“air-fluid levels” seen in bowel obstruction part ii
TRANSCRIPT
The Gastrointestinal System:
Digestive Disorders
“Air-Fluid Levels” seen in bowel obstructionJ. Carley MSN, MA, RN, CNE
Part II
PHARMACOLOGY
ASSESSMENT
Physical Assessment Inspection Palpation Percussion AuscultationKEY ASSESSMENTSLab Monitoring
Care PlanningPlan for client adl’s, Monitoring, med admin.,Patient education, more…basedOn Nursing Process: A_D_O_P_I_E***Preparing for Diagnostic Tests
Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary
Pathophysiology
Upper GI Lower GI
Inflammatory Inflammatory
Non-Inflammatory
G.E.R.D.UlcersGastritis
G.E.R.D.Hiatus Hernias
Acute AppendicitisPeritonitisUlcerative colitisCrohn’s DiseaseDiverticulitis
Non-Inflammatory
Constipation & DiarrheaIrritable Bowel SyndromeDumping SyndromeIntestinal ObstructionHemorrhoids & PolypsMalabsorption
A Concept Map : Selected Topics in Gastro-Intestinal
Nursing
***Diagnostic Testing
Anti-Acids (Antacids)Prototype: aluminum hydroxide gel (Amphojel)
Prokinetic Agents:Prototype: metoclopramide (Reglan)
Histamine 2 Receptor AgonistsPrototype: ranitidine hydrochloride (Zantac)
Proton Pump Inhibitors)Prototype: omeprazole (Prilosec)
Mucosal BarriersPrototype: sucralfate (Carafate)
Disease Specific Medications:
Nursing Skills: NG Tube Insertion Enteral Feedings
A Rough Outline (for the Left Hemispheric Dominant…)
Gastritis Dumping Syndrome Small & Large Intestines Appendicitis Peritonitis Diverticulitis Ulcerative Colitis Crohn’s Disease Bowel Obstruction Irritable Bowel Syndrome (IBS) Hemorrhoids Polyps Bowel Cancer
Gastritis Inflammation of the gastric mucosa Types: erosive vs. non-erosive Acute vs. Chronic S&S: Abdominal tenderness,
bloating, hematesis, melena Diagnostic: EGD with biopsy Management: see GERD
Dumping Syndrome Rapid gastric emptying into the small
intestines usually occurs after a gastric surgery
Types: Early and Late
Dumping Syndrome S&SEARLY LATE
30 min after eating Rapid emptying Vertigo Syncope Pallor Diaphoresis Tachycardia palpitations
90 min-3 hr after eating Excessive insulin release Abdominal distention Cramping Nausea Dizziness Diaphoresis confusion
Nursing Interventions Lying down after a meal Eliminate liquids with meals Avoid milk, sweets, or sugars Eat small frequent meals Consume high protein and fat with
low to moderate carbohydrate
Medication Treatment Pectin Oral: slows absorption of carbs Octreotide SQ: blocks gastric and
pancreatic hormones
Complication Postprandial Hypoglycemia
Time-----------
BLOOD
GLUCOSE
LEVEL
“The Somogyi Effect”, a.k.a., “Rebound Effect”
Increased blood glucose level increases the release of insulin. Insulin causes the blood glucose levels to go down….
Small Intestines = “-entero”
Functions of Small Intestines
Movement Digestion Absorption
Large Intestines, “-colo-”
Function of Large Intestines
Movement Absorption Elimination
Appendicitis Acute inflammation of veriform
appendix
Signs and Symptoms Lower right quadrant pain Low grade fever Nausea and vomiting Rebound tenderness @Mc Burney’s
point Rosving sign positive Increased WBC
Medical Management Monitor pain (severe rebound
tenderness) Monitor bowel sounds (absent) NPO, IVF, NO laxatives or enemas Surgical management: -Open or laparoscopic appendectomy
Diagnostic Tests Ultrasound Abdominal x-ray Abdominal CT scan
Nursing Diagnosis Acute pain Alteration in comfort Risk for injury Knowledge deficit Risk for infection
Nursing Interventions
Monitor vital signs Assess bowel sounds Monitor pain Monitor lab values Post operative management: -Vitals signs, bowel sounds, diet
resumption, antibiotic therapy as ordered
Peritonitis Acute inflammation of the visceral /
parietal peritoneum and endothelial lining of abdominal cavity
Types: primary and secondary
PeritonitisPRIMARY SECONDARY
Acute bacterial infection Contamination of
peritoneum via vascular system
TB (tuberculin infection) Alcoholic cirrhosis Leakage
Usually caused by a bacterial invasion in the abdomen
Gangrenous bowel Blunt or penetrating
trauma Leakage
Sign and Symptoms Rigid board like abdomen Abdominal pain/tenderness Distended abdomen Nausea and vomiting Diminished to no bowel sounds No stools or flatus Fever Tachycardia
Diagnostic Test CBC (WBC, H&H) Electrolytes CR (creatinine) & BUN (Blood urea
nitrogen) Abdominal x-ray CT scan Peritoneal lavage Surgery
Medical interventions Non-surgical: -IV fluids -Broad spectrum antibiotics -Intake and outputs (I&O) -NG (nasogastric) tube -NPO -Pain management
Medical Interventions Surgical: Optimal treatment Exploratory laparotomy: repair or
remove inflamed organ
Complications Peritonitis: EMERGENCY / Life Threatening
-Symptoms: rigid abd., distended abd., absent bowel sounds, high fever, decreased urine output, hypotension
Fluid shifts from extracellular to peritoneal cavity
Diverticulitis Inflammation of one or more
diverticula. Results when diverticulum perforates and a local abscess forms
Symptoms Abdominal pain, tenderness to
palpation Elevated temperature >101, may
have chills Abdominal guarding, rebound
tenderness
Diagnostic tests CT scan Abdominal flat plate EGD DO NOT do barium enema with active
untreated diverticulitis
Medical Management Non Surgical: -Broad spectrum antibiotics -Anticholinergics -NPO until clear liquids tolerated -Stop fiber therapy until attack is limited -NO enemas or laxatives
Medical Management Surgical -completed for ruptured peritonitis,
fistula formation, bleeding, bowel obstruction, or unresponsive medical management
Nursing Interventions Health teaching: diet, fiber, symptom
recognition, activity
Post op management: -Monitor colostomy, if present -monitor VS, urine output, wound
condition -Psychosocial adjustment to stoma
Ulcerative Colitis Ulcerative colitis: Chronic
inflammatory process affecting mucosal lining of colon or rectum
Symptoms 10-20 liquid stools per day Tenesmus (Straining) Anemia Fatigue LLQ pain/cramping Wt loss
Diagnostic Tests CT scans Colonoscopy or Siqmoidoscopy Barium Swallow studies Stools for O&P, occult blood, & C&S Labs: electrolyte panel and CBC
Medication Management Salicylate: -inhibit prostglandins to reduce
inflammation Corticosteroids: -Suppress immune system and
reduce inflammation Immunomodulators: -reduce steroid use and overrides
body immune system
Medication Management Antibiotics: -acute exacerbations prone to
infection Anti-diarrheals: -Symptomatic relief of severe
diarrhea
Diet Therapy NPO if symptoms are severe TPN if NPO for extended time Elemental formula Low fiber foods Lactose free products No caffeine, spices, alcohol, or
smoking
Surgical Management Surgery is curative Total colectomy with permanent
ileostomy Total colectomy with continent
ileostomy (Kock’s pouch)
Nursing Diagnosis Pain acute and chronic Fluid volume deficit Alteration in nutrition
Nursing Interventions Nutritional assessment Monitoring fluid and electrolytes Monitor lab values Monitor for complications Monitor weight Psychosocial assessment Post operative care
Complications Hemorrhage/perforation Coagulation problems Malabsorption Increase risk for colon cancer Toxic megacolon
Crohn’s Disease Inflammatory disease of small
intestines, colon, or both (terminal ileum)
Symptoms 5-10 fatty stools per day
(steatorrhea) Flatus Malabsorption Weight loss Diffuse bilateral lower quadrant pain Fever with perforation or fistula Fluid, electrolyte and vitamin deficits
Diagnostic Tests CBC Electrolyte panels Vitamin & folic acid levels Albumin & nutritional labs Barium studies Colonoscopy
Medical Management Drug Therapy -Salicylate -Corticosteriods -Immunomodulators -Biologic Therapy -Antibiotics (abscess/perforation)
Diet Therapy TPN for long term use Nutritional supplements Elemental supplements No caffeine or carbonated beverages No ETOH Prebiotics (non-digestive food
ingredients)
Surgical Management Surgery is NOT a “cure” Repair of fistulas Release of intestinal obstructions Partial resection with primary
anastamosis Ileostomy
Complications Intestinal obstruction Fistulas Malabsorption syndrome Liver and biliary diseases Kidney stones Arthritis
Nursing Considerations Administering PPN and TPN Provide adequate nutrition: pre-
medicate as ordered Assess stools: quality, frequency,
amount, and pain issues with stooling Assess vital signsTeach relaxation techniques
Health Teaching Education for ileostomy or colostomy
for both client and family Reduce or eliminate factors that
cause diarrhea and pain Chronic pain management Provide small frequent meals with
specific dietary preferences Detailed abdominal assessment
Bowel Obstruction
SMALL INTESTINES LARGE INTESTINES Pain is spasmodic Peristaltic waves Profuse projectile
vomiting Feculent odor to emesis
Vague diffuse constant pain
Abdominal distention Infrequent vomiting Possible diarrhea
“Air-Fluid Levels” in intestinal obstruction
CauseMECHANICAL NON-MECHANICAL
Adhesions Tumors Volvulus Intussusception Fecal impactions Foreign Bodies / Objects
Decreased peristalsis Electrolyte imbalance Inflammatory response Neurogenic disorder Vascular disorder
Foreign Body in the Colon
Complications Dehydration Perforation Ischemic or strangulated bowel Metabolic acidosis and Alkalosis
Irritable Bowel Syndrome(IBS)
Chronic disorder of diarrhea and constipation
No exact cause known Affects women 3x more then men Possible causes: diet and behavioral
(psychological) illness
Signs and Symptoms “Manning Criteria:” -abdominal pain relieved by
defecation -abdominal distention -sensation of incomplete BM (bowel movement) -Presence of mucus
Sign and Symptoms Exacerbation (flare up):
-worsening cramps -abdominal pain (LLQ) -diarrhea or constipation -increased pain after eating -nausea with defecation and
mealtime
Diagnosis
CBC Serum albumin Stools for occult blood Sigmoidoscopy Colonscopy
Nursing Intervention Stress Management Diet Therapy: -Avoid lactose products, caffeine, ETOH, sorbitol or fructose -Increase fiber (30-40 gm) -Fluid intake of 8-10 cups per day -meal planning
Nursing Intervention Monitor Drug Therapy
-laxatives -diarrheals / antidiarrheals -anticholinergic -tricyclic antidepressants -muscarinic receptor antagonist -antispasmatics -5HT4 (Zelnorm)
Hemorrhoids Swollen or distended veins in rectal
region Internal & external Cause: pregnancy, obesity,
constipation Symptoms: bleeding, edema, and
prolapsed Treatment: cold packs, sitz bath, diet,
Tucks ®, topical anesthetics, and surgery
“The Jackknife Position”Rectal Surgery
Polyps Small growths covered with mucosa
and attached to the surface of intestines
Asymptomatic-bleeding, obstruction, &
intussusception
Benign vs. malignant
Colorectal cancer
Colorectal Cancer Colon and rectum=large intestines
Molecular changes
Metastasize to blood, lymph, surrounding & tissue
Naso-Gastric Tubes (NGT) Purpose for Naso-
Gastric Tubes:
1. Decompression 2. Feeding 3. Administration of
Medications ***4. Lavage
General Golden Rule for Feeding Tubes:
Ensure correct placement prior to putting ANYTHING DOWN a TUBE!!!
X-Ray Confirmation
Problems with Nasogastric Tube (NGT) Placement
Misplaced Feeding Tube
At 1st looks OK but distal tip NOT SEEN
This tube ended up exiting the mid abdomen with the feedings entering the peritoneal cavity
Tube feeding formula
remaining in contact with gastric acid can result in the precipitation of casein and the subsequent formation
of a solid mass around the tube
NGT insertion documentation to include:
Date & time Reason for insertion Type of tube Size of tube Length of tube Nostril tube inserted Number of attempts
required
Additional comments Any complications Method of placement
confirmation Signature: name &
designate of Nurse inserting tube
APPENDIX
Pharmacology:
Anti-Acids (Antacids)Prototype: aluminum hydroxide gel ( Amphojel )
Pharmacological Action Neutralize gastric acid and inactivate pepsin.
Mucosal protection may occur by the antacid’s ability to stimulate the production of prostaglandins.
Therapeutic Uses Treat peptic ulcer disease (PUD) by promoting
healing and relieving pain. Symptomatic relief for clients with GERD.
Nursing Interventions and Client Education
Clients taking tablets should be instructed to chew the tablets thoroughly and then drink at least 8 oz of water or milk.
Teach the client to shake liquid formulations to ensure even dispersion of the medication.
Compliance is difficult for clients because of the frequency of administration.
Administered seven times a day: 1 hr before and 3 hr after meals, and again at bedtime.
Teach clients to take all medications at least 1 hr before or after taking an antacid.
Evaluation of Medication Effectiveness
Depending on therapeutic intent, effectiveness may be evidenced by:
Healing of gastric and duodenal ulcers.
Reduced frequency or absence of GERD symptoms.
No signs or symptoms of GI bleeding.
Back to Concept Map
Pharmacology:
Prokinetic AgentsPrototype : metoclopramide ( Reglan )
Pharmacological Action
Block dopamine and serotonin receptors in the chemoreceptor trigger zone (CTZ), and thereby suppress emesis.
Prokinetic agents augment action of acetylcholine which causes an ↑ in upper GI motility.
Therapeutic Uses
Control postoperative and chemotherapy-induced nausea and vomiting.
Prokinetic agents are used to treat GERD.
Prokinetic agents are used to treat diabetic gastroparesis.
Side Effects / Adverse Effects
Extra Pyramidal Symptoms (EPS) Sedation Diarrhea
Contraindications / Precautions
Contraindicated in clients with GI perforation, GI bleeding, bowel obstruction, and hemorrhage
Contraindicated in clients with a seizure disorder due to ↑ risk of seizures
Use cautiously in children and older adults due to the ↑ risk for EPS.
Nursing Interventions and Client Education
Monitor clients for CNS depression and EPS. Can be given orally or intravenously. If dose is <
10 mg, it may be administered undiluted over 2 min. If the dose is > 10 mg, it should be diluted and
infused over 15 min. Dilute medication in at least 50 mL of D5W or lactated Ringer’s solution.
Evaluation of Medication Effectiveness
Control of nausea and vomiting
Back to Concept Map
**Tardive Dyskinesia Overview
Tardive dyskinesia is a disorder that involves involuntary movements, especially of the lower face. Tardive means "delayed" and dyskinesia means "abnormal movement."
Symptoms
Facial grimacing Jaw swinging Repetitive chewing Tongue thrusting
Causes
Tardive dyskinesia is a serious side effect that occurs when you take medications called neuroleptics. It occurs most frequently when the medications are taken for a long time, but in some cases it can also occur after you take them for a short amount of time.
The drugs that most commonly cause this disorder are older antipsychotic drugs, including:
Haloperidol Fluphenazine Trifluoperazine
Other drugs, similar to antipsychotic drugs, that can cause tardive dyskinesia include:
Cinnarizine Flunarizine (Sibelium) Metoclopramide
Prognosis If diagnosed early, the condition may be reversed by stopping the drug
that caused the symptoms.
Even if the antipsychotic drugs are stopped, the involuntary movements may become permanent and in some cases may become significantly worse.
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Pharmacology:
Histamine 2 (H2) Receptor AgonistsPrototype : ranitidine hydrochloride (Zantac)
Pharmacological Action
Suppress the secretion of gastric acid by selectively blocking H2 receptors in parietal cells lining the stomach.
Therapeutic Uses
Gastric and peptic ulcers, gastroesophageal reflux disease (GERD), and hypersecretory conditions, such as Zollinger-Ellison syndrome.
Used in conjunction with antibiotics to treat ulcers caused by H. pylori.
Therapeutic Nursing Interventions and Client Education
Encourage client to avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).
Ranitidine can be taken with or without food.
Treatment of peptic ulcer disease is usually started as an oral dose twice a day until he ulcer is healed, followed by a maintenance dose, which is usually taken once a day at bedtime.
Evaluation of Medication Effectiveness
Depending on therapeutic intent, effectiveness may be evidenced by:
Reduced frequency or absence of GERD symptoms (e.g., heartburn, bloating, belching).
No signs or symptoms of GI bleeding.
Healing of gastric and duodenal ulcers.
Back to Concept Map
Pharmacology:
Proton Pump InhibitorsPrototype : omeprazole (Prilosec)
Pharmacological Action
Reduce gastric acid secretion by irreversibly inhibiting the enzyme that produces gastric acid.
Reduce basal and stimulated acid production.
Therapeutic Uses
Prescribed for gastric and peptic ulcers, GERD, and hypersecretory conditions (e.g., Zollinger-Ellison syndrome).
Precaution:
Increases the risk for pneumonia. Omeprazole ↓ gastric acid pH, which promotes bacterial colonization of the stomach and the respiratory tract.
Use cautiously in clients at high risk for pneumonia (e.g., clients with COPD).
Nursing Interventions and Client Education
Do not crush, chew, or break sustained-release capsules.
The client may sprinkle the contents of the capsule over food to facilitate swallowing.
The client should take omeprazole once a day prior to eating.
Encourage the client to avoid irritating medications (e.g., ibuprofen and alcohol).
Active ulcers should be treated for 4 to 6 weeks.
Pantoprazole (Protonix) can be administered to the client intravenously.
Monitor the client’s IV site for signs of inflammation (e.g., redness, swelling, local pain) and change the IV site if indicated.
Teach clients to notify the primary care provider for any sign of obvious or occult GI bleeding (e.g., coffee ground emesis).
Evaluation of Medication Effectiveness
Depending on therapeutic intent, effectiveness may be evidenced by:
Healing of gastric and duodenal ulcers. Reduced frequency or absence of GERD
symptoms (e.g., heartburn, sour stomach). No signs or symptoms of GI bleeding.
Other PPI’s: omeprazole; lansoprazole; rabeprozole;
pantoprazole; esomeprazole;
Back to Concept Map
Pharmacology:
Mucosal BarriersPrototype: sucralfate ( Carafate )
Pharmacological Action
Changes into a viscous substance that adheres to an ulcer; protects ulcer from further injury by acid and pepsin.
Viscous substance adheres to the ulcer for up to 6 hr.
Sucralfate has no systemic effects.
Therapeutic Uses
Acute duodenal ulcers and maintenance therapy.
Investigational use in gastric ulcers and gastroesophageal reflux disease. (GERD)
Nursing Interventions and Client Education
Assist the client with the medication regimen. Instruct the client that the medication should
be taken on an empty stomach. Instruct the client that sucralfate should be
taken four times a day, 1 hr before meals, and again at bedtime.
The client can break or dissolve the medication in water, but should not crush or chew the tablet.
Encourage the client to complete the course of treatment.
Evaluation of Medication Effectiveness
Depending on therapeutic intent, effectiveness may be evidenced by:
Healing of gastric and duodenal ulcers. No signs or symptoms of GI bleeding.
Back to Concept Map
***Diagnostic Tests
Blood Tests Complete Blood Count (CBC c Diff) Stool Tests: Stool for occult blood; (Guiac) Stool for ova & parasites (O&P); Stool for Clostridium difficile (C-Diff) Stool Culture & Sensitivity (C&S) Upper GI Series (UGI) Upper GI Series with Small Bowel Follow-Through
(UGI-SBFT) Barium Enema Endoscopy
Return toConcept Map
Tube Feedings: Enteral Nutrition
http://www.saddleback.edu/alfa/n170/tubefeeding.aspx
Key Nursing Assesments:Patient on Enteral Feedings
Tum-E-Vac?
Salem Sump
Levin Tube(single lumen)
FDA advisoryFD&C Blue No. 1
Maloney JPEN 2002;26:S34-42
4 methods to deliver nutrition
IntermittentIntermittent gravity
Via Pump:-continuous (or)cyclic
Any Questions