INTERVENTIONS FOR
CLIENTS WITH
GASTROINTESTINAL
PROBLEMS
PEPTIC ULCER
CHOLYCYSTITIS
PANCREATITIS 2010
HOW DO ULCERS DIFFER?
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PEPTIC ULCER
GASTRIC ULCER
DUODENAL ULCERS
STRESS ULCER
PAIN COMPARED
• Gastric Ulcer: occurs 30-60 min after a
meal, rarely at night, accentuated by
food
• Duodenal Ulcer: Occurs 1 1/2 - 3 hours
after a meal, often awakened at night
between 1-2 AM, relieved by ingestion
of food
COMPLICATIONS OF
ULCERS
• HEMORRHAGE
• PERFORATION
• PYLORIC OBSTRUCTION
Assessment indicating
hemorrhage
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Hematemesis
Melena
Coffee Ground Emesis
Black stool
Hematochezia
Profuse upper GI hemorrhage
Assessment indicating
Perforation
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Sudden sharp pain
Apprehension
Abdominal assessment
Client position
peritonitis
Bowel sounds
MEDICAL EMERGENCY, LIFE
THREATENING
Assessment indicating
Obstruction
PYLORIC OBSTRUCTION:
Nausea/Vomiting
GASTRIC OUTLET OBSTRUCTION:
• Abdominal bloating
• Nausea/Vomiting
• F & E imbalances
Assessment indicating
Obstruction
PYLORIC OBSTRUCTION:
Nausea/Vomiting
GASTRIC OUTLET OBSTRUCTION:
• Abdominal bloating
• Nausea/Vomiting
• F & E imbalances
TEACHING CAUSE
• Use of certain drugs
• Bacterial infection
• Genetics
ASSESSMENT
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HISTORY
Physical assessment
What is the most common symptom?
Where is pain?
How is the pain described?
How is the pain different from gastric to
duodenal ulcer?
• What other symptom is associated?
LABORATORY
ASSESSMENT
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Hgb, Hct
Stool specimen
Ba enema
Upper right abdomen series
***EGD
(esophagogastroduodenoscopy)
• Biopsy
ASSESSMENT CONTINUED
SMOKING CESSATION:
• smoking decreases the secretion of
bicarbonate from the pancreas into the
duodenum
• Acidity of the duodenum is higher when
one smokes
Assessment Continued
SMOKING CESSATION:
• smoking decreases the secretion of
bicarbonate from the pancreas into the
duodenum
• Acidity of the duodenum is higher when
one smokes
NURSING DIAGNOSIS
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Knowledge deficit RT
Imbalanced nutrition RT
Disturbed sleep RT
Risk for falls RT
Fatigue RT
Nausea RT
Ineffective Health Maintenance RT
Fear RT
DRUG THERAPY
GOALS:
DRUGS for H. pylori
bismuth compound or proton pump inhibitor and two antibiotics
BISMUTH: Pepto-Bismol
PROTON PUMP INHIBITORS: omeprazole (Prilosec)
COMBINATION OF ANTIBIOTICS:
metronidazole (Flagyl) & Tetracycline
clarithromycin & amoxicillin
CHALLENGE WITH THIS REGIMEN?
HYPOSECRETORY DRUGS
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Reduces gastric acid secretions
1. antisecretory agents
2. H2 receptor antagonists
3. Prostaglandin analogues
ANTISECRETORY AGENTS
Or PROTON PUMP INHIBITORS
EXAMPLES:
• omeprazole (Prilosec)
• lansoprazole (Prevacid)
• rabeprazole (Aciphex)
• pantoprazole (Protonix)
• esomeprazole magnesium (Nexium)
H2 Receptor Antagonists
• Block histamine stimulated gastric
secretions
• OTC
Examples:
• rantidine (Zantac)
• famotidine (Pepcid)
• nizatidine (Axid)
PROSTAGLANDIN
ANALOGUES
• HOW: reduce gastric acid secretion and
enhance gastric mucosal resistance to
tissue injury
• EXAMPLES:
• Misoprostol (Cytotec)
DRUGS CONTINUED
Hyposecretory Drugs
antisecretory Agents
H2 receptor antagonist
Prostaglandin analogues
Antacids
ANATACIDS
• HOW:
– buffer gastric acid and prevent the formation of pepsin
– Speeds up healing of duodenal ulcers
EXAMPLES:
• Mylanta (magnesium containing)
• Maalox (aluminum containing)
• TUMS (calcium containing)
• Simethicone Combination products: Gelusil &
Mylanta
Problems: INTERACTION WITH DRUGS &
• HIGH SODIUM CONTENT
MUCOSAL BARRIER
FORTIFIERS
• Forms a protective coat
• EXAMPLE:
– Sucralfate (Carafate)
• INSTRUCTIONS FOR
ADMINISTRATION:
DIET
• CONTROVERSY
• What is known about food?
• Instruct client about foods that increase
gastric acid secretion
SURGICAL INTERVENTION
• Seen in 10-15% of pts
INDICATIONS FOR SURGERY:
• life threatening bleeding
• Perforation
• Obstruction
TYPE OF SURGERY:
• GASTRIC RESECTION: remove the
gastrin producing portion of the stomach
ADDITIONAL SURGERY:
BILROTH I AND II
• Used to remove ulcers and cancer, not for
peptic ulcer disease
• Bilroth I (gastroduodenostomy): fundus of
stomach anastomosed to duodenum
• Bilroth II (gastrojejunostomy) duodenum is
closed, fundus of stomach anastomosed into
the jejunum
• Heineke-Mikulicz pyloroplasty: enlarges
pyloric stricture (most common)
ASSESSMENT POSTOP
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Observe for blood from NGT
Observe for abdominal distention
REPORT TO SURGEON
IRRIGATION OF NGT: not done
POSTOP PROBLEMS RELATED
TO BILROTH PROCEDURES
DUMPING SYNDROME: vasomotor symptoms after
eating after Billroth II procedure
RESULTS from rapid emptying of gastric contents into
the small intestine which shifts fluid into the gut
causing abdominal distention
• EARLY S&S seen 30 min after eating:vertigo,
tachycardia, syncope, sweating, pallor, palpitations
and desire to lie down
• LATE S&S: 90 min-3hrs after eating caused by
excessive amt of insulin: dizziness.
• Light headedness, palpitations, diaphoresis,
confusion
TREATMENT OF DUMPING
SYNDROME
• 6 small meals a day high in protein and fat
and low in CHO; avoid fluids during meals
• Avoid refined or concentrated CHO because
they leave the stomach quickly
• Eat slowly
• Vitamins for nutritional deficiencies
• Anticholinergics: decrease stomach motility
• Somatostatin analogue: octreotide
(Sandostatin) Synthetic form of the hormone
found in GI tract used to inhibit dumping
syndrome
OTHER COMPLICATIONS
• Alkaline Reflux gastropathy or bile reflux
gastropathy
• Delayed gastric emptying
• Afferent loop syndrome
• Recurrent ulceration
REVIEW ALL OF THESE: see page
1303-1304
NUTRITIONAL PROBLEMS
POSTOP
• deficiencies of :
– vitamin B12
– folic acid
– iron
– impaired calcium metabolism
– reduced absorption of calcium &vitamin D
• WHY?
• WHAT ASSESSMENTS?
• WHAT TREATMENT?
BILIARY DISORDERS
DEFINITIONS
• CHOLECYSTITIS: Inflammation of GB
• CHOLELITHIASIS: caused by presence of
stones
• ACALCULOUS CHOLECYSTITIS:
inflammation of the GB without stones
• CALCULOUS CHOLECYSTITIS:
Follows obstruction of the cystic duct by a
stone creating an inflammation
• CHOLANGITIS: infection of the bile ducts
• CHOLEDOCHOLITHIASIS:
common bile duct stones
CHOLECYSTITIS WITH
CHOLELITHIASIS
STONES composed of cholesterol, bile pigment
and calcium
• INCIDENCE: higher in women over age 40
• PREDISPOSING FACTORS: Runs in
families, obesity, middle age, multiparity, use
of birth control pills, pregnancy, diabetes,
after rapid weight loss, alcholism
NON-SURGICAL APPROACH
• Low fat diet
• Replacement of fat soluable vitamins (A, D, E, K),
bile salts
• Weight reduction
• NGT for uncontrolled vomiting
• Broad spectrum antibiotics (ampicillin, tetracycline,
cephalosporins)
• Dissolution therapy (chenodeoxycholic acid or CDCA;
ursodeosycholic acid or UDCA)
• Lithotripsy
• Endoscopic Retrograde Cholangiopancreatography
(ERCP)
NON-SURGICAL APPROACH
CONTINUED
DRUG THERAPY:
• Meperidine hydrochloride (Demerol): pain
AVOID USE OF MORPHINE (causes spasm
and constriction of the sphincter of Oddi)
• atropine sulfate (Atropine): anticholinergic
• dicyclomine (Bentyl, Lomine): antispasmodic
ASSESSMENT OF
CHOLECYSTITIS AND
CHOLELITHIASIS
• Abdominal pain, usually in the right upper
quadrant, may radiate to back or right
shoulder
• Pain triggered by high fat/high volume meal
• Full feeling
• Eructation
• Dyspepsia
• Flatulence
• Nausea/Vomiting
• Low grade fever
ASSESSMENT CONTINUED:
done by MD and NP
• Blumberg’s sign
• Murphy’s sign
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ASSESSMENT CONTINUED
FOR CHRONIC
CHOLECYSTITIS
Jaundice
Clay-colored stools
Dark urine
Steatorrhea
DIAGNOSTIC ASSESSMENT
• Serum alkaline
phosphatase
• AST (aspartate
aminotransferase)
• LDH (lactate
dehydrogenase)
• Direct serum
bilirubin
• Indirect serum
bilirubin
DIAGNOSTIC ASSESSMENT
CONTINUED
• WBC:
• Serum amylase
• Serum lipase
DIAGNOSTIC ASSESSMENT
Ultrasound of right upper quadrant:
Hepatobiliary Scan:
SURGICAL TREATMENT
• CHOLECYSTECTOMY: removal of
gallbladder and cystic duct
• CHOLEDOCHOSTOMY: opening into the
common bile duct through the abdominal wall
with insertion of T-tube to keep duct open for
healing
• LAPAROSCOPIC CHOLECYSTECTOMY:
removal of gallbladder via umbilical incision
POST-OP NURSING CARE FOR
LAP CHOLECYSTECTOMY
• May be same day surgery/ or 1-2 hospital
stay
• Must be able to tolerate food, ambulate, and
have stable vital signs to be discharged
• Mild to moderate pain for two days postop
• Mild discomfort for one week
• No lifting heavier than 5 lbs
• Normal activity in 1-3 weeks
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POSTOP NURSING CARE FOR
PT WITH OPEN
CHOLECYSTECTOMY
PCA for severe postop pain (avoid morphine)
Low to semi Fowler’s position
C &DB
Change dressing (usually off in 24 hrs)
IV fluids/NPO
Advance from low fat clear liquids to low fat bland
diet as tolerated; many clients don’t need special diet
• Antiemetics
• Surgical drain for 24 hours
• T-tube (placed to keep the common bile duct open)
COMPLICATIONS
OBSTRUCTION:
• Clay colored stool or steatorrhea means
no bile in intestinal track
• CALL SURGEON!
HEMORRHAGE:
• Check VS, incisions, tubes, increased
tenderness or rigidity of abdomen
• CALL SURGEON!
COMPLICATIONS
INFECTION
• Pain
• fever
DISRUPTION OF GI TRACT FUNCTION:
• Vomiting, abdominal distension, increased
pain
PATIENT EDUCATION
• Care of T-tube
When to call MD:
• Jaundice, dark urine, pale colored stools,
pruritus (signs of obstructed bile flow)
• Pain or fever (signs of infection)
PATIENT EDUCATION
• Teach patient to expect loose bowel
movements for a few weeks to several
months
• Teach about low fat diet: trim fat from food,
lean meats, remove skin from poultry, limit
use of eggs, no frying goods, use skim milk,
low fat cottage cheese, no sauces, gravies or
rich desserts, increase fish and seafood.
T TUBE
• T-tube: biliary drainage tube Avoid tension
and obstruction of tubing
• Keep pt in semi Fowler’s position
• Drains to bile bag kept below the level of the
GB
• Initially blood tinged immediately postop, then
changes to green-brown bile
• Assess q 2-4 hours initially then q 8 hours
after 1st 24 hrs
T TUBE
• BILE OUTPUT: about 400 + ml/day with
gradual decrease in output
• REPORT DRAINAGE AMOUNTS IN
EXCESS OF 1000 ml/DAY TO MD
• REPORT SUDDEN INCREASES IN
BILE OUTPUT AFTER NORMALLY
DECREASING PATTERN
T TUBE
• Collect and administer excess bile
output to the client via NGT
(uncommon) or five synthetic bile salts
(dehydrocholic acid (Decholin)
• Check for infection, inflammation,
irritation
• NEVER IRRIGATE, ASPIRATE,
CLAMP a T tube without a MD order
T TUBE
• Observe for pulling, kinking, tangling
• When client allowed to eat, clamp T-tube for
1-2 hours before and after meals AS MD
ORDERS
• Assess client’s response to determine
tolerance of food
• Change dressing: remove dressing once a
day, clean skin around tube, apply precut
dressing around catheter and tape in place
• Empty T tube same time each day
PANCREATITIS
NORMAL
Pancreas has two functions: endocrine
and exocrine
• ENDOCRINE FUNCTION:
• EXOCRINE FUNCTION:
ENZYMES: trypsin, chymotrypsin,
amylase, lipase
PANCREATITIS DEFINED
• An acute or chronic inflammation of the
pancreas
• Caused by autodigestion
PATHOPHYSIOLOGY:
4 PROCESSESS OCCUR
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LIPOLYSIS
PROTEOLYSIS
NECROSIS OF BLOOD VESSELS
INFLAMMATION
LIPOLYSIS
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What happens to the lipase
What happens to Fatty acids
What do they combine with
What do they form after
combining
• What is the end result?
PROTEOLYSIS
• After the trypsin is activated what
happens to the pancreas?
• What is the end result of this to the
pancrease
NECROSIS OF THE BLOOD
VESSELS
• What happens after elastase is
activated by trypsin?
• What happens with the necrosis of the
blood vessels?
• What happens when the client starts to
hemorrhage?
• What is the risk to the client?
INFLAMMATION
• leukocytes cluster around
– hemorrhagic areas
of pancreas
– necrotic areas
• What happens next?
COMPLICATIONS:JAUNDICE
Jaundice
• CAUSED BY:
COMPLICATIONS: BLOOD
SUGAR
Transient Hyperglycemia
Diabetes
COMPLICATIONS:
OXYGENATION
• Left lung pleural effusion
• Atetelectasis & pneumonia
• ARDS
COMPLICATIONS:
• Multisystem Organ Failure
COMPLICATIONS:
coagulation problems
• DIC (disseminated intravascular
coagulation)
• CAUSED BY: release of necrotic tissue
and enzymes into blood leads to altered
coagulation
COMPLICATION:
• acute renal failure
• CAUSED BY:
COMPLICATION:
• paralytic ileus
• CAUSED BY
TEACHING ABOUT CAUSE
• Inherited
• Alcohol and drug abuse
• Ask about history of :
– Gall Bladder Disease
– Gastric/duodenal ulcer disease
– Abdominal trauma
– Drug toxicity
– Complication of ERCP
ASSESSMENT: PAIN
• LOCATION:
• INTENSITY:
• DURATION:
• WHAT CAUSES PAIN:
• WHAT RELIEVES PAIN:
ASSESSMENT: abdominal
• 1. Jaundice
• 2. Cullens Sign:
• 3. Turner’s sign:
• 4. Absent/decreased bowel sounds
• 5. Rigidity/guarding:
DIAGNOSTIC TESTS
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Abdominal xray
Chest xray
CT scan
MRI
Ultrasonography
NURSING DIAGNOSIS:
complete the cause
• Acute pain RT
• Imbalanced nutrition RT
• Nausea RT
• Risk for infection RT
• Ineffective breathing pattern RT
• Risk for activity intolerance
• Disturbed sleep pattern RT
LABORATORY TESTS: which are
elevated/lowered and why?
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Serum amylase
Serum lipase*******
Serum trypsin
Serum elastase
WBC
Serum glucose
Serum ALT (alanine
aminotransferase)
• Bilirubin
• Alkaline phosphatase
• Serum calcium
• Serum
magnesium
IMPLEMENTATION
GOAL:
• Decrease GI pain
• Decrease GI tract activity
• Decrease pancreatic stimulation
HOW?
1.Fasting
2.Drug Therapy
3.Comfort
4.Manage life threatening complications
WHAT WILL BE ORDERED
TO MEET THE GOALS?
1.Fasting
2.Drug Therapy
3. Activity
3.psychosocial
MEDICATIONS: PAIN
• Demerol (meperidine)
• Transdermal fentanyl (Duragesic)
• Epidural morphine with bupivacaine
MEDICATIONS:
GOAL:
To decrease vagal stimulation
To decrease GI motility
To inhibit pancreatic secretions
WHAT DRUGS:
• Anticholinergics: atropine (Urised)
• Calcium gluconate IV
• Antibiotics: cefuroxime (Zinacef),
ceftazidime (Ceptaz), imipenem cilastin
(Primaxin)
• Antacids and Histamine blockers (ranitidine
(Zantac)
MEDICATIONS
ENZYME REPLACEMENT contains
what?
• EXAMPLES:
– pancreatin(Donnazyme, Creon)
– Pancrelipase (Cotazym, Viokase,
Pancrease)
• What is the PURPOSE:
What to teach client about
ENZYME REPLACEMENT:
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When to take around meals?
What to take it with?
Can the drug be broken, crushed, chewed?
What can be done with capsules?
What foods shouldn’t be mixed with?
What precautions should be told to client?
What is the therapeutic outcome?
REFERRALS
• Counselor
• Self help group
• Alcoholics Anonymous if appropriate