Gastrointestinal (GI) Disorders Disorder Mouth Caries & Gingivitis Ulcers Candidiasis (aka thrush or monoliasis) Etiology Signs & Symptoms 1 ursing N Considerations The starting point in digestion. Teeth mechanically break down food, salivary glands secrete enzymes to start breaking down carbohydrates, the tongue enables taste and movement of contents, and mucous membranes keep cavity moist. Decay of the teeth and Plaque is visible on the Depends on extent but Teach patient essentials inflammation of the surfaces of teeth. should be directed by of good oral hygiene. If gums. Caused by poor dentist. pain occurs, instruct hygiene of the oral patient about gargles or cavity: retention of food, rinses. Also instruct saliva, acids. Causes patient about need for increased bacteria and routine dental exams. promotes inflammation and tissue breakdown n erosion of the A visible lesion which A membranes within the may have exudates or oral cavity. May be due other signs of infection. to bacterial or fungal infection, cancer, or poor oral hygiene. n infection with C. A Albicans, a fungus. Sometimes a result of poor hygiene or the result of antibiotics for other infection. Treatments epends of primary D cause of lesions. Oral hygiene important to prevent infections early white covering of A P ntifungal medications mucous membranes, such as nystatin / especially tongue. Often mycostatin. creates pain in mouth and throat I nspect oral cavity for lesions, provide gentle oral care and rinses, encourage nutrition of soft foods and teach to perform oral hygiene after every meal. I nspect oral cavity for s/s, especially if patient on antibiotics or unable to brush own teeth. Teach patient essentials of good oral hygiene and cleaning of items placed into mouth. Encourage adequate nutrition and provide soft or pureed foods until pain diminishes. Gastrointestinal (GI) Disorders Oral Cancer Esophagus Esophagitis alignancy of lips, M tongue, cavity, or pharynx. Various types of cancer possible. Alcohol, tobacco, and AIDS are all risk factors. ppears as an ulceration A or Leukoplakia (white area) which will not heal or rub off. 2 adiation therapy is R primary treatment but can lead to nutrition issues. irway management A required for advanced cases. Provide and promote nutrition. Supportive care necessary when body image has been affected muscular tube between the mouth and stomach. Uses peristalsis to move oral contents into the stomach A for digestion. The esophageal (cardiac) sphincter stops the backward motion of contents from stomach. Inflammation of the esophagus due to multiple etiologies. See below for specific conditions chalasia A (aka cardiospasm or esophageal stricture) he inability of a muscle T to relax, especially the cardiac sphincter between the esophagus and stomach. Causes decreased peristalsis of the esophagus. ood is unable to enter F the stomach, thus causes extreme malnutrition, dysphagia, and regurgitation. Bad breath common due to retention of food in esophagus. urgical dilatation of the S esophageal sphincter is often required. Medications to dilate or relax the cardiac sphincter. bserve for weight loss O and other signs of malnutrition. Encourage nutrition such as high-nutrient liquids or alternative intravenous nutrition. Maintain airway as aspiration possible. Esophageal Reflux (GERD) I nflammation and erosion of the esophagus caused by the backward flow of gastric contents and acids. yrosis – heartburn. Pain P in the substernal area often described as burning. Sometimes presumed to be cardiac angina until ruled otherwise. Regurgitation causes acid taste in mouth or throat. GD to visualize E esophagus and gastric sphincter. Antacids, PPI, H2 receptor antagonists, anti-ulcer medications, and promotility agents. If severe, surgical fundoplication is I nstruct patient to remain in sitting position for 1-2 hours after any oral intake. Education about diet and lifestyle changes. Gastrointestinal (GI) Disorders 3 erformed to strengthen p the sphincter Barrett’s Esophagus A complication of untreated GERD in which the normal esophageal lining is replaced with columnar epithelium. ondition pre-disposes C person to esophageal cancer Esophageal Varices ilated collateral blood D vessels in the esophagus as a complication of portal hypertension. Most often seen in alcoholic cirrhosis. Complications include hemorrhage in the esophagus, anemia, and death. ften presentation is O upper GI bleeding or hematemesis. Esophageal Cancer alignancy in the M ysphagia most D esophagus, which can be common presentation. adenocarcinoma or squamous cell carcinoma. Risk factors include achalasia, Barretts esophagus, alcoholism, or smoking. ncourage patient to E have condition monitored regularly ontrol of bleeding C paramount but often difficult. NPO status if bleeding. Esophageal banding procedure to prevent further hemorrhage. aintain NPO status M during acute stage, then teach patient about diet to prevent irritation to dilated varices. Monitor labs and administer medications as ordered. Educate patient about risk factors and provide resources for alcohol treatment. arly detection needed E for optimum outcomes. Positive diagnosis through EGD with biopsy. Chemotherapy and radiation common treatments. Surgical interventions include removal of affected portion and gastrostomy placement. irway maintenance A required. Education about risk factors, diet, and treatments. Provide oral hygiene and nutrition. Support patient with body image issues. Gastrointestinal (GI) Disorders Stomach Gastritis Peptic Ulcers Stress Ulcers 4 sing both mechanical and chemical processes, the stomach is the primary site of food breakdown for U digestion. Contains hydrochloric acid to begin digestion of proteins. Chyme, a semi-liquid substance, is produced from the contents and continues to move through the pyloric sphincter into the intestines. Inflammation of the Epigastric or abdominal Symptom management Check stools of occult gastric lining. Can be pain, nausea, vomiting, (pain control, blood, O&P, or culture. caused by excessive loss of appetite. May antiemetics, PPI or Maintain NPO status acid, organisms, or also have diarrhea or GI anti-ulcer, antibiotics). when severe symptoms. stress. Can lead to bleeding. EGD or colonoscopy Patient education about ulcerations, perforation, required for diagnosis if risk factors and or GI bleeding. Acute or bleeding occurs. treatment regimens. chronic condition. lceration of the GI tract U as a result of acids or pepsin imbalances. May also occur as a result of stress, use of NSAIDs, aspirin, or other medications which damage the mucosal lining. H.Pylori bacterium most common causative organism. Gastric Ulcers - Ulceration within the stomach.Duodenal Ulcers -Ulceration within the duodenum. ain, often described as P burning and located in epigastric region. Pain usually associated with food intake as acids are secreted and irritate the ulcer. GD for diagnosis. E Biopsy for H.Pylori. heck stools for occult C blood or sudden increase in pain (possible Antibiotics for H. Pylori perforation). Insertion (Flagyl, TCN, and maintenance of NG Amoxicillin, tube for gastric Clarithromycin). distension and removal of contents. lso: Dyspepsia - A nausea, vomiting, and diarrhea common. lcerations of the GI U ymptoms same as with S tract due to stress. peptic ulcers but occur at Common in hospitalized times of stress patients, especially those ducation about dietary E changes to reduce irritation – small, frequent meals preferred. ducation about risk E factors. revention best option in P hospitalized patients. Prophylactic treatment with PPIs most common onitor patient for s/s M presence of ulcers. Education of patient and family about prophylactic treatment. Gastrointestinal (GI) Disorders 5 in critical care or undergoing surgery. Gastric Cancer Intestines Irritable Bowel Syndrome alignancy in the M stomach, often in pyloric area. Often as complication from repeated injury to mucosal lining due to ulcers, smoking, diet, or concurrent disease process. Easily metastasizes to liver, spleen, pancreas, or esophagus as well as lymph nodes. ymptoms often result S of metastasis. Poor appetite, weight loss, and cachectic appearance. Also, vague epigastric discomfort, feelings of stomach fullness, anorexia, weakness, melena, hematemesis, anemia. Pernicious anemia development. iagnosis made through D endoscopic examination and biopsy. CEA (lab) with positive result. reatment includes T surgical removal of tumor or portion of stomach involved. eeding tube placement F into jejunum common. atient teaching and P support required, especially as prognosis very poor at time of diagnosis. Promote adequate alternative nutrition. Post-op care includes wound management, airway management, bleeding, and nutrition. he small intestine is approximately 20 feet long and contains the duodenum, jejunum, and ileum. 90% of T digestion takes place here. In the duodenum the juices from the gallbladder (bile) and pancreas enter through the common bile duct to further digest foods. The colon is approximately 3 feet long beginning at the illeal-cecal junction and contains the cecum, directional (ascending, transverse, descending) colon, sigmoid colon, and rectum. isorder causes D intermittent periods of diarrhea and constipation as well as abdominal pain. Caused by hypersensitivity of bowel wall, especially in times of stress. bdominal pain, often A relieved by defecation. Flatulence, constipation and diarrhea. Stools may appear to have mucous in them. edical management is M primarily directed towards symptoms. Stress reduction also promoted. ducation about diet, E stress, and use of medication and alternative means paramount. Teaching: High-fiber diet and limit in gas-producing foods. Gastrointestinal (GI) Disorders 6 Chronic Inflammatory C hronic diseases include constant but controlled symptoms and exacerbations of more serious symptoms in Bowel Disease an intermittent basis. Inflammatory diseases are often related to immune responses and may be genetic. Ulcerative Colitis Continuous Frequent episodes of Colon resection often Teaching about diet, inflammation and Diarrhea with blood or required. surgery, and stress ulcerations in the pus. Abdominal cramps control. Pre-procedure mucosa and submucosa at onset of each stool Medications: Anti bowel prep, post-op of the colon. May lead to common. May lead to inflammatory, wound care, teaching megacolon, fistulas or incontinence of stool and antidiarrheal, antibiotics, ostomy care. Emotional perforations of colon. severe electrolyte and corticosteroids used. support necessary due to High risk for disturbances. body-image disturbance. development of colon cancer. Crohn’s Disease I ntermittent inflammation and ulceration anywhere within the GI tract and affects all layers of the bowel wall. May lead to bowel obstruction (from scar tissue development) , fistulas, fissures, and abscesses. iarrhea (steatorrhea), D fatigue, abdominal pain or cramps, weight loss, and fever. Weight loss, electrolyte imbalance, and malnutrition develop due to inability of intestines to absorb nutrients. GD or colonoscopy – E tissue with inflammation and often cobblestone appearance. emission is primary R objective. Recurrence is frequent edications: Anti M inflammatory, corticosteroids, and vitamins. urgical interventions S when severe bleeding or perforation occurs. utrition support N necessary. Tube feeding or TPN often needed. Dietary teaching includes low residue, high protein, high calorie diet. areful I/O, fluid C encouragement, and emotional support needed. Skin (peri) care required with frequent stooling. Post-op care and teaching. Gastrointestinal (GI) Disorders Diverticulosis Diverticulitis Peritonitis ondition in which C pouch-like herniations occur in colon, especially in sigmoid. Inflammation of Diverticulum in colon. Can lead to obstruction, perforation, peritonitis, and septicemia ymptoms occur only S with perforation or inflammation. I nfection within the abdominal (peritoneal) cavity and tissues. Often as result of perforation, abscess rupture, other infection of an organ, or surgical infection. Infection can cause necrosis of organs and tissues within abdomen. Bacteria must have a fluid environment to flourish. bd. Pain: rebound A tenderness, muscular rigidity, and spasms are common. Fever, nausea, and vomiting often occur. Abdominal distension (look), tympanic bowel sounds (listen), and firmness/rigidity with tenderness (feel). Tachycardia, ever, abdominal pain, F elevated WBCs. Diarrhea or constipation common. 7 iagnosis made by GI D radiographic exams (barium enema) or colonoscopy. ursing care includes N teaching about disease and diets: high fiber, low residue and nothing with seeds. I n acute episodes, NPO status and gastric decompression required. Antibiotics for causative organism or prophylaxis for peritonitis owel prep for B colonoscopy or surgery. If ostomy created, ostomy care and teaching required. Post op care includes Surgical intervention monitoring for return of may become necessary if bowel function, obstruction or infection, and wound perforation occurs. care. Resection (removal) of affected colon, often with colostomy. -ray shows “free air”. X Aggressive antibiotic therapy required. Surgical correction of cause. Sometimes open laparotomy to visualize and remove areas of pus or exudate performed and wound left open for further lavage until signs of infection decreased, then closed in additional surgical procedure. ollect stool, urine, and C blood cultures. Insert and maintain NG tube to suction to relieve distention. Alternative nutrition required. Pre and Post-op care. Strict sterile technique with any wound care. Gastrointestinal (GI) Disorders 8 yperthermia, and h hypotension also occurs. Paralytic Illeus ommon complication C of surgery or hospitalization. Anesthesia and immobility often temporarily paralyzes the bowels. bdominal distension, A nausea and vomiting, liquid stools, and abdominal Pain. Obstruction bstruction can occur anywhere within the O intestinal tract. Can be due to retained stool, tumor, stricture, scar tissue, or foreign body. edical and nursing management depends on the M cause of obstruction. Appendicitis I nflammation or infection of the appendix, often caused by obstruction of the entry point and infection with E. Coli bacteria. Most common in teen years. mergent surgical E removal of inflamed appendix (appendectomy) required. Laparotomy and lavage of periotoneum if perforated or ruptured. ebound tenderness in R RLQ (McBurney’s point). Rigid abdomen and guarding. Nausea, vomiting, fever, hypoactive or absent bowel sounds. ain often diminishes if P ruptured, but signs of peritonitis begin. oal is to prevent from G occurring. Slow introduction of nutrition, medications to stimulate gastric motility, and gastric decompression common. urses must encourage N early ambulation and mobility in post-op period to prevent. Diet should be advanced only when patient has active bowel sounds. If occurs, enemas may be required. Harris flush enema helps relieve colon impaction and is more effective than other enemas. ost-op care including P monitoring of fever and signs of infection. Age-related care needed. Pain control only after MD has seen patient so pain is not masked. Gastrointestinal (GI) Disorders Colorectal Cancer alignancy within the M colon or rectum. 3rd most prevalent cancer in the US. Risk factors include history of other colon disorders and heredity. ymptoms include those S of other pre-disposing diseases. Constipation common when tumors obstruct passage. Hemorrhoids ilated veins in the anal C D onstipation, rectal canal either interior or bleeding, and anal exterior. Most common pruritis. heal problem in humans. Occurs with any increase in abdominal pressure such as chronic constipation, pregnancy, portal hypertension, or prolonged sitting or standing. 9 asily diagnosed on E routine colonoscopy. Chemotherapy, radiation, and surgery are required to remove tumors. romote routine P colorectal exams and CEA tests for patients at risk or >50 years old. Post-op care, ostomy care, and extensive teaching necessary. Emotional support needed as surgery may create body-image disturbances. reatment directed at T cause. Stool softeners, fiber laxatives, and symptom relief. Rubber-band ligation common. Rarely is surgery necessary (hemorrhoidectomy). each about diet and T control of symptoms. Gentle peri care required to prevent rupture. Emotional support needed. Accessory Organs Although not a part of the digestive system, these organs are important to the digestive process. Liver argest glandular organ in body. Produces bile, manufactures cholesterol, produces coagulation factors, L filters toxins and bacteria in bloodstream, detoxifies poisons, converts ammonia to urea, stores and converts glycogen to glucose, and breaks down waste from protein metabolism. Gastrointestinal (GI) Disorders Cirrhosis condition in which A fibrous scar tissue replaces the functional areas of the liver. Blood vessels and ducts within the liver dilate, constrict, and change pathways. This leads to necrosis and tissue destruction. Digestive and coagulation issues occur. isk factors include R alcoholism and chronic hepatitis. Liver Cancer alignancy of the liver. M Once rare in the US, the incidence of primary liver cancer has increased due to the increase of Hepatitis C. Cancers from elsewhere 10 lu-like symptoms, F weakness, abd pain (RUQ), dyspepsia, diarrhea (yellowish), proteinuria and orange/brown urine, dry skin and pruritis, anemia, ascites, lower extremity edema, upper body muscle atrophy, Hepatomegaly, jaundice (skin and sclera), ecchymosis, and spider telangiectasis. Confusion and lethargy as ammonia builds up. ab results include L elevated bilirubin and liver enzymes (AST, ALT, LDH, GGT), elevated PT/INR and ammonia, low blood glucose, protein, and cholesterol. Treatment is to eliminate cause and treat symptoms including prevention of hemorrhage. ERCP (endoscopic retrograde cystic pyelogram) for diagnosis of bile duct involvement, paracentesis to remove ascites fluid, TIPS (transjugular intrahepatic portosystemic shunt) for portal hypertension, or transplant may be necessary. each patient to T eliminate alcohol and acetaminophen. Provide nutritional support including high calorie and nutrient, low fat and sodium. Protein restrictions during acute exacerbations. ymptoms are similar to S those of cirrhosis. Bleeding is especially concerning as coagulation factors are involved. urgical intervention S possible in only 5% cases as often disease is very advanced on diagnosis. Lobectomy possible if cancer is localized. alliative care P interventions. rovide transfusions P (RBCs and plasma) as ordered, prevent bleeding, promote safety, and prevent skin breakdown are also necessary nursing interventions. Gastrointestinal (GI) Disorders 11 e asily metastasize to the liver due to portal circulation. Hepatitis A cute Inflammation of A the liver caused by the hepatitis A virus. Hep A is most often caused by fecal/oral contamination by infected person at restaurants or other food establishments egins with flu-like B symptoms of vague abd. Pain, nausea, vomiting, fever, and malaise. Later symptoms include jaundice. ymptomatic care. S Gamma globulin administration as soon as possible after diagnosis. Vaccines are available and required for persons traveling outside US. ymptomatic care. Teach S patients about disease transmission and need for good hand hygiene. eportable to public R health department. Hepatitis B cute or chronic A inflammation of the liver caused by the Hep B virus transmitted through blood and body fluids, breast milk, and sexual contact. ealth care workers and H babies usually receive a vaccination (serial) to prevent Hep B. I V drug addicts are at high risk due to sharing of needles and other personal items. egins with flu-like B symptoms of vague abd pain, nausea, vomiting, diarrhea, fever, and malaise. Later symptoms include those related to liver failure such as jaundice, abd distension/ascites, bleeding. hronic disease with C acute exacerbations. etected through D positive Hepatitis B antigen in blood sample. Other labs similar to cirrhosis. ymptom control and S prevention of spread required. Reportable to public health department. edications include M combination therapy with Interferon, hepsera, and epivir to decrease the viral load. ymptomatic care. Teach S patients about disease transmission, prevention of spread, and life-long use of medication regimen. Prevention of complications such as bleeding, encephalopathy, and ascites. Gastrointestinal (GI) Disorders Hepatitis C n illness caused by the A Hep C virus and transmitted through infected blood. ep C was commonly H transmitted in blood transfusions prior to 1992 when screening became available. egins with flu-like B symptoms of vague abd. Pain, nausea, vomiting, fever, and malaise. Later symptoms include jaundice, abd distension, and liver failure. urses are at high risk of N contracting Hep C unless effective barrier precautions (PPE) are used. There is NO vaccine available at this time. 12 etected through D positive Hepatitis C antigen in blood sample. Other labs similar to cirrhosis. Other treatment options similar to Hepatitis B, but transplant possible if patient proves avoidance to high-risk behaviors. Unfortunately, the new liver can also become infected with the virus. ymptomatic care. Teach S patients about disease transmission, prevention of spread, and life-long use of medication regimen. Prevention of complications such as bleeding, encephalopathy, and ascites. ymptom management, S blood and plasma transfusions, bleeding control, paracentesis for ascites, transplant. Supportive care. omeless, IV drug H addicts, and alcoholics are high risk End stage Liver Disease he result of chronic T J aundice, ascites, lower inflammation and extremity edema, portal scarring of the liver hypertension which prevents adequate functioning. Usually result of Hepatitis or cirrhosis. Not reversible Gastrointestinal (GI) Disorders 13 e xcept through transplant Gallbladder Cholecystitis Cholelithiasis tores and releases bile in response to fats eaten S Inflammation of the gall Indigestion, abdominal bladder. Can be cause or epigastric (referred) by obstruction in biliary pain especially after ducts, gallstones, or intake of fatty food, tumor. If stone lodges in nausea and vomiting, common bile duct, steatorrhea or pancreatitis can also be clay-colored stools, dark seen. or tea colored urine. Symptoms occur only Development of stones when obstruction occurs. within the gallbladder ymptoms often mimic S those of cardiac angina. Pancreas Pancreatitis holecystectomy is C surgery of choice. May be laparoscopic but open choleycystecomy is required if gallbladder ruptures and peritonitis occurs. ithotripsy can help L break stones into passable sizes and prevent need for surgery. ducate about need for E Low-fat diet and avoidance of spicy foods. ost op care includes P management of T-tube (which drains bile), incision care, early ambulation, and progressive nutrition. *If laparoscopic * surgery is done, the CO2 used to inflate the abdomen during surgery sometimes is trapped under the diaphragm and causes “chest pain” or pressure. Early ambulation helps relieve this pressure. Produces and releases several digestive enzymes: protease, lipase, and amylase. Sodium bicarbonate is also secreted to help neutralize the hydrochloric acid from the stomach before the chime continues through the digestive tract. Inflammation of the Causes extreme pain, NPO status to allow the Maintain strict NPO pancreas caused by nausea and vomiting, decrease in enzyme status including no use either an organism or by especially after any oral production. Antibiotics of lemon-glycerin repeated irritation by intake. Elevated if bacterial infection swabs. Oral care to keep substances such as pancreatic enzymes suspected. Monitor labs, cavity moist but prevent Gastrointestinal (GI) Disorders Pancreatic Cancer a lcohol. Can also be caused by obstruction of the common bile duct which blocks release of pancreatic enzymes Malignancy of the pancreas. Invasive and aggressive, mortality high and rapid and often occurs in people of middle age. Mortality often as high as 80% within one year. ajor factor in m diagnosis. ague symptoms V initially, progresses to abdominal pain, jaundice. Symptoms of hyperglycemia prevalent. 14 e specially enzymes. Elevated Lipase most pertinent lab. s wallowing of secretions. Pain management and IV fluids necessary. Teach patient about risk factors Diagnosis often made in Post-surgical mediation late stage, therefore must include often inoperable. replacement of pancreatic enzymes and Whipple procedure insulin. Care is mostly (removal of part of palliative and pancrease, antrum of supportive. Because stomach, duodenum, and often occurs in middle gallbladder with multiple age, patients may have anastomoses) is surgical young families which intervention which must need support. be followed by chemotherapy. Overall Nursing Considerations: Nutrition and elimination are major factors in all disorders of the GI system. 1. Depending on the location of the disorder, enteral feeding may be possible through alternative sites below the level of disease. 2. Depending on the location of the disorder, alternatives in elimination may be necessary. 3. During acute phases of disease, NPO status is required to rest the GI system; reintroduction of enteral nutrition occurs slowly. 4. Nutrition includes control of fluids and electrolyte absorption. Fluid balance important as is electrolyte maintenance or supplements. 5. Many disorders have similar signs and symptoms as well as similar nursing interventions. 6. For any disorder of the upper GI tract it is important to first maintain airway by preventing aspiration of gastric contents to lungs
