GI Disorders Nursing
description
Transcript of GI Disorders Nursing
DESCRIPTION• The backflow of gastric and duodenal
contents into the esophagus• Caused by an incompetent lower
esophageal sphincter, pyloric stenosis, or a motility disorder
• Symptoms may mimic those of a heart attack
From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders.
ASSESSMENT• Pyrosis• Dyspepsia• Regurgitation• Pain and difficulty with swallowing• Hypersalivation
IMPLEMENTATION• Instruct the client to avoid factors that
decrease lower esophageal sphincter pressure or cause esophageal irritation
• Instruct the client to eat a low-fat, high-fiber diet; avoid caffeine, tobacco, and carbonated beverages; avoid eating and drinking 2 hours before bedtime; avoid wearing tight clothes; and to elevate the head of the bed on 6- to 8- inch blocks
IMPLEMENTATION• Avoid the use of anticholinergics, which delay
stomach emptying• Instruct the client regarding prescribed
medications, such as antacids, histamine H2-receptor antagonists, or gastric acid pump inhibitors
• Instruct the client regarding the administration of prokinetic medications if prescribed, which accelerate gastric emptying
IMPLEMENTATION• If medical management is unsuccessful,
surgery may be required and involves a fundoplication (wrapping a portion of the gastric fundus around the sphincter area of the esophagus); may be performed by laparoscopy
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
DESCRIPTION• Also known as esophageal or diaphragmatic
hernia • A portion of the stomach herniates through
the diaphragm and into the thorax • It results from weakening of the muscles of
the diaphragm and is aggravated by factors that increase abdominal pressure such as pregnancy, ascites, obesity, tumors, and heavy lifting
DESCRIPTION• Complications include ulceration,
hemorrhage, regurgitation and aspiration of stomach contents, strangulation, and incarceration of the stomach in the chest with possible necrosis, peritonitis, and mediastinitis
From Monahan FD, Neighbers M: Medical-surgical nursing: foundations for clinical practice, ed. 2, Philadelphia, 1998, W.B. Saunders.
ASSESSMENT• Heartburn• Regurgitation or vomiting• Dysphagia• Feeling of fullness
IMPLEMENTATION• Medical and surgical management is similar
to that for GER• Provide small, frequent meals and minimize
the amount of liquids• Advise the client not to recline for 1 hour
after eating• Avoid anticholinergics, which delay stomach
emptying
DESCRIPTION• Inflammation of the stomach or gastric
mucosa• Can be acute or chronic
ACUTE• Caused by the ingestion of food contaminated
with disease-causing microorganisms or food that is irritating or too highly seasoned, the overuse of aspirin or other nonsteroidal antiinflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, or radiation therapy
ASSESSMENT• Abdominal discomfort• Headache• Anorexia, nausea, and vomiting• Hiccuping
CHRONIC• Caused by benign or malignant ulcers, or by
the bacteria Helicobacter pylori; may also be caused by autoimmune diseases, dietary factors, medications, alcohol, smoking, or reflux
ASSESSMENT• Anorexia, nausea, and vomiting• Heartburn after eating• Belching• Sour taste in the mouth• Vitamin B12 deficiency
From Stevens A, Lowe J: Pathology, London, 1995, Mosby.
IMPLEMENTATION• Acute: Food and fluids may be withheld until
symptoms subside; then ice chips followed by clear liquids and then solid food is introduced
• Monitor for signs of hemorrhagic gastritis such as hematemesis, tachycardia, and hypotension, and notify the physician if these signs occur
IMPLEMENTATION• Instruct the client to avoid irritating foods,
fluids, and other substances such as spicy and highly seasoned foods, caffeine, alcohol, and nicotine
• Instruct the client in the use of prescribed medications, such as antibiotics and bismuth salts (Pepto-Bismol)
• Provide the client with information about the importance of vitamin B12 injections, if a deficiency is present
DESCRIPTION• An ulceration in the mucosal wall of the
stomach, pylorus, duodenum, or esophagus, in portions that are accessible to gastric secretions; erosion may extend through the muscle
• May be referred to as gastric, duodenal, or esophageal ulcer depending on location
• The most common peptic ulcers are gastric ulcers and duodenal ulcers
From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 5, Philadelphia: W.B. Saunders.
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From Wilcox CM: Atlas of clinical gastrointestinal endoscopy, Philadelphia, 1995, W.B. Saunders.
From Damjanov I, Linder J, editors: Anderson’s pathology, ed. 10, St. Louis, 1996, Mosby.
DESCRIPTION• Involves ulceration of the mucosal lining that
extends to the submucosal layer of the stomach
• Predisposing factors include stress, smoking, the use of corticosteroids, nonsteroidal antiinflammatory drugs (NSAIDs), alcohol, a history of gastritis, a family history of gastric ulcers, or infection with Helicobacter pylori
• Complications include hemorrhage, perforation, and pyloric obstruction
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From Cotran KS, Kumar V, Collins T: Robbins’ pathologic basis of disease, ed. 6, Philadelphia, 1999, W.B. Saunders.
From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders.
From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders.
ASSESSMENT• Gnawing, sharp pain in or left of the
midepigastric region 1 to 2 hours after eating
• Nausea and vomiting• Hematemesis
IMPLEMENTATION• Monitor vital signs and for signs of bleeding• Administer small, frequent, bland feedings
during the active phase• Administer histamine H2-receptor
antagonists as prescribed to decrease the secretion of gastric acid
• Administer antacids as prescribed to neutralize gastric secretions
IMPLEMENTATION• Administer anticholinergics as prescribed to
reduce gastric motility• Administer mucosal barrier protectants as
prescribed 1 hour before each meal• Administer prostaglandins as prescribed for
their protective and antisecretory actions
CLIENT EDUCATION• Avoid consuming alcohol and substances
that contain caffeine or chocolate• Avoid smoking• Avoid aspirin or NSAIDs• Obtain adequate rest and reduce stress
IMPLEMENTATION: ACTIVE BLEEDING• Monitor vital signs closely• Assess for signs of dehydration,
hypovolemic shock, sepsis, and respiratory insufficiency
• Maintain NPO status and administer IV fluid replacement as prescribed; monitor I&O
• Monitor hemoglobin and hematocrit
IMPLEMENTATION: ACTIVE BLEEDING• Administer blood transfusions as prescribed• Assist with the insertion of a nasogastric (NG)
tube for decompression and for lavage access• Assist with normal saline or tap water lavage at
room temperature to reduce active bleeding• Prepare to assist with administering
vasopressin (Pitressin) by IV as prescribed to induce vasoconstriction and reduce bleeding
TOTAL GASTRECTOMY• Also called esophagojejunostomy• Removal of the stomach with attachment of
the esophagus to the jejunum or duodenum VAGOTOMY
• Surgical division of the vagus nerve to eliminate the vagal impulses that stimulate hydrochloric acid secretion in the stomach
GASTRIC RESECTION• Also called antrectomy• Involves removal of the lower half of the
stomach and usually includes a vagotomy
BILLROTH I• Also called gastroduodenostomy; partial
gastrectomy, with remaining segment anastomosed to duodenum
BILLROTH II• Also called gastrojejunostomy; partial
gastrectomy, with remaining segment anastomosed to jejunum
PYLOROPLASTY• Enlarges the pylorus to prevent or
decrease pyloric obstruction, thereby enhancing gastric emptying
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
Monitor vital signs Position in Fowler's for comfort and to
promote drainage Administer fluids and electrolyte
replacements by IV as prescribed; monitor I&O
Assess bowel sounds Monitor NG suction as prescribed
Do not irrigate or remove the NG tube; assist the physician with irrigation or removal
Maintain NPO status as prescribed for 1 to 3 days until peristalsis returns
Progress the diet from NPO to sips of clear water to 6 small, bland meals a day as prescribed when bowel sounds return
Monitor for postoperative complications of hemorrhage, dumping syndrome, diarrhea, hypoglycemia, and vitamin B12 deficiency
DESCRIPTION• A break in the mucosa of the duodenum • Risk factors and causes include alcohol intake,
smoking, stress, caffeine, the use of aspirin, corticosteroids, and NSAIDs, and infection with Helicobacter pylori
• Complications include bleeding, perforation, gastric outlet obstruction, and intractable disease
• Surgery is performed only if the ulcer is unresponsive to medications or if hemorrhage, obstruction, or perforation occurs
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
From McCance, K. & Huether, S. (2002). Pathophysiology, ed 4, St Louis: Mosby. Courtesy of David Bjorkman, MD, University of Utah, School of Medicine, Department of Gastroenterology.
From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders.
ASSESSMENT• Burning pain in the midepigastric area 2 to
4 hours after eating and during the night• Pain that is often relieved by eating• Melena
IMPLEMENTATION• Monitor vital signs• Perform abdominal assessment• Instruct the client in a bland diet with small,
frequent meals• Provide for adequate rest• Encourage the cessation of smoking
IMPLEMENTATION• Instruct the client to avoid alcohol intake,
caffeine, the use of aspirin, corticosteroids, and NSAIDs
• Administer antacids as prescribed to neutralize acid secretions
• Administer histamine H2-receptor antagonists as prescribed to block the secretion of acid
DESCRIPTION• Rapid emptying of the gastric contents into
the small intestine • Occurs following gastric resection
ASSESSMENT• Symptoms occurring 30 minutes after
eating• Nausea and vomiting• Feelings of abdominal fullness and
abdominal cramping • Diarrhea• Palpitations and tachycardia• Perspiration • Weakness and dizziness• Borborygmi
CLIENT EDUCATION • Eat a high-protein, high-fat, low-
carbohydrate diet• Eat small meals and avoid consuming fluids
with meals• Avoid sugar and salt• Lie down after meals• Take antispasmodic medications as
prescribed to delay gastric emptying
DESCRIPTION• Results from either an inadequate intake of
vitamin B12 or a lack of absorption of ingested vitamin B12 from the intestinal tract
• Pernicious anemia results from a deficiency of intrinsic factor, which is necessary for intestinal absorption of vitamin B12
ASSESSMENT• Severe pallor • Fatigue • Weight loss• Smooth, beefy, red tongue• Slight jaundice• Paresthesias of the hands and feet• Disturbances with gait and balance
IMPLEMENTATION• Increase dietary intake of foods rich in
vitamin B12 if the anemia is the result of a dietary deficiency
• Administer vitamin B12 injections as prescribed on a weekly basis initially, and then monthly for maintenance (lifelong) if the anemia is the result of a deficiency of the intrinsic factor
DESCRIPTION • Dilated and tortuous veins in the
submucosa of the esophagus • Caused by portal hypertension, often
associated with liver cirrhosis, and high risk for rupture if portal circulation pressure rises
• Bleeding varices is an emergency • The goal of treatment is to control bleeding,
prevent complications, and prevent the reoccurrence of bleeding
From Gitlin N, Strauss RM: Atlas of clinical hepatology, Philadelphia, 1995, W.B. Saunders.
ASSESSMENT• Hematemesis• Tarry stools, melena• Ascites• Jaundice• Hepatomegaly and splenomegaly• Dilated abdominal veins• Hemorrhoids• Signs of shock
IMPLEMENTATION• Monitor vital signs • Elevate the head of the bed• Monitor for orthostatic hypotension• Monitor lung sounds and for the presence of
respiratory distress • Administer oxygen as prescribed to prevent
tissue hypoxia • Monitor level of consciousness (LOC)
IMPLEMENTATION• Maintain NPO status• Administer IV fluids as prescribed to restore
fluid volume and correct electrolyte imbalances; monitor I&O
• Monitor hemoglobin, hematocrit, and coagulation factors
• Administer blood transfusions or clotting factors as prescribed
IMPLEMENTATION• Assist in inserting an NG tube or a balloon
tamponade as prescribed• Assist with the administration of iced saline
irrigations to achieve vasoconstriction of the varices
• Prepare to assist with administering vasopressin (Pitressin) by IV or intra-arterial infusion as prescribed to induce vasoconstriction and reduce bleeding
IMPLEMENTATION• Prepare to assist with administering
nitroglycerin (Tridil) with vasopressin (Pitressin) to prevent vasoconstriction of the coronary arteries
• Instruct the client to avoid activities that will initiate vasovagal responses
• Prepare the client for endoscopic procedures or surgical procedures as prescribed
ENDOSCOPIC INJECTION (SCLEROTHERAPY)• Injection of a sclerosing agent into and
around bleeding varices• Complications include chest pain, pleural
effusion, aspiration pneumonia, esophageal stricture, and perforation of the esophagus
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
ENDOSCOPIC VARICEAL LIGATION• Ligation of the varices with an elastic rubber
band• Sloughing, followed by superficial
ulceration, occurs in the area of ligation within 3 to 7 days
SPLENORENAL• Involves splenectomy, with anastomosis of
the splenic vein to the left renal vein PORTACAVAL
• Shunting of the blood from the portal vein to the inferior vena cava
MESOCAVAL• Involves a side anastomosis of the superior
mesenteric vein to the proximal end of the inferior vena cava
From Beare, P. & Myers, J. (1998). Adult health nursing, ed 3, St Louis: Mosby.
TRANSJUGULAR INTRAHEPATIC PORTAL/SYSTEMIC• Uses the normal vascular anatomy of the
liver to create a shunt with the use of a metallic stent
• The shunt is between the portal and systemic venous system within the liver and is aimed at relieving portal hypertension
DESCRIPTION • Ulcerative and inflammatory disease of the
bowel that results in poor absorption of nutrients
• Commonly begins in the rectum and spreads upward toward the cecum
• Characterized by various periods of remissions and exacerbations
• The colon becomes edematous and may develop bleeding lesions and ulcers; the ulcers may lead to perforation
DESCRIPTION • Scar tissue develops and causes loss of
elasticity and loss of ability to absorb nutrients
• Acute ulcerative colitis results in vascular congestion, hemorrhage, edema, and ulceration of the bowel mucosa
• Chronic ulcerative colitis causes muscular hypertrophy; fat deposits; and fibrous tissue with bowel thickening, shortening, and narrowing
DESCRIPTION • Surgical intervention involves creation of an
ostomy; the ostomy can be created within the ileum or at various sites within the large bowel
• An ileostomy is the surgical creation of an opening into the ileum or small intestine that allows for drainage of fecal matter from the ileum to the outside of the body
• A colostomy is the surgical creation of an opening into the colon that allows for drainage of fecal matter from the colon to the outside of the body
From Rosai J: Ackerman’s surgical pathology, ed. 8, St. Louis, 1996, Mosby.
From Damjanov I, Linder J, editors: Anderson’s pathology, ed. 10, St. Louis, 1996, Mosby.
ASSESSMENT• Anorexia• Weight loss • Malaise• Abdominal tenderness and cramping• Severe diarrhea that may contain blood and
mucus• Dehydration and electrolyte imbalances• Anemia• Vitamin K deficiency
IMPLEMENTATION• Acute phase: Maintain NPO status,
administer IVs and electrolytes, or total parenteral nutrition (TPN) as prescribed
• Restrict the client’s activity to reduce intestinal activity
• Monitor bowel sounds and for abdominal tenderness and cramping
• Monitor stools, noting color, consistency, and the presence or absence of blood
IMPLEMENTATION• Monitor for perforation, peritonitis, and
hemorrhage• Following the acute phase, the diet progresses
from clear liquids to low-residue as tolerated• Instruct client to consume a low-residue, high-
protein diet; vitamins and iron supplements may be prescribed
• Instruct client to avoid gas-forming foods and milk products and foods such as whole-wheat breads, nuts, raw fruits and vegetables, pepper, alcohol, and caffeine-containing products
IMPLEMENTATION• Instruct the client to avoid smoking• Administer bulk-forming agents such as
bran, psyllium, or methylcellulose, to decrease diarrhea and relieve symptoms
• Administer antimicrobial, corticosteroids, and immunosuppressants as prescribed to prevent infection and reduce inflammation
TOTAL PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY• Curative and involves the removal of the
entire colon (colon, rectum, and anus with anal closure)
• The end of the terminal ileum forms the stoma, which is located in the right lower quadrant
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
KOCK ILEOSTOMY (CONTINENT ILEOSTOMY)• An intra-abdominal pouch (stores the feces)
is constructed from the terminal ileum• The pouch is connected to the stoma with a
nipple-like valve constructed from a portion of the ileum; the stoma is flush with the skin
• A catheter is used to empty the pouch, and a small dressing or adhesive bandage is worn over the stoma between emptyings
From Beare, P. & Myers, J. (1998). Adult health nursing, ed 3, St Louis: Mosby.
ILEOANAL RESERVOIR• A two-stage procedure that involves the
excision of the rectal mucosa, an abdominal colectomy, construction of a reservoir to the anal canal, and a temporary loop ileostomy
• The ileostomy is closed in approximately 3 to 4 months after the capacity of the reservoir is increased
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
ILEOANAL ANASTOMOSIS (ILEORECTOSTOMY)• Does not require an ileostomy• A 12- to 15-cm rectal stump is left after the
colon is removed and the small intestine is inserted into this rectal sleeve and anastomosed
• Requires a large, compliant rectum
From Phipps WJ, Sands, J, Marek JF: Medical-surgical nursing: concepts and clinical practice, ed. 6, St. Louis, 1999, Mosby.
Consult with enterostomal therapist to assist in identifying optimal placement of the ostomy
Instruct the client to eat a low-residue diet for a day or two prior to surgery as prescribed
Administer intestinal antiseptics and antibiotics as prescribed to cleanse the bowel and to decrease the bacterial content of the colon
Administer laxatives and enemas as prescribed
Place a petrolatum gauze over the stoma as prescribed to keep it moist, followed by a dry sterile dressing if a pouch (external) system is not in place
Place a pouch system on the stoma as soon as possible
Monitor the stoma for size, unusual bleeding, or necrotic tissue
Monitor for color changes in the stoma The normal stoma color is pink to
bright red and shiny, indicating high vascularity
A pale pink stoma indicates low hemoglobin and hematocrit levels
A purple-black stoma indicates compromised circulation, requiring physician notification
Assess the functioning of the colostomy
Expect that stool is liquid in the immediate postoperative period, but becomes more solid depending on the area of the colostomy• Ascending colon - liquid• Transverse colon - loose to semi-formed• Descending colon - close to normal
From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.
Monitor the pouch system for proper fit and signs of leakage
Empty the pouch when it is one-third full
Fecal matter should not be allowed to remain on the skin
Administer analgesics and antibiotics as prescribed