Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN The Gastro-Intestinal System Review
of the GIT Anatomy and Physiology
Review
of
The GIT System: Anatomy and Physiology • The GIT is composed of two general parts
•
Review Review
of Common Common Sympto Symptoms ms and their their nursing interventions
Review
of common disorders of the:
Esophagus Stomach Stomach Small intestine Large Intestine Gallbladder exocrine pancreas liver
Organs of the Digestive System
The The
main main GIT GIT
star starts ts from from the the
mout mouth h Esophagus
Stomach SI LI Rectum • 23-26 foot-long • The accessory organs are the - Salivary glands - Liver - Gallbladder - Pancreas The Mouth
•
Anatomy - Contains the lips, cheeks, palate, tongue, teeth, salivary glands, masticatory/facial muscles and bones - Anteriorly bounded by the lips - Posteriorly bounded by the oropharynx
• Physiology
- Important for the mechanical digestion of food - The saliva contains SALIVARY AMYLASE or PTYALIN that starts the INITIAL digestion of carbohydrates The Esophagus • Anatomy
A hollow muscular tube Length- 25 cm Made up of stratified squamos epithelium Loca Locatted in the media edias stin tinum, um, ant anteri erior to the the spine,posterior to the trachea and heart - The upper third contains skeletal muscles, contains the upper esophageal or hypopharyngeal sphincter - The middle third third contains contains mixed skeletal skeletal and smooth smooth muscles The lower lower third third contai contains ns smooth smooth muscl muscles es and and the the - The esophago-gastric/ esophago-gastric/ cardiac sphincter is found here -
• Physiology
- Functions to carry or propel foods from the oropharynx to the stomach - Swallowing or deglutition is composed of three phases:
Upper 3rd Miidle 3rd Lower 3rd The stomach • Anatomy
- J-shaped organ in the LUQ - Contains four parts- the fundus, the cardia, the body and the pylorus - The cardiac sphincter prevents the reflux of the contents into the esophagus(entrance) esophagus(entrance) - The The pylo pyloric ric sphi sphinc ncte terr regu regula late tes s the the rate rate of gast gastri ric c emptying into the duodenum(exit) duodenum(exit) - Capacity is 1,500 ml!
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN
Decreased gastric secretions Decreased GIT motility Sphincters and blood vessels constrict
- Parasympathetic
•
Generally EXCITATORY!
Physiology
Increased gastric secretions Increased gastric motility Sphincters relax Terms
- The functions of the stomach are generally to digest the food (proteins) and to propel the digested materials into the SI for final digestion - The Glands and cells in the stomach stomach secrete secrete digestive digestive enzymes: 1. Parietal cells- HCl acid and Intrinsic factor
2.
Chief cells- pepsin digestion of PROTEINS! 3. Antral G-cells- gastrin gastrin 4. Argentaffin cells- serotonin serotonin 5. Mucus neck cells- mucus mucus The Small intestine
• Digestion: phase of the digestive process that occurs when
enzymes enzymes mix with ingested ingested food and when proteins, proteins, fats, and sugars are broken down into their component molecules • Absorption: phase of the digestive process that occurs when small molecules, molecules, vitamins, vitamins, and minerals minerals pass through through the wall walls s of the the smal smalll and and larg large e inte intest stin ine e and and into into the the bloodstream • Elimination: phase of the digestive process that occurs after dige digest stio ion n and and abso absorp rpti tion on,, when when wast waste e prod produc ucts ts are are eliminated from the body
• Anatomy
- Longest segment, about 2/3 of the total length
-
Gros Grossl sly y divi divide ded d into into the the Duod Duoden enum um (pro (proxi xima mal) l),, Jejunum(middle) Jejunum(middle) and Ileum(distal) - Duodenum w/ampulla of vater-common bile duct empties, passage of bile and pancreatic secretions - The ileum is the longest part (about 12 feet)
•
Physiology
-
The intes intestin tinal al glands glands secre secrete te digest digestive ive enzyme enzymes s that that finalize the digestion of all foodstuffs Enzymes for carbohydrates Enzymes for proteins Enzyme for lipids
disaccharidases
dipeptidases and aminopeptidases aminopeptidases
intestinal lipase
Functions of the GIT • The breakdown of food particles into the molecular form for
digestion • The absorp absorptio tion n
into into the the bloods bloodstea team m of small small nutri nutrien entt molecules produced by digestion • The eliminati elimination on of undigest undigested ed unabsorbe unabsorbed d foodstuff foodstuffs s and other waste products
Digestive Processes • Chewing
- 1.5m 1.5mll of sali saliva va is secr secret eted ed daily daily from from the the paro paroti tid, d, submaxillary and sublingual glands - PTYALIN or SALIVARY AMYLASE is an enzyme that begins the digestion of starches
The Large intestine • Swallowing begins as a voluntary act, w/c is regulated by • Anatomy
the swallowing center in the medulla oblongata of the CNS
- Approximately 5 feet long, with parts:
1.
The cecum widest diameter, prone to rupture 2.The appendix 3. The ascending ascending colon 4. The transverse colon 5. The descending colon
6. The sigmoid most mobile, prone to twisting 7.The rectum 8.The Anus BLOOD SUPPLY - GIT recieves blood from arteries that originate along the entire length of the thoracic and abdominal aorta - The portal venous system is composed of 5 large veins: superior mesenteric, inferior mesenteric, gastric, splenic, and cystic veins w/c form the vena portae that enters the liver - Oxygen and nutrients are supplied to the stomach by the gastri gastric c artery artery and to the intest intestine ines s by the the mese mesente nteric ric arteries. • Physiology
- Sympathetic
Generally INHIBITORY!
• Gastric Function
- stomach-secretes a highly acidic fluid in response to the presence of ingested food - fluid can total as 2.4L/day can have a ph as low as 1 and derives its acidity from hydrochloric acid (HCl) a. to break breakdown down food into more absorbable absorbable componen components ts b. to aid aid in the destr destruct uction ion of inges ingested ted bact bacteri eria a Gastric Enzymes Secreted by zymogens or chief cells Amylase=for starch digestion Lipase=for fat digestion Pepsin=for protein digestion Rennin=for milk and protein digestion Secreted by parietal cells HCl - maintains acidity 1.0 pH destroy some bacteria ingested aids also in digestion of food Intrinsic factor - aids in absorption of vit B12 * pernicious anemia Secreted by endocrine cells Gastrin, somatostatin and serotonin
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN • Small Intestine Function
- duodenal duodenal secretion secretions s come from the accessory accessory digestive digestive organs- pancreas, liver and gallbladder and the glands on the intestinal walls pancreatic secretions secretions have alkaline pH due to the high - pancreatic concentra concentration tion of bicarbona bicarbonatete- this neutralizes neutralizes the acid entering the duodenum from the stomach
• Upper GIT study: Barium swallow
-
Examines the upper GI tract Barium sulfate is usually used as contrast
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Pre-test: NPO post-midnight Post-test: Laxative is ordered, increase pt fluid intake, inst instru ruct ct that that stoo stools ls will will turn turn whit white, e, moni monito torr for for obstruction
Digestive enzymes secreted by the pancreas: - trypsin aids in digesting protein - amylase aids in digesting starches - lipase aids in digesting fats pancreatic secretions pancreatic duct ampulla of vater 2 Types of contractions in the small intestines a. segmental contractions- mixing waves that move the intestinal contents back and forth in a churning motion b. intestinal peristalsis- propels the contents towards the colon * both movements are stimulated by the presence of chyme Finger like projections/villi are present throughout the small intest intestine iness- absorp absorptio tion-b n-begi egins ns in the the jejunu jejunum m by active active transport and diffusion
• Colonic Function
- bacteria make up a major component of the contents of the large intestine, assist in completing the breakdown of waste waste material material esp undigest undigested ed and unabsorbe unabsorbed d proteins proteins and bile salts 2 types of colonic secretions: a. electrolyte solution- is chiefly bicarbonate bicarbonate solution that act to neutralize the end products formed by the colonic bacterial action b. mucus- protects the colonic mucosa • Waste Products of Digestion
-
-
Feces - undigested foodstuff, inorganic materials, water and bacteria 75% fluid 25% solid material brown color results from the breakdown of bile gases- methane, hydrogen sulfide and ammonia Eliminati Elimination on begins begins with distention distention of the rectum w/c initia initiate tes s contra contracti ctions ons of the rectal rectal muscu musculat lature ure and and relaxes the closed internal anal sphincter internal anal sphincter- autonomic nervous system external anal sphincter- cerebral cortex; maintained in tonic contraction
Gastrointestinal Gastrointestinal Assessment Laboratory Procedures • FECALYSIS
- Examination of stool consistency, color and the presence of occult blood. - Special tests for fat, nitrogen, parasites, ova, pathogens and others • FECALYSIS: Occult Blood Testing
- Instruct the patient to adhere to a 3-day meatless diet - No intake of NSAIDS, aspirin and anti-coagulant anti-coagulant - Screening test for colonic cancer
• Lower GIT study: Barium enema
- Examines the lower GI tract
-
Pre-test : Clea Clearr liqu liquid id diet diet and and laxa laxati tive ves, s, NPO postpostmidnight, cleansing enema prior to the test
-
Post-test: Laxati Laxative ve is ordere ordered, d, increa increase se patien patientt fluid fluid intake, intake, instruct that stools will turn white, white, monitor monitor for obstruction
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN
• Gastric analysis
- Aspiration Aspiration of gastric gastric juice juice to measure measure pH, appearan appearance, ce, volume and contents - Pre-test: NPO 8 hours, avoidance of stimulants, drugs and smoking
•
Post-test: resume normal activities
EGD - esophagogastroduodenoscopy esophagogastroduodenoscopy - Visualization of the upper GIT by endoscope
-
Pre-test: Pre-test: ensure ensure consent, consent, NPO 8 hours, hours, pre-medica pre-medications tions like atropine and anxiolytics
Gastroscopy
• Lower GI- scopy
-
Intra-test: position position : LEFT lateral lateral to facilitate facilitate salivary drainage and easy access
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Post-test : NPO until gag reflex returns, place patient in SIM SIMS posit ositio ion n until ntil he awa awakens kens,, monito r for complications, saline gargles for mild oral discomfort
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Intra-test: position is LEFT lateral, lateral, right right leg is is bent and placed anteriorly
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Post-test: bed rest, rest, monito monitorr for compli complicat cation ions s like like bleeding and perforation
• Lower GI- scopy
- Use of endoscope to visualize the anus, rectum, sigmoid and colon
-
Pre-test: consent, consent, NPO 8 hours, hours, cleansing cleansing enema until return is clear
• Colonoscopy
• Cholecystography
- Examination of the gallbladder to detect stones, its ability to concentrate, store and release the bile
-
Pre-test: ensure consent, ask allergies to iodine, seafood and dyes; dyes; contrast contrast medium medium is administe administered red the night prior , NPO after contrast administration
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN -
Post-test: Advise that dysuria is common as the dye is excreted in the urine, resume normal activities
• Paracentesis
- Removal of peritoneal fluid for analysis
-
Pre-test: Pre-test: ensure consent, consent, instruct instruct to VOID and empty empty bladder, measure abdominal girth
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Intra-test: Upright on the edge of the bed, back supported and feet resting on a foot stool
• Liver biopsy
- Pretest Consent NPO Check for the bleeding parameters - Intratest Position: Semi fowler’s LEFT lateral to expose right side of abdomen Post-t -tes est: t: posi positi tion on on RIGH RIGHT T late latera rall with with pill pillow ow - Post underneath, monitor VS and complications like bleeding, perforation. Instruct to avoid lifting objects for 1 week The NURSING PROCESS in GIT Disorders Assessment - Health history Nursing History - PE - Laboratory procedures Assessment: Assessment: History
Quadrants of the Abdomen
- Include all information related to GI function pain pain,, dysp dyspep epsi sia, a, gas, gas, naus nausea ea and and vomi vomiti ting ng,, consti constipat pation ion,, diarrh diarrhea, ea, fecal fecal contin continen ence, ce, change change in bowel bowel patter patterns ns,, chara characte cteris ristic tics s of stool, stool, jaund jaundice ice,, histor history y of GI surgery or problems, appetite and eating patterns, teeth, and nutritional assessment, including weight patterns - Psychosocial, spiritual, and cultural factors - Assess knowledge; need for patient education
• Abdo Abdomi mina nall
Common Sites of Referred Abdominal Pain
COMMON GIT SYMPTOMS AND MANAGEMENT CONSTIPATION DIARRHEA DUMPING SYNDROME • Constipation
An abnormal infrequency and irregularity of defecation Multiple causations
The ABDOMINAL examination The sequence to follow is: - Inspection - Auscultation - Percussion - Palpation
Examination of the Abdomen
Pathophysiology Interference with three functions of the colon 1. Mucosal transport 2. Myoelectric activity 3. Process of defecation Nursing I nterventions nterventions 1. Ass Assist ist physic physician ian in treat treating ing the under underlyi lying ng cause cause of constipation 2. Encourage to eat HIGH fiber diet to increase the bulk 3. Increase fluid intake 4. Administer prescribed laxatives, stool softeners 5. Assist in relieving stress
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN • Diarrhea
- Abnormal fluidity of the stool - Multiple causes Gastrointestinal Diseases Gastrointestinal Hyperthyroidism Food poisoning
- Nursing Interventions Interventions
1.
Increase fluid intake- ORESOL is the most important treatment! 2. Determine and manage the cause 3.Anti-diarrheal drugs
PERNICIOUS ANEMIA - Results from Deficiency of vitamin B12 due to autoimmune destruction of the parietal cells, lack of INTRINSIC FACTOR or total removal of the stomach
- Assessment Severe pallor Fatigue Weight loss Smooth BEEFY-red tongue Mild jaundice Paresthesia of extremities Balance disturbance - Nursing Intervention Lifetime injection injection of Vitamin Vitamin B 12 weekly initially, then Lifetime MONTHLY Conditions of the GIT • UPPER GI system
Conditions of the Oral Cavity Disorders Of The Teeth 1. Dental Plaque and and Caries - tooth decay is an erosive process that begins w/ the acti action on of bact bacter eria ia on ferm fermen enta tabl ble e CHO CHO in the the mout mouth, h, w/c w/c prod produc uces es acid acid that that diss dissol olve ve toot tooth h enamel - the extent of damage to the teeth depends on the ff: presen presence ce of dental dental plaque plaque-- gluey, gluey, gelat gelatin in like like substance that adheres to the teeth streng strength th of the the acid acid and and abilit ability y of the saliva saliva to neutrlize the length of time the acids are in contact susceptibility of the teeth to decay - Prevention Mouth h Care Care-- brus brushi hing ng and and flos flossi sing ng,, norm normal al Mout mastication (chewing), normal flow of saliva
Diet- ↓ the amount of sugar & starch Fluoridation Pit and Fissure Sealants- special coating to fill and seal pits and fissures, can last to 5-10 years
Chronic - slowly progressive, a fully formed abscess may occur w/o the pt’s knowledge, leads to a “blind dental dental absces abscess” s” w/c w/c is a peria periapic pical al granul granuloma oma,, discovered on X-ray, treated w/ root canal therapy
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Clinical Clinical Manifesta Manifestation tions s - dull, gnawing, gnawing, continuous continuous pain pain w/ surrou surround nding ing cellul celluliti itis s and and edema edema of the adjacent facial structures and mobility of the involved tooth, difficult to open the mouth, fever, malaise
Managementnt- needle needle aspiration aspiration or drill an opening opening - Manageme into the pulp chamber to relieve pressure and pain, drai draina nage ge thru thru an incis incisio ion n in the the ging gingiv iva a to the the jawbone, antibiotics - Nursin Nursing g Manage Managemen mentt- ass assess ess the the pt for bleedi bleeding, ng, instruct to use warm saline, take medications, follow up
3.Malocclusion - Misalignment of the teeth of the upper and lower dental arcs when the jaws are closed - Inherited or acquired - Makes the teeth difficult to clean and can lead to decay, gum disease - Corrections requires an orthodontist, treatments begins when the pt has shed the last primary tooth and the last permanent successor has erupted Disorders Of The Jaw Categorized as follows: a.myof a.myofas asci cial al pain pain-- disc discom omfo fort rt in the the musc muscle le contro controllin lling g jaw jaw functi function on and neck neck and should shoulder er muscles b.internal derangement of the joint- dislocated jaw, displaced disc, or injured condyle c. degenera degenerative tive joint diseasedisease- rheumato rheumatoid id arthritis arthritis or osteoarthritis of the jaw Clinical Manifestations - dull, throbbing, debilitating pain that can radiate radiate to the ears, teeth, neck muscle, facial sinuses, restricted jaw motion, locking of the jaw, difficult chewing and swallowing Assessment and Diagnostic Findings- diagnosis is based on the pt’s report of pain, limitation of motion, dysphagia, diff diffic icul ulty ty in chew chewin ing, g, diff diffic icul ulty ty w/ spee speech ch,, hear hearin ing g difficulties. Management- stress reduction, range of motion exercises, pain pain mana manage geme ment nt w/ NSAI NSAIDS DS,, musc muscle le rela relaxa xant nts, s, if irreversible- surgery
2. Dentoalveolar abscess abscess or Periapical Abscess
-
Collec Collectio tion n of pus in the the apical apical dental dental perios periosteu teum m (fibrous (fibrous membrane membrane supportin supporting g the tooth tooth structure structure)) and the tissue surrounding the apex (in the jaw bone) - May be acute or chronic Acute - secondary to a suppurative pulpitis that arises from an infection from a dental caries
Disorders of The Salivary Glands 1. PAROTITIS- inflammation inflammation of the parotid gland MUMPSMUMPS- epidemic epidemic parotitis, parotitis, a communica communicable ble disease disease caused by a viral infection mostly affect children - elderly, elderly, acutely acutely ill, debilitat debilitated ed people people w/ decreased decreased salivary salivary flow from dehydration dehydration or medicati medications ons are at higher risk - organism is usually staphylococcus aureus
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN - onset is sudden, fever, the gland swells and becomes tense and tender, pain, difficult swallowing, - manageme managementnt- adequat adequate e nutrition nutrition and fluid intake, good oral hygiene, antibiotics, analgesic, parotidectomy 2. SIALADENITISSIALADENITIS- inflammation of the salivary gland - caused caused by dehydr dehydrat ation ion,, radiat radiation ion therap therapy, y, stres stress, s, malnu malnutri tritio tion, n, saliva salivary ry gland gland calcul calculi, i, improp improper er oral oral hygiene - organisms: Staph.aureus, Strep. viridans - manifestation- pain, swelling, purulent discharge - treatme treatmentnt- antibioti antibiotics, cs, massage, massage, hydration hydration,, warm compresse compresses, s, corticoste corticosteroids roids,, surgical surgical drainage drainage of the gland or excision 3. SALIVARY CALCULUS (SIALOLITHIASIS) (SIALOLITHIASIS) - occurs in the submandibular glands - formed mainly from calcium phosphate - PE- gland is swollen, tender, palpable w/ stone -Tx - extraction, lithotripsy Aphthous Stomatitis - Canker Sore - Shallow ulcer w/ white or yellow center and red border; seen on the inner side of the lip, cheek or on the tongue - Begins Begins w/ burning burning or tingling tingling sensation sensation and slight swelling; swelling; painful - Lasts 7-10 days and heals w/o a scar Assoc w/ emotio emotional nal or menta mentall stres stress, s, fatigu fatigue, e, hormon hormonal al - Assoc factor factors, s, minor minor trauma trauma,, allerg allergies ies,, acidic acidic foods foods and and juice juices, s, dietary deficiencies - Assoc w/ HIV infection - Instruct pt on comfort measures, soft or bland diet - Give prescribed antibiotics or corticosteroids Stomatitis
CANCER OF THE ORAL CAVITY - Often assoc w/ use of alcohol and tobacco - 95% occur among 40 y/o and older affecting more men than women - Regardless of the stage of cancer at diagnosis, the 5 yr survival rate is 56% and the 10 yr survival rate is 41% - Usual Usually ly squamo squamous us cell cell cance cancers, rs, affect affects s lips, lips, latera laterall aspects of the tongue, floor of the mouth - S/SX S/SX-- pain painle less ss sore sore or mass mass that that does does not not heal heal,, difficulty in chewing, swallowing and speaking - DX- assessment of oral cavity, biopsy, - MX- chemotx, radiationTx, surgical resection
Condition Of The Esophagus Hiatal Hernia - The opening in the diaphragm through w/c the esophagus passes becomes enlarged and part of the upper stomach tends to move up - More common among women
-
Two types- Sliding or type I hiatal hernia (most common90%) and Paraesophageal hiatal hernia: type II, III and IV ( IV- greatest herniation)
- Assessment Findings 1.Heartburn 2.Regurgitation 3.Dysphagia 4. 50%- without symptoms symptoms implicated in reflux hemorrhage, obstruction, strangulation Sliding Esophageal and Paraesophageal Hernia
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN 3. Ascites 4. jaundice 5. hepatomegaly/splenomegaly hepatomegaly/splenomegaly Signs of Shock- tachycardia, hypotension, tachypnea, cold clammy skin, narrowed pulse pressure
- Diagnostic Test Barium swallow and fluoroscopy
DIAGNOSTIC PROCEDURE Esophagoscopy NURSING INTERVENTIONS INTERVENTIONS FOR EV 1. Monitor VS strictly. Note for signs of shock 2. Monitor for LOC 3. Maintain NPO 4. Monitor blood studies 5. Administer O2 6. Prepare for blood transfusion 7. Prepare to administer Vasopressin and Nitroglycerin 8. Assist in NGT and Sengstaken-Blakemore tube insertion for balloon tamponade 9. Prepare to assist in surgical management: Endoscopic sclerotherapy Variceal ligation Shunt procedures Gastro-esophageal Gastro-esophageal reflux - Backflow of gastric contents into the esophagus - Usually due to incompetent lower esophageal sphincter , pyloric stenosis or motility disorder - Symptoms may mimic ANGINA or MI - Incidence increase w/ aging
- Assessment (For Gerd) Heartburn / Pyrosis Dyspepsia / Indigestion Regurgitation Odynophagia Dysphagia / Difficulty swallowing Excessive salivation - Diagnostic test Endoscopy or barium swallow Gastric ambulatory pH analysis Note for the pH of the esophagus, usually done for 24 hours The The pH probe is locate located d 5 inches inches above above the lower lower esophageal sphincter The machine registers the different pH of the refluxed material into the esophagus
Nursing Interventions
1. 2. 3.
Provide small frequent feedings AVOID supine position for 1 hour after eating
Elevate the head of head of the bed on 8-inch block 4. Provide pre-op and post-op care
Esophageal Varices Dilation and tortuosity of the submucosal veins in the distal esophagus ETIOLO ETIOLOGY: GY: common commonly ly cause caused d by PORTA PORTAL L hypert hypertens ension ion secondary to liver cirrhosis This is an Emergency condition! ASSESSMENT ASSESSMENT findings for EV 1. Hematemesis 2. Melena
- Nursing Interventions Interventions 1.Instruct the patient patient to AVOID AVOID stimulus stimulus that increases increases stomach pressure and decreases LES pressure 2. Instruct to avoid spices, coffee, tobacco and carbonated drinks 3. Instruct to eat LOW-FAT, HIGH-FIBER HIGH-FIBER diet 4. Avoid foods and drinks TWO hours before bedtime 5.Elevate the head of the bed with an approximately 8inch block 6.Administer 6.Administer prescribed prescribed H2-blocke H2-blockers, rs, PPI and prokineti prokinetic c meds like cisapride, metochlopromide 7. Advise proper weight reduction reduction
Conditions of the Stomach Gastritis - Inflammation of the gastric mucosa
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN - May be Acute or Chronic - Etiology: Acute - irritating foods, highly seasoned or contaminated w/ disease causing microorganism, NSAIDS, alcohol, bile reflux and radiationTx Chroni Chronicc- Ulcera Ulceratio tion, n, bacter bacteria ia (Heli (Helicob cobact acter er pylori pylori), ), Auto Autoim immu mune ne dise diseas ase e (per (perni nici ciou ous s anem anemia ia), ), diet diet (caffeine),alcohol, (caffeine),alcohol, smoking, bile reflux
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Pathophysiology of Gastritis Insults cause gastric mucosal damage inflammation, hyperemia and edema superficial erosions decreased gastric gastric secretio secretions ns of gastric juice (very (very little acid more mucus), ulcerations and bleeding
- ASSESSMENT (Acute) Abdominal discomfort Headache Anorexia Nausea/Vomiting (Chronic) Pyrosis Singultus Sour taste in the mouth Dyspepsia N/V/anorexia Pernicious anemia - Diagnostic Procedure EGD- to visualize the gastric mucosa for inflammation Absen bsentt (Ach (Achllorhy orhydr dria ia)) or Low Low leve levels ls of HCl (hypochlorhydri a) a) or High Levels of HCl (hyperchlorhydria) Biopsy to establish correct diagnosis whether acute or chronic
- NURSING INTERVENTIONS
1.
Give BLAND diet 2.Monitor 2.Monitor for signs signs of complic complicat ation ions s like like bleedi bleeding, ng, obstruction and pernicious anemia 3.Instruct to avoid spicy foods, irritating foods, alcohol and caffeine, NSAIDS, 4. Conditions of the Stomach 5.Adminis 5.Administer ter prescr prescribe ibed d medica medicatio tionsns- H2 blocke blockers, rs, antibiotics, mucosal protectants 6. Inform the need for Vitamin B12 injection if deficiency is present
Erosive Gastritis
Peptic Ulcer Disease - An ulceration of the esophageal, gastric and duodenal lining - May be referred as to location as Gastric ulcer in the pylor pylorus us of the the stom stomac ach, h, or Duod Duoden enal al ulce ulcerr in the the duodenum, or in the esophagus ulceration: anterior part of the - Most common Peptic ulceration: upper duodenum - Common between 40-60 y/o, blood type O - Causes: H.pylori infection, excessive secretion of HCl, stress, stress, alcohol, alcohol, smoking, smoking, caffeina caffeinated ted beverage beverage,, spicy foods
- PATHOPHYSIOLOGY PATHOPHYSIOLOGY of PUD Disturbance in acid secretion and mucosal protection
Increased acidity or decreased mucosal resistance erosion and ulceration
Zollinger-Ellison SyndromeSyndrome- sever severe e peptic peptic ulcer, ulcer, extreme gastric hyperacidity, and gastrin secreting benign or
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN malign malignant ant tumor tumors s medical treatment
of the the
pancre pancreasas-res resist istan antt
to standa standard rd
Relieved by food, antacids, H2 blockers; is not not assoc ssocia iatted with ith vomi vomiti ting ng (if (if atypi typica call featur features es occ occur ur think think of complications) High gastric levels H. pylori+++ Does Does not not repr repres ese ent a malignancy Usually not accompanied by a high high compli complicat cation ion rate; when complications do occu occurr it is usua usuall lly y ploric stenosis or posterior penetration
Stress Stress ulcer ulcer - occurs occurs after after physiologic physiological al stressfu stressfull event events s such such as burns, burns, shock, shock, sepsis sepsis,, trauma trauma,, ventil ventilato atorr assisted pt,
Cushing’s ulcer - common in pts w/ head injury and brain trauma, more penetrating and deeper than stress ulcer, involves esophagus, stomach and duodenum
Curling’s ulcer - observ observed ed about about 72 hours hours after after extensive burns, involves stomach and duodenum - Duodenal Ulcer Age: 30-60 y/o M/F=3:1 80% of peptic ulcers are duodenal Weight Gain Hypersecretion of HCL acid Pain occurs 2-3 h after meal Ingestion of food relieves pain Vomiting uncommon Hemorrhage less likely Melena more common than hematemesis Most likely to perforate Possibility of Malignancy is rare Risk Factors: H.pylori, alcohol, smoking, stress - Gastric Ulcer Usually 50 and over Male:Female = 1:1 Weight Loss Pain occurs ½ to 1 hour after meal Ingestion of food does not help, causes pain Vomiting common Hemorrhages more likely Hematamesis more common than melena Hematamesis Possibility of Malignancy: occasional Risk Factors: H.pylori, alcohol, smoking, NSAID
- Gastric Ulcer Usually 50 and over Male:Female = 1:1 Weight Loss Pain occurs ½ to 1 hour after meal Ingestion of food does not help, causes pain Vomiting common Hemorrhages more likely Hematamesis Hematamesis more common than melena Possibility of Malignancy: occasional Risk Factors: H.pylori, alcohol, smoking, NSAID
Duodenal Ulcer Pain occurs 90 min to 3h after after meals meals;; wakes wakes up patient midnight to 3AM
Gastric Ulcer Common Commonly ly pain pain occ occurs urs with within in a shor shortt time time of food intake
-
Commonly Accompanied by nusea, vomiting with food intake, and a vari variab able le resp respon onse se to medication Low gastric acid levels H. pylori+++ Malignancy+ 25% of GU will be accompanied by signi igniffica icant bleed leedin ing g highe igherr mort mortal alit ity y and and morbididty than DUs
Clinical Manifestations - dull, gnawing pain or a burning sensation in the midepigastrium or in the back, pyrosis, vomiting, vomiting, constipat constipation ion or diarrhea, diarrhea, bleeding bleeding (melena(melenablack tarry stool)
- Assessment and Diagnostic Findings epigastric tenderness or abdominal distention endoscopy endoscopy is the preferred preferred procedure procedure bec of direct direct visualization and biopsy can be done stool exam gastric secretory studies, urea breath test
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN
- Diagnostic Tests EGD and Biopsy
Management - Medical Management Pharmacologic therapy- combination of antibiotics, prot proton on pump pump inhi inhibi bittors ors and and bism bismut uth h salt salt to eradicate H.pylori for 10-14 days, Histamine-2 (H2) recept receptor or antag antagoni onist st and PPI PPI are used used to treat treat NSAID induced ulcers Stress reduction and rest Smoking cessation Dietary modification
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN
Surgical Management Pharmacotherapy Histamine-2 (H2) receptor antagonists (PO/IV)
Action: ↓ HCl production
taken with meals or at H.S., cigarettes reduces its action SE: heada headache che,, dizzin dizziness ess,, nause nausea/v a/vomi omitin ting g & urticaria 8 weeks weeks medication medication (if s/sx does not improve, start antibiotics) Cimetidine (Tagamet) Ranitidine (Zantac) Famotidine (Pepcid) Nizatidine (Axid) Antibiotics
Action: antibacterial to eradicate H. pylori
Amoxicillin (Amoxil) Clarithromycin (Biaxin) Metronidazole (Flagyl) Tetracycline Can be combined with other drugs Mucosal Barrier Action: forms protective barrier, adheres to ulcer surface 30 min interval before taking antacids SE: constipation, and nausea/vomiting nausea/vomiting Give 1-2 hour after meal or during bedtime on an empty stomach 5 hours duration Sucralfate (Carafate) Pharmacotherapy Antacids (non absorbable)
Vagotomy
Action: ↓ gastric acidity
Chew then swallow, taken 1 hr after meals or at H.S. Aluminum Hydroxide SE: constipation Don’t Don’t give give other other drugs drugs w/in w/in 1-2 hrs after after the the antacids Magnesium Oxide SE: diarrhea Taken in between meals or at bedtime May increase serum Magnesium level in RF client Chew follow with water
Calcium Carbonate SE: ↑ uric acid
Taken in between meals or at bedtime with milk
NaHCO3 SE: metabolic alkalosis and tetany
Proton Pump Inhibitor
Action: Action: ↓ gastric gastric acid secretio secretion n of the parietal parietal
cells 4-8 weeks medications Esomeprazole (Nexium) Omeprazole (Prilosec) Lansoprazole (Prevacid) Pantoprazole (Protonix)
- Surgical Procedures For Pud
-
Total gastrectomy, vagotomy, gastric resection, Billroth I and II, pyloroplasty
Pyloroplasty
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN Billroth I-Gastroduodenostomy I-Gastroduodenostomy
Billroth II-Gastrojejunostomy II-Gastrojejunostomy
Nursing Interventions Interventions 1. Give BLAND diet, small frequent meals during the active phase of the disease 2. Administer prescribed medicationsH2 blocke blockers, rs, PPI, PPI, mucosa mucosall barrie barrierr prote protecta ctants nts and antacids 3. Monitor for complications of bleeding, perforation and intractable pain 4. provide t ea eaching a bo bout s tr tress r ed eduction a nd nd relaxation techniques Nursing Interventions For Bleeding 1.Maintain on NPO 2. Administer IVF and medications 3.Mon 3.Monit itor or hydr hydrat atio ion n stat status us,, hema hemato tocr crit it and and hemoglobin 4. Assist with SALINE lavage lavage 5. Insert NGT for decompression and lavage 6. Prepare to administer blood transfusion 7.Pre 7.P repa pare re to give ive VASOPRE OPRES SSIN SIN to indu induce ce vasoconstriction to reduce bleeding 8. Prepare patient for SURGERY if warranted
Surgical Procedures For Pud Post-operative Nursing management management 1.Monitor VS 2.Post-op position: FOWLER’S 3. NPO until peristalsis returns returns 4.Monitor for bowel sounds 5.Monitor for complications of surgery 6.Monitor I and O, IVF 7.Maintain NGT
8.
Diet progress: clear liquid bland meals 9. Manage DUMPING SYNDROME SYNDROME Dumping Syndrome
-
-
−
Vagotomy – severing of the vagus nerve Decreases gastric acid Diminishin Diminishing g cholinerg cholinergic ic stimulat stimulation ion to the parietal parietal cells- less responsive to gastrin Billroth I – Gastroduodenostomy Removal of the lower portion of the antrum Antrum contains the cells that secretes gastrin Small portion of duodenum and pylorus Remaining portion is anastomosed to the duodenum Billroth II – Gastrojejunostomy Gastrojejunostomy Remaining portion is anastomosed to the jejunum Billroth I Feeling of fullness Dumping syndrome Diarrhea Recurrence rate is <1% Billroth II Dumping syndrome Anemia Malabsorption Weight loss Recurrence rate of ulcer is 10-15%
full liquid
six
A condition of rapid emptying of the gastric contents into the small intestine usually after a gastric surgery. Symptoms occur 30 minutes after eating
Pathophysiology - Foods high in CHO and electrolytes must be diluted in the jejunum before absorption takes place. - The rapid influx of stomach contents will
-
cause distention of the jejunum early symptoms - The hypertonic hypertonic chyme will draw fluid from the blood vessels vessels to dilute dilute the high concentra concentrations tions of CHO and electrolytes - Later, there is increased blood glucose - stimulating the increased secretion of insulin
-
Then Then,, bloo blood d hypoglycemia
gluc glucos ose e
Assessment Findings:
-
Early symptoms 1. Nausea and Vomiting Vomiting 2.Abdominal fullness 3.Abdominal cramping 4.Palpitation 5.Diaphoresis
will will
fall fall
causin causing g
reacti reactive ve
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN 6.Weakness 7.Diarrhea
-
- Abnormal hardening of stools - Irregularity of elimination - Retention of stool for a prolonged period
Late symptoms: 8. Hypo Hypogl glyc ycem emia ia 9. Weakne Weakness ss and Dizzin Dizziness ess 10.Drowsiness 11.Perspiration 12.Palpaitation 13.Pallor
Nursing Interventions Interventions
1.
LOW-carbohydrate
2.
frequent frequent meals,
3.
Instruct Instruct to AVOID AVOID consumin consuming g FLUIDS FLUIDS with
Advi Advise se pati patien entt to eat eat HIGH-fat and HIGH-protein diet
Inst Instru ruct ct to eat eat SMA SMALL LL include MORE dry items. items.
meals
4.
Instruct to LIE DOWN after meals 5.Administer 5.Administer anti-spas anti-spasmodic modic medicati medications ons to delay delay gastric emptying Gastric Cancer -
40-70 y/o, more common among men Diet high in smoke foods, low in fruits and vegetables Chronic inflammation of the stomach Pernicious anemia Gastric ulcers H. Pylori infections Chronic Smoking Previous Subtotal Gastrectomy Genetics
Pathophysiology Adenocarcinoma inomas s w/c occur anywhere anywhere in the stomach - Adenocarc affecting the gastric mucosa Clinical Manifestations - Asymptomatic in the early stage - Pain relieved with antacids - Anorexia, dyspepsia, weight loss - Constipation, anemia - Nausea and vomiting Assessment and Diagnostic Findings - Advanced Gastric Ca- palpable mass - Ascites and Hepatomegaly- if cancer cells metastasized to the liver - Sister Mary Joseph’s Nodule- palpable nodules around the umbilicus - EGD/Endoscopy w/ biopsy and cytology - Barium x-ray exam - CT Scan, Bone Scan, Liver Scan - Medical Management - Removal of the tumor - Chemotherapy
Conditions of the Lower Tract Small and Large Intestine CONDITIONS OF THE SMALL INTESTINE Abnormalities of Fecal Elimination Constipation
Caused by: - Medications Iron, antacids with aluminum - Hemorrhoids - Cancer of the bowel - Endocrine disorders - Clinical Manifestation Manifestation - Abdominal distention - Borborygmus - gurgling sound caused by passage of gas in the intestine - Pain and pressure - Indigestion - Sensation of incomplete emptying - Straining - Hard, dry stools Medical Management Management - Bowel habit training - Increased fiber and fluid intake - Discontinue laxative abuse - Exercise to strengthening abdominal muscles Diarrhea
-
Increased frequency of bowel movement more than 3x a day - Increased amount of stool - Altered consistency Clinical Manifestations - Abdominal cramps, Distention - Intestinal rumbling/borborygmus - Anorexia and thirst
Assessment and Diagnostic Findings - CBC count - Chemical profile - Urinalysis - Stool exam Medical Management Management - Control symptoms - Treat the underlying disease Fecal Incontinence - Involuntary passage of stool from the rectum - Inability of the rectum to sense and accommodate stool - Amount and consistency of the stool - Integrity of the anal spinchter - Rectal motility Clinical Manifestation Manifestation Soiling Occasional urgency and loss of control Complete incontinence Poor control of flatus Medical Management Management Biofeedback therapy Bowel training programs
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN Surgical reconstruction, spinchter spinchter repair or fecal diversion
Crohn’s Disease - Also called Regional Enteritis - An inflammatory disease of the GIT affecting usually the distal ileum and colon - Usually first diagnosed in adolescents and young adults - More often seen among smokers
-
Etiology: unknown - The terminal terminal ileum thickens thickens w/ edema edema formation, formation, with scarring, ulcerations, abscess formation and narrowing of the lumen - The clusters of ulcers- classic cobblestone appearance Clinical Manifestations of Crohn’s Dse 1.Fever 2. Abdominal distention distention 3.Diarrhea 4. Crampy RLQ abdominal pain 5.Anorexia/N/V 6.Weight loss 7.Anemia Assessment and Diagnostic Findings - Proctosigmoidoscopy initially - stool exam- maybe (+) for occult blood and steatorrhea
-
barium study of the upper GI tract- is confirmatory w/c shows shows the classi classic c string string sign sign on x-ray x-ray film film indica indicatin ting g constriction the segment involved
-
CBC, CBC, ESR ESR (↑), Albu Albumi min n and and prot protei ein n (↓)
- Barium enema - MRI and CT scan Complications - toxic megacolon megacolon,, perforati perforation, on, bleeding, bleeding, osteoporo osteoporotic tic fracture
Nursing Interventions For Cd And Uc 1. Maintain NPO during the active phase 2.Moni 2.Monito torr for for comp compli lica cati tion ons s like like seve severe re blee bleedi ding ng,, dehydration, electrolyte imbalance 3. Monitor bowel sounds, stool and blood studies 4. Restrict activities= rest and comfort
5.
Administe Administerr IVF, electrolytes electrolytes and TPN if prescribe prescribed d Monitor complications of diarrhea 6.Instruct the patient to AVOID gas-forming foods, MILK products products and foods such as whole whole grains, grains, nuts, RAW fruits fruits and veget vegetabl ables es especi especiall ally y SPINA SPINACH, CH, pepper pepper,, alcohol and caffeine
7.
Diet progressionprogression- clear liquid LOW residue, residue, high protein diet 8.Adminis 8.Administer ter drugsdrugsantianti-inf inflam lamma mator tory, y, antibi antibioti otics, cs, ster steroi oids ds,, bulk bulk-f -for ormi ming ng agen agents ts and and vita vitami min/ n/iro iron n supplements
Appendicitis - Inflammation of the vermiform appendix
Complications intestinall obstruct obstruction,s ion,strict trictures, ures, perianal perianal dse, fluid and - intestina electrolyte imbalances, malnutrition
CONDITIONS OF THE LARGE INTESTINE Ulcerative Colitis
-
Recurrent Recurrent ulcerative ulcerative and inflamma inflammatory tory condition condition of the mucosal and submucosal layers of the colon and rectum - The colon colon becom becomes es edema edematou tous s and develo develops ps bleedi bleeding ng ulcerations - Scar Scarri ring ng deve develo lops ps over overti time me with with impa impair ired ed wate waterr absorption and loss of elasticity Clinical Manifestations Manifestations SEVER SEVERE E diarrh diarrhea ea (10-20 (10-20 liquid liquid stools stools/da /day) y) with with Rectal Rectal bleeding 1.Weight loss 2.Fever 3.Anorexia 4. Anemia and Hypocalcemia Hypocalcemia 5.Dehydration 6. LLQ Abdominal pain and cramping cramping 7.Tenesmus Assessment and Diagnostic Findings
-
assess assess for tachycard tachycardia, ia, tachypne tachypnea, a, hypotensi hypotension, on, fever fever and pallor, level of hydration and nutritional status - stool exam- (+) for blood
-
↓ hematocrit and hemoglobin and albumin
↑ WBC - Sigmoidoscopy, colonoscopy
Etiology: usually fecalith, lymphoid hyperplasia, foreign body and helminthic obstruction Pathophysiology - Obstruction of lumen increased pressure decreased blood blood supply supply bacter bacterial ial prolif prolifera eratio tion n and mucos mucosal al inflammation ischemia necrosis rupture Assessment Findings 1. Abdominal pain: begins in the umbilicus then localizes localizes in the RLQ (Mc Burney’s point) 2.Anorexia 3. Nausea and Vomiting Vomiting 4.Fever
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN 5.Rebo 5.Reboun und d tend tender erne ness ss and and perforated) 6.Constipation or diarrhea
abdo abdomi mina nall
rigi rigidi dity ty
(if (if
ASSESSMENT ASSESSMENT findings for Hemorrhoids - Internal hemorrhoids- cannot be seen on the peri-anal area - External hemorrhoids- can be seen - Bright red bleeding with each defecation - Rectal/ perianal pain - Rectal itching - Skin tags Diagnostic Test - Anoscopy - Digital rectal examination
Trearments - Nonsurgical treatments Infrared photocoagulation Laser therapy - Conservative surgical treatment rubberband ligation procedure cryosurgical hemorrhoidectomy hemorrhoidectomy - Hemorrhoidectomy For advance thrombosed vein
Diagnostic Tests - CBC- reveals increased WBC count - Ultrasound - Abdominal X-ray Nursing Interventions - Preoperative care - NPO - Consent - Monitor for perforation and signs of shock - Monitor bowel sounds, fever and hydration status - POSI POSITI TION ON of Comf Comfor ort: t: RIGH RIGHT T SIDE SIDELY LYIN ING G in a FOWLER’S - Avoid Laxatives, enemas & HEAT APPLICATION - Post-operative care - Monitor VS and signs of surgical complications - Maintain NPO until bowel function returns - If rupture occurred, expect drains and IV antibiotics
Nursing Interventions Interventions Advise patient patient to apply cold packs to the anal/recta anal/rectall - Advise area followed by a SITZ bath - Apply astringent like witch hazel soaks - Encourage HIGH-fiber diet and fluids low low
-
POSITION post-op: RIGHT side-lying, SEMI- FOWLER’S to decrease tension tension on incision, and legs flexed to promote drainage - Administer prescribed pain medications
Hemorrhoids - Abnormal dilation and weakness of the veins of the anal canal - Variously classified as Internal or External, Prolapsed, Thrombosed and Reducible PATHOPHYSIOLOGY
-
Increased pressure in the hemorrhoidal tissue tissue due to straining, pregnancy, etc dilatation of veins
Internal hemorrhoids - These dilated veins lie above the internal anal sphincter - Usually, the condition is PAINLESS External hemorrhoids - These dilated veins lie below the internal anal sphincter - Usually, the condition is PAINFUL
-
Administer stool softener as prescribed
Post-operative care for hemorrhoidectomy
-
Position: Prone or Side-lying Maintain dressing over the surgical site Monitor for bleeding Administer analgesics and stool softeners Advise the use of SITZ bath 3-4 times a day
DIVERTICULOSIS AND DIVERTICULITIS Diverticulosis - Abno Abnorm rmal al outout-po pouc uchi hing ng of the the inte intest stin inal al muco mucosa sa occurring in any part of the LI most commonly in the sigmoid Diverticulitis - Inflammation of the diverticulosis Diverticular Disease - Diverticu Diverticulum: lum: sac-like herniations herniations of the lining of the bowel that extend through a defect in the muscle layer - May May occ occur ur anywh anywhere ere in the intesti intestine, ne, but are most most common in the sigmoid colon - Diverticulosis: multiple diverticula without inflammation - Diverticulitis: infection and inflammation of diverticula - Diverticular disease increases with age and is associated with a low-fiber diet - Diagnosis is usually by colonoscopy PATHOPHYSIOLOGY
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN -
Increase Increased d intralum intraluminal inal pressure, pressure, LOW volume volume in the lumen lumen and Decre Decreas ased ed muscl muscle e stren strength gth in the colon colon wall herniation of the colonic mucosa
ASSESSMENT ASSESSMENT findings for D/D 1. Left lower Quadrant Quadrant pain 2.Flatulence 3. Bleeding per rectum 4. nausea and vomiting 5.Fever 6. Palpable, tender rectal mass DIAGNOSTIC STUDIES 1. If no active inflammation, COLONOSCOPY and Barium Enema 2. CT scan is the procedure of choice! choice! 3.Abdominal X-ray
- Volvulus
NURSING INTERVENTIONS 1. Maintain NPO during acute phase 2.Provide bed rest 3.Administer antibiotics, analgesics like meperidine (morphine is not used) and anti-spasmodics 4.Mon 4.Monit itor or for for pote poten ntial tial comp compli lica cati tion ons s like like perf perfor ora ation tion,, hemorrhage and fistula 5. Increase fluid intake intake 6.Avoid gas-forming foods or HIGH-roughage foods containing seeds, nuts to avoid trapping 7.introduce soft, high fiber foods ONLY after the inflammation subsides 8.Instruc 8.Instructt to avoid avoid activi activitie ties s that that increa increase se intraintra-ab abdom domina inall pressure
Intestinal Obstruction - Partial or complete blockage prevents the flow of intestinal contents thru the intestinal tract Mechanical Mechanical Obstruction - Intr Intral alum umin inal al obst obstru ruct ctio ion n or mura murall pressure on the intestinal wall occurs Stenosis, adhesions, hernias
- Hernia (Inguinal) obst obstru ruct ctio ion n
from from
Functional Functional obstruction - The intestina intestinall musculat musculature ure cannot cannot propel propel the contents contents along the bowel Musc Muscul ular ar dyst dystro roph phy, y, endo endocr crin ine e diso disord rder ers s or neurologic disorders Mechanical - Adhesions – fibrous band of scar tissue from surgery - Hernias – incarcerated or strangulated strangulated - Volvulus – twisting of bowel
-
Intussusception Intussusception – telescoping of the bowel upon itself Tumors Hematoma Fecal impaction Intraluminal obstruction Intussusception
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN Neurogenic - Paralytic ileus - Adynamic ileus Vascular - Occlusion of arterial blood supply - Mesenteric thrombosis - Abdominal angina - Small Bowel Obstruction - Intestinal contents, fluids and gas accumulate above the intestinal obstruction - Reduce the absorption of fluids and stimulate more gastric secretion - Pressure within the intestinal lumen increases - Decrease in venous and arteriolar capillary pressure
-
Edema, congestion, necrosis, and rupture or perforation of intestinal wall → peritonitis
-
Reflux Reflux vomiting vomiting leads leads to ↓K+, ↓Clˉ in blood, blood, with fluid losses resulting to shock - Clinical Manifestations - Crampy pain, wavelike and colicky blood and mucous, mucous, but no fecal fecal matte matterr and - May pass blood flatus; vomiting occurs
-
Nursing Management - intestina intestinall tube insertion insertion (miller (miller abott, abott, cantor cantor tube) tube) for decompression - fluid and electrolyte electrolyte replacement - prophylactic antibiotic - v/s, I&O - stool exam - surgery
Conditions of the GIT accessory organs Liver Anatomy - The largest internal organ - Located in the right upper quadrant Contains two lobes- the right and the left, covered covered w/ - Contains connective tissue hepatic ducts ducts join together together with the cystic duct to - The hepatic become the common bile duct Liver and Biliary System
If obstru obstructi ction on is comple complete, te, vigoro vigorous us perist peristals alsis, is, and assume assume a reverse reverse direction direction with the intestinal intestinal content content propelled toward the mouth If obstruction is in the ileum, fecal vomiting takes place Dehydrati Dehydration: on: thirst, thirst, drowsine drowsiness, ss, malaise, malaise, and a parched parched tongue and mucous membranes The lower the the GI obstru obstructi ction, on, the the more more marked marked the the abdominal distention Uncorrected obstruction leads to shock Diagnostics and Management Management Abdominal X-ray and CT Scan Electrolyte studies and CBC
Management - Medical Management Decompression of the bowel through a nasogatric or small bowel tube - Surgical treatment, if completely obstructed Removal, repair, and anastomosis Large Bowel Obstruction Obstruction Accumu mula lati tion on of inte intest stin inal al cont conten ents ts,, flui fluid, d, and and gas gas - Accu proximal to the obstruction blood supply supply is cut off, off, intes intestin tinal al strang strangula ulatio tion n and and - If blood necrosis occur - Dehydration occurs more slowly - Caused by adenocarcinoid tumors
-
Symptoms Symptoms develop develop slowly, slowly, constipa constipation, tion, bloody bloody stoo stooll → iron deficiency anemia - Distented abdomen and crampy lower abdominal pain - Fecal vomiting develops - Shock may occur
Medical Management Management - IV therapy, NGT aspiration & decompression - Colonoscopy: untwist and decompress the bowel
-
Cecostomy: surgical opening made into the cecum, urgent relief from obstruction Surgical resection: remove the obstruction A temporary or permanent colostomy Ileoanal anastomosis, if necessary to remove the entire large bowel Rectal tube used to decompress area lower in the bowel
Liver -
Right and left lobe separated by falciform ligament Caudate lobe near the IVC Quadrate lobe between left lobe and gall bladder Receives oxygenated blood from hepatic artery Receives food-laden blood from GIT Blood from both sources mix in the liver sinusoids Oxygen Oxygen,, nutri nutrien ents ts and certa certain in toxic toxic subst substan ances ces are extracted by hepatic cells
FUNCTIONS OF THE LIVER - Glucos Glucose e Metab Metabolis olism m and Regula Regulatio tion n of blood blood glucos glucose e concentration - Ammoni Ammonia a Conver Conversio sionn- amino amino acids acids from from protei protein n for glucon gluconeog eogene enesis sis result results s in ammoni ammonia a format formation ion as a byprod byproduct uct.. Liver Liver conver converts ts to urea urea and and excret excreted ed in the urine - Protein Metabolism- synthesizes all of the plasma proteins (except (except gamma gamma globulins) globulins),, including including albumin, albumin, alpha & beta globulins, globulins, blood clotting clotting factors, factors, transport transport proteins and plasma lipoproteins. Vit K is required by the liver for the synthesis synthesis of clotting clotting factors. Amino acids serve serve as building blocks for CHON synthesis
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN - Fat Metab Metabolis olismm- fatty fatty acids acids are broke broken n down down for the production of ketone bodies, esp occurs during starvation and uncontrolled DM - Vitamin and Iron storage- Vit A, B, D, several B complex, iron, copper - Drug Drug Metab Metaboli olismsm- results results in the loss of activi activity ty of the medication, one impt pathway is conjugation - Bile FormationFormation- formed in the hepatocytes, hepatocytes, composed composed mainly of water and electrolytes bile is collected & stored in the the gall gallbl blad adde derr is empt emptie ied d into into the the inte intest stin ines es for for digestion - Bilirubin Excretion- bilirubin is a pigment derived from the breakdown of Hgb by the REC including the Kupffer cells of the liver Liver Function Studies Serum aminot aminotran ransf sfera erases ses:: AST(SG AST(SGOT= OT=4.8 4.8-19 -19U/L U/L), ), - Serum ALT(SGPT=2.4-7U/L), ALT(SGPT=2.4-7U/L), GGT, GGTP, LDH - Serum protein studies - Pigment studies: direct and indirect serum bilirubin, urine bilirubin, and urine bilirubin and urobilinogen - Prothrombin time - Serum alkaline phosphatase - Serum ammonia - Cholesterol Additional Diagnostic Studies - Liver biopsy - Ultrasonography - CT - MRI - Other Hepatic Dysfunction - Acute or chronic (more common) - Cirrhosis of the liver
- Causes: Most common cause is malnutrition related to alcoholism. Infection Anoxia Metabolic disorders Nutritional deficiencies Hypersensitivity states Manifestations - Jaundice- increased bilirubin conc. in blood Portal hyperten hypertension, sion, ascites, and varices varices -results -results from - Portal circulator circulatory y changes changes w/in the diseased diseased liver & produces produces severe GI hge, marked sodium & fluid retention - Hepa Hepati tic c ence enceph phal alop opat athy hy or coma coma -acc -accum umul ulat atio ion n of ammonia in the serum - Nutritional deficiencies-results from inability to metabolize vitamins
Jaundice - Yellow- or greenish yellow-tinged body tissues, sclera, and skin due to increased serum bilirubin levels - Levels exceed 2.5mg/dl - Types - Hemolytic - Hepatocellular - Obstructive - Hereditary hyperbilirubinemia - Hepatocellular and obstructive jaundice types are most associated with liver disease. Hemolytic Jaundice due to:
-
rapi rapid d RBC RBC destruc tructtion ion incr increa eas sed in indi indire rect ct,, unconjugated unconjugated or B2 - due due to hemo hemoly lyti tic c tran transf sfus usio ion n reac reacti tion on and and othe otherr hemolytic disorders experience symptoms symptoms or complicat complications ions unless - Do not experience extreme hyperbilirubinemia - Predisposes to pigment stones in the Gallbladder, and in extremely severe jaundice poses a risk for brain stem damage
Obstructive Jaundice due to: - occlusion of the bile duct - gallstone - biliary atresia - inflammation of the biliary tract - tumors
-
chole cholest stat atic ic agen agenttanti antith thyr yroid oid,, phen phenot othi hiaz azin ines es,, sulfonylureas, tricyclic antidepressants, antidepressants, nitrofurantoin, androgens and estrogens - total bilirubin is increased
-
bile is dammed into the liver and reabsorbed into the circulation
s/sx: - deep orange, foamy urine - dark tea colored urine - clay colored stool - severe itchiness - steatorrhea Hepatocellular Jaundice due to: - Diseased liver (hepatitis or cirrhosis) - Inability of the liver to clear normal amount of bilirubin from the blood - Increased bilirubin and albumin
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN - Bed rest during acute stage
Signs Signs and Symptoms Symptoms Associated Associated with Hepatocellula Hepatocellularr and Obstructive Jaundice - Hepatocellular Patient may appear mildly or severely ill. Lack of appetite, nausea, weight loss Malaise, fatigue, weakness Headache, chills, and fever if infectious in origin - Obstructive Dark orange-brown urine and light clay-colored stools Dyspepsia and intolerance of fats, impaired digestion Pruritus Jaundice
Management:
- Control pruritus calamine baking soda NaHCO3 Antihistamine Soothing baths - Drug
Cholestyramine = it binds bile salts in the intestine and
eliminated via feces. Look for the cause and manage it
Hepatitis - Viral Viral hepa hepatit titis: is: a system systemic ic viral viral infect infection ion that that cause causes s necrosis and inflammation of liver cells with characteristic symptoms and cellular and biochemical changes A B C D E Hepatitis G and GB virus-C - Nonviral hepatitis: toxin- and drug-induced - Hepatitis A and E- fecal-oral route - Hepatitis B, C, D share many characteristics Hepatitis A (HAV) - 20-25% of clinical hepatitis, infectious hepatitis - Fecal-oral transmission Spread primar primarily ily by poor poor hygien hygiene; e; handhand-toto-mou mouth th - Spread contact, close contact, or through food and fluids
• Incubation: 15-50 days Illness may last 4-8 weeks.
- Mortality is 0.5% for younger than age 40 and 1-2% for those over age 40. • Manifestations:
1.mild flu-like symptoms 2.low-grade fever 3.anorexia 4. later jaundice and dark urine urine 5. indigestion and epigastric distress 6. enlargement of liver and spleen - Anti-HAV antibody in serum after symptoms appear
-
• Management Prevention Good handwashing, safe water, and proper sewage disposal Vaccine Immunoglobulin for contacts to provide passive immunity
-
Nutritional support
Hepatitis B (HBV) - Transmitted through blood, saliva, semen, and vaginal secretions, sexually transmitted, transmitted transmitted to infant at the time of birth - A major worldwide cause of cirrhosis and liver cancer • At Risk: surgeons, nurses, lab workers - Mortality rate: 10% - Has Has a carrie carrierr state state and can devel develop op to chroni chronic c state state and hepatocellular hepatocellular injury - Long incubation period: 1-6 months • Manifestations: Manifestations: insidious and variable
- similar to hepatitis A: anorexia, dyspepsia abd’l pain generalized itching malaise weakness w/ or w/o jaundice - The The virus virus has antig antigen enic ic partic particles les that that elicit elicit specif specific ic antibody markers during different stages of the disease. • ASSESSMENT AND DIAGNOSTIC FINDINGS
- HBV HBV is a DNA DNA viru virus s comp compos osed ed the the ff anti antige geni nic c particles: HBcAg- hep B core antigen HBsAg- hep B surface antigen HBeAg- independent CHON circulating in the blood HBxAg- gene product of X gene of HBV/DNA - Each antigen elicits its specific antibody and is marker for the diff stages of the disease process: Anti-HBc- persists during acute illness, may indicate continuing HBV in the liver Anti-HBsAnti-HBs- detected detected during during late convalesc convalescence ence and indicates recovery and devt of immunity Anti-HBe- usually signifies reduced infectivity • Management - Prevention Vacc Vaccin ine: e: for for pers person ons s at high high risk risk,, rout routin ine e vaccination of infants Passive immunization for those exposed Standard precautions/infection control measures Screening of blood and blood products - Bed rest - Nutritional support - Medic Medicat atio ions ns for for chro chroni nic c hepa hepati titi tis s type type B incl includ ude e alph alpha a interfero interferon n and antiviral antiviral agents: agents: lamivudine lamivudine (Epivir), (Epivir), adefovir adefovir (Hepsera).
Hepatitis C - Transm Transmitt itted ed by blood blood and sexual sexual contac contact, t, includ including ing needlesticks and sharing of needles - The most common bloodborne infection - A cause of 1/3 of cases of liver cancer and the most common reason for liver transplant
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN • Risk factors
- Liver physiology and Pathophysiology Normal Function Abnormality in function
Incubation period is variable.
1.
- Symptoms are usually mild. - Chronic carrier state frequently occurs. • Management
Prevention Screening of blood Prevention of needlesticks for health care workers Measures to reduce spread of infection as with hepatitis B - Alcohol encourages the progression of the disease, so alcohol and medications that affect the liver should be avoided. - Antiviral agents: interferon and ribavirin (Rebetol) -
Stores glycogen
= Hypoglycemia
2.Syn 2.S ynth the esize sizes s pro prote tein ins s
= Hyp Hypop opro rote tein inem emia ia
3.Syn 3.S yntthesi hesize zes s glob globu ulins lins
= Decre ecreas ase ed Anti Antib body ody formation = Bleeding tendencies
4.Synthe 4.Synthesize sizes s Clothi Clothing ng factors 5. Se Secreting bile 6.Converts 6.Converts ammonia ammonia to urea 7. St Stores Vit and minerals 8.Met 8.Metab abol oliz izes es estro stroge gen n
= Jaundice and pruritus = Hyperammonemia Hyperammonemia =Defi =Deficie cienci ncies es of Vit and and min = Gyne Gyneco coma mast stia ia,, test testes es atrophy
Hepatitis D and E Hepatitis D - Only persons with hepatitis B are at risk for hepatitis D. - Transmission is through blood and sexual contact. - Symptoms and treatment are similar to hepatitis B, but patient patient is more likely to develop develop fulminant fulminant liver failure failure and chronic active hepatitis and cirrhosis. Hepatitis E Transmitted by fecal-oral route - Transmitted - Incubation period 15-65 days - Resembles hepatitis A and is self-limited, with an abrupt onset. No chronic form. - Other Liver Disorders - Nonviral hepatitis - Toxic hepatitis - Drug-induced hepatitis - Fulminant hepatic failure Liver Cirrhosis - A chronic, progressive disease characterized by a diffuse damage to the hepatic cells The liver liver heals heals with with sca scarrin rring, g, fibros fibrosis is and and nodula nodularr - The regeneration ETIOLOGY:
Post ost-inf -infec ecttion, ion,
Alcoh lcohol ol,, Cardi ardia ac Schisostoma, Biliary obstruction
dise disea ases, ses,
Assessment Findings 1. Anorexia and weight loss loss 2.Jaundice 3.Fatigue
- Types: • Laennec’s Cirrhosis
most common alcoholic cirrhosis scar tissue surrounds the portal areas chronic disease
• Postnecrotic Cirrhosis
a sequelae of viral hepatitis Biliary Cirrhosis due to chronic biliary obstruction and infection
- Pathogenesis:
•
repeated destruction of hepatic cell → scar tissue formation (fibrotic) → regeneration of liver cell follows → another destruction will occur → cycle (scarring and regenerat regeneration) ion) will be repeated repeated until until hepatocyt hepatocytes es becomes becomes fibrotic and liver function is compromised
4. Early morning nausea and vomiting 5.RUQ abdominal pain 6.Ascites 7. Signs of Portal hypertension hypertension
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN Cancer of the Liver - Primary liver tumors - Few cancers originate in the liver. - Usually associated with hepatitis B and C - Hepatocellular carcinoma (HCC) - Liver metastasis - Liver is a frequent site of metastatic cancer. Manifestations - Pain, dull continuous ache in RUQ, epigastrium, or back - Weight Weight loss, loss of strength strength,, anorexia, anorexia, anemia may occur. - Jaundice Jaundice if bile ducts occluded, occluded, ascites if obstructe obstructed d portal veins Nonsurgical Management of Liver Cancer - Underlying cirrhosis, which is prevalent in patients with liver cancer, increases risks of surgery. - Major effect of nonsurgical therapy may be palliative. - Radiation therapy - Chemotherapy - Percutaneous Percutaneous biliary drainage - Other nonsurgical treatments
NURSING INTERVENTIONS 1.Moni 1.Monito torr VS, VS, I and and O, Abdo Abdomi mina nall girt girth, h, weig weight ht,, LOC LOC and and Bleeding 2.Promote 2.Promote rest rest.. Elevat Elevated ed the the head head of the bed bed to mini minimiz mize e dyspnea 3.Provide 3.Provide Modera Moderate te to LOW-pr LOW-prote otein in (1 g/kg/d g/kg/day) ay) and LOWLOWsodium diet 4. Provide supplemental supplemental vitamins (especially K) and minerals 5.Administer prescribed Diuretics= to reduce ascites and edema Lactulose= to reduce NH4 in the bowel Antacids and Neomycin= to kill bacterial flora that cause NH production 6. Avoid hepatotoxic drugs drugs Paracetamol Anti-tubercular drugs Anti-tubercular 7. Reduce the risk of injury Side rails reorientation Assistance in ambulation Use of electric razor and soft-bristled toothbrush 8. Keep equipments ready including Sengstaken-Blakemore Sengstaken-Blakemore tube, IV fluids, Medications to treat hemorrhage Nursing Interventions 1. Low sodium Diet 2. Low protein diet 3. Benadr Benadryl yl and and mild mild soap soap 4. Pressure onto injection site 5. Assist in paracentesis paracentesis 6. Administer Medications: • Diuretics, Diuretics, Neomycin Neomycin,, Lactulose • Albumin, Amino acid • Vitamin K (Menadione)
Rationale To reduce edema To reduce NH production To relie relieve ve prurit pruritus us To prevent bleeding Done to relieve abdominal pressure
Surgical Management of Liver Cancer - Treatment of choice for HCC if confined to one lobe and liver function is adequate - Liver has regenerative capacity. - Types of surgery Lobectomy Cryosurgery Liver transplant Nursing Care of the Patient Undergoing a Liver Transplant - Preoperative nursing interventions - Postoperative nursing interventions - Patient teaching The Gallbladder Anatomy - The gallbladder - Located below the liver - The cystic duct joins the hepatic duct to become the common bile duct - The common bile duct joins the pancreatic duct in the the sphi sphinc ncte terr of Oddi Oddi in the the firs firstt part part of the the duodenum Liver, Biliary System, and Pancreas
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN Physiology - Stores and concentrates bile - Contracts during the digestion of fats to deliver the bile
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Cholecystokinin-pancreozymin is a hormone rele releas ased ed by the the duod duoden enal al cells cells,, caus causin ing g the the contraction of the gallbladder and relaxation of the sphincter of Oddi
Cholecystitis - Inflammation of the gallbladder - Can be acute or chronic - Acute cholecystitis usually is due to gallbladder stones
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Chronic cholecystitis is usually due to long standing gall bladder inflammation
ASSESSMENT ASSESSMENT findings for cholecystitis 1. Indigestion, belching and flatulence 2.Fatty food intolerance 3.Epigast 3.Epigastric ric pain pain that that radiat radiates es to the sca scapu pula la or localized at the RUQ Mass at the RUQ 4. 5.Murphy’s sign 6.Jaundice 7.dark orange and foamy urine DIAGNOSTIC PROCEDURES 1. Ultrasonography- can detect the stones 2.Abdominal X-ray 3.Cholecystography 4.WBC count increased 5.Ora 5.Orall chol cholec ecys ysto togr grap aphy hy cann cannot ot visu visual aliz ize e the the gallbladder 6. ERCP: revels inflamed gallbladder with gallstone NURSING INTERVENTIONS 1. Maintain NPO in the active phase 2. Maintain NGT decompression
3.
Administer prescribed medications to relieve pain. Usually Demerol (MEPERIDINE)
4.
Codeine and Morphine may cause spasm of the Sphincter Sphincter increased increased pain. Morphine Morphine cause cause MOREPAIN
5.
Instruct patient to AVOID HIGH- fat diet and GAS-forming foods 6. Assist in surgical and non-surgical measures 7.Sur 7.S urg gica ical proce roced dure uresChole holecy cyst ste ectom tomy, Choledochotomy, laparoscopy
- Formation of GALLSTONES in the biliary apparatus Predisposing FACTORS - “F” Female Fat Forty Fertile Fair - Pathophysiology Supersaturated bile, Biliary stasis Supersaturated
↓ - Stone formation
↓ -
Blockage of Gallbladder
↓ - Inflammation, Mucosal Damage and WBC infiltration
PHARMACOLOGIC PHARMACOLOGIC THERAPY 1.Analgesic- Meperidine 2. Chenodeoxycholic Chenodeoxycholic acid= to dissolve the gallstones 3.Antacids 4.Anti-emetics
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN The pancreas: Exocrine function The pancreas Anatomy A retroperitoneal gland Functions as an endocrine and exocrine gland The pancreatic pancreatic duct (major) (major) joins joins the common bile duct in the sphincter of Oddi Physiology - The exocrine function of the pancreas is the secretion of digest digestive ive enzym enzymes es for carboh carbohydr ydrat ates, es, fats fats and proteins
-
- Cholesterol Gallstones and Pigment Gallstones -
Pancreatic amylase
carbohydrates
Pancreatic lipase (steapsin)
fats
Trypsin, Chymotrypsin and Peptidases proteins Bicarbonate to neut neutra rali lize ze Stimulated by SECRETIN!
the the
acid acidic ic
chym chyme. e.
Pancreatitis - Inflammation of the pancreas - Can be acute or chronic - Pancreatitis - A severe severe disorder disorder that can lead to death. death. Acute Acute panc pancre reat atit itis is doe does not not usua usuall lly y lead lead to chro chroni nic c pancreatitis. - Acut Acute e panc pancre reat atit itis is:: panc pancre reat atic ic duct duct beco become mes s obstructed and enzymes back up into the pancreatic duct, causing autodigestion and inflammation of the pancreas - Chroni Chronic c pancre pancreat atiti itis: s: a progre progressi ssive ve inflam inflammat matory ory disorder with destruction of the pancreas. Cells are replaced replaced by fibrous fibrous tissue, tissue, and pressure pressure within the pancreas pancreas increases increases.. Mechanica Mechanicall obstructi obstruction on of the pancreatic and common bile ducts and destruction of the secreting cells of the pancreas occur. Etiology and predisposing factors - Alcoholism - Hypercalcemia - Trauma - Hyperlipidemia
-
Biliary tract disease - cholelithiasis - Bacterial disease - PUD - Mumps
PATHOPHYSIOLOGY PATHOPHYSIOLOGY of acute pancreatitis - Self-diges Self-digestion tion of the pancreas pancreas by its own digestive digestive enzymes principally TRYPSIN
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Post-operative nursing interventions interventions - Monitor for surgical complications
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Post Post-o -ope pera rati tive ve posi positi tion on afte afterr reco recove very ry from from anesthesia- LOW FOWLER’s Encourage early ambulation Administ Administer er medicatio medication n before before coughing coughing and deep breathing exercises Advise Advise clien clientt to splint splint the abdomen abdomen to preven preventt discomfort during coughing Administer analgesics, antiemetics, antacids Care of the biliary drainageor T-tube drainage Fat restriction is only limited to 4-6 weeks. Normal diet is resumed
Spasm, Spasm, edema edema or block block in the the Ampull Ampulla a of Vater Vater reflux of proteolytic enzymes auto digestion of the pancreas inflammation - Autodigestion of pancreatic tissue
↓ - Hemorrhage, Necrosis and Inflammation
↓ - KININ ACTIVATION will result to increased permeability
↓ - Loss of Protein-rich fluid into the peritoneum
↓ - HYPOVOLEMIA
Medical Surgical Nursing The GASTRO-INTESTINAL system By: Maricel S. Jose MD,RN
Manifestations • Acute - Severe abdominal pain - Patient appears acutely ill. - Abdominal guarding
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Nausea and vomiting - Fever, jaundice, confusion, and agitation may occur. - Ecchymosis in the flank or umbilical area may occur. - Patie Patient nt may develo develop p respir respirato atory ry distre distress, ss, hypoxi hypoxia, a, renal renal failure, hypovolemia, and shock. • Chronic - Recurrent attacks of severe upper abdominal and back pain accompanied by vomiting - Weight loss - Steatorrhea
Assessment Findings 1.Abdomin 1.Abdominal al painpain- acute acute onset, onset, occ occurr urring ing after after a heavy meal or alcohol intake 2.Abdominal guarding 3. Bruising on the flanks and umbilicus umbilicus 4.N/V, jaundice 5. Hypotension and hypovolemia 6.Signs of shock Diagnostic Tests 1. Serum amylase and serum lipase 2.Ultrasound 3.WBC 4.Serum calcium 5.CT scan 6. Hemoglobin and hematocrit Nursing Interventions
1. Assist Assist
in pain manageme management. nt. Usually, Usually, Demerol is given. given. Morphine is AVOIDED 2. Assist Assist in correction correction of Fluid Fluid and and Blood loss loss
3. Plac Place e
pati patien entt on NPO NPO to inhibi inhibitt pancre pancreat atic ic stimulation 4. NGT NGT inse insert rtio ion n to deco decomp mpre ress ss dist disten enti tion on and and remove gastric secretions 5. Mainta Maintain in on bed bed rest rest
6. Position Position
patient patient in SEMI-FOW SEMI-FOWLER’s LER’s to decrease decrease pressure on the diaphragm 7. Deep breath breathing ing and coughin coughing g exercises exercises 8. Provide Provide paren parentera terall nutriti nutrition on 9. Introd Introduce uce oral feedi feedings ngs graduall graduallyy- HIGH HIGH carbo, carbo, LOW FAT 10.Maintain skin integrity 11.Manage shock and other complications
Quick Summary • Peptic Ulcer
-
Ulceration of mucosa; In the stomach or duodenum Outstanding Symptom: PAIN Nursing Goal: Allow ulcer to heal, prevent complication Rest: physical and Mental Eliminate certain foods Medic Medicat atio ions ns:: anta antaci cid, d, H2 bloc blocke kers, rs, Prot Proton on Pump Pump inhibitors, antibiotics, mucosal protectants Surgery: Vagotomy, Billroth 1 and 2 Quick Summary Liver Cirrhosis Destruction of liver with replacement by scars Common causes: alcoholism, post-hepatitic post-hepatitic Manifestations Manifestations related to liver derangements Jaundice, Ascites, splenomegaly, bleeding, enceph Nursing goal: Control manifestations and maximize liver function
• Liver Cirrhosis
-
Encourage rest Avoid hepatotoxic drugs Diet: HIGH calorie, Restricted protein, LOW Na Weight client and measure abdominal girth daily Provide skin care for jaundice and edema Assess for bleeding: esophageal, rectal, cutaneous DRUGS: DRUGS: Antacids, Antacids, Diuretics, Diuretics, Albumin, Neomycin Neomycin and Lactulose
• Cholecystitis
Inflammation tion of the gallbladde gallbladderr commonly commonly caused caused by - Inflamma cholelithiasis (Female, Fat, Forty, Fertile, Fair) - Manifestations: Fat intolerance, RUQ pain, Nausea and vomiting, Jaundice, Murphy’s sign - Nursing Nursing Goal: Relieve Relieve symptoms symptoms and assist assist in stone stone removal - Administer MEPERIDINE, avoid morphine - Maintain Fluid and electrolyte balance - Maintain a LOW fat diet - Semi-fowler’s position - Assist in surgery - Care of the T-tube • Pancreatitis
Inflammat mation ion of the the pancre pancreas as brough broughtt about about by the - Inflam digestion of the organ by the enzyme it produces - Common causes: Alcoholism, stone Manifestations: Extreme upper abdominal pain radiating - Manifestations: into the back, vomiting, nausea, Abdominal distention, Steatorrhea and weight loss - Laboratory: ELEVATED lipase and amylase - Nurs Nursin ing g Goal Goal : reli reliev eve e symp sympto toms ms,, main mainta tain in bloo blood d volume and GIT rest - NPO - Provide IVF and Parenteral nutrition Drugs: s: MEPE MEPERI RIDI DINE NE,, neve neverr morp morphi hine ne,, Anta Antaci cids ds,, - Drug anticholinergics - After Acute phase: LOW fat diet, avoid alcohol, fat and vitamin r eplacements eplacements
