Part II
“Air-Fluid Levels” seen in bowel obstruction
Anti-Acids (Antacids)
Prototype: aluminum hydroxide
gel (Amphojel)
Physical Assessment
Inspection
Palpation
Percussion
Auscultation
KEY ASSESSMENTS
Lab Monitoring
Prokinetic Agents:
Prototype: metoclopramide
(Reglan)
Histamine 2 Receptor Agonists
Prototype: ranitidine
hydrochloride (Zantac)
***Diagnostic Testing
Proton Pump Inhibitors)
Prototype: omeprazole (Prilosec)
Mucosal Barriers
Prototype: sucralfate (Carafate)
Disease Specific
Medications:
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
Nursing Interventions &
Evaluation
Execute the care plan, evaluate for
Efficacy, revise as necessary













Gastritis
Dumping Syndrome
Small & Large Intestines
Appendicitis
Peritonitis
Diverticulitis
Ulcerative Colitis
Crohn’s Disease
Bowel Obstruction
Irritable Bowel Syndrome (IBS)
Hemorrhoids
Polyps
Bowel Cancer
 Inflammation
of the gastric mucosa
 Types: erosive vs. non-erosive
 Acute vs. Chronic
 S&S: Abdominal tenderness, bloating,
hematesis, melena
 Diagnostic: EGD with biopsy
 Management: see GERD
 Rapid
gastric emptying into the small
intestines usually occurs after a gastric
surgery
 Types: Early and Late
EARLY








30 min after eating
Rapid emptying
Vertigo
Syncope
Pallor
Diaphoresis
Tachycardia
palpitations
LATE








90 min-3 hr after eating
Excessive insulin release
Abdominal distention
Cramping
Nausea
Dizziness
Diaphoresis
confusion
 Lying
down after a meal
 Eliminate liquids with meals
 Avoid milk, sweets, or sugars
 Eat small frequent meals
 Consume high protein and fat with low to
moderate carbohydrate
 Pectin
Oral: slows absorption of carbs
 Octreotide SQ: blocks gastric and
pancreatic hormones
 Postprandial
B
L
O
O
D
G
L
U
C
O
S
E
L
E
V
E
L
Hypoglycemia
Increased blood glucose level increases the release of insulin.
Insulin causes the blood glucose levels to go down….
Time-----------
“The Somogyi Effect”,
a.k.a., “Rebound Effect”
 Movement
 Digestion
 Absorption
 Movement
 Absorption
 Elimination
 Acute
inflammation of veriform appendix
 Lower
right quadrant pain
 Low grade fever
 Nausea and vomiting
 Rebound tenderness @Mc Burney’s point
 Rosving sign positive
 Increased WBC
 Monitor
pain (severe rebound
tenderness)
 Monitor bowel sounds (absent)
 NPO, IVF, NO laxatives or enemas
 Surgical management:
-Open or laparoscopic appendectomy
 Ultrasound
 Abdominal
x-ray
 Abdominal CT scan
 Acute
pain
 Alteration in comfort
 Risk for injury
 Knowledge deficit
 Risk for infection
 Monitor
vital signs
 Assess bowel sounds
 Monitor pain
 Monitor lab values
 Post operative management:
-Vitals signs, bowel sounds, diet
resumption, antibiotic therapy as ordered
 Acute
inflammation of the visceral /
parietal peritoneum and endothelial
lining of abdominal cavity
 Types: primary and secondary
PRIMARY





Acute bacterial infection
Contamination of
peritoneum via vascular
system
TB (tuberculin infection)
Alcoholic cirrhosis
Leakage
SECONDARY




Usually caused by a
bacterial invasion in the
abdomen
Gangrenous bowel
Blunt or penetrating trauma
Leakage
 Rigid
board like abdomen
 Abdominal pain/tenderness
 Distended abdomen
 Nausea and vomiting
 Diminished to no bowel sounds
 No stools or flatus
 Fever
 Tachycardia
 CBC
(WBC, H&H)
 Electrolytes
 CR (creatinine) & BUN (Blood urea nitrogen)
 Abdominal x-ray
 CT scan
 Peritoneal lavage
 Surgery
 Non-surgical:
-IV fluids
-Broad spectrum antibiotics
-Intake and outputs (I&O)
-NG (nasogastric) tube
-NPO
-Pain management
 Surgical: Optimal
treatment
 Exploratory laparotomy: repair or
remove inflamed organ
 Peritonitis: EMERGENCY / Life Threatening
-Symptoms: rigid abd., distended abd.,
absent bowel sounds, high fever,
decreased urine output, hypotension
 Fluid shifts from extracellular to
peritoneal cavity
 Inflammation
of one or more diverticula.
Results when diverticulum perforates and
a local abscess forms
 Abdominal
pain, tenderness to palpation
 Elevated temperature >101, may have
chills
 Abdominal guarding, rebound
tenderness
 CT
scan
 Abdominal flat plate
 EGD
 DO NOT do barium enema with active
untreated diverticulitis
 Non
Surgical:
-Broad spectrum antibiotics
-Anticholinergics
-NPO until clear liquids tolerated
-Stop fiber therapy until attack is limited
-NO enemas or laxatives
 Surgical
-completed for ruptured peritonitis,
fistula formation, bleeding, bowel
obstruction, or unresponsive medical
management
 Health
teaching: diet, fiber, symptom
recognition, activity
 Post
op management:
-Monitor colostomy, if present
-monitor VS, urine output, wound
condition
-Psychosocial adjustment to stoma
 Ulcerative
colitis: Chronic inflammatory
process affecting mucosal lining of colon
or rectum
 10-20
liquid stools per day
 Tenesmus (Straining)
 Anemia
 Fatigue
 LLQ pain/cramping
 Wt loss
 CT
scans
 Colonoscopy or Siqmoidoscopy
 Barium Swallow studies
 Stools for O&P, occult blood, & C&S
 Labs: electrolyte panel and CBC
 Salicylate:
-inhibit prostglandins to reduce
inflammation
 Corticosteroids:
-Suppress immune system and reduce
inflammation
 Immunomodulators:
-reduce steroid use and overrides body
immune system
 Antibiotics:
-acute exacerbations prone to infection
 Anti-diarrheals:
-Symptomatic relief of severe diarrhea
 NPO
if symptoms are severe
 TPN if NPO for extended time
 Elemental formula
 Low fiber foods
 Lactose free products
 No caffeine, spices, alcohol, or smoking
 Surgery
is curative
 Total colectomy with permanent
ileostomy
 Total colectomy with continent ileostomy
(Kock’s pouch)
 Pain
acute and chronic
 Fluid volume deficit
 Alteration in nutrition
 Nutritional
assessment
 Monitoring fluid and electrolytes
 Monitor lab values
 Monitor for complications
 Monitor weight
 Psychosocial assessment
 Post operative care
 Hemorrhage/perforation
 Coagulation
problems
 Malabsorption
 Increase risk for colon cancer
 Toxic megacolon
 Inflammatory
disease of small intestines,
colon, or both (terminal ileum)
 5-10
fatty stools per day (steatorrhea)
 Flatus
 Malabsorption
 Weight loss
 Diffuse bilateral lower quadrant pain
 Fever with perforation or fistula
 Fluid, electrolyte and vitamin deficits
 CBC
 Electrolyte
panels
 Vitamin & folic acid levels
 Albumin & nutritional labs
 Barium studies
 Colonoscopy
 Drug Therapy
-Salicylate
-Corticosteriods
-Immunomodulators
-Biologic Therapy
-Antibiotics (abscess/perforation)
 TPN
for long term use
 Nutritional supplements
 Elemental supplements
 No caffeine or carbonated beverages
 No ETOH
 Prebiotics (non-digestive food
ingredients)
 Surgery
is NOT a “cure”
 Repair of fistulas
 Release of intestinal obstructions
 Partial resection with primary
anastamosis
 Ileostomy
 Intestinal
obstruction
 Fistulas
 Malabsorption
syndrome
 Liver and biliary diseases
 Kidney stones
 Arthritis
 Administering
PPN and TPN
 Provide adequate nutrition: pre-medicate
as ordered
 Assess stools: quality, frequency, amount,
and pain issues with stooling
 Assess vital signs
Teach relaxation techniques
 Education
for ileostomy or colostomy for
both client and family
 Reduce or eliminate factors that cause
diarrhea and pain
 Chronic pain management
 Provide small frequent meals with
specific dietary preferences
 Detailed abdominal assessment
SMALL INTESTINES




Pain is spasmodic
Peristaltic waves
Profuse projectile vomiting
Feculent odor to emesis
“Air-Fluid Levels” in intestinal obstruction
LARGE INTESTINES




Vague diffuse constant pain
Abdominal distention
Infrequent vomiting
Possible diarrhea
MECHANICAL






Adhesions
Tumors
Volvulus
Intussusception
Fecal impactions
Foreign Bodies / Objects
NON-MECHANICAL





Decreased peristalsis
Electrolyte imbalance
Inflammatory response
Neurogenic disorder
Vascular disorder
Foreign Body in the Colon
 Dehydration
 Perforation
 Ischemic
or strangulated bowel
 Metabolic acidosis and Alkalosis
 Chronic
disorder of diarrhea and
constipation
 No exact cause known
 Affects women 3x more then men
 Possible causes: diet and behavioral
(psychological) illness
 “Manning
Criteria:”
-abdominal pain relieved by defecation
-abdominal distention
-sensation of incomplete BM (bowel
movement)
-Presence of mucus
 Exacerbation
(flare up):
-worsening cramps
-abdominal pain (LLQ)
-diarrhea or constipation
-increased pain after eating
-nausea with defecation and mealtime
 CBC
 Serum
albumin
 Stools for occult blood
 Sigmoidoscopy
 Colonscopy
 Stress
Management
 Diet Therapy:
-Avoid lactose products, caffeine, ETOH,
sorbitol or fructose
-Increase fiber (30-40 gm)
-Fluid intake of 8-10 cups per day
-meal planning
 Monitor
Drug Therapy
-laxatives
-diarrheals / antidiarrheals
-anticholinergic
-tricyclic antidepressants
-muscarinic receptor antagonist
-antispasmatics
-5HT4 (Zelnorm)
 Swollen
or distended veins in rectal
region
 Internal & external
 Cause: pregnancy, obesity, constipation
 Symptoms: bleeding, edema, and
prolapsed
 Treatment: cold packs, sitz bath, diet,
Tucks ®, topical anesthetics, and surgery
“The Jackknife Position”
Rectal Surgery
 Small
growths covered with mucosa and
attached to the surface of intestines
 Asymptomatic-bleeding, obstruction, &
intussusception
 Benign
vs. malignant
 Colorectal
cancer
 Colon
and rectum=large intestines
 Molecular
changes
 Metastasize
& tissue
to blood, lymph, surrounding
 Purpose
for Naso-Gastric
Tubes:
 1.
Decompression
 2. Feeding
 3. Administration of
Medications
 ***4. Lavage
 General
Golden Rule
for Feeding Tubes:
 Ensure
correct
placement prior to
putting ANYTHING
DOWN a TUBE!!!
 X-Ray
Confirmation
 At
1st looks OK but
distal tip NOT SEEN
 This
tube ended up
exiting the mid
abdomen with the
feedings entering the
peritoneal cavity
 Tube
feeding formula
remaining in contact
with gastric acid can
result in the
precipitation of
casein and the
subsequent formation
of a solid mass
around the tube







Date & time
Reason for insertion
Type of tube
Size of tube
Length of tube
Nostril tube inserted
Number of attempts
required




Additional comments
Any complications
Method of placement
confirmation
Signature: name &
designate of Nurse
inserting tube

Pharmacological Action

Neutralize gastric acid and inactivate pepsin.







Evaluation of Medication
Effectiveness
Mucosal protection may occur by the antacid’s
ability to stimulate the production of
prostaglandins.

Depending on therapeutic intent, effectiveness
may be evidenced by:
Therapeutic Uses

Healing of gastric and duodenal ulcers.

Reduced frequency or absence of GERD
symptoms.

No signs or symptoms of GI bleeding.
Treat peptic ulcer disease (PUD) by promoting
healing and relieving pain.
Symptomatic relief for clients with GERD.
Nursing Interventions and Client
Education
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.
Back to Concept Map




Pharmacological Action
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.




Therapeutic Uses





Control postoperative and chemotherapyinduced nausea and vomiting.
Prokinetic agents are used to treat GERD.
Prokinetic agents are used to treat diabetic
gastroparesis.



Side Effects / Adverse Effects




Extra Pyramidal Symptoms (EPS)
Sedation
Diarrhea

Contraindications / Precautions
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.
Nursing Interventions and Client
Education
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
Control of nausea and vomiting
Back to Concept Map


Overview

Tardive dyskinesia is a disorder that
involves involuntary movements,
especially of the lower face. Tardive
means "delayed" and dyskinesia
means "abnormal movement."

Symptoms




Facial grimacing
Jaw swinging
Repetitive chewing
Tongue thrusting


Tardive dyskinesia is a serious side effect that occurs when you
take medications called neuroleptics. It occurs most frequently
when the medications are taken for a long time, but in some cases it
can also occur after you take them for a short amount of time.
The drugs that most commonly cause this disorder are older
antipsychotic drugs, including:



Haloperidol
Fluphenazine
Trifluoperazine

Other drugs, similar to antipsychotic drugs, that can cause
tardive dyskinesia include:



Cinnarizine
Flunarizine (Sibelium)
Metoclopramide

Prognosis


Next Page
Causes
If diagnosed early, the condition may be reversed by stopping the
drug that caused the symptoms.
Even if the antipsychotic drugs
are stopped, the involuntary
movements may become
permanent and in some cases
may become significantly
worse.

Pharmacological Action








Suppress the secretion of gastric acid by
selectively blocking H2 receptors in
parietal cells lining the stomach.
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.
Evaluation of Medication
Effectiveness
Therapeutic Uses

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.


No signs or symptoms of GI bleeding.
Therapeutic Nursing Interventions
and Client Education

Healing of gastric and duodenal ulcers.

Depending on therapeutic intent, effectiveness
may be evidenced by:
Reduced frequency or absence of GERD
symptoms (e.g., heartburn, bloating, belching).
Encourage client to avoid aspirin and other
nonsteroidal anti-inflammatory drugs (NSAIDs).
Ranitidine can be taken with or without food.
Back to Concept Map

Pharmacological Action






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).








Precaution:

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:
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).

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.

Other PPI’s:
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.


omeprazole; lansoprazole; rabeprozole;
pantoprazole; esomeprazole;
Back to Concept Map



Pharmacological Action
Changes into a viscous substance that
adheres to an ulcer; protects ulcer from
further injury by acid and pepsin.
Viscous substance adheres to the ulcer for
up to 6 hr.

Sucralfate has no systemic effects.

Therapeutic Uses


Acute duodenal ulcers and
maintenance therapy.
Investigational use in gastric ulcers
and gastroesophageal reflux disease.
(GERD)










Nursing Interventions and Client
Education
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.
Evaluation of Medication
Effectiveness
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
 Blood Tests

Complete Blood Count (CBC c Diff)
 Stool Tests:

Stool for occult blood; (Guiac)

Stool for ova & parasites (O&P);

Stool for Clostridium difficile (C-Diff)

Stool Culture & Sensitivity (C&S)
 Upper GI Series (UGI)
 Upper GI Series with Small Bowel Follow-
Through (UGI-SBFT)
 Barium Enema
 Endoscopy
Return to
Concept Map
http://www.saddleback.edu/alfa/n170/tubefeeding.aspx
 Tum-E-Vac?
Salem Sump
Levin Tube
(single lumen)
Maloney JPEN 2002;26:S34-42
FDA advisory
FD&C Blue No. 1
Intermittent gravity
Intermittent
Via Pump:
-continuous (or)
cyclic