“Air-Fluid Levels” seen in small bowel obstruction

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Supplemental
Learning Objects:
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Flash Cards (Terminology)
See the email I sent you yesterday
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G-I System Games
Meds for the Gastro Intestinal System http://www.quia.com/rr/612817.html
G-I System Part I http://www.quia.com/rr/612592.html
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GI System Part 2 http://www.quia.com/rr/612897.html
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G-I System Part 3 http://www.quia.com/rr/612899.html

LEARNING OUTCOMES
At the conclusion of this learning activity, the nurse will be able to:
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1.
Describe the mechanism of action, signs and symptoms, complications, treatments and nursing interventions for gastrointestinal disorders
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2.
Compare and describe the pathophysiology for
Crohn’s Disease and ulcerative colitis
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3.
Explain pathophysiology, types, risk factors, and treatment for gastritis

LEARNING OUTCOMES
At the conclusion of this learning activity, the nurse will be able to:
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4
. Explain the use of radiography in diagnosis of GI health problems
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Discuss the physical assessment findings in a client with digestion, nutrition, and elimination health problems
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Describe procedures, risk factors, potential complications, nursing monitoring, and interventions for scope procedures

LEARNING OUTCOMES
At the conclusion of this learning activity, the nurse will be able to:
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7.
Describe preparation, post-op interventions, and teaching needs for a patient with a new colostomy
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8.
Analyze medications, usage, precautions, side effects, and mechanism of action
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9.
Apply the nursing process to medication administration and usage

LEARNING OUTCOMES
At the conclusion of this learning activity, the nurse will be able to:
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10.
Explain causes, sign/ symptoms, nursing interventions, treatments, and complications of a bowel obstruction
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11.
Explain pathophysiology, risk factors, and medical management of gastrointestinal disorders
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12.
Explain causes of bowel obstruction

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Terminology
A&P
GI Disorders
GERD
Hiatal Hernias
PUD
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G-I Pharmacology
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Antacids
Prokinetic Agents
H 2 Receptor Antagonists
Proton Pump Inhibitors
Mucosal Barriers
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G-I Diagnostic
Testing

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-algia
-dynia volvulus dyspepsia regurgitation hypersalivation pyrosis eructation dysphagia odynophagia
-enter/o
-col/o
-gastr/o
-esophag/o
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 ulceration aspiration ischemia diverticula diverticulitis colostomy illeostomy tenesmus steatorrhea diarrhea fistula defecation
--rrhea steato-

Length =
27-30 feet
(9-10 meters)

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Secretion
Digestion
Absorption
Motility
Elimination

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Involves: esophagus, stomach, small intestines, gallbladder, and large intestines
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Parasympathetic: stimulates motor and secretory activity, relaxes sphincters

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Teeth: chewing
Mucin and amylase: breaks down food
Tongue
Pharynx
Esophagus: 2 sphincters

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Ingestion of food
Food reservoir
Digestive process:
-movement
-gastrin secretion: hydrochloric acid and pepsin
-chyme

Physical Assessment
Inspection
Palpation
Percussion
Auscultation
KEY ASSESSMENTS
Lab Monitoring
***Diagnostic Testing
Care Planning
Plan for client adl’s,
Monitoring, med admin.,
Patient education, more…based
On Nursing Process:
A_D_O_P_I_E
***Preparing for Diagnostic Tests
Nursing Skills:
NG Tube Insertion
Enteral Feedings
Anti-Acids (Antacids)
Prototype: aluminum hydroxide gel (Amphojel)
Prokinetic Agents:
Prototype: metoclopramide
(Reglan)
Histamine 2 Receptor Agonists
Prototype: ranitidine hydrochloride (Zantac)
Proton Pump Inhibitors)
Prototype: omeprazole (Prilosec)
Mucosal Barriers
Prototype: sucralfate (Carafate)
Disease Specific
Medications:
Nursing Interventions &
Evaluation
Execute the care plan, evaluate for
Efficacy, revise as necessary

INFLAMMATORY
Upper GI
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Gastroesphageal Reflux
Disease
Ulcers
Gastritis
NON-INFLAMMATORY
Upper GI
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Gastroesphageal Reflux
Disease
Hiatus Hernia/hernias

INFLAMMATORY
Lower GI
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Acute Appendicitis
Peritonitis
Ulcerative colitis
Crohn’s Disease
Diverticulitis
NON-INFLAMMATORY
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Lower GI
Constipation & Diarrhea
Irritable bowel syndrome
Dumping syndrome
Intestinal Obstruction
Hemorrhoids and polyps
Malabsorption syndrome

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Acute local inflammation:
-edema, pain, heat, and redness
-exudates may or may not be present
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Acute systemic inflammation:
-fever
-leukocytosis (increased WBC)
-plasma protein synthesis

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Chronic Inflammation:
-increased duration>2 weeks
-proceeds after unsuccessful acute inflammatory response
-may occur without distinct inflammation

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GERD : common condition
(affects 14% of Americans) characterized by gastric content and enzyme leakage into the esophagus.
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These corrosive fluids irritate the esophageal tissue and limit its ability to clear the esophagus.
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Causes are related to the weakness or transient relaxation of the lower esophageal sphincter (LES) at the base of the esophagus, or delayed gastric emptying.
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The chief symptom of GERD is frequent and prolonged retrosternal heartburn
(dyspepsia) and regurgitation
(acid reflux) in relationship to eating or activities.
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Other symptoms can include chronic cough, dysphagia, belching (eructation), flatulence (gas), atypical chest pain, and asthma exacerbations.

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Backward flow of gastrointestinal contents into esophagus

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Inappropriate relaxation of lower esophageal sphincter (food, medication, etc)

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ETIOLOGY: 
CONTIBUTING FACTORS:
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Any factor that relaxes the
LES, such as smoking, caffeine, alcohol, or drugs.
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Any factor that increases the abdominal pressure, such as obesity, tight clothing at the waist, ascites, or pregnancy.
Older age and/or a debilitating condition that weakens the LES tone.
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Excessive ingestion of foods that relax LES, e.g., fatty / fried foods, chocolate, tomatoes, alcohol
Distended abdomen from overeating or delayed emptying
Increased abdominal pressure resulting from obesity, pregnancy, bending at the waist, ascites or tight clothing at the waist
Drugs that relax the LES, such as theophylline, nitrates, calcium channel blockers, anticholinergics, and diazepam
(Valium)
Drugs, such as NSAIDs, or events (stress) that increase gastric acid
Debilitation or age-related conditions resulting in weakened LES tone
Hiatal hernia (LES displacement into the thorax with delayed esophageal clearance)
Lying flat

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Classic symptoms:
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Other symptoms:
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Dyspepsia, especially after eating an offending food / fluid, and regurgitation.
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Symptoms from throat irritation (chronic cough, laryngitis), hypersalivation, eructation, flatulence, or atypical chest pain from esophageal spasm.
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Chronic GERD can lead to dysphagia
(difficulty swallowing).

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Irritation to esophagus and mucosal injury
Aspiration
Barrett’s esophagus
Esophageal erosions, ulcerations, or tears
Chronic bronchitis
Asthma (adult onset)
Barrett’s Esophagus

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History and Physical
Dietary monitoring
24 hour ambulatory pH monitoring
Esophageal manometry
Endoscopy

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Barium Upper GI:
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Endoscopy :
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Prepare the client for the procedure.
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Conscious sedation to observe for tissue damage
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Post procedure:
Assess for bowel sounds and potential constipation.
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Post procedure:
Verify gag response prior to providing oral fluids or food.

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Goals: relief of symptoms and prevent complications
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Life style changes:
-Diet: smaller meals more frequent, limit or avoid carbonated beverages, coffee, chocolate, fats, mints, spicy or acidic food

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Life Style Changes:
-Elevate HOB, sleep on LEFT side
-AVOID smoking and ETOH
-Avoid tight or restrictive clothing
-Lose weight

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Antacids,
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E.g., aluminum hydroxide (Mylanta), neutralize excess acid. -- should be administered when the acid secretion is highest (1 to 3 hr after eating and at bedtime). --Antacids should be separated from other medications by at least 1 hr.
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Proton Pump
inhibitors (PPI)
E.g., pantoprazole
(Protonix),omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid) reduce gastric acid by inhibiting the cellular pump necessary to secrete it.
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Histamine 2 (H2) receptor antagonists
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E.g., ranitidine (Zantac), famotidine
(Pepcid), nizatidine (Axid), and cimetidine (Tagamet), reduce the secretion of acid.
The onset is longer than antacids, but the effect has a longer duration.
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Studies show that PPI are more effective than H2 antagonists.
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Other Medications
E.g., metoclopramide hydrochloride (Reglan), increase the motility of the esophagus and stomach.

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Endosopic therapy: BESS (Bard
EndoCinch Suturing System), Stretta, and
Enteryx procedures
Surgery: Laparoscopic Nissen
Fundoplication (The”Gold Standard”)

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Post operative or procedure management:
- Monitor vital signs
-Monitor swallow/gag reflex
-Assess for abdominal pain
-Monitor for bleeding
-Assess incision sites
-Assess and monitor NG tube

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Altered Nutrition
Acute or Chronic pain
Risk for aspiration
Alteration in sleep patterns
Knowledge Deficit
Impaired Swallowing
Potential for complications

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EDUCATION:
-Medication Compliance
-Dietary changes
-Lifestyle changes
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Post operative or procedure management

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Involve protrusion of the stomach wall through the esophageal hiatus of the diaphragm

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Sliding: (Most Common) esophagogastric junction and portion of the fundus slide upward through the esophageal hiatas
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Rolling: the fundus and portions of the stomach rolls through the esophageal hiatas

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Muscle weakness
Anatomic defects
Congenital weakness
Prolonged increased abdominal pressure
Surgery
Trauma
Obesity

SLIDING
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Adult onset asthma
Symptoms worse after meals
Symptoms worse in recumbent position
ROLLING
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Feeling full after eating
Breathlessness or feeling of not be able to breath
Chest pain like angina feeling of suffocation
Symptoms worse in recumbent position

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Barium Swallow Study

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Diet
Medications (GERD)
Weight Loss
Avoid late night food
Avoid straining/vigorous exercise
No restrictive or binding clothes
Surgical repair:
Laparoscopic Nissen Fundoplication

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Education:
-Medication compliance
-Dietary changes and monitoring
-Lifestyle changes and monitoring
Post-op management
Assess coping mechanisms

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A mucosal lesion of the stomach or duodenum

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Results when gastric mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin

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Gastric Ulcers:
-a break in mucosal barrier, hydrochloric acid injures epithelium
-back diffusion of acid or dysfunction of the pyloric sphincter
-Mucosal Inflammation
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Duodenal Ulcers:
-increase acid content dumped into duodenum

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“Stress Ulcers:”
-Unknown etiology, presence of increased levels of hydrochloric acid, ischemia, and erosive gastritis seen
-Trauma, head injuries, respiratory failure, shock sepsis

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Intermittent sharp, burning, or gnawing pain
Gastric pain occurs to the left and may be relieved by food
A change in appetite with or weight loss
(gastric)
Nausea or vomiting
Bloody stools

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Frequent burping or bloating
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Duodenal pain is usually to the right of the epigastruim and pain occurs 90 min-3 hours after eating.
Pain often awakes patient’s up at night
A change in appetite with weight gain
(duodenal)

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History and Physical (family history)
Endoscopy (EGD)
Stool for occult blood
H-pylori test (carbon ureas breath test)
Gastric secretion studies
Biopsy

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Drug Therapy
Diet Therapy
Lifestyle Changes
Surgical Intervention

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Actual pain
Anxiety/Fear
Ineffective individual coping
Potential fluid volume deficit
Knowledge deficit
Disturbed sleep pattern
Nutrition deficit

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Assessment of symptoms and family history
Assess for complications
Medication and diet education
Monitor pain management
Monitor nutritional status
Encourage smoking and alcohol cessation

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Gastrointestinal bleeding
Gastric Perforation
Pyloric obstruction

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GI bleed
Perforation
Pyloric obstruction

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Vagotomy & Pyloroplasty
Gastroenterostomy

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Assess patient
Assess vital signs
Monitor gastric decompression and output
Monitor labs
Monitor continued ileus
Monitor for gastric delay emptying and recurrent ulcerations

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(Medication Information, etc…)

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Pharmacological Action
Neutralize gastric acid and inactivate pepsin.
Mucosal protection may occur by the antacid’s ability to stimulate the production of prostaglandins.
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Therapeutic Uses
Treat peptic ulcer disease (PUD) by promoting healing and relieving pain.
Symptomatic relief for clients with GERD.
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Nursing Interventions and Client
Education
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Clients taking tablets should be instructed to chew the tablets thoroughly and then drink at least 8 oz of water or milk.
Teach the client to shake liquid formulations to ensure even dispersion of the medication.
Compliance is difficult for clients because of the frequency of administration.
Administered seven times a day: 1 hr before and 3 hr after meals, and again at bedtime.
Teach clients to take all medications at least 1 hr before or after taking an antacid.
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Evaluation of Medication
Effectiveness
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Depending on therapeutic intent, effectiveness may be evidenced by:
Healing of gastric and duodenal ulcers.
Reduced frequency or absence of GERD symptoms.
No signs or symptoms of GI bleeding.
Back to Concept Map

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Pharmacological Action
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Block dopamine and serotonin receptors in the chemoreceptor trigger zone (CTZ), and thereby suppress emesis.
Prokinetic agents augment action of acetylcholine which causes an ↑ in upper
GI motility.
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Therapeutic Uses
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Control postoperative and chemotherapyinduced nausea and vomiting.
Prokinetic agents are used to treat GERD.
Prokinetic agents are used to treat diabetic gastroparesis.
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Side Effects / Adverse Effects
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Extra Pyramidal Symptoms (EPS)
Sedation
Diarrhea
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Contraindications / Precautions
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Contraindicated in clients with GI perforation, GI bleeding, bowel obstruction, and hemorrhage
Contraindicated in clients with a seizure disorder due to ↑ risk of seizures
Use cautiously in children and older adults due to the ↑ risk for EPS.
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Nursing Interventions and Client
Education
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Monitor clients for CNS depression and EPS.
Can be given orally or intravenously. If dose is < 10 mg, it may be administered undiluted over 2 min.
If the dose is > 10 mg, it should be diluted and infused over 15 min. Dilute medication in at least 50 mL of D5W or lactated Ringer’s solution.
Evaluation of Medication
Effectiveness
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Control of nausea and vomiting
Back to Concept Map

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Pharmacological Action
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Suppress the secretion of gastric acid by selectively blocking H2 receptors in parietal cells lining the stomach.
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Therapeutic Uses
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Gastric and peptic ulcers, gastroesophageal reflux disease (GERD), and hypersecretory conditions, such as
Zollinger-Ellison syndrome.
Used in conjunction with antibiotics to treat ulcers caused by H. pylori.
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Therapeutic Nursing Interventions and Client Education
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Encourage client to avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).
Ranitidine can be taken with or without food.
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Treatment of peptic ulcer disease is usually started as an oral dose twice a day until he ulcer is healed, followed by a maintenance dose, which is usually taken once a day at bedtime.
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Evaluation of Medication
Effectiveness
Depending on therapeutic intent, effectiveness may be evidenced by:
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Reduced frequency or absence of GERD symptoms (e.g., heartburn, bloating, belching).
No signs or symptoms of GI bleeding.
Healing of gastric and duodenal ulcers.
Back to Concept Map

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Pharmacological Action
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Reduce gastric acid secretion by irreversibly
inhibiting the enzyme that produces gastric acid.
Reduce basal and stimulated acid production.
Therapeutic Uses
Prescribed for gastric and peptic ulcers,
GERD, and hypersecretory conditions (e.g.,
Zollinger-Ellison syndrome).
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Precaution:
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Increases the risk for pneumonia. Omeprazole ↓ gastric acid pH, which promotes bacterial colonization of the stomach and the respiratory tract.
Use cautiously in clients at high risk for pneumonia
(e.g., clients with COPD).
Nursing Interventions and Client Education
Do not crush, chew, or break sustained-release capsules.
The client may sprinkle the contents of the capsule over food to facilitate swallowing.
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The client should take omeprazole once a day prior to eating.
Encourage the client to avoid irritating medications (e.g., ibuprofen and alcohol).
Active ulcers should be treated for 4 to 6 weeks.
Pantoprazole (Protonix) can be administered to the client intravenously.
Monitor the client’s IV site for signs of inflammation (e.g., redness, swelling, local pain) and change the IV site if indicated.
Teach clients to notify the primary care provider for any sign of obvious or occult GI bleeding (e.g., coffee ground emesis).
Evaluation of Medication Effectiveness
Depending on therapeutic intent, effectiveness may be evidenced by:
Healing of gastric and duodenal ulcers.
Reduced frequency or absence of GERD symptoms (e.g., heartburn, sour stomach).
No signs or symptoms of GI bleeding.
Back to Concept Map

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Pharmacological Action
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Changes into a viscous substance that adheres to an ulcer; protects ulcer from further injury by acid and pepsin.
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Viscous substance adheres to the ulcer for up to 6 hr.
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Sucralfate has no systemic effects.
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Therapeutic Uses
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Acute duodenal ulcers and maintenance therapy.
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Investigational use in gastric ulcers and gastroesophageal reflux disease.
(GERD)
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Nursing Interventions and Client
Education
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Assist the client with the medication regimen.
Instruct the client that the medication should be taken on an empty stomach.
Instruct the client that sucralfate should be taken four times a day, 1 hr before meals, and again at bedtime.
The client can break or dissolve the medication in water, but should not crush or chew the tablet.
Encourage the client to complete the course of treatment.
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Evaluation of Medication
Effectiveness
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Depending on therapeutic intent, effectiveness may be evidenced by:
Healing of gastric and duodenal ulcers.
No signs or symptoms of GI bleeding.
Back to Concept Map

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Blood Tests
 Complete Blood Count (CBC c Diff) 
Radiology:
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Stool Tests:
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Stool for occult blood; (Guiac)
 Stool for ova & parasites (O&P);
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Stool for Clostridium difficile (C-Diff)
Stool Culture & Sensitivity (C&S)
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Upper GI Series (UGI)
Upper GI Series with Small Bowel
Follow-Through (UGI-SBFT)
Barium Enema
Endoscopy
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Endoscopy:
Clostridium difficile
Return to
Concept Map