Chapter 34 Lee Resurreccion Assessment of Digestive and Gastrointestinal Function

Organs of the Digestive System

Examination of the Abdomen p.1128, fig. 34-4 Rovsing's sign Rovsing's sign is a sign of appendicitis. [1] If palpation of the lower left quadrant of a person's abdomen results in more pain in the right lower quadrant, the patient is said to have a positive Rovsing's sign and may have appendicitis

Gastroscopy p. 1134, fig. 34-6

Colonoscopy p. 1135, fig. 34-7

Sigmoidoscopy p. 1137, fig. 34-8

Chapter 35 Management of Patients Esophageal Disorders

Upper GI Complications GERD Hiatal hernia CA Upper GI Complications covered in today’s handouts include:

Gastroesophageal Reflux Disease (GERD) Causes: Impaired motility of the esophagus Delayed gastric emptying Defective defenses of the esophagus Dysfunction of the lower esophageal sphincter (LES) Not a disease but a syndrome and no single cause Causes: Impaired motility of the esophagus Delayed gastric emptying Defective defenses of the esophagus Dysfunction of the lower esophageal sphincter (LES) causes a decreased pressure in the lower esophagus leading to a backwash of gastric contents.

Hiatal (Hiatus) Hernia : Pathophysiology Structural changes Weakening muscles of diaphragm Increased intraabdominal pressure Obesity/pregnancy/ascites/tumors/physical exertion Age Poor nutrition (atrophy) Prolonged illness (confined to bed) Most common abnormality found on x-ray examination of the upper GI tract. Occurs when there is herniation of a portion of the stomach into the esophagus through an opening or hiatus in the diaphragm. Pathophysiological changes increasing the risk for hiatal hernias: Structural changes weakening muscles of diaphragm at the esophogastric opening Increased intraabdominal pressure Obesity/pregnancy/ascites/tumors/physical exertion such as lifting Advanced Age Poor nutrition with muscle wasting Prolonged illness (confined to bed)

Sliding Esophageal and Paraesophageal Hernia

Chapter 36 Gastrointestinal Intubation and Special Nutritional Modalities

Types of Tubes Gastric tubes Levin Sump Enteric tubes

TPN / T-Lumen

Management of Patients With Gastric and Duodenal Disorders Chapter 37: Management of Patients With Gastric and Duodenal Disorders

Gastritis A common GI problem that causes inflammation of the stomach Acute: rapid onset of symptoms usually caused by dietary indiscretion. Other causes include medications, alcohol, bile reflux, and radiation therapy. Ingestion of strong acid or alkali may cause serious complications. Chronic: prolonged inflammation due to benign or malignant ulcers of the stomach or Helicobacter pylori. May also be associated with some autoimmune diseases, dietary factors, medications, alcohol, smoking, and chronic reflux of pancreatic secretions or bile. Gastritis is the inflammation of the gastric mucosa. This can cause a breakdown in the normal gastric mucosal barrier which protects the stomach tissue from autodigestion by acid and pepsin.

Gastritis Gastritis is the inflammation of the gastric mucosa. This can cause a breakdown in the normal gastric mucosal barrier which protects the stomach tissue from autodigestion by acid and pepsin.

Erosive Gastritis Gastritis is the inflammation of the gastric mucosa. This can cause a breakdown in the normal gastric mucosal barrier which protects the stomach tissue from autodigestion by acid and pepsin.

Manifestations of Gastritis Acute: abdominal discomfort, headache, lassitude, nausea, vomiting, and hiccupping Chronic: epigastric discomfort, anorexia, heartburn after eating, belching, sour taste in the mouth, nausea, vomiting, and intolerance of some foods; may cause vitamin deficiency due to malabsorption of B12 May be associated with achlorhydria, hypochlorhydria, and hyperchlorhydria Diagnosis is usually by UGI x-ray or endoscopy and biopsy

Medical Management of Gastritis Acute Refrain from alcohol and food until symptoms subside If due to strong acid or alkali treatment to neutralize the agent, avoid emetics and lavage due to danger of perforation and damage to the esophagus Supportive therapy Chronic Modify diet, promote rest, reduce stress, and avoid alcohol and NSAIDs Pharmacologic therapy: see Table 37-1

Gastritis Signs and Symptoms: Anorexia Nausea and vomiting Epigastric tenderness Feeling of fullness Gastritis is the inflammation of the gastric mucosa. This can cause a breakdown in the normal gastric mucosal barrier which protects the stomach tissue from autodigestion by acid and pepsin. Signs and Symptoms: Anorexia Nausea and vomiting Epigastric tenderness Feeling of fullness Complications: Hemorrhage commonly associated with alcohol abuse. Causes: Reflux of gastric secretions H. Pylori

Gastritis Therapy Acute phase: NPO IV fluids Possible NG tube Antiemetics Antacids H2 antagonists or proton pump inhibitor Antibiotics for H. pylori (for chronic) Blood transfusions for hemorrhage Bed rest Acute phase treatment: Bed rest NPO IV fluids Possible NG tube Antiemetics Antacids H2 antagonists or proton pump inhibitor Antibiotics for H. pylori (for chronic) Blood transfusions for hemorrhage

Nursing Management Gastritis Assessments Dry mucous membrane, poor skin turgor, bowel sound Coffee ground emesis electrolytes Interventions Diet IV Positioning Environment Emotional support Antiemetics Nursing Management: Assessments Weight, Sunken eyeballs, Dry mucous membranes, Poor skin turgor, Bowel sounds, Distention I/0, Electrolytes, vomitus amount, color, coffee ground appearance Interventions NPO until diagnosis then add carbs as tolerated, IV fluid replacement, possible NG tube, position to prevent aspiration, VS, maintain quiet, odor-free environment, provide emotional support, administer antiemetics (see p. 1004 – 1005.

Nursing Process—Assessment of the Patient With Gastritis History including presenting signs and symptoms Dietary history and dietary associations with symptoms Monitor dietary intake and keep 72-hour diet diary Abdominal assessment

Nursing Process—Diagnosis of the Patient With Gastritis Anxiety Imbalanced nutrition Risk for fluid volume imbalance Deficient knowledge Acute pain

Nursing Process—Planning the Care of the Patient With Gastritis Major goals include: reduced anxiety avoidance of irritating foods adequate intake of nutrients maintenance of fluid balance increased awareness of dietary management and relief of pain

Interventions Reduce anxiety; use calm approach and explain all procedures and treatments Promote optimal nutrition. For acute gastritis, the patient should take no food or fluids by mouth; introduce clear liquids and solid foods as prescribed. Evaluate and report symptoms. Discourage caffeinated beverages, alcohol, and cigarette smoking. Refer patient for alcohol counseling and smoking cessation. Promote fluid balance; monitor I&O for signs of dehydration, electrolyte imbalance, and hemorrhage Measures to relieve pain: diet and medications See Chart 37-1

Peptic Ulcer Erosion of a mucous membrane forms an excavation in the stomach, pylorus, duodenum, or esophagus Associated with infection of H. pylori Risk factors include excessive secretion of stomach acid, dietary factors, chronic use of NSAIDs, alcohol, smoking, and familial tendency Manifestations include a dull gnawing pain or burning in the midepigastrium; heartburn and vomiting may occur Treatment includes medications, lifestyle changes, and occasionally surgery: see Tables 37-1 and 37-3

Erosion

Helicobacter pylori spiral shape with flagella to move through the mucus of the stomach Helicobacter pylori attach to the epithelial cells Diagram 2: Features of H. pylori H. pylori — so-named because of its shape and where it is found — is spiral shaped when it is actively growing and invading the epithelial cells of the stomach and duodenum. The bacteria use their spiral shape and flagella to move through the mucus of the stomach, which is present to protect the cells against the hydrochloric acid and enzymes that break down ingested food. The mucus also protects the bacteria against the effects of the acids. H. pylori that do not have flagella are unable to colonise the epithelial cells and cause ulcers. Diagram 4: H. pylori invades epithelial cells H. pylori are able to attach to the epithelial cells of the stomach and duodenum which stops them from being washed out of the stomach. Once attached, the bacteria start to cause damage to the cells by secreting degradative enzymes, toxins and initiating a self-destructive immune response.

Ulcer Drug Therapy H2 antagonists Misoprostol (Cytotec) Sucralfate Antisecretory H2 antagonists Cimetidine Ranitidine Famotidine Nizatidine Proton pump inhibitors Omeprazole Lansoprazole Pantoprazole Anticholinergics Antisecretory and cytoprotective Misoprostol (Cytotec) Cytoprotective Sucralfate Pepto-bismol Antacids Antibiotics for H. pylori Amoxicillin Metronidazole Tetracycline Be familiar with these drugs: H2 receptor blockers – block action of histamine on the H2 receptors decreasing HCL acid secretion PPI – block ATPase enzyme that is important for HCL secretion Anticholinergics – not often used (never for gastric ulcers) – decreases cholinergic (vagal) stimulation of HCL Cytoprotective – covers the ulcer Antacids - neutralize Step up approach – antacid – H2 blocker - PPI Step down approach- Start with a PPI and then switch meds

Deep Peptic Ulcer Erosion

Surgical Procedures for Peptic Ulcers Vagotomy: Surgical division of fibers of the vagus nerve, used to diminish acid secretion of the stomach and control a duodenal ulcer The Billroth I gastroduodenostomy specifically joins the upper stomach back to the duodenum Vagotomy Pyloroplasty Billroth I-Gastroduodenostomy Billroth II-Gastrojejunostomy

Nursing Process—Assessment of the Patient With Peptic Ulcer Assess pain and methods used to relieve pain Lifestyle and habits such as cigarette and alcohol use Provide medications, including use of NSAIDs Monitor for signs and symptoms of anemia or bleeding Provide abdominal assessment

Nursing Process—Diagnosis of the Patient With Peptic Ulcer Acute pain Anxiety Imbalanced nutrition Deficient knowledge

Collaborative Problems/Potential Complications Hemorrhage: Excessive discharge of blood from the blood vessels Perforation: A hole or series of holes punched or bored through something Penetration: act or process of piercing or penetrating something Pyloric obstruction (gastric outlet obstruction)

Nursing Process—Planning the Care of the Patient With Peptic Ulcer Major goals for the patient may include: relief of pain anxiety reduction maintenance of nutritional requirements knowledge about the management and prevention of ulcer recurrence and absence of complications

Anxiety Assess anxiety Maintain calm manner Explain all procedures and treatments Help identify stressors Explain various coping and relaxation methods such as biofeedback, hypnosis, and behavior modification

Patient Teaching Medication usage Dietary restrictions Lifestyle changes See Chart 37-2

Management of Potential Complications Management of hemorrhage Assess for evidence of bleeding, hematemesis (vomiting blood), or melena (black, tarry stool), and symptoms of shock/impending shock and anemia Treatment includes IV fluids, NG, and saline or water lavage; oxygen; treatment of potential shock including monitoring of VS and UO; may require endoscopic coagulation or surgical intervention Management of Potential Complications (cont.) Pyloric obstruction Symptoms include nausea, vomiting, constipation, epigastric fullness, anorexia, and (later) weight loss Insert NG tube to decompress the stomach and provide IV fluids and electrolytes; balloon dilation or surgery may be required Management of perforation or penetration Signs include severe upper abdominal pain that may be referred to the shoulder, vomiting and collapse, tender board-like abdominal, and symptoms of shock/impending shock Patient requires immediate surgery

Gastric Cancer Incidence is deceasing, but accounts for 12,000 U.S. deaths annually Increased incidence: in men Native Americans Hispanic Americans African Americans typically between the ages of 40 to 70

Risk factors diet H. pylori infection pernicious anemia smoking, chronic inflammation of the stomach Achlorhydria gastric ulcers previous subtotal gastrectomy And genetics Risk factors include diet, chronic inflammation of the stomach, H. pylori infection, pernicious anemia, smoking, achlorhydria, gastric ulcers, previous subtotal gastrectomy, and genetics

Gastric Cancer (cont.) Manifestations include pain relieved by antacids , dyspepsia early satiety weight loss abdominal pain loss or decrease in appetite , bloating after meals nausea and vomiting diagnosis of the disease is often late Treatment is surgical removal of the tumor if possible, and palliative care if the tumor is not resectable or has metastasized

Treatment surgical removal of the tumor if possible palliative care if the tumor is not resectable or has metastasized

Nursing Process—Assessment of the Patient With Gastric Cancer Dietary history and nutritional status Risk factors and smoking and alcohol history Social support, individual and family coping Resources Physical assessment including assessment of the abdomen

Nursing Process—Diagnosis of the Patient With Gastric Cancer Anxiety Imbalanced nutrition Pain Anticipatory grieving Deficient knowledge

Nursing Process—Planning the Care of the Patient With Gastric Cancer Major goals include reduced anxiety, optimal nutrition, relief of pain, adjustment to the diagnosis, and anticipated lifestyle changes

Anxiety Provide a relaxed, nonthreatening atmosphere Allow patient to express fears and concerns Provide support and encourage family support Promote positive coping measures Explain treatments and procedures Provide referral to support persons such as social workers or clergy

Promote Optimal Nutrition Encourage small, frequent meals of non-irritating foods Provide foods high in calories and vitamins A and C and iron Provide diet and teaching for potential dumping syndrome after gastric resection Provide 6 small feedings low in carbohydrates and sugar, with fluids between, not with, meals Assess I&O, daily weights, signs of dehydration, and nutritional status

Other Interventions Pain Psychosocial support Administer analgesics as prescribed Provide nonpharmacologic pain relief measures Psychosocial support Allow patient to express fears, concern, and grief Allow patient to participate in decisions Include family members and significant others Provide referral/involvement of other support persons as needed Patient teaching: see Chart 37-5

Nursing Process—Assessment of the Patient With Gastric Surgery Patient and family knowledge Nutritional status Abdominal assessment Postoperatively assess for potential complications

Nursing Process—Diagnosis of the Patient With Gastric Surgery Anxiety Pain Deficient knowledge Imbalanced nutrition

Collaborative Problems/Potential Complications Hemorrhage Dietary deficiencies Bile reflux Dumping syndrome

Nursing Process—Planning the Care of the Patient With Gastric Surgery Major goals include reduced anxiety, increased knowledge, optimal nutrition, management of complications that can interfere with nutrition, relief of pain, avoidance of hemorrhage and steatorrhea, and enhanced self-care skills at home

Interventions Provide interventions to reduce anxiety Pain Administer analgesics as prescribed so patient may perform pulmonary care, leg exercises, and ambulation activities Maintain patient in Fowler’s position Maintain function of NG tube Provide patient teaching: see Chart 37-6 Provide individualized nutritional care and support

Care and Prevention of Complications Gastric retention May require reinstatement of NPO and Ng suction; use low-pressure suction Bile reflux Agents that bind with bile acid: cholestyramine Malabsorption of vitamins and minerals Supplementation of iron and other nutrients Parenteral administration of vitamin B12 due to lack of intrinsic factor

Care and Prevention of Complications (cont.) Dumping syndrome Due to rapid passage of food into the jejunum and drawing of fluid into the jejunum due to hypertonic intestinal contents Causes vasomotor and GI symptoms with reactive hypoglycemia Avoid fluid with meals Avoid high carbohydrate/sugar intake Steatorrhea Reduce fat intake and administer loperamide

Dietary Self-Management To delay stomach emptying and dumping syndrome, assume low-Fowler’s position after meals; lie down for 20 to 30 minutes Take antispasmodics as prescribed Avoid fluid with meals Meals should contain more dry items than liquid items Eat fat as tolerated but keep carbohydrate intake low, and avoid concentrated carbohydrates Eat small frequent meals Take dietary supplements as prescribed: vitamins, medium-chain triglycerides, and B12 injections

Chapter 38 Management of Patients With Intestinal and Rectal Disorders

Constipation Abnormal infrequency or irregularity of defecation; any variation from normal habits may be a problem Causes include medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intraabdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise Increased risk in older age Perceived constipation: a subjective problem in which the patient’s elimination pattern is not consistent with what he or she believes is normal

Manifestations Fewer than 3 bowel movements per week Abdominal distention Decreased appetite Headache Fatigue Indigestion A sensation of incomplete evacuation Straining at stool Elimination of small-volume, hard, dry stools

Complications Hypertension Fecal impaction Hemorrhoids Fissures Megacolon

Patient Learning Needs Normal variations of bowel patterns Establishment of normal pattern Dietary fiber and fluid intake Responding to the urge to defecate Exercise and activity Laxative use See Chart 38-1

Diarrhea Increased frequency of bowel movements (more than 3 per day), increased amount of stool (more than 200 g per day), and altered consistency (ie, looseness) of stool Usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors May be acute or chronic Causes include infections, medications, tube feeding formulas, metabolic and endocrine disorders, and various disease processes

Manifestations Increased frequency and fluid content of stools Abdominal cramps Distention Borborygmus Painful spasmodic contractions of the anus Tenesmus

Complications Fluid and electrolyte imbalances Dehydration Cardiac dysrhythmias

Patient Learning Needs Recognition of need for medical treatment Rest Diet and fluid intake Avoid irritating foods (caffeine, carbonated beverages) and very hot and cold foods Perianal skin care Medications May need to avoid milk, fat, whole grains, fresh fruit, and vegetables Lactose intolerance: see Chart 38-2

Malabsorption The inability of the digestive system to absorb one or more of the major vitamins, minerals, and nutrients Conditions: see Table 38-2 Mucosal (transport) disorders Infectious disease Luminal disorders Postoperative malabsorption Disorders that cause malabsorption of specific nutrients

Diverticular Disease Diverticulum: sac-like herniations of the lining of the bowel that extend through a defect in the muscle layer May occur anywhere in the intestine, but are 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

Nursing Process—Assessment of the Patient With Diverticulitis Patients may have chronic constipation preceding development of diverticulosis, frequently asymptomatic but may include bowel irregularities, nausea, anorexia, bloating, and abdominal distention With diverticulitis, symptoms include mild or severe pain in lower left quadrant, nausea, vomiting, fever, chills, and leukocytosis Determine the onset and duration of pain, and past and present elimination patterns Encourage nutrition that includes fiber intake Inspect stool and monitor for symptoms of potential complications

Nursing Process—Diagnosis of the Patient With Diverticulitis Constipation Acute pain

Collaborative Problems/Potential Complications Perforation Peritonitis Abscess formation Bleeding

Nursing Process—Planning the Care of the Patient With Diverticulitis Major goals include attainment and maintenance of normal elimination patterns, pain, relief, and absence of complications

Maintaining Normal Elimination Pattern Encourage fluid intake of at least 2 L/d East soft foods with increased fiber, such as cooked vegetables Participate in an individualized exercise program Use bulk laxatives (psyllium) and stool softeners

Inflammatory Bowel Disease (IBD) Regional enteritis (Crohn’s disease) Ulcerative colitis See Table 38-4

Nursing Process—Assessment of the Patient With Inflammatory Bowel Disease Perform health history to identify onset, duration, and characteristics of pain, diarrhea, urgency, tenesmus, nausea, anorexia, weight loss, bleeding, and family history Discuss dietary patterns, alcohol, caffeine, and nicotine use Assess bowel elimination patterns and stool Perform abdominal assessment

Nursing Process—Diagnosis of the Patient With Inflammatory Bowel Disease Diarrhea Acute pain Deficient fluid Imbalanced nutrition Activity intolerance Anxiety Ineffective coping Risk for impaired skin integrity Risk for ineffective therapeutic regimen management

Collaborative Problems/Potential Complications Electrolyte imbalance Cardiac dysrhythmias GI bleeding with fluid loss Perforation of the bowel

Nursing Process—Planning the Care of the Patient With Inflammatory Bowel Disease Major goals include attainment of normal bowel elimination patterns, relief of abdominal pain and cramping, prevention of fluid deficit, maintenance of optimal nutrition and weight, avoidance of fatigue, reduction of anxiety, promotion of effective coping, absence of skin breakdown, increased knowledge of disease process and therapeutic regimen, and avoidance of complications

Maintaining Normal Elimination Pattern Identify relationship between diarrhea and food, activities, or emotional stressors Provide ready access to bathroom/commode Encourage bed rest to reduce peristalsis Administer medications as prescribed Record frequency, consistency, character, and amounts of stools

Other Interventions Assessment and treatment of pain/discomfort, anticholinergic medications prior to meals, analgesics, positioning, diversional activities, and prevention of fatigue Assess fluid deficit, I&O, daily weight, symptoms of dehydration/fluid loss; encourage oral intake; and initiate measures to decrease diarrhea Provide optimal nutrition; elemental feedings that are high in protein and low residue or PN may be needed Reduce anxiety, exhibit a calm manner, allow patient to express feelings, listen, and provide patient teaching

Patient Teaching Understanding of disease process Nutrition/diet Medications Information sources: National Foundation for Ileitis and Colitis Ileostomy care if applicable See Chart 38-3

The Patient With an Ileostomy Preoperative care Postoperative care Emotional support Skin and stoma care Irrigation of a Kock pouch (continent ileostomy): see Chart 38-6 Diet and fluid intake Prevention of complications See Charts 38-4, 38-5, and 38-7

Pouching Options

Colorectal Cancer The third most common cause of U.S. cancer deaths Risk factors: see Chart 38-8 Importance of screening procedures Manifestations include change in bowel habits; blood in stool—occult, tarry, bleeding; tenesmus; symptoms of obstruction; pain, either abdominal or rectal; feeling of incomplete evacuation Treatment depends upon the stage of the disease

Areas Where Cancer Can Occur

Abdominoperineal Resection for Carcinoma of the Rectum

Placement of Colostomies

Nursing Process—Assessment of the Patient With Cancer of the Colon or Rectum Health history Fatigue and weakness Abdominal or rectal pain Nutritional status and dietary habits Elimination patterns Abdominal assessment Characteristics of stool

Nursing Process—Diagnosis of the Patient With Cancer of the Colon or Rectum Imbalanced nutrition Risk for deficient fluid Anxiety Risk for ineffective therapeutic regimen management Impaired skin integrity Disturbed body image Ineffective sexuality patterns

Collaborative Problems/Potential Complications Intraperitoneal infection Complete large bowel obstruction GI bleeding Bowel perforation Peritonitis, abscess, and sepsis

Nursing Process—Planning the Care of the Patient With Cancer of the Colon or Rectum Major goals include attainment of optimal level of nutrition, maintenance of fluid and electrolyte balance, reduction of anxiety, knowledge of diagnosis and treatment, self-care ability, optimal tissue healing, protection of peristomal skin, patient expression of feelings and concerns about the colostomy and its impact, and avoidance of complications

Interventions Preparation for surgery Postoperative care Emotional support Monitoring for postoperative complications: see Table 38-6 Interventions to maintain optimal nutrition Wound care Colostomy care Supporting positive body image and discussing sexuality