Alterations of GI System
Nur 302 Unit I
Carcinoma of Oral Cavity
Predisposing factors: tobacco & alcohol
S/S: leukoplakia, erythroplakia, ulcer,
sore or rough spot
Diagnosis: biopsy
Collaborative Care: surgery, radiation,
chemo or combination
Health Promotion
Expected Outcomes
Mandibular Fracture
Rx: immobilization by wiring- 4-6 weeks
Pre-op teaching
Post-op Care: Airway, oral hygiene,
communication, nutrition
Nausea & Vomiting
Problems- Dehydration, loss of electrolytes,
decreased plasma volume, metabolic
alkalosis,aspiration.
History, regurgitation, projectile, fecal odor,
partially digested food, color, time of day,
emotional stressors.
Antiemetics, med’s that stimulate gastric
emptying
IV and NG tube, begin diet with clear liquids.
GERD
Predisposing Factors
Hiatal hernia
Incompetent lower esophageal sphincter
Decreased esophageal clearance
Decreased gastric emptying.
Esophagitis- trypsin & bile salts.
Hiatal Hernia Etiology
Weakening of diaphragm muscles, increased
intraabdominal pressure, age, trauma, poor
nutrition, recumbent position.
Types: Sliding & Paraesophageal or rolling.
Complications: hemorrhage from erosion,
stenosis, stomach ulceration, strangulation
hernia, esophagitis.
Treatment : See GERD, elevate HOB on 4-6”
blocks, lose weight.
GERD & Hiatal Hernia
Signs & Symptoms
Heartburn
Wheezing, coughing, dyspnea
Hoarseness, sore throat
Post eating bloating
N/V, regurgitation
Hiatal hernia s/s mimic GB disease,
angina, peptic ulcer
Diagnostic Studies
Barium swallow
Esophagoscopy
Biopsy
Esophageal motility studies
Check ph
GERD & Hiatal Hernia Treatment
Med’s: Antacids, H2-Blockers, Prokinetic
drugs, Antisecretory drugs.
Nutritional Therapy: diet high in P & low in
Fat, avoid milk, chocolate, peppermint,
coffee and tea, small frequent meals, avoid
spicy foods and late meals.
Teaching: avoid smoking, decreased stress,
do not lie down three hours after eating.
Hiatal Hernia Treatment
Surgery: valvuloplasties or antireflux
procedures.
Post-op care:
Prevent respiratory complications maintain
fluid & electrolyte balance prevent
infection.
 Chest tube
 NG tube.

Esophageal Cancer
Barrett’s esophagus/syndrome.
Etiology: smoking, alcohol, chronic
trauma, poor oral hygiene, asbestos.
S/S: progressive dysphagia, late s/s
pain.
Complication: hemorrhage, mets to liver
and lung.
Treatment: surgery, radiation, & chemo.
Esophageal Cancers
Pre-op care:



high calorie, high P, liquid diet or TPN
oral care
teaching
Post-op care :
NG bloody 8-12 hours
 semi-Fowler’s position
 prevent resp. complication

Gastritis
Types: Acute or Chronic, Type A (Fundal) &
Type B (Antral).
Etiology: breakdown in normal mucosa
barrier
Corticosteroids, NSAIDS, ASA,spicy foods,
alcohol
Presence of Helicobacter pylori
Gastritis Signs & Symptoms
Anorexia
N/V
Epigastric tenderness
Feeling of fullness
Hemorrhage
Diagnostic Studies
Endoscopic exam
CBC
Stool for occult blood
Cytologic exam
Gastritis
Treatment: eval. & eliminate the specific
cause, double & triple antibiotic
combinations for H. pylori, no smoking,
bland diet.
Assessment: dehydration, vomiting,
hemorrhage.
Teaching: stress close medical followup, diet, meds.
Peptic Ulcers
Types: acute or chronic, gastric or duodenal
(80%).
Person with a gastric ulcer has normal to less
than normal gastric acidity compared with a
person with a duodenal ulcer.
Etiology: H.pylori disrupted mucosal barrier,
increased vagal nerve stimulation (eg.
emotions), genetic, medications
Peptic Ulcer Signs & Symptoms
May have no pain
Gastric ulcer pain


epigastric, burning, “gassy”
1- 2 hrs after meals, stomach empty or when eat
food
Duodenal ulcer pain


back or mid-epigastric, burning, cramp-like
2-4 hrs after meals, antacids relieve pain
Peptic Ulcers
Complications: hemorrhage, perforation,
gastric outlet obstruction.
Diagnostics: fiberoptic endoscopy,
H.pylori tests, barium contrast studies,
gastric analysis, CBC, urine analysis,
liver enzymes studies, serum amylase,
stool for occult blood.
Conservative therapy: (see gastritis).
Nursing Care
Acute care: NPO, NG, IV fluid,v/s qh till
stable
Hemorrhage: assess color of
hematemesis, s/s shock.
Perforation: assess for sudden severe
pain to abd. & shoulder, rigid abdomen,
decreased or absent B.S.
Surgical Therapy
Partial gastrectomy


Billroth I – Gastroduodenostomy, removes distal
2/3 stomach & attaches to duodenum
Billroth II – Gastrojejunostomy, removes distal 2/3
stomach & attaches to jejunum
Vagotomy-eliminates stimulus for acid
secretion
Pyloroplasty –enlarges pyloric sphincter,
increases gastric emptying
Post-op Care
Observe NG tube drainage
Red, decreasing in color 1st 24 hours
 Observe for clogged NG tube
 Do not irrigate without MD order, surgeon
replaces NG if pt pulls out tube

Observe for decreased peristalsis
I&O, VS
Post-op Care
Observe for bleeding/ hemorrhage, NG
& dressing
Pain management
What are the general post-op
complications & nursing care?
If you do not have HCl, what disease
are you at risk for?
Case Scenario & Prioritization
BK is post-op Bilroth I and is to receive 2 units of
blood. As you get out of report, lab calls and says the
first unit of blood is ready. Prioritize:
Verify order to transfuse blood and consent
Take initial set VS
Pick up blood from lab
Assess IV site
Start transfusion
Verify pt ID, & blood compatability
Prioritization
Pre-transfusion T98.6, P80, R18, BP136/78. Transfusion
started, slow …..15 minutes later- T98.2, P90, R22, BP 130/70,
no itching, rate increased 100/h……20 minutes later- skin
flushed, p 120, R32, BP100/60, c/o chest pain & chills.
Priority problem??? What do you do first? Prioritize:
Stop transfusion
Save transfusion unit
Inform MD/RN
Save next voided specimen
Start 0.9NS
Take VS
Post-op complications
Dumping Syndrome
Postprandial hypoglycemia
Bile reflux gastritis
Dumping Syndrome
Large amount hyperosmolar chyme in
intestine->fluid is drawn in->decrease of
plasma volume
Bowel also becomes distended>increased motility
15-30 minutes after eating->s/s last 1 hr
Weakness, sweating, dizzy, cramps,
urge to have BM
Postprandial Hypoglycemia
Like dumping syndrome
2 hours after eating
Bolus of high CHO fluid into small
intestine->bolus of insulin secretion>hypoglycemia
What are the s/s of hypoglycemia?
Bile Reflux Gastritis
Alkaline gastritis from bile salts
Continuous epigastric s/s which
increase after meals & relieved by
vomiting (temporarily)
Treatment – Questran ac or pc,
Aluminum hydroxide antacids
Nutrition Postgastrectomy
Dumping Syndrome
Six small meals
Do not have fluids with meals

Fluids 45 minutes before or after meals
Dry foods low CHO, moderate protein &
fats
Avoid concentrated sweets (jams,
candy, etc)
Lie down after meals, short rest period
Ca of the stomach
Etiology: smoked, spicy, highly salted foods
may be carcinogenic, genetics, Type A blood,
p.anemia, polyps.
S/S of anemia, peptic ulcer disease, or
indigestion.
Diagnostics: CEA test, stool and gastric
analysis, CBC, liver enzymes, amylase,
barium studies, endoscopic exams.
Surgery: (see peptic ulcer disease).
Radiation & chemo
Food Poisoning
S/S: n/v, diarrhea, colicky abdominal
pain
Types: acute bacterial gastroenteritisstaph, clostridial, salmonella, botulism,
escherichia coli, see table 42-27
Food Poisoning
Health Promotion
Correct food preparation
Cleanliness
Cooking
Refrigeration
Diarrhea
“Symptom”, acute or chronic
Etiology: decreased fluid absorption,
increased fluid secretion, motility
disturbance.
Dx studies: H&P, labs, endoscopy
Care: replace fluid & lytes, decrease #
stools, treat cause, meds
Acute Infectious Diarrhea
Assessment: freq & duration, char &
consistency, laxatives, antibiotics, diet
travel, stress, family history, food prep
VS, ht & wt, skin turgor, skin breakdown
BS, distention, abdominal tenderness
Nsg Care: hand washing, contact
isolation, teach pt & family
Constipation
Etiology: insufficient dietary fiber, inadeq fluid
intake, meds, little exercise
Complications: hemorrhoids, Valsalva’s
maneuver, diverticulosis
Teaching: 20 – 30 g of fiber/day, drink 3
qts/day, exercise 3X/week, avoid
laxatives/enemas, record elimination pattern,
do not delay defecation & establish a pattern
“Acute Abdomen”
Etiology: see table 43-12
S/S: PAIN, abd tenderness, vomiting,
diarrhea, abd tenderness, constipation,
flatulence, fatigue, fever, increased abd
girth
DX: H&P, preg test, rectal & pelvic
exam, CBC, U/A, abd x-rays
Emergency management: table 43-13
“Acute Abdomen”
Assess: VS, inspect, palpate &
auscultate abdomen, pain, n/v, change
in bowel habits, vaginal discharge
Pre-op Care: CBC, type & cross match,
clotting studies, cath, skin prep, NG
Post-op care of NG tube, mouth & nare
care, control of n/v, abd distention & gas
pains
Chronic Abdominal Pain
Irritable bowel syndrome, peptic ulcer ,
diverticulitis, chronic pancreatitis,
hepatitis, cholecystitis, pelvic inflam.
disease, vascular insuffic., psychogenic
Diagnosis & treatment: “critical thinking
skills”
Abdominal Trauma
Etiology: blunt trauma or penetrating injuries
Lacerated liver, ruptured spleen, pancreatic
trauma, mesenteric artery tears,
diaphragmatic rupture, urinary bladder
rupture, great vessel tears, renal injury,
stomach or intestinal rupture
S/S: abd guarding & splinting, distended,
hard abd, decr or absent BS, contusions,
abrasions, bruising on abd, pain, shock,
hematemesis or hematuria, Cullen’s sign
Abdominal Trauma
Dx: CBC, u/a, abd cat, x-rays, periton. lavage
Assessment: shock – decreased LOC & BP,
increased resp & P; check abd, flank for
abrasions, open wounds, impaled objects, old
scars; n/v, hematuria, abd pain, distention,
rigidity,pain radiating to shoulder & back,
rebound tenderness
Interventions: airway, control bleeding, cover
protruding organs, IV, labs, foley, VS, LOC,
see table 43-14
Appendicitis
S/S: periumbilical pain, then shifting to RLQ &
localizing @ McBurrey’s point, tenderness,
rebound tenderness, muscle guarding,
Rovsing’s sign, anorexia, n/v, low grade fever
Complic: perforation, peritonitis, abscess
Dx: H&P, WBC, u/a
Nsg Care: NPO, no laxatives or heat to area,
post-op: OOB next day & advance diet
Peritonitis
Etiology: rupture of an organ, trauma,
pancreatitis, peritoneal dialysis
S/S: tenderness over area, rebound
tenderness, muscle rigidity & spasms, abd
distention, n/v, tachycardia, tachypnea, alt
bowel habits
Complications: hypovolemic shock,
septicemia, abscess, paralytic ileus, organ
failure
DX: CBC, C&S perit. Fld, CT, x-ray
Nursing Care
Assess pain, BS, distention, guarding,
temp, labs, s/s shock
VS, I&O, lytes, NPO, antiemetics, NG
Surgical site drains (penrose, Jackson
Pratt, “open belly”) check color & amt
drainage, I & O if irrigation of wound
Antibiotics, analgesics, maybe TPN
Gastroenteritis
S/S: n/v, diarrhea, fever abd cramps
Rx: NPO til stop vomiting, then flds with
glucose & electrolytes (Pedialyte)
Complication: dehydration, loss of lytes
Strict handwashing & medical asepsis,
rest & increased fld intake
Ulcerative Colitis
Inflammation, abscesses in mucosa break
into submucosa & ulcerate, decreased area
for absorption, granulation tissue forms &
mucosa becomes thick & short.
S/S: bloody diarrhea & abd pain - acute or
chronic, mild or severe exacerbations. Fever,
malaise, anorexia, wt loss, dehydration,
anemia, tachycardia
Complications
Intestinal: hemorrhage, strictures, perforation,
toxic megacolon, colonic dilatation, risk for
colon cancer
Extraintestinal: due to malabsorbtion or
problem with immune system – joints, skin,
mouth & eyes
Dx: CBC, lytes, albumin, stool analysis,
sigmoidascope & colonoscopy, barium
enema
Nursing & Collaborative Care
Rest bowel
Control inflammation
Prevent / treat infection
Correct malnutrition
Meds to relieve s/s
Alleviate stress
See NCP 40-3
Meds
Sulfasalazine – maintenance &
remission, for 1 year
5-ASA – active disease, 4-ASA given as
retention enemas
Corticosteroids :IV, enema, Prednisone
Cyclosporin
Sedatives, antibiotics, vitamins
Surgery
Total proctocolectomy with perm. ileostomy
Total protocolectomy with continent ileostomy
called a Knock pouch
Total colectomy & ileal reservoir
Surgery “cures” disease
Post-op: stoma care, skin integrity, I&O,
observe for hemorrhage, abscess, small
bowel obstruction, electrolyte imbalance &
dehydration, diet teaching & care of ileostomy
Crohn’s Disease
Inflammation of segments GI tract esp
ileum,jejunum, colon & involves all layers of
bowel wall
Classic “cobblestone” appearance, normal
bowel between diseased, longitudinal, deep
ulcerated parts
Thickening bowel wall & strictures
Abscesses & fistulas with bladder, vagina,
bowel
Crohn’s Disease
Chronic disease, intermittent remissions &
recurrences
S/S: diarrhea & abd pain, arthritis may
precede s/s, progressive disease – wt loss,
dehydration, anemia, pain RLQ & umbilicus
Complications: fistulas, malabsorption of
A,D,E,K, gluten intolerance, arthritis, liver
disease, cholelithiasis, nephrolithiasis, uveitis
Dx: same as ulcerative colitis
Collaborative Care
Sulfasalazine – large intestine involvement
Corticosteroids – taper off when s/s subside
Immunosuppressive meds if steroids
ineffective
Flagyl – perianal area
Fish oil, B-12 IM,
Balloon dilation of strictures
Element diet- hi calorie, hi Nitrogen no fat;
OR lo residue & roughage, hi calorie & P,
possibly lactate free diet
Surgery
Indications: fistulas, abscess, intestinal
obstruction, perforation, ? Carcinoma,
hemorrhage, no response to therapy
Surgery is not a cure, high recurrence
Procedure – intestinal resection with
anastomosis
Nursing Care
Patient & family teaching regarding
nature of disease & limitations of tx
Teach: diet, importance of rest, meds,
when to seek medical care, reduce
stress, perianal care
Post-op: ulcerative colitis NCP 43-3
Skin care, referral to wound care nurse
for abscess / fistulas
Intestinal Obstruction
Mechanical: adhesions, neoplasms, hernias
Nonmechanical: paralytic ileus,
pseudoobstructions, vascular
Pathophysiology: feces, fld & gas collect
proximal to obstruction, distention, collapse
distal bowel, decr absorption of fld, incr
pressure, flds & lytes into peritoneal cavity.
Edema, necrosis, congestion from decr bld
supply, possible bowel rupture & shock
Intestinal Obstruction
Obstructions: simple, closed loop,
strangulated, incarcerated
S/S: n/v, pain, distention, inability to pass gas,
hi pitched BS above area of obstruction
Dx: H&P, abd x-rays, barium enema,
sigmoidoscopy, colonoscopy, CBC, lytes,
BUN, amylase, WBC, guiac stool
Tx: decompress intestine, surgery
Nursing Care
Assessment: pain, s/s, BS, dehydration,
labs
Insertion & care NG tube
Intestinal tubes: Harris tube, MillerAbbott tube, Cantor tube
Colon & Rectal Cancer
Risk factors
Adenomatous polyps->adenocarcinoma
Spread thru walls of intestine -> lymph
system, metastasis to liver-> portal vein
S/S: L lesions- rectal blding, alt constipation &
diarrhea, ribbon like stools, sensation of
incomplete evacuation, s/s obstruction.
R lesions- vague abd pain, weakness &
fatigue from anemia
Colon & Rectal Cancer
Dx: H&P, rectal exam, sigmoidoscopy, air
contrast barium enema, CT scan
colonoscopy, CBC, clotting studies, liver
enzymes, CEA
Staging: primary tumor, regional lymph node
involvement, distant metastasis
Surgery: R or L hemicolectomy, abdominal
perineal resection
Chemo & radiation: post-op or palliative
Health Promotion
Assess risk factors
American Ca Society recommends screening
@ age 40- rectal exam q yr. Age 50
sigmoidoscopy q 5 yrs & stool occult bld q yr:
if + findings->colonoscopy, BE. Hi risk ptscolonoscopy q? depends on risk
Barriers: lack of info & fear of dx
Research: use of anti-inflammatory drugs or
long term use of ASA
Diet
Nursing Care
Abd-Perineal Resection
Teach extent of surgery for abdom-perineal
resection, positioning for comfort & sitz bath,
ostomy questions
Abd wound, perineal wound, stoma
Profuse drainage from perineal wound immed
post op – reinforce dsg. Keep clean & dry.
Packing left 2-3 days then irrigate wound with
NS; drains left in 3-5 days; closed wound- sitz
bath. Check s/s infection. C/O pain, itching.
Home Care
Psychological support
Pain/discomfort management
Nutrition
Care of perineal wound
Home health nurse – assessment &
teaching of pt & family
Community Services
Ostomy Surgery
Temporary or permanent
Stoma
Ileostomy, knock pouch, ileoanal reservoir
Cecostomy
Colostomy, loop & double barrel
Ostomy Care: assess stoma, skin care,
select pouch/bag, psychol support &
adaptation to stoma, sexual dysfunction
Diverticular Disease
Lack of fiber, retention of stool & bacteria,
fecalith-> inflammation, small perforations,
edema, abscess, peritonitis
S/S diverticulosis: none or LLQ crampy abd
pain, alt constipation & diarrhea.
Diverticulitis: localized pain, tender LLQ
mass, fever, chills, n/v, anorexia,
leukocytosis, elderly-afebrile, little tenderness
Diverticulitis
Complications: perforation & peritonitis,
abscess & fistula, bowel obstruction, bleeding
– hematochezia (maroon stools)
Tx uncomplicated disease: hi fiber diet, bulk
laxatives (Metamucil), anticholinergic meds
(Donnatal), incr flds, obese->loose wt, avoid
staining @ stool
Diverticulitis: rest bowel- NPO, IV, BR,NG,
antibiotics, complications->surgery
Hernias
Protrusion of viscous thru wall of cavity.
Reducible, irreducible or incarcerated,
strangulated
Types: inguinal, femoral, ventral or incisional
S/S: bulge, discomfort, pain->strangulated
Tx: herniorrhaphy, hernioplasty, truss
Post-op: check voiding, scrotal support, ice
pack, no coughing, splint incision with mouth
open if sneeze, no lifting 6-8 weeks
Malabsorption Syndrome
Causes: biochemical or enzyme deficiency,
bacterial profileration, disruption sm intestine
mucosa, disturbed lymph or vascular
circulation,surface area loss
Lactose intolerance, inflam bowel disease,
celiac, tropical sprue, cystic fibrosis
S/S: steatorrhea (except lactose intol)
Dx: stool for fat, screening for CHO
absorption, pancreatic secretion test, BE, sm
bowel biopsy, CBC, lytes, PT, Ca, Chol, vit A
Short Bowel Syndrome
Excessive resection of small intestine.
Rapid intestinal transit, impaired digestion &
absorption, fld & lyte loss
S/S: diarrhea & steatorrhea, malnutrition &vit
& mineral deficiencies, wt loss, lactase def,
bacterial overgrowth, kidney stones
Tx: antidiarrheal meds, TPN-> hi CHO, low F
diet, 6 meals/day
Anorectal Problems
Hemorrhoids- internal or external dilated
veins
Tx: hi fiber diet, increase fld, prevent
constipation, nupercaine oint, astringents,
suppositories, ice pack, sclerosing agent or
ligate, hemorrhoidectomy
Post-op: pain, sitz baths, packing removed 12 days, stool softener, teaching- diet, avoid
constipation, complication- bleeding
Anorectal Problems
Anal fissure –crack or skin ulcer in anal wall,
associated with constipation
Anorectal abscess- perirectal infection E. coli,
staph or strep, foul smell, sepsis
Surgically drained, packed q day with
petroleum jelly gauze, keep clean, heal by
granulation, sitz bath, lo residue diet
Pilonidal cyst- tract @ sacrcoccyx, congenital,
lined with epithelium & hair, abscess forms
Tx- I&D