Gastrointestinal Disorders
N635 Medical Surgical - Disease Management II
02-23-10
Presenters:
Maria M. Stone
Alicia Talavera
Amy Davidson
Amanda Durazo
Timothy Wong
1
Gastrointestinal Disorders
Review at a Glance
•
Barrett’s epithelium: esophageal epithelial tissue that has undergone
change as a result of repeated exposure to gastric juice and is more
resistant to erosion, but is premalignant.
•
Body mass index (BMI): estimates total body fat stores in relation to
height and weight.
•
Bulk-forming agents: high-fiber supplements that increase fecal bulk.
•
Cholecystitis and Choleithiasis:
•
•
Cholecystitis: an acute inflammation of the gallbladder.
Cholelithiasis: The formation or presence of stones in the gallbladder.
•
Cirrhosis: Degeneration of liver tissue causing enlargement, fibrosis,
and scarring.
•
Crohn’s Disease (Regional Enteritis): Subacute, chronic inflammation
extending throughout the entire intestinal mucosa (most frequently
found in terminal ileum).
•
Chyme: stomach contents – partially digested food mixed with
gastric juice.
2
Gastrointestinal Disorders
Review at a Glance
•
Colostomy: surgical diversion of large intestine fecal contents to an
external collection device.
•
Diarrhea: increase in frequency, amount or liquidity of stool that is a
change from the individual’s normal pattern.
•
Diverticular Disease: manifested in two clinical forms – 1)
Diverticulosis and 2) diverticulitis.
1.
2.
Diverticulosis: bulging pouches in the GI wall (diverticula) push the mucosa
lining through the surrounding muscle.
Diverticulitis: inflamed diverticula, (may cause obstruction, infection, and/or
hemorrhage.)
•
Dumping syndrome: complication of gastric resections where there
is a rapid emptying of stomach contents into the jejunum causing
physiologic manifestations.
•
Esophagogastroduodenoscopy (EGD): direct visualization of
esophagus, stomach, and duodenum through a fiberoptic endoscope
and used to diagnose disorders of aforementioned structures.
3
Gastrointestinal Disorders
Review at a Glance - continued
•
Esophagogastric tube: also known as the Sengstaken-Blakemore and
Minnesota tube, consisting of a tube with several lumens used to
inflate a gastric balloon, esophageal balloon and drain stomach
contents.
•
Fistula: abnormal pathway been structures or from an internal organ
to an outside surface.
•
Gastroesophageal reflux: the backward flow of gastric contents into
the lower portion of the esophagus.
•
Gavage: referring to intermittent feeding through a tube in the
stomach or jejunum.
•
Hepatitis: Widespread inflammation of liver cells usually caused by a
virus.
Hernia: referring to a protrusion of an organ through a weakness in
muscle.
•
•
Hiatal Hernia: herniation of the stomach and other abdominal viscera
through an enlarged esophageal opening in the diaphragm. Etiology
unknown.
4
Gastrointestinal Disorders
Review at a Glance - continued
•
Esophagogastroduodenoscopy (EGD): direct visualization of
esophagus, stomach, and duodenum.
•
Ileostomy: surgical diversion of fecal contents at the level of the
ileum to an external collection device.
•
Inflammatory Bowel Diseases: consists of Crohn’s disease and
ulcerative colitis.
•
Intestinal Obstruction: Partial or complete blockage of the intestinal
flow (fluids, feces, gas).
•
Intestinal tube: long tube, 6 to 10 feet in length, used to decompress
the intestines.
•
Lavage: irrigation of the stomach using a tube inserted into the
stomach.
5
Gastrointestinal Disorders
Review at a Glance - continued
•
Lower esophageal sphincter (LES): the sphincter located at the
esophageal gastric junction.
•
Nasogastric (NG) tube: a tube inserted through the nose and into the
stomach and used to drain contents or for feeding.
•
Non-steroidal anti-inflammatory drugs (NSAIDs): medications
usually used for analgesia and to reduce inflammation.
•
Pancreatitis: Nonbacterial inflammation of the pancreas.
•
Peptic Ulcer Disease (PUD): ulceration which penetrates the mucosal
wall of the GI tract.
•
Ulcerative Colitis: disease which affects the superficial mucosa of the
colon, causing the bowel to eventually narrow, shorten, and thicken
due to muscular hypertrophy. Occurs in the large bowel and rectum.
•
Zollinger-Ellison syndrome: disorder in which a pancreatic tumor
secretes gastrin, which then stimulates secretion of acid and pepsin.
6
Gastrointestinal Disorders
Case Study

MW, a 47-year-old female, is admitted to the hospital to rule out
chronic gastro esophageal reflux disease (GERD) versus peptic ulcer
disease (PUD). You are the nurse assigned to care for this client.
1.
What diagnostic tests should you anticipate being ordered to
differentiate her diagnoses?
7
Gastrointestinal Disorders
Case Study – Answer and Rationale
•
An upper-GI series will probably be ordered and can show lower
esophageal sphincter (LES) function as well as ulceration. An
esophagogastroduodenoscopy can be more diagnostic because it is
a direct visualization of the tissue of the esophagus and can show
inflammation. The gastric and duodenal mucosa are also visualized
directly and ulcerations are evident. The advantage of endoscopy
over an upper-GI series is that tissue samples can be obtained for
determining the presence of cancer, Barrett’s epithelium, or H.
pylori. Gastric analysis may also be used to determine the pH and
acid output of the stomach.
8
Gastrointestinal Disorders
Case Study

MW, a 47-year-old female, is admitted to the hospital to rule out
chronic gastro esophageal reflux disease (GERT) versus peptic ulcer
disease (PUD). You are the nurse assigned to care for this client.
1.
What are the priorities of care after these tests?
9
Gastrointestinal Disorders
Case Study – Answer and Rationale
•
An upper-GI series usually involves the ingestion of barium, which is
constipating. The client should be encouraged to drink fluids and
ambulate. Aspiration of barium during the procedure is a possibility,
so the nurse should assess lung sounds and monitor for signs of
aspiration such as fever, cough, and dyspnea. For the client after
esophagogastroduodenoscopy, it is extremely important to assess
for return of swallowing and the gag reflex since the throat is
anesthetized for the procedure, therefore, general safety measures
should be instituted (side rails up, bed in low position).
10
Gastrointestinal Disorders
Case Study

MW, a 47-year-old female, is admitted to the hospital to rule out
chronic gastro esophageal reflux disease (GERT) versus peptic ulcer
disease (PUD). You are the nurse assigned to care for this client.
1.
What instructions about lifestyle changes should you give MW if she
has gastro esophageal reflux disease (GERD)?
11
Gastrointestinal Disorders
Case Study – Answer and Rationale
•
Lifestyle and diet modifications are key to controlling GERD. The
client should be instructed to avoid eating within 2 hours of bedtime
and should remain in an upright position after eating. Tight clothing
(belts, tight waistbands), straining (weight lifting, bending over,
lifting heavy objects), and vigorous physical activity increase intraabdominal pressure aggravate GERD and should be avoided. A
reduction in dietary fat and an increase in complex carbohydrates
encourage more rapid gastric emptying and reduction in symptoms
of GERD. The client should be instructed to avoid substances that
decrease LES tone such as caffeinated beverages, chocolate,
peppermint, spearmint, smoking, and fried foods. The client should
be encouraged to elevate the head of the bed about 12 inches to
prevent reflux at night
12
Gastrointestinal Disorders
Case Study

MW, a 47-year-old female, is admitted to the hospital to rule out
chronic gastro esophageal reflux disease (GERT) versus peptic ulcer
disease (PUD). You are the nurse assigned to care for this client.
1.
What instructions about signs and symptoms of complications of GERD
and PUD should you provide to MW?
13
Gastrointestinal Disorders
Case Study – Answer and Rationale
•
The complications of GERD are limited to the development of
Barrett’s epithelium, cancer, and esophageal stricture. Symptoms
include dysphagia, pain, and more systemic symptoms such as
fatigue, dyspnea, and activity intolerance. Complications of PUD are
perforation, hemorrhage, gastric cancer (gastric ulcer), and pyloric
obstruction. The client should be instructed to report any of the
following symptoms: vomiting, hematemesis, black tarry stools,
pain, rapid heart rate, abdominal rigidity, and fever as they may
indicate a complication.
14
Gastrointestinal Disorders
Case Study

MW, a 47-year-old female, is admitted to the hospital to rule out
chronic gastro esophageal reflux disease (GERT) versus peptic ulcer
disease (PUD). You are the nurse assigned to care for this client.
1.
If MW asks you about the possibility of developing cancer, how would
you respond?
15
Gastrointestinal Disorders
Case Study – Answer and Rationale
•
Clients with GERD may develop Barrett’s epithelium and be at a
greater risk for cancer if GERD remains untreated, so it is important
that the client follow the treatment regimen. If the client has a
duodenal ulcer, the risk for developing cancer as a result are
minimal; however, there is an increased incidence of gastric cancer
in people with gastric ulcers. Continued follow-up is therefore
important in this population.
16
Gastrointestinal Disorders
HESI Hints
•
A Fowler’s or semi-Fowler’s position is beneficial in reducing the amount
of regurgitation as well as preventing the encroachment of the stomach
tissue upward through the opening in the diaphragm.
•
Stress can cause or exacerbate ulcers. Teach stress reduction methods
and encourage those with a family history of ulcers to obtain medical
surveillance for ulcer formation.
•
Clinical manifestations of GI Bleeding:





Pallor: conjunctival, mucous membranes, nail beds.
Dark tarry stools
Bright red or coffee-ground emesis.
Abdominal mass or bruit.
Decreased BP, rapid pulse, cool extremities
•
The GI tract usually accounts for only 100 to 200ml fluid loss per day,
although it filters up to 8 liters per day. Large fluid losses can occur if
vomiting and/or diarrhea exists.
•
Opiate drugs tend to depress gastric motility. However, they should be
given with care, and those receiving them should be closely monitored
because distended intestinal wall accompanied by decreased muscle
17
tone may lead to intestinal perforation.
ALICIA
18
GI – Hesi Review Question
•
Which of the following assessments is essential for the nurse to
make when caring for a client who has just had an
esophagogastroduodenoscopy (EGD)?
1.
2.
3.
4.
Auscultate bowel sounds
Check gag reflex
Monitor gastric pH
Measure abdominal girth
19
Answer
Answer is 2.
•
The posterior pharynx is anesthetized for easy passage of the
endoscope into the esophagus. The return of the gag reflex
indicates that normal function is returning and the client is able to
swallow (option 2). Bowel sounds (option 1) and abdominal girth
(option 4) are associated with caring for a client with a nasogastric
tube in place. Gastric pH (option 3) is related to the client with
peptic ulcer disease.
20
GI – Hesi Review Question
•
The client is admitted to the hospital with ulcerative colitis. The
nurse should assess the client for which sign that indicates a
complication of the disease?
1.
2.
3.
4.
Low hemoglobin and hematocrit
Low platelet count
Epigastric or right-sided pain following a high-fat meal
Presence of fat in the stools
21
Answer
Answer is 1.
•
Hemorrhage and bleeding are a common feature of ulcerative
colitis, and over time this can lead to significant loss of RBCs, the
client should be assessed for possible anemia (option 1).
Steatorrhea is seen in malabsorption syndrome (option 4).
Thrombocytopenia may occur if the client is treated with
immunosuppressants (option 2) to control the disease. Signs of
cholelithiasis are unrelated to ulcerative colitis (option 3).
22
GI – Hesi Review Question
•
A client is admitted to the hospital with a bowel obstruction. Which
of these findings by the nurse would indicate that the obstruction is
in the early stages?
1.
2.
3.
4.
High-pitched tinkling bowel sounds
Low rumbling bowel sounds
No bowel sounds auscultated
Normal bowel sounds heard in all four quadrants
23
Answer
Answer is 1.
•
Early in a bowel obstruction, the bowel attempts to move the
contents past the obstruction, and this is heard as high-pitched
tinkling bowel sounds (option 1). As the obstruction progresses,
bowel sounds will diminish and may finally become absent (option
3). Bowel sounds in all four quadrants (option 4) and rumbling
bowel sounds (option 2) are normal.
24
GI – Hesi Review Question
•
A client with gastroesophageal reflux disease (GERD) is prescribed
famotidine (Pepcid). In order to provide effective teaching, the
nurse must include which information about the action of the drug?
1.
2.
3.
4.
It improves motility
It coats the distal potion of the esophagus
It increases the gastric pH
It decreases the secretion of gastric acid
25
Answer
Answer is 4.
•
Famotidine is a histamine-2 receptor antagonist and reduces the
secretion of gastric acid (option 4). This class of drugs does not have
a direct effect on reflux or GI motility. Metoclopramide improves GI
motility (option 1). Sucralfate coasts the ulcer (option 2). Antacids
neutralize the hydrochloric acid in the stomach (option 3).
26
AMY
27
GI – Hesi Review Question
•
A 65-year old man presents to the Emergency Department
complaining of recurring burning chest pain after eating. His history
consists of obesity, type-II diabetes, sedentary behavior, and
commonly takes TUMS on a regular basis. As his ED nurse, which
nursing diagnosis would be suitable for this patient?
1.
2.
3.
4.
At risk for severe pain related to an angina attack.
At risk for hyperglycemic hyperosmolar nonketotic syndrome
related to poorly controlled diabetes.
Deficient knowledge related to GERD.
Possible nutritional deficiency related to overuse of antacids.
28
Answer
Answer is 3.
•
Chest pain only after eating is a common complaint of
Gastroesophaegeal reflux disease (GERD). Chest pain before eating
is related to Peptic Ulcer Disease. Commonly taking TUMS is another
indication of acid reflux.
29
GI – Hesi Review Question
•
Name the three causes of intestinal obstruction.
1.
2.
3.
4.
Constipation, neurogenic, and vascular.
Mechanical, neurogenic, and vascular.
Mechanical, diverticulitis, and vascular.
Mechanical, constipation, and diverticulitis.
30
Answer
Answer is 2
•
The three main causes of intestinal obstruction are due to
Mechanical (adhesions, hernias, volvulus [twisting of the gut],
intussusceptions, tumors), neurogenic (paralytic illeus, lesions on
the spinal cord), and vascular causes (artery occlusions).
31
GI – Hesi Review Question
•
A patient is being admitted to post-op recovery for a hip
replacement. It is 12-hours post-op and she is complaining that she
has not eaten in 24 hours and wants some ice cream to soothe her
irritated throat. What is the next nursing intervention for this
patient?
1.
2.
3.
4.
Give her the ice cream right away to soothe her irritated throat
and document the amount on her I&O’s.
Tell her she cannot have any liquids or food until she
ambulates for the first time.
Contact doctor to increase IV fluids because her output is
decreasing.
Ascultate for bowel sounds, if bowel sounds are heard, allow
her to eat some ice cream.
32
Answer
Answer is 4
•
After surgery, it is important to determine if the intestines have
begun to move or are still paralytic. The nurse must determine, via
auscultation of the abdomen, if bowel sounds have returned. If food
and liquid is given too early, an intestinal obstruction may occur.
33
GI – Hesi Review Question
•
A 45-year old woman presents in your outpatient facility concerned
with her family history of colorectal cancer. What interventions
would be suitable to suggest for this woman?
1.
2.
3.
4.
Eat more cruciferous vegetables.
Tell her that there is nothing she can do; this type of cancer
cannot be prevented.
Decrease fiber intake, and increase more foods from animal
sources.
Begin colonoscopy examinations every year after 50.
34
Answer
Answer is 1
•
The only valid answer is to eat more cruciferous vegetables
(broccoli, cauliflower, etc…). Preventative screening is important.
Rectal examinations should be given every year after age 40, and
colonoscopies/sigmoidoscopies should only be given every 3 -5
years after age 50. Fiber intake should increase, and foods from
animal sources should decrease for preventive measures.
35
TIMOTHY
GI – Hesi Review Question
•
A client is to receive gavage feeding through a nasogastric (NG)
tube. Which of the following nursing actions should be performed
to prevent complications?
1.
2.
3.
4.
Flush with 20 mL of air
Place client in high Fowler’s position
Advance tube 1 cm
Plug the air vent during feeding
Answer
Answer is 2. Keeping the client in a high Fowler’s position minimizes the
risk of aspiration (option 2). Flushing with air (option 1) will increase
abdominal distention and increase discomfort and risk of aspiration.
Advancing the tube (option 3) is only relevant if it is a nasoduodenal
tube that has not advanced beyond the pylorus. Plugging the air
vent (option 4) is unnecessary.
Strategy: The NG tube bypasses the oropharynx and the gag reflux, which
concludes that the airway is compromised. Select the answer that
protects the airway.
GI – Hesi Review Question
•
The nurse should question the client with gastroesophageal reflux
disease (GERD) about the use of which type of medications that
decrease lower esophageal sphincter (LES) tone?
1.
2.
3.
4.
Antidepressants
Calcium channel blockers
Antiestrogen agents
Alpha-adrenergic blocking agents
Answer
Answer is 2. Many common substances contribute to decreased LES tone
including fatty foods, caffeinated beverages, nicotine, betaadrenergic blocking agents, calcium channel blockers (option 2),
nitrates, theophylline, alcohol, and anticholinergic drugs.
Antidepressants, antiestrogen agents, and alpha adrenergic blockers
have no effect on LES tone.
Strategy: Identify how the lower esophageal sphincter contributes to the
symptoms of GERD and select the drug that increases that effect.
GI – Hesi Review Question
•
The client with irritable bowel syndrome (IBS) asks the nurse what
causes the disease. Which of the following response by the nurse
would be most appropriate?
1.
2.
3.
4.
This is an inflammation of the bowel caused by eating too
much roughage.
IBS is caused by a stressful lifestyle
The cause of this condition if unknown
There is thinning of the intestinal mucosa caused by ingestion
of gluten
Answer
Answer is 3. There is no known cause of IBS, and diagnosis is made by
excluding all other diseases that cause the symptoms (option 3).
There is no inflammation of the bowel (option 1). Some factors
exacerbate the symptoms (option 2), including anxiety, fear, stress,
depression, some foods (options 1 and 4) and drugs, but these do
not cause the disease.
Strategy: Know the different forms of inflammatory bowel disease and
causative factors vs exacerbating factors.
GI – Hesi Review Question
•
A client with Crohn’s disease (regional enteritis) who is taking
sulfasalazine (Azulfidine) asks the nurse why this medication is
necessary. When information should the nurse include in her
response.
1.
2.
3.
4.
The drug decreases abdominal cramping by slowing peristalsis.
The drug decreases prostaglandin production in the bowel so it
decreases inflammation.
The drug inhibits neurotransmission of pain impulses.
The drug stimulates the release of endorphins so pain is
relieved.
Answer
Answer is 2. Sulfasalazine is a GI anti-inflammatory medication that
exerts its action by decreasing prostaglandin production in the
bower (option 2). Peristalsis is decreased by anticholinergic agents
(option 1). Analgesics affect pain impulses (options 3 and 4).
Strategy: Review the goals of treatment for inflammatory bowel disease
and select the answer that directly decreases the inflammatory
response.
Amanda
Question #1
•
Colace works by?
1.
Stimulating muscles and nerves in the bowels to help move stool
along
Forming bulk that absorbs liquid to produce a soft bulky stool,
stimulating bowel normally by the presence of the bulk
Encouraging bowel movements by drawing water into the bowel
from surrounding body tissues, providing soft stool mass and
increased bowel action
2.
3.
Answer is 2
•
•
Rationale: Colace is a bulk-forming laxative.
Nursing Intervention:
We should encourage our patients to increase their fluid intake during
their use of Colace because water is being lost to the colon.
Question #2
•
When a client has peptic ulcer disease, the nurse would expect a
priority intervention to be?
1.
2.
3.
4.
Assisting in inserting a Miller-Abbott tube
Assisting in inserting an arterial pressure line
Inserting a nasogastric tube
Inserting an IV
Answer is 3
•
•
Insert a NG tube
Rationale:
NG tube needs to be inserted to determine the presence of active GI
bleeding. A Miller-Abbott tube is a weighted, mercury-filled
ballooned tube used to resolve bowel obstructions. There is no
evidence of shock or fluid overload in the client; therefore an arterial
line is not indicated and an IV is optional.
Question #3
•
A 55 year old patient with severe epigastric pain due to acute
pancreatitis has been admitted to the hospital. The client’s activity
at this time should be?
1.
2.
3.
4.
Ambulation as desired
Bedrest in supine position
Up ad lib and right side-lying position in bed
Bedrest in Fowler’s position
Answer is 4
•
•
Bedrest in Fowler’s position
Rationale:
The pain of pancreatitis is made worse by walking and by laying in the
supine position. The client is more comfortable sitting up and leaning
forward.
Question #4
•
A client has had a cystectomy and ureteroileostomy (ileal conduit).
The nurse observes this client for complications in the postoperative
period. Which of the following symptoms indicates an unexpected
outcome and requries priority care?
1.
2.
3.
4.
Edema of the stoma
Mucus in the drainage appliance
Reddness of the stoma
Feces in the drainage applance
Answer is 4
•
•
Feces in the drainage appliance
Rationale:
The ileal conduit procedure incorporates implantation of the ureters
into a portion of the ileum which has been resected from its
anatomical position and now functions as a reservoir or conduit for
urine. Feces should not be draining from the conduit. Edema a red
color of the stoma are the expected outcomes in the immediate postop period, as is mucus from the stoma.
Question #5
•
Most cleft palates are repaired at what age?
1.
2.
3.
4.
Immediately after birth
1 to 2 months
3 to 4 months
1 to 2 years
Answer is 4
•
•
1 to 2 years
Rationale:
Most surgeons will correct the cleft at 1 to 2 years old before faulty
speech patterns develop to take advantage of palatal changes during
infancy
Question #6
•
To clear Dr. B out of the classroom as quickly as possible, so we can
all go home, we should have all eaten which food for lunch?
1.
2.
3.
4.
Beans
Donuts
Wine and cheese
Pizza
Question #6 Answer
Do you really need the answer and rationale?
We are done people!
Let’s go home!
Thank you for your participation!!
The GI Group