GI EXAM 7 OUTLINE





Assessment Techniques
o History

Health

CA, anemias, heart disease, etc

Diet

Types of food, amounts, time of day you eat, general appetite

Personal & family

Current health problems

Maybe you just don’t feel good, symptoms are vague and hard to describe to a doctor

Even socioeconomic status

Some people can afford better food than others. It’s cheaper to eat McDonalds than to buy organic crap
o Psychosocial

Maybe you get the runs when you get nervous before a test
Physical Assessment
o Mouth & pharynx

Look at the color of the membranes, are there any lesions there, are our teeth ok, are we able to chew well, etc
o Abdomen

Inspect

Auscultate

Listen to bowel sounds for an entire minute to properly assess

Percuss

To determine the density of a body part

When we hear a high pitch that can mean air (like in an intestine)

When we hear a dull or medium pitched it means the part is solid

Palpate

Tenderness, masses, etc…
Nasogastric and Nasoenteric Tube Feedings
o Given to meet nutritional requirements when oral intake is inadequate or not possible so long as the GI tract is functioning
normally
o Nasogastric - feeding delivered to stomach
o Nasoenteric - feeding delivered to distal duodenum or proximal jejunum

used when esophagus and stomach need to be bypassed or pt has a risk for aspiration
Total Parenteral Nutrition (TPN)
o Method of supplying nutrients to body
o Goal - to attain improved nutritional status, weight gain, and improve healing ability
o Contain H20, amino acids, glucose, vitamins, & electrolytes . Provides approx 1000 cal & 6 g nitrogen/liter of TPN

Most costly of all of the supplemental feedings for your patient. Cost can get up to thousands of dollars for bag
o Initiate & discontinue therapy slowly

Rebound hypoglycemia if done too quickly

TPN is high in glucose

May have to have insulin by injection while on TPN to help out the pancreas
o Central line for administration (usually required)
o Aseptic site care

b/c the high glucose concentration makes it desirable to bacteria and what not
o Dedicated IV line

This line gets TPN and TPN only!
Gastrointestinal Intubation
o Insertion of short or long flexible rubber or plastic tube into the stomach or intestine by way of mouth or nose.
o Used for:

decompression of stomach

lavage stomach and remove toxic substances

diagnose GI motility and gastric analysis

administer meds and feedings

treatment for obstruction or bleeding





o Be sure suction equipment is avl at the bedside when you are inserting a tube in case they aspirate
Gastrostomy
o Types

Stamm - temporary & permanent

Janeway - permanent

Percutaneous endoscopic gastrostomy (PEG)

upper midline or left upper quad incision for Stamm & Janeway
o Gastrostomy not recommended for pt w/severe GERD because risk for aspiration
Laxative Use
o Bulk Forming – Causes colon to swell and leads to stimulation of peristalsis (Metamucil)

Drink lots of H2O!!
o Saline Agent – draws H2O into intestines and leads to stimulation of peristalsis (Milk of Mag)
o Lubricant – softens fecal matter (mineral oil)

Not for use with meals
o Stimulant – irritates colon causing increase in mucosal secretions (Dulcolax)
o Fecal Softener – hydrates stool by increasing wetness of intestinal H2O. No laxative action. (Colace)
o Osmotic Agent – Cleanses colon rapidly and induces diarrhea (Colyte)
Laboratory Assessment
o CBC

Looking for anemias, infections
o Serum electrolytes

Looking for depletions or excessive amounts of these guys
o Watch K with vomiting! Know This!

Clotting factors
o Liver function

Amylase and Lipase, will be elevated in problems like pancreatitis
o Urine

Looking for billiruben
o Stool (FOBT)

Fecal Occult Blood Test

Not expensive, can be done at home

Looking for blood in your poo
RadioGraphic Tests
o Upper GI series

To dx ulcers, tumors, varices, anatomic or functional derangement, malabsorption

Pt prep

NPO for 8 hours before test

No use of opiods or anticholinergic drugs for 24 hrs prior to exam – decreases motility

No smoking morning of exam (can stimulate gastric motility)

May need laxatives after the procedure
o Lower GI series (Barium enema)

Patient Preparation

Measures necessary to empty, clean bowel

Clear liquids evening before

Potent laxative evening before

NPO p MN

Cleansing enemas till clear unless contraindicated

Detects stuff in the colon
Gastric Analysis
o Basal Gastric secretion

Measures HCL acid secreted between meals
o Gastric stimulation test

Done if small amounts of secretions collected with basal gastric secretion test

Histalog give SC. Specimens collected at 15 minute intervals
o Decreased gastric secretion suggests gastric carcinoma
o Increased levels indicate Zollinger-Ellison syndrome and duodenal ulcers




Upper GI Endoscopy (EGD)
o Allows direct visualization of gastric mucosa through lighted endoscope
o Used to detect esophageal, gastric, or duodenal abnormalities
o Fiberscope is flexible, fiberoptic lens, can take color photos
o ERCP - retrieves CBD stones
o Patient Prep

NPO p MN or 8-12 hours pre-procedure

Conscious sedation

Atropine to dry secretions

Local anesthetic to depress gag reflex
o Follow up care:

Instruct pt not to eat or drink until gag reflex returns (1-2 hrs) to prevent aspiration

Observe for bowel perforation (abdominal pain, unusual swallowing, rectal bleed, distension,  temp, HR

Lozenges, saline gargle for minor throat irritation
Lower GI Endoscopy
o Proctosigoidoscopy

Direct view of lower bowel via instruments (rigid or flexible)

Can detect ulceration, polyps, tumors, or other pathological conditions

Polyps & cancer most often found in left side of colon

Indications for sigmoidoscopy: rectal bleeding, positive occult blood & anemia with negative BE

Flexible sigmoidoscopy can view 16-20" from anus

recommended as screening at age 50 the repeat in 1 year then q 3 years

Patient prep

Liquid diet for 24 hours prior

Cleansing enemas

Laxative may be given

Procedure

Left side, knee chest position

No sedation

May biopsy, remove polyps
Colonoscopy
o Direct visual inspection of entire colon
o Used as diagnostic aid for removal of foreign bodies, polyps, or tissue for biopsy
o Patient Prep

Limit intake to liquids for at least 24 hrs

NPO p MN

May order laxatives, suppositories, enemas

Golytely given day prior to evacuate bowel

Remember, you lose Na and K when you’re on laxatives…
o Procedure

Left side w/legs drawn up

Discomfort from instilling air to open colon

Conscious sedation

May obtain specimens

Perforation & hemorrhage possible but rare
o Follow up care

Fullness, cramping, flatus is normal for several hours

Observe for excessive bleeding, s/s perforation
Other Diagnostic Procedures
o Abdominal Ultrasound (US)

Non-invasive, no radiation

Used for diagnosis of choleliathiasis, cholecyctitis, appendicitis

If barium studies ordered, must follow US
o Computed Tomography (CT)

Provides cross-sectional images

Scans liver, spleen, kidney, pancreas, and pelvic organs





High radiation doses

If barium studies ordered must follow CT
o Magnetic Resonance Imaging (MRI)

Used to supplement US & CT

Creates image based on the magnetic field created between machine and target structure

May induce feeling of claustrophobia

Noisy

Contraindicated for pt w/permanent pacemakers and defibrillators, artificial heart valves, implanted insulin pumps,
TENs units, or internal metal devices (joint implants, aneurysm clips)
Stool Exams
o Occult blood - Hemetest

Inexpensive, done at home, non invasive

CI in presence of hemorrhoidal bleeding

Specimen applied to dry paper slide- sent to MD

False positives - diet restrictions, medications

Eat red meat, poultry, salmon, things like that right before the test.

Iron, Iodines, indocin, Vit C, salcilates all give false positives

Recommended annual screening beginning at age 50
o Stool exams looking for

Color - varies from light to dark brown

effected by foods, meds, blood

Consistency & appearance

Steatorrhea - commonly due to pancreatic disease
o bulky, greasy, foamy, foul in odor
o stool is gray and has silvery sheen

Biliary obstruction

acholic, light gray or clay colored

Chronic ulcerative colitis

mucus or pus visible

Constipation, obstipation or fecal impaction

passage of small, dry, rocky hard masses called scybala
General Care Considerations
o Hydration
o Blood transfusion
o Nutrition
o Gastric intubation
o Laxative use
Nursing Interventions for Gastric Surgery Patient
o Preoperative

Reduction of anxiety

Patient teaching

Bowel prep
o Postoperative

Pain relief

Maintenance of nutrition

Early ambulation

Relief of dumping syndrome
Conditions of the Oral Cavity (Beginning of 2nd powerpoint)
o Stomatitis

Inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums,
tongue, lips, and roof or floor of the mouth. The word "stomatitis" literally means inflammation of the mouth.

Usually painful, associated with redness, swelling, and occasional bleeding from the affected area. Bad breath may
also be present
o Aphthous stomatitis

Not infectious, usually occurs on the soft palate or buccal mucosa, sides of the tongue. Shallow and very painful
ulcerations of the mouth, can last for months
o




Herpes simplex

Cold sore, fever blister, etc. Can last up to 20 days. Sometimes a single lesion or in clusters. Usually last 10-14 days
after they erupt. Caused from a virus and can occur readily in a person that is immunosuppressed. Very contagious,
hand hygiene is important
o Candidiasis

Produces cheesy white plaque in the mouth and when rubbed off leaves a red, bleeding base on the skin. Most
common is candidia albicans (sp?)

DM’s can get this, immunosuppressed, steroids inhalers can cause this

Treated with antifungal meds. May see a swish and spit thing at the hospital written to prevent them from getting this
if they’re on a drug that causes this
Nursing Considerations
o Oral exam
o Oral hygiene

Can be painful for people with mouth problems
o Dietary considerations

Stay away from too hot or too cold foods, really spicy foods, etc
o Drug Therapy

Antiinfectives

Antibiotics, antifungals, antivirals, chlorhexidine oral rinse, and analgesics
Cancer of the Oral Cavity
o May occur in any part of the mouth
o Highly curable if found early
o Associated w/tobacco & alcohol use

Synergistic carcinogenic effect
o 75% occurs after 60 y/o with men more often afflicted
o Increasing incidence in men under 30
o Types

Leukoplakia

Like thrush, but can’t be scraped off. White, painless places. Caused by long term irritaiton. Sometimes
called “smokers patch”

Erythroplakia

Red, velvity lesions in the mouth. Higher degree of malignancy than leukoplakia. Most are squamous cell,
grow slowly, and develop over many years. Take many years to cause symptoms

Oral cancer

Produces few or no symptoms in the first years, no s/s. Most frequent s/s is usually a painless sore that
wont heal. A lot of times since it’s painless people aren’t likely to go in and get it checked out. If it doesn’t
heal in 2 weeks, go in and have it checked out

Lip cancer

Unhealing owund on the lip. Often caused by sunlight
o Diagnosis

Physical exam

Assessment of cervical lymph nodes

Biopsy
o Medical Interventions

Resection surgery

Radical Neck dissection

Radiation and/or chemotherapy
Salivary Gland Disorders
o Sialadenitis – inflammation of a salivary gland

Infectious agents – staph, strep, E. coli

Irradiation – cancer therapy

Immunologic disorders – HIV
o Tumors

Relatively rare

Malignant or benign
General Nursing Considerations for Oral Disorders

o Oral cavity health
o Nutrition
o Airway management
o Cough enhancement
o Aspiration precautions
o Patient education
Conditions of the Esophagus
o Achalasia

Loss of esophageal motility

lack of peristaltic activity of the esophagus with failure of the LES to relax in response to swallowing

Symptoms are hallmark of achalasia

dysphagia -1° symptom
•weight loss

regurgitation
•cough

noncardiac chest pain
o Gastroesophageal Reflux Disease (GERD)

LES not working properly allowing stomach contents to reflux into esophagus

Symptoms

pyrosis
•hoarseness

dyspepsia
•dysphagia

regurgitation
•need clear throat

Interventions

diet and lifestyle changes

avoid eating 3 hrs before bedtime

stop smoking

avoid fatty foods, chocolate, peppermint

elevate HOB 6-8 inches on blocks

lose weight

medication -H2 blockers, PPIs, Reglan

surgery

Barrett’s esophagus - continuous irritation to esophagus causing scarring, narrowing and stricture; precursor to
esophageal cancer
o Hiatal Hernia

Opening in the diaphragm through which the upper stomach passes, pushing up into the chest cavity

Types

Sliding- about 95%
o Signs & symptoms – sliding
o Associated with reflux
o Heartburn
o Regurgitation/aspiration
o Dysphagia

Paraesophageal
o Signs & symptoms – paraesophageal
o Associated with stretching or displacement
o Feeling of fullness p eating
o Feeling of breathlessness/suffocation
o No reflux because LES is patent

Treatment

same as for GERD
o Frequent small feedings
o Do not recline for 1 hr p meals
o Elevate HOB
o Increase ambulation
o Medications

Complications - hemorrhage, obstruction, strangulation (bowel inside can twist and then die…major
problem)

Surgical intervention – Nissan repair
o





Trauma
o
o
o
o
o
o
Tumors
o
DIverticulum

Outpouching of mucosa and submucosa that protrudes thru weakened musculature

Zenkers - pharyngoesophageal (upper)
o most common type
o 3x more frequent in males
o usually over 60 years old

Symptoms
o dysphagia
• halitosis
o belching
•sour taste in mouth
o regurgitation of undigested food

Management
o Dietary Modifications
o Positioning
o Surgical removal of diverticulum
Blunt injuries
Chemical burns
Endoscopy/surgery
Protracted vomiting
Foreign objects
Will be candidates for TPN
Benign or Malignant

Malignant

Primary risk factors
o Tobacco use
o Alcohol ingestion
o Gastric reflux

Rapid growth and metastasis

5% - 5 year survival rate
o Signs & symptoms

Primary symptoms – dysphagia & weight loss

Lump in throat

Foul breath
o Interventions

Esophagectomy - total resection of esophagus. May use jejunum or colon to rebuild esophagus

Chemo and radiation for palliation
General Nursing Interventions for Esophageal Disorders
o Encourage adequate nutritional intake
o Decrease risk of aspiration
o Relieve pain
o Provide patient education
Geriatric Considerations
o Drier mucous membranes
o Decreased salivary gland activity
o Taste buds reduced (esp. sweet & sour)
o Teeth
o Decreased esophageal motility, gag reflex
o Reduced stomach motility
o Reduced hunger contractions
o Decreases HCL & enzymes
o Decreased absorption of nutrients & vitamins
Gastrointestinal System Lecture 3
o Geriatric Considerations

 in HCL, pepsin, lipase, pancreatic enzymes

more susceptible to gastroenteritis






increased symptomology
 in motility

increased abdominal discomfort

may eat less due to symptoms produced
Gastritis
o Gastritis - inflammation of gastric mucosa

most common pathologic condition of stomach

stomach mucosal barrier destroyed reducing protection from self destruction of lining (auto acid digestion)

More prevalent in heavy smokers and persons who abuse ETOH
o Acute Gastritis

Short lived

Infectious agent

NSAID and other drug use

NPO status

Stress

Usually heals quickly

Repeated bouts can be a precursor to ulcers
o Chronic gastritis

H. pylori infection most common cause

Possible autoimmune pathogenesis

Surgical procedures

Other systemic disorders
o Chronic atrophic gastritis

Older adults

Occurs thru all layers of stomach

Decreased number of parietal and chief cells
o Clinical Manifestations of Gastritis

Acute

Rapid onset

N/V

Hematemesis/gastric hemorrhage

Dyspepsia

Anorexia

Chronic

May be vague or absent

Anorexia

Dyspepsia, belching, N/V

Food intolerances

Pernicious anemia
Pernicious Anemia
o Vitamin B12 deficiency due  intrinsic factor secretion
o Chronic condition and can cause neurological damage if left untreated.
o Intrinsic factor deficiency most common after gastrectomy and with atrophic gastritis
o Develops slowly, symptoms may not be apparent until HgB falls below 8 b/dL
o Treatment - 1000u Vit B12 daily x 1 wk then weekly x 1 month, then monthly for life
Helobacter pylori
o Spawned new body of medical literature
o Fragile bacteria lodges in gastric mucosa
o Probably from contaminated foods
o Found in saliva, vomitus
o Found in every part of the world
o Implicated in most gastritis, peptic ulcer and may be predisposing to gastric CA
o Diagnosis by endoscopy, serum for HP antibodies, breath test
o If HP present and ulcers have developed treatment is Peptobismol & antibiotics
o Eradication prevents ulcers and may lead to more rapid healing of present ulcers
Peptic Ulcer Disease
o
o





Umbrella term that refers to ulcerations in the mucosal lining of the lower esophagus, stomach, or duodenum.
Common causes of PUD

Helicobacter pylori---number 1 cause

NSAIDS (most common cause in HP (-) pt.

HCL
GI Ulceration
o Decrease in mucosal synthesis of prostaglandins  decreased mucous production
o If mucosal barrier penetrated gastritis occurs with exposure to HCL
o Chronic gastritis
o Small vessel injury can lead to edema, hemorrhage, or ulceration
Duodenal Ulcers
o Most common type of ulcer – 80%
o Major causes

H. pylori confirmed in 95-100% of patients with duodenal ulcers

Hypersecretion of acid & pepsin, inadequate secretion of bicarbonate by duodenum

Pain usually occurs 30min-2 hours after eating
o Other contributing Factors

Greater number of parietal cells in gastric mucosa

High serum gastrin levels

Failure of feedback mechanisms

Rapid gastric emptying

Use of NSAIDS

Cigarette smoking
o Clinical Manifestations

Pain as stomach empties

Nocturnal pain

Hematemesis or melena (blood in the stool)

More likely to bleed
Gastric Ulcers
o Occur in stomach – usually antral region
o Chronic gastritis frequently precedes ulcer formation
o H. pylori found in 60%-80% of patients
o Decreased mucosal synthesis of prostaglandins
o Duodenal reflux of bile
o Longer healing time
Management of Peptic Ulcer Disease
o Stress reduction & rest
o Smoking cessation
o Dietary modifications
o Medications
o Endoscopy
o Drug therapy

Antacids

Histamine Receptors Antagonists (H2 blockers)

Antibiotics & Bismuth salts

Proton Pump Inhibitors

Cytoprotective drugs/mucosal barrier fortifiers
Other Types of Ulcers
o Zollinger-Ellison Syndrome (Gastrinoma)

Hypersecretion of gastric acid

Multiple duodenal ulcers

Resistant to standard ulcer therapy

Steatorrhea

Treatment

High dose PPIs

High dose H2 blockers

Surgery
Stress Ulcers

acute ulceration of duodenum or gastric areas

follow stressful event - physical trauma

treated prophylactically
o Cushings ulcers - common w/brain trauma
o Curlings ulcers - frequently occurs 72 hours post burn
o NSAID Induced

mostly gastric

often asymptomatic

Risk factors

>65 y/o

high NSAID doses

long acting NSAID

concurrent glucocorticoid use

history of ulcers

Treatment as with other ulcers but may take longer to heal
Nursing Assessment
o GI & Vascular Status

VS, skin color

Pain

Bowel patterns/ Bowel sounds

Hemoglobin & Hematocrit (H & H)

Nutritional status
o Medication history
o Coping style
o Knowledge of condition
Nursing Interventions
o Pain relief
o Reduction of anxiety
o Patient education

Drug therapy

Diet therapy

Symptoms of complications

Life style modifications
Nursing Interventions for Complications of PUD
o Hemorrhage

assessment

transfusion

lavage
o Emergency treatment

large bore IV

treat hypovolemic shock

NG tube/lavage

O2

Monitor VS
Surgical Intervention
o Less frequent due to med therapy
o 6-10 units of blood infused in 48 hours
o Life threatening hemorrhage
o Used for intractable ulcers
o Perforation - erosion of ulcer thru gastric serosa into peritoneal cavity---surgical emergency

sudden, severe upper abdominal pain with radiation to shoulders

vomiting & collapse

extremely tender & rigid abdomen

shock
o




o




Penetration - ulcer penetrates to adjacent structures such as pancreas, biliary tract----EMERGENCY

pain in back & epigastric area not relieved by pain meds
o Pyloric obstruction - distal pylorus becomes scarred from repeated ulcers

NG tube

UGI or endoscopy

Antrectomy or vagotomy
Dumping Syndrome
o Info

Occurs in 15-20% following gastric surgery

Passage of food from stomach to jejunum too rapid

Fluid ingestion causes  passage of contents to jejunum

Rapid distension of jejunal loop

Hypertonic intestinal contents draw fluid from circulating blood volume to dilute
o S/S

Vasomotor response

Vertigo

Tachycardia

Syncope

Sweating

Pallor

Palpitations

Desire to lie down

Distension response

Epigastric fullness

Cramping

Nausea

Vomiting

Diarrhea
o Treatment

small, frequent feedings

semi-recumbant position for meals

limit CHO intake

lie down 20-30 minutes after meals

no liquids with meals

limit salt to prevent further fluid shift

antispasmotic drugs
Gastric Cancer
o Occurs in antrum of stomach
o Usually adenocarcinomas
o Approx 14,000 deaths per year
o 2x more frequent in men than women
o Much greater incidence in Japan
o Cause - unknown
o Prognosis - poor
o Diagnosis - EGD,UGI, CT of abdomen
o Treatment - surgery, radiation, chemo
Gastrointestinal System Lecture 4
Irritable Bowel Syndrome
o Info

One of the most common GI problems

More common in women

Occurs mainly in colon
o Patho

Functional disorder of intestinal motility

May be related to neurologic regulatory system, infection or irritation, or a vascular or metabolic disturbance

Peristaltic wave affected at specific segments of intestine

No inflammation or tissue changes in intestinal mucosa**
Causes

Certain foods - coffee, alcohol, spices

Smoking

Infections & illnesses

Most common cause is psychological stress
o Diagnosis

Stool tests

Barium enema

Endoscopy
o Treatment

Change in diet

Exercise

Stress reduction

Medications
Conditions of Malabsorption
o Info

Mucosal disorders (celiac sprue, Crohn’s disease, radiation enteritis)

Infectious diseases -tropical sprue, small bowel intestinal overgrowth, Whipple’s disease)

Luminal problems - bile acid deficiency, ZES

Postoperative - gastric or intestinal surgery

Nutrient uptake - lactose intolerance
o Symptoms

Hallmark of malabsorption is loose, bulky, foul-smelling stools that have an increased fat content and are often
grayish.

Usually patient is weak and malnourished

Vitamin and mineral deficiencies
o Treatment

Vitamin supplements

Antibiotics if infectious cause

Antidiarrheals if indicated

Fluids for hydration

Education
Abdominal Hernias
o Anatomical Locations

Inguinal

Umbilical

Ventral or incisional

Femoral
o Classifications

Reducible

Strangulated
Intestinal Obstruction
o Mechanical: obstruction of lumen

intussusception

volvulus

tumors

strictures
o Nonmechanical: neuromusculature disturbance

endocrine or neurological disorders

surgery –paralytic or adynamic ileus
Small Bowel Obstruction
o Info

85% occur in small intestine

Adhesions most common cause of small bowel obstruction (SBO)

Obstruction can be partial or complete
o





o


Severity depends on region, degree of occlusion, and degree of ischemia
S/S

Crampy pain that is wavelike and colicky

May pass blood & mucus but no fecal matter and no flatus

Vomiting

Dehydration

Abdominal distention

Shock if uncorrected
o Management

Decompression of bowel with NG or small bowel tube

Surgical intervention

Type depends on

location of obstruction

duration of obstruction

condition of intestine at time of surgery
Large Bowel Obstruction
o Info

15% of obstruction in large bowel

Most found in sigmoid colon

Most common causes

carcinoma

diverticulitis

inflammatory bowel disorders

benign tumors
o S/S

Constipation for several days

Crampy lower abdominal pain

Visualization of bowel thru abdominal wall

Fecal vomiting

Shock
o Management

Colonoscopy

Cecostomy

Rectal tube

Usually surgical resection

Temporary or permanent colostomy
o Nursing Interventions

Monitor for symptoms of obstruction worsening

Maintain hydration/electrolytes

Patient teaching

pre-op

self-care
Colorectal Cancer
o Info

Most often found in elderly

2nd leading cause of cancer mortality in 55-74 y/o

Cancer of colon more common in women

Cancer of rectum more common in men
o S/S

Right colon cancer

silent disease

dull abdominal pain & melena

unexplained wt loss

anemia

Left colon cancer

disturbance of bowel habits







lower abdominal pain

blood in stools---later s/s

Rectal cancer

sensation of incomplete evacuation of stool

rectal bleeding

mucus discharge

Tenesmus—painful bowel movements

Other symptoms
o Fatigue, weight loss, anemia, and bowel obstruction
o Treatment

Surgery to remove tumor

Segmental resection with anastomosis

Abdominoperineal resection with permanent sigmoid colostomy

Temporary colostomy

Permanent colostomy

Due to improved surgical techniques, colostomies are performed on less than 1/3 of pt with colon cancer
Complications of Colostomy
o Prolapse of stoma (usually due to obesity)
o Perforation-due to improper stoma irrigation
o Stoma retraction
o Fecal impaction
o Skin irritation
o Leakage from anastomotic site
Nursing Interventions
o Prepare patient for surgery
o Provide emotional support
o Provide post op care

skin care

colostomy care

manage complications
o Maintain nutrition & hydration
Polyps of Colon and Rectum
o Mass of tissue that protrudes into the lumen of the bowel
o Can be found anywhere in the intestinal tract
o Classified as neoplastic or non- neoplastic
o May cause rectal bleeding & abdominal pain
o Removed & biopsied when found
Diseases of Anorectum
o Hemorrhoids

dilated portions of veins in the anal canal

by age 50, 50% of people have them

internal or external

symptoms are itching & pain, bright red bleeding with defecation, may have severe pain when inflamed

may thrombose

Hemorrhoid Treatment

Good hygiene & avoid straining

High fiber diet

Sitz baths, ointments, analgesics

Surgery
Lecture 5 Stuff
Appendicitis
o Info

Appendix serves no definite function

Most common cause of emergency surgery

1-2 out of 100 young adults are effected
o S/S




RLQ pain at McBurney’s point(half way between the umbilicus and anterior superior Iliac spine on right side.

Rovsing’s Sign—palpation of LLQ causes pain on RLQ.

Rebound tenderness

Low grade fever

Elevated WBC’s usually greater 10,000
Chronic Inflammatory Bowel Disease
o Regional Enteritis (Crohn’s Disease)

Info

Inflammation extends thru all layers of the bowel wall from the intestinal mucosa. Bowel wall thickens.

S/S

Insidious, abdominal pain and diarrhea. Crampy, increased pain after meals, anorexia, malnutrition, anemia.

Treatment

Reduce inflammation

Rest bowel

Medications anti-inflammatory, antidiarrheals, antibiotics
o Ulcerative Colitis

Info

Affects superficial mucosa of colon.

Diffuse inflammation.

Begins in rectum and may involve entire colon.

Bowel narrows, shortens and thickens

S/S

Diarrhea—10-20 per day

Cramping abdominal pain, rebound tenderness.

Rectal bleeding

Anorexia

Complications

Perforation

Megacolon

Bleeding

Treatment—Bowel rest, reduce inflammation, maintain nutrition.

Meds—anti-inflammatory
Liver and Biliary Disorders (Lecture 6)
Cirrhosis
o Info

Diffuse fibrotic bands of connective tissue that distort the normal architecture of the liver

Extensive degeneration and destruction of hepatocytes

With regeneration, disorganized nodular formation develops

Alterations in flow of blood et lymph

Hepatic Cirrhosis

Chronic and progressive

Irreversible reaction to hepatic inflammation/necrosis

Alteration in vascular system/lymphatic bile duct channels

Etiology unknown, may be genetic component

Chronic HBV is #1 cause of cirrhosis in the world!
o Types of Cirrhosis

Laennec’s or alcoholic cirrhosis

Postnecrotic cirrhosis

Biliary cirrhosis

Cardiac cirrhosis
o Clinical Manifestations of Cirrhosis

Early signs

Generalized weakness---first key is the weakness!

Weight loss

GI symptoms

Abdominal pain/liver tenderness

o


Late signs

GI bleeding

Jaundice

Ascites

Spontaneous bruising
Cirrhosis Interventions

Nonsurgical management

Diet therapy
o If going into a coma they will be on a low protein diet

Drug therapy

Paracentesis

Comfort measures

Fluid and electrolyte

Gastric intubation

Esophagogastric balloon tamponade

Surgical management
Jaundice
o Increase in bilirubin concentration in blood
o Seen in

Sclerae

Skin

Mucus membranes
o Levels above 2.5 mg/dl
o Hemolytic
o Hepatocellular
o Obstructive
o Hereditary hyperbilirubinemia
Ascites
o Definition –

Accumulation of free fluid containing almost pure plasma within the peritoneal cavity
o Pathophysiology

Increased hydrostatic pressure from PH causes plasma to leak into peritoneal cavity

This decrease, + inability of damaged liver to produce albunin results in decrease in effective serum colloid osmotic
pressure in circulatory system

Liver Sweat - weeping of liver plasma
o Decrease of effective intravascular circulation from massive ascites may cause

Renal vasoconstriction

Triggers renin-angiotension system

Sodium and water retention
o Increases hydrostatic pressure and lymph formation
o Resulting in Viscous cycle of ASCITES
o Clinical Manifestations

Increased abdominal girth

Rapid weight gain

SOB

Striae et distended veins

Fluid et electrolye abnormalities

Bulging flanks in supine position
o Assessment

Abdominal percussion

fluid wave & scratch test
o Treatment

Goal – Negative Na balance to decrease fluid retention

Dietary

Avoid High Na food

500 mg Na et Diuretics if no response


Diuretics




Vitamin supplementation
Spirinolactone (Aldactone)
Complications F/E abn et encepthalopathy
Salt poor albumin
Paracentesis – no longer std is temporary
o




Nursing





Lecture 7 Stuff
Gallbladder
o Info



Cholelithiasis
o Info



Pancreatitis
o Info




o
o
Daily measurement abdominal girth
Daily weight
Pt teaching important due to poor pt compliance
Monitor serum ammonia levels
Electrolytes et response to tx
Pear shaped bulbous sac
Concentrates et stores bile
Cystic ductHepatic CBD
Presence of one or more gallstones
Stones form when bile hardens into stone like material
Abnormal metabolism of cholesterol/bile salts
Inflammatory process of the pancreas
Self-limiting to rapidly fatal
Acute et chronic forms
Autodigestion of pancreas- the pancreas itself is disintegrating

obstruction

hypersecretion of enzymes

Many times people will become diabetic bc of lack of beta cells.
Assessment

Lab values

Calcium

Amylase

Lipase

Urine amylase

Bilirubin

Have severe pain so pain management is crucial.

Recurring upper and abdominal pain, loose weight. And steatorrhea- big bulky greasy stools.

Medical Management

Pain Mgmt

ICU

Respiratory

Biliary drainage

Surgical intervention

Postacute mgmt

Gerontologic consideration
Chronic Pancreatis Medical Management

Pain Mgmt

Give the pancreas rest

Nonsurgical

exocrine

endocrine

Surgical




pancreaticojejunostomy
Pancreatic Tumors
o 4th leading cause of cancer deaths
o Clinical picture

pain, jaundice will cause itching/dryness…need lots of good skin care.
o Assessment/Dx/Mgmt

US/CT/ERCP/Needle asp/Tumor markers

Extensive surgery
o Nsg Mgmt

pain, skin care …
Lecture 8 Stuff
Hepatitis
o Info

Widespread inflammation of liver cells

Most prevalent type - viral hepatitis

Can result from
o
transfusion of contaminated blood products,

exposure to infected person

parenteral drug use

Five major categories of viruses
o Forms

Enteral Forms

1. Hepatitis A and E

2. Transmitted by fecal-oral route (hand washing techniques)

Parenteral Forms

1. Hepatitis B, C, D

2. Transmitted through venous blood/sexual contact

Acute or chronic
o More Info

Definition – widespread inflammation of liver cells

Causes-Viral, Toxic, Drug-Induced

Types, ABCDE… F,G

Transmission - Incubation

Prevention

Three Phases

Pre Icteric,Icteric,Post Icteric
o Complications of Hepatitis

Fulminant Hepatitis

Failure of liver cells to regenerate

Progression of necrosis

Massive hepatic necrosis
o Severe, often fatal

Chronic Hepatitis

Inflammation lasts longer than 6 months
o Clinical Manifestations of Hepatitis

Icteric or Illness stage

Few days to few weeks later

Jaundice

Dark-colored urine

Light-colored stools

Steatorrhea

Hepatomegaly

Other sx my continue

Abdominal pain

Arthralgia/myalgia
o

Diarrhea/constipation

Fever/irritability

Lethargy/malaise

Nausea/vomiting
Goals of Treatment for Hepatitis

Goals

SLOW OR HALT PROGRESSION OF LIVER DISEASE

AVOID HEPATOCELLULAR CARCINOMA AND NECESSITY OF TRANSPLANTATION

TREATMENT IS NOT ALWAYS EFFECTIVE