker3. Anticholinergics4. Cytoprotective

B. Surgical Interventionso Gastrectomyo (Billroth 1)o Billroth 2o Roux-en-y modifiedo VagotomyComplication of Surgery

1. Dumping SyndromeS/Sx: Epigastric fullness, distention, abdominal cramping, N and V, occasionally diarrhea 15-30

min. pc and last for 20-60 minutes

Nursing Responsibilities

1. Small frequent meals (avoid heavy carbohydrate meals bread, rice, pasta)2. Do not take fluids while eating3. Lie down, left side lying after eating to prolong stay of food in stomach

2.

Pernicious Anemia upon ingestion of Vit B12, covered by intrinsic factor (produced in thepylorus) and delivered to ileum, intrinsic factor fades and Vit B12 is absorbed; Vit B12 is needed

in RBC synthesis; IV or IM B12 supplements

3. Steatorrhea foul, frothy, fatty (FFF) stool; high fat diet6. Appendicitis

- Causes:o Fecalith (small hard stool)o Kinking if the intestineo Swellingo Fibrous conditiono External occlusion of the bowel adhesion

- Assessmento RLQ pain, McBurneys point (steady dull pain)o Rovsings sign flex the opposite areao Low grade fevero Increased WBC 5000-10000mm3o Rebound tenderness

8/4/2019 NCM 202 GIT

16/24


125

o Do not give analgesics, pre diagnosis; give analgesics after diagnosis, absence of pain may mean ruptureof appendix

- Treatmento Appendectomyo Management of peritonitis, shock, dehydration, and infection

- Nursing Careo Avoid:

Enemas or laxatives Hot compress

o If perforated/ruptures Penrose drains are in place, position in semi-Fowlers or on the right side with legs flexed post-op

7. Diverticular Diseasea. Diverticulosis

- Presence of non-inflamed Diverticula- Asymptomatic Diverticula- Common Sites:

Sigmoid and Descending colon

b. Diverticulitis- An inflammation of Diverticula- Possible causes:

o Age (weakening of colon wall)o Chronic constipationo Congenital weakening of the intestinal wallo Low intake of roughage and fibero Straining during defecationo

Stress- Assessment Findings

o Anorexiao Stool with blood and mucuso Constipation and diarrheao Fevero Flatulenceo Intermittent LLQ pain or midabdominal pain that radiates to the backo Nauseao Rectal bleeding

Management- Generally no treatment for asymptomatic Diverticulosis- Colon resection- High residue diet with no seeds for diverticulosis (high fiber) to prevent further outpouching; Green

leafy vegetable, oatmeal

- Low residue diet with diverticulitis to prevent further inflammation; refined wheat; fruit juice- Temporary colostomy

8/4/2019 NCM 202 GIT

17/24


126

8. Ulcerative Colitis- Chronic inflammation limited to the mucosal and submucosal layers of the colon and rectum- Possible Causes

o Geneticso Idiopathico Allergieso Infectiono Abnormal immune response

- Assessment Findingso Abdominal cramping, urgency, distention, and tendernesso Anorexiao Severe diarrhea (20 or more per day) Pathognomonic sign leading to DHN in the interstitial fluid

compartment

o Bloody, purulent, mucoid, watery stoolso DHN (confusion, poor skin turgor) and electrolyte imbalanceo Fevero Hyperactive bowel sounds (Borborygmus)o Weaknesso Weight loss

- Diagnostic Testso Ba enema, Colonoscopy, Rectosigmoidoscopy, UTZ, CT scan, MRI, blood chemistry

- Surgical Management Colectomy, Total Proctocolectomy with ileostomy- Nursing Management

o V/S, MIO, Laboratory values, WODAC, feed client with Bland diet right after surgeryo Amount of stool and frequencyo

NDx: Fluid and electrolyte imbalance r/t sever bloody stool as evidenced by poor skin turgor,sunken eyeballs, and lab values dec Se Na and Se K. |Risk for injury related to body weakness/dec

Se K and Se Na | Alteration in tissue perfusion related to ulceration in the colon as evidenced by

[lab values]

9. Intestinal ObstructionsREAD about this in MedSurg books- Partial or complete impairment of the forward flow of intestinal contents- 90% occurs in the small intestine- Bowel Obstructions

o Strangulated Hiatal Herniao Ileocecal Intussusceptiono Intussusception from polypso Volvulous - twistingo Neoplasms 80% of clients with intestinal obstruction has neoplasmso Adhesionso Mesenteric occlusion

10.Hemorrhoids READ about this in MedSurg- Perianal varicose veins

8/4/2019 NCM 202 GIT

18/24


127

- Internal or External- Ages 20-50- Predisposing factors

o Constipationo Straining during defecationo Pregnancy (pressure of the uterus to the perianal area)o Obeseo Those who are always carrying heavy objects (more than 10lbs everyday)o Prolonged standingo Prolonged standing

- Signs and Symptomso Bright red bleeding with defecationo Pain when the client sits, stands or walkso Protrusion of an enlarged mass at the anus (external hemorrhoid)

- Diagnostic Testo DREo Proctoscopyo Hgb/Hct Count

- Managemento Hemorrhoidectomyo Rubber band ligation (8-10 days, the hemorrhoid will slough off)o Laser therapyo Analgesic for pain

- Nursing Managemento Hot sitz bath 12h post-opo

Flotation pad if client is lying or sitting downo Stool softenerso Diet modification (High Fiber, High in Protein for tissue repair-not meat products)o Force fluids of 2.5-3L/dayo Use an antiseptic solution after defecation

11.HepaticCirrhosis/Liver Cirrhosis- A chronic, progressive disease characterized by widespread fibrosis and nodule formation- Liver has nodular formation- Client has Ascites- Causes

o Excessive alcohol consumptiono Genetico Hypersensitivity to alcohol

- Types READ about this in MedSurg books regarding on what is most common1. Laennecs (alcoholic cirrhosis)2. Post necrotic cirrhosis3. Biliary cirrhosis4. Cardiac cirrhosis

8/4/2019 NCM 202 GIT

19/24


128

- Incidence is higher in Alcoholics Malnourished Hx of hepatitis

- As liver failure progresses: Inc secretion of aldosterone (has capacity to retain fluids) Dec absorption and utilization of the fat soluble vitamins (ADEK) supplement is given to client Ineffective detoxification of CHON wastes ammonia (CNS depressant-client will have cognitive

deficiency) is never excreted, but processed by liver to produce urea

- Signs and Symptomso Early Signs

General body malaise RUQ discomfort GI disturbances such as lack of appetite (anorexia), indigestion, bowel habit changes

o Late Signs Jaundice nodular formation makes secretion of bile difficult, blood vessels will absorb the bile

Conjugated indirect-cannot be excreted by the body further converted by the liver to direct

bilirubin for defecation or urination Unconjugated direct

Esophageal varices (portal vein is blocked, causes pressure on the veins) Spider angiomas face, neck, shoulders Anemia-Thrombocytopenia-coagulation disorders liver is responsible for synthesis of blood

coagulants

Ascites albumin is synthesized in the liver, keeps fluid in intravascular space; feed client withegg whites

Collateral veins visible on abdominal wall d/t ascites

Hemorrhoids d/t pressure of ascites Sexual characteristics changes Males: decreased in libido; decrease in size of testacles,

gynecomastia Female: Amenorrhea

Hepatomegaly and Spleenomegaly Edema d/t high amount of aldosterone Changes in mental responsiveness and memory caused by ammonia Palmar Erythema d/t presence of jaundice Peripheral Neuropathy lack of sensation due to poor circulation; usually in the lower

extremities/feet

- Complications1. Portal HTN

o Persistent inc in B in the portal venous system caused by an obstruction to blood flow whichcauses a rise in portal venous pressure

2. Hepatic Encephalopathy/Comao The livers inability to metabolize ammonia to form urea

3. Asciteso Accumulation of fluid within the peritoneal cavity

8/4/2019 NCM 202 GIT

20/24


129

4. Bleeding esophageal variceso Fragile, thin-walled, distended esophageal veins that become irritated and rupture

- Interventions1. Rest2. Restriction of alcohol, hepatotoxic drugs3. Vitamin therapy: especially the fat soluble vitamins and Vit B (Thiamine chloride and nicotinic acid)

increase nerve transmission

4. Diuretics5. Neomycin (the greater the bacteria, the greater the ammonia level) and Lactulose (has special

affinity to ammonia)

6. Paracentesis aspiration of fluid from the peritoneal cavity7. Surgical Intervention (to decrease portal hypertension): shunt8. Esophageal varices management

Sengstaken-Blakemore tube lavage and inflates balloon to exert pressure on the bleeding

esophageal varices

9. Dietary Modificationa. Cirrhosis

1. CHON as tolerated (80-100g)2. Inc CHO, mod fat; vitamin, mineral, and electrolyte supplements3. Dec Na (500-1000mg daily)4. Soft foods if esophageal varices are present5. Alcohol is contraindicated

- Diagnostic Testo Liver biopsyo SGPT/SGOTo

MRIo CT Scano Hgb/Hcto Abdominal UTZo Se Bilirubin level and Se Albumin

12.HepatitisSee Daniels book Unit 2- Inflammation of the liver- ABCDE- A food born, oral-fecal route- B Serum; STD- C virus; serum- D virus; serum- E water born

13.Cholelithiasis/Cholecystitis- 5 Fs Fat, Female, Forty and above, Fertile, Fair skinned- Made up of Ca, bile pigments, cholesterol- Etiology and Phatophysiology

1. Presence of stones (cholesterol, bile, pigments, and Ca

8/4/2019 NCM 202 GIT

21/24


130

2. Unable to contract in response to fatty foods3. Bile is unable to pass into the duodenum and is absorbed into the blood4. Obese women

- Signs and Symptoms1. Fever and Leukocytosis inc in WBC2. Jaundice bile in the gall bladder is absorbed by the blood vessels3. N and V4. RUQ Pain or epigastric pain may radiate to back, inc pain with deep breath5. Steatorrhea fat indigestion/intolerance6. Feeling of fullness/abdominal distention

- Diagnostic Tests1. Inc serum bilirubin2. UTZ3. ERCP (Endoscopic Retrograde Cholangiopancreatography)4. X-ray of gall bladder with stones

- Nursing Careo Teach dietary modification (low cholesterol, low fat), Inc OFIo Relieve pain both preoperatively and postoperativelyo Observe for sings of bleeding (stones may cause abrasions), administer vitamin K preparation as

ordered

o Provide care following a Cholecystectomy: surgical/laparoscopic lasero Monitor NGT attached to suction

1. Maintain patency2. Assess and measure drainage

o Provide fluid and electrolyte via IV routeo

Low Fowlers positiono Cough and deep breath

- Treatment of Stones:o Cholesterol Dissolvement

Moctanin

Nasal biliary catheter 1-3 weeks

o Oral Bile Acids:Chenodiol (chenix) ursodiol (actigall)

Dissolve small stones 6 months and 2 years Success rate is only 30%

o Shockwave Lithotripsy Small number of stones and mild to moderate symptoms. Patient will be immersed in a pool of water, there will be a current that will dissolve the gall

stones

1-2 hours Candidates must have no cardiac problems

8/4/2019 NCM 202 GIT

22/24


131

After the procedure, tell the px to return to MD if there is presence of hematuria,hematoma, nausea, biliary colic

14.Pancreatitis- Types

Acute pancreatitis

o Autodigestion of the pancreas by its own enzymesChronic pancreatitis

o Progressive inflammatory destructive disease of the pancreas- Causes

Acute

o Alcoholismo Cholelithiasiso Abdominal traumao Metabolic factors

Chronic

oIdiopathic

o Hereditaryo Chronic alcoholism

- Symptomso Pain (aching, burning, stabbing) in the LUQ or mid epigastric areao Weight losso Increase Se Amylase, lipase and trypsino Cullens sign bluish discoloration in the periumbilical areao Grey Turner bluish discoloration in the flank area

- Therapeutic Interventions1. MedicalManagement

o NGT suctioningo Narcotics: avoid morphine SO4 and codeine SO4 can cause spasm of the sphincter of Oddi

and the movement causes pain

o Give antispasmodico Antibiotic therapy

2. NursingManagement1. Avoidance of alcohol2. NPO, TPN, Bland, dec fat, inc CHON diet, with restricted intake of caffeine, alcohol, and gas

forming foods

3. Bed rest4. IVF, BT-PRCBC, FWB5. Surgical intervention6. Maintain position, patency, and low suction of NG tube7. Monitor I/O, wt OD, abdominal girth, electrolytes8. Monitor blood glucose levels9. Meds: meperidine, H2 blockers, anticholinergics, antacids, Ca Gluconate, pancreatic enzyme

replacements (Viokase, Pancreatin, Pancrease)

8/4/2019 NCM 202 GIT

23/24


132

10.Semi-Fowlers position11.Turn patient q2h, or utilize a specialty rotation bed12.Quiet, restful environment

8/4/2019 NCM 202 GIT

24/24


133

Topics for skills lab

1. Administering Intravenous Hyperalimentation (TPN) 4152. Inserting a Nasogastric tube 4183. Assisting in gastric lavage 4224. Administering gastric gavage/tube feeding -4255. Caring for a colostomy 4456. Manual fecal extraction

Documents

NCM 202 GIT