GI Linton Ch38 Powerpoint 2


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GI Linton Ch38 Powerpoint 2

  1. 1. <ul><li>Learn to see things backwards, inside out and upside down </li></ul><ul><li>John Heider </li></ul>
  3. 3. Nursing Assessment <ul><li>Health History and Physical Examination </li></ul><ul><li>SUBJECTIVE DATA : </li></ul><ul><li>HEALTH HISTORY </li></ul><ul><li>1. CHIEF COMPLAINT and HISTORY OF PRESENT ILLNESS </li></ul><ul><ul><ul><li>RN performs initial assessment, LPN contributes </li></ul></ul></ul><ul><ul><ul><li>Detailed description of present illness </li></ul></ul></ul><ul><li>What types of questions do we ask? ??? </li></ul>
  4. 4. Chief Complaint—Questions <ul><li>Where it is </li></ul><ul><li>How it feels </li></ul><ul><li>Aggravating and alleviating factors </li></ul><ul><li>Timing </li></ul><ul><li>Severity </li></ul><ul><li>Useful data for associated symptoms </li></ul><ul><li>Perception by the patient of the problem </li></ul>
  5. 5. COMMON SYMPTOMS OF ABDOMINAL DISEASE <ul><li>Pain </li></ul><ul><li>Nausea / Vomiting </li></ul><ul><li>Change in appetite </li></ul><ul><li>Change in bowel habits </li></ul><ul><li>Rectal bleeding </li></ul><ul><li>Jaundice </li></ul><ul><li>Abdominal distention </li></ul><ul><li>Mass </li></ul>
  6. 6. SOME PAIN QUESTIONS TO CONSIDER <ul><ul><li>Onset and duration </li></ul></ul><ul><ul><ul><li>Sudden, gradual, persistent, or intermittent </li></ul></ul></ul><ul><ul><li>Character </li></ul></ul><ul><ul><ul><li>Dull, sharp, burning, stabbing, aching </li></ul></ul></ul><ul><ul><ul><li>Location </li></ul></ul></ul><ul><ul><ul><li>Radiation, superficial, deep, changing </li></ul></ul></ul><ul><ul><li>Associated symptoms </li></ul></ul><ul><ul><ul><li>N/V/D, change in abdominal girth, belching </li></ul></ul></ul>
  7. 7. MORE PAIN QUESTIONS <ul><li>What makes the pain better? </li></ul><ul><ul><li>Belching, eating, vomiting, change in position </li></ul></ul><ul><li>What makes the pain worse? </li></ul>
  8. 8. Health History (cont) <ul><li>2. PAST MEDICAL HISTORY </li></ul><ul><ul><li>Chronic/serious illnesses/infections: diabetes, hepatitis, anemia </li></ul></ul><ul><ul><li>History of GI diseases i.e. peptic ulcers, CA, Crohn’s disease, colitis </li></ul></ul><ul><ul><li>Previous GI surgeries </li></ul></ul>
  9. 9. PAST MEDICAL HX (CONT) <ul><li>MEDICATIONS: </li></ul><ul><li>Ask about medication use such as NSAIDs, aspirin, vitamins, laxatives, enemas, or antacids </li></ul><ul><ul><li>Carefully note meds that can cause bleeding or irritation of the GI tract i.e. NSAID, aspirin </li></ul></ul><ul><li>Assess pt knowledge of side effects to identify education needs </li></ul><ul><ul><li>Regular use of laxatives can cause dependence </li></ul></ul><ul><ul><li>Educate on normal bowel patterns </li></ul></ul><ul><li>OTC medications, herbal / natural products </li></ul>
  10. 10. MEDICATIONS (CONT’D) <ul><li>Clostridium Dificile </li></ul><ul><ul><li>Recent hospitalizations or antibiotic use -> risk factor for C. Dificile </li></ul></ul><ul><ul><li>Can cause diarrhea, colitis, dehydration, colonic perforation, death </li></ul></ul><ul><ul><li>S/S diarrhea, nausea, anorexia, abd tenderness, pain </li></ul></ul><ul><ul><li>Pts with + C. dificile require isolation </li></ul></ul><ul><ul><li>Hand washing </li></ul></ul><ul><ul><li>Can be carried on hands, nails, rings, shoes </li></ul></ul>
  11. 11. Health History (cont) <ul><li>3. FAMILY HISTORY—some conditions are hereditary </li></ul><ul><li>4. Review of Systems </li></ul><ul><ul><li>Pt general health state </li></ul></ul><ul><ul><li>S/S </li></ul></ul><ul><ul><li>Normal bowel pattern; changes in bowel habits </li></ul></ul><ul><ul><li>Unexplained weight loss/ gain </li></ul></ul><ul><ul><li>S/S of disease i.e. bloody/ tarry stools, rectal bleeding, stomach / abdominal pain </li></ul></ul>
  12. 12. HEALTH HISTORY (cont) <ul><ul><li>N/V, abdominal distention, gas </li></ul></ul><ul><ul><li>Work activities and work setting </li></ul></ul><ul><ul><li>Exposure to liver toxic substances </li></ul></ul><ul><ul><li>Use of alcohol </li></ul></ul><ul><ul><li>Recent blood transfusions/ products, dental procedures, body piercing, tattooing, IV injection with contaminated needle </li></ul></ul><ul><ul><li>Fatigue, stressors </li></ul></ul>
  13. 13. HEALTH HISTORY (CONT) <ul><li>5. FUNCTIONAL ASSESSMENT </li></ul><ul><li>Nutrition, activity, stressors </li></ul><ul><ul><li>Diet History: </li></ul></ul><ul><ul><li>Usual foods and fluids </li></ul></ul><ul><ul><li>Allergies/ intolerance </li></ul></ul><ul><ul><li>Appetite patterns </li></ul></ul><ul><ul><li>Swallowing difficulty </li></ul></ul><ul><ul><li>Nutritional herbal supplements </li></ul></ul><ul><li>Effect of chief complaint on usual functioning </li></ul>
  14. 14. Cultural Influences <ul><li>Many cultures have special dietary practices and restrictions </li></ul>
  15. 15. Objective Data <ul><li>Physical Exam </li></ul><ul><ul><li>Height, Weight, Vital Signs, Body Mass Index </li></ul></ul><ul><ul><ul><li>Should be normal </li></ul></ul></ul><ul><ul><ul><li>BMI should be 18.5-24.9 </li></ul></ul></ul><ul><ul><li>Oral Cavity </li></ul></ul><ul><ul><ul><li>Moist, pink, teeth intact, proper fitting dentures </li></ul></ul></ul><ul><ul><ul><li>No lesions, inflammation, tenderness, discoloration,odor </li></ul></ul></ul><ul><ul><li>Abdomen </li></ul></ul><ul><ul><ul><li>Contour, shape, skin, bowel sounds </li></ul></ul></ul>
  16. 16. Objective Data (cont’d) <ul><li>Inspection </li></ul><ul><li>Auscultation </li></ul><ul><li>Percussion </li></ul><ul><li>Palpation </li></ul><ul><li>(goal is to prevent palpation from changing other assessment findings) </li></ul>
  17. 17. Physical Assessment <ul><li>Preparation </li></ul><ul><ul><li>Gather equipment—examination gown, drape, examination light, gloves, stethoscope, skin-marking pen, ruler, tape measure </li></ul></ul><ul><ul><li>Wash your hands </li></ul></ul><ul><ul><li>Explain the procedure to the client </li></ul></ul><ul><ul><li>Ask the client to void-- </li></ul></ul><ul><ul><li>Be sure the room is warm and draft free with proper lighting </li></ul></ul>
  18. 18. Physical Assessment <ul><li>REMEMBER: </li></ul><ul><li>Ensure client privacy </li></ul><ul><li>Use universal precautions </li></ul><ul><li>Determine if abd pain is present before proceeding and examine painful area last </li></ul><ul><li>Inspection, auscultation, percussion, palpation </li></ul><ul><li>Visualize underlying structures before proceeding </li></ul><ul><li>Have client relax abd muscles by taking several deep breaths </li></ul><ul><li>Observe for nonverbal signs of pain or discomfort (facial grimacing, legs flexed at knees/hips, abd guarding w/ hands) </li></ul><ul><li>Stand on right side of client to conserve energy (liver, spleen, and right kidney assessed from clients right side) </li></ul>
  19. 19. Inspection <ul><li>Place client in supine position with arms at sides </li></ul><ul><li>Place small pillow under clients head and knees </li></ul><ul><li>Drape examination gown over chest, exposing abdomen </li></ul><ul><li>Place drape at symphisis pubis, covering pelvic area and legs </li></ul><ul><li>Map the abdomen-imaginary horizontal and vertical lines delineating abdominal quadrants </li></ul><ul><li>Visualize underlying structures </li></ul>
  20. 20. Inspection (cont) <ul><li>Note condition of skin and contour </li></ul><ul><li>Contour: Flat, rounded (convex), Sunken (concave), Distended (protuberant) </li></ul><ul><ul><li>Distention, tumors, hernia, previous surgeries </li></ul></ul><ul><li>Umbilicus—center of abdomen, clean and free of inflammation </li></ul><ul><li>Note abdominal pulsations and peristalsis—may be visible in thin persons or may indicate an abdominal aortic aneurysm </li></ul><ul><li>Wounds, tubes, ostomy device </li></ul>
  21. 21. Inspection (cont) <ul><li>Scars, striae (stretch marks), bruising, caput medusae (bluish purple swollen vein pattern extending from navel), spider angiomas, petechiae </li></ul><ul><li>Visible masses, movement, or peristalsis </li></ul><ul><li>Jaundice (icterus)—yellowing of skin and sclerae (liver and GB disease, or RBC disorders)—elevated bilirubin </li></ul>
  22. 22.   Abdominal Auscultation
  23. 23. Auscultation <ul><li>Clockwise from RUQ </li></ul><ul><li>2 minutes per quadrant </li></ul><ul><li>Press lightly, listen for soft clicks and gurgles every 5-15 seconds (5-30X per minute) </li></ul><ul><li>Peristalsis moves air and fluid through GI tract: normal, hyperactive, hypoactive, absent </li></ul>
  24. 24. Bowel Sounds <ul><li>Hyperactive—rapid, high pitched, and loud—may occur with hunger or gastroenteritis </li></ul><ul><li>Hypoactive—infrequent—may occur with paralytic ileus or after abd surgery </li></ul><ul><li>Absent—no sounds after listening for a full 5 minutes </li></ul><ul><li>Bowel obstruction—high pitched, tinkling sound proximal to obstruction and absent distal to obstruction </li></ul><ul><li>Vascular sounds or bruits (swooshing) over aorta normally not present </li></ul>
  25. 25. Percussion/Palpation <ul><li>Percussion: Produces sound that identifies density of organs beneath and is performed by the physician or advanced nurse practitioner </li></ul><ul><li>Palpation: Light palpation concludes the phys assessment. Painful areas palpated last. </li></ul><ul><ul><li>Note muscle tension, rigidity, masses or expressions of pain </li></ul></ul><ul><ul><li>Deep palpation done only by physicians and highly skilled nurses (nurse practitioners) </li></ul></ul><ul><li>Abdominal Girth-mark made so subsequent measurements taken at the same location </li></ul><ul><li>Rebound tenderness--? appendicitis </li></ul>
  26. 26. Rectum and Anus <ul><li>Inspect perianal skin for color, rashes, lesions, hemorrhoids </li></ul><ul><li>You may be asked to assist the examiner with the rectal exam </li></ul>
  27. 27. D IAGNOSTIC TESTS <ul><li>Use Standard precautions when obtaining specimens of body fluids, substances, or blood </li></ul>
  28. 28. Radiographic Tests <ul><li>Linton p. 736-737 </li></ul><ul><li>Flat Plate o f t he Abdome n </li></ul><ul><ul><li>organs, tumors, obstructions, strictures </li></ul></ul><ul><ul><li>Hospital gown with no metal </li></ul></ul><ul><ul><li>Avoid during pregnancy </li></ul></ul><ul><li>Upper gastrointestinal series (barium swallow), small bowel series, barium enema </li></ul>
  29. 29. Upper GI Series <ul><ul><li>Upper GI Series (Barium Swallow) </li></ul></ul><ul><ul><li>Radiographs of the esophagus, stomach, duodenum </li></ul></ul><ul><ul><li>oral liquid radiopaque constrast medium (barium) and x-rays </li></ul></ul><ul><ul><li>detect strictures, ulcers, tumors, polyps, hiatal hernias, motility problems </li></ul></ul><ul><ul><li>Clear liquid dinner, then NPO until test (no smoking, no gum—can stimulate gastric motility) </li></ul></ul>
  30. 30. Upper GI (cont) <ul><li>Pt drinks barium and Xrays taken at specific intervals to visualize outline of organs and note passage of barium through GI tract </li></ul><ul><li>Procedure may take several hours </li></ul><ul><li>Laxative given afterward to help expel barium and prevent constipation or barium impaction </li></ul><ul><li>Drink 12 8-oz glasses of water per day for several days </li></ul><ul><li>Stool monitored, will look white X2-3 days </li></ul><ul><li>Complication: constipation with distention= barium impaction </li></ul>
  31. 32. Small Bowel Series <ul><li>Detects abnormalities of small intestine </li></ul><ul><li>Pt drinks contrast; Films taken at 20-30 min intervals </li></ul><ul><li>Preparation same as UGI </li></ul>
  32. 33. Lower GI Series <ul><li>BARIUM ENEMA </li></ul><ul><li>Visualize position, movements and filling of colon </li></ul><ul><li>Detects tumors, diverticula, stenosis, obstructions, inflammation, ulcerative colitis, and polyps </li></ul><ul><li>Low residue or clear liquid diet X2 days </li></ul>
  33. 34. Lower GI (Barium enema) <ul><li>Laxatives, bowel-cleansing solutions (GoLYTELY) and enemas evening before </li></ul><ul><li>GoLYTELY chilled and drunk full strength—8 oz every 10 min for a total of 4L </li></ul><ul><li>Watery diarrhea X5 hours </li></ul><ul><li>Clear liquids in am or NPO after midnight </li></ul><ul><li>Lower GI contraindicated if active inflammatory disease, suspected perforation or obstruction, active GI bleeding </li></ul>
  34. 35. Barium enema (cont) <ul><li>Barium instilled rectally and xrays taken </li></ul><ul><li>Cramping and urge to have a BM </li></ul><ul><li>Slow deep breaths and tighten anal sphincter </li></ul><ul><li>Stools monitored after to ensure barium is passed </li></ul><ul><li>Monitor for constipation </li></ul><ul><li>Increase fluids and laxative might be ordered </li></ul><ul><li>Instructions: report abd pain, bloating, absence of stool, or rectal bleeding </li></ul>
  35. 36. Endoscopy <ul><li>Tube and fiberoptic system </li></ul><ul><li>View structures, remove polyps, biopsy specimens, coagulate bleeding sites </li></ul><ul><li>Must have consent </li></ul><ul><ul><li>Esophagoscopy </li></ul></ul><ul><ul><li>Gastroscopy </li></ul></ul><ul><ul><li>Gastroduodenoscopy </li></ul></ul><ul><li>Esophagogastroduodenoscopy [EGD] </li></ul><ul><li>Endoscopic Retrograde Cholangiopancreatography (ERCP) </li></ul><ul><ul><li>Lower Gastrointestinal Endoscopy </li></ul></ul><ul><ul><li>Colonoscopy </li></ul></ul><ul><ul><li>Proctoscopy </li></ul></ul><ul><ul><li>Sigmoidoscopy </li></ul></ul>
  36. 39. Esophagogastroduodenoscopy <ul><li>EGD visualizes esophagus, stomach, and duodenum </li></ul><ul><li>Inflammation, cancer, bleeding, injury, infection </li></ul><ul><li>Consent, preop checklist </li></ul><ul><li>NPO 8-12 hrs (prevent aspiration) </li></ul><ul><li>Sedatives diazepam (Valium) and midazolam (Versed) </li></ul><ul><li>May be given atropine sulfate to dry oral secretions </li></ul><ul><li>Local anesthetic spray or gargle inhibits gag reflex </li></ul><ul><li>Placed on left side, tube passed orally down GI tract </li></ul>
  37. 40. EGD (cont) <ul><li>Photos or video </li></ul><ul><li>Specimens obtained </li></ul><ul><li>Afterward: VS, pt remains on side to prevent aspiration until sedation and anesthetic wear off </li></ul><ul><li>NPO until gag reflex returns (4hrs) </li></ul><ul><li>S/S perforation: bleeding, fever, dysphagia, pain—in various areas depending on site of perforation, cyanosis </li></ul><ul><li>Sore throat for a few days </li></ul>
  38. 44. G astroscopy
  39. 45. Endoscopic Retrograde Cholangiopancreatography <ul><li>ERCP visualize liver, GB, and pancreas </li></ul><ul><li>Direct viewing and use of contrast </li></ul><ul><li>Endoscope passed into duodenum and dye injected—outlines pancreatic and bile ducts </li></ul><ul><li>NPO night before, Iodine allergies </li></ul><ul><li>Lab studies i.e. Prothrombin time </li></ul><ul><li>Remove dentures </li></ul>
  40. 46. Endoscopic Retrograde Cholangiopancreatography
  41. 47. ERCP (cont) <ul><li>Afterward note RUQ pain, fever, chills—infection </li></ul><ul><li>Hypotension, tachycardia, increasing RUQ pain, n/v—perforation or onset of pancreatitis </li></ul>
  42. 48. Lower GI Endoscopy <ul><li>Proctosigmoidoscopy—examination of distal sigmoid colon, rectum and colon using rigid or flexible endoscope </li></ul><ul><ul><li>Detects ulcerations, punctures, lacerations, tumors, hemorrhoids, polyps, fissures, fistulas, abscesses </li></ul></ul><ul><ul><li>Annual exam for 40+ </li></ul></ul><ul><ul><li>Lower bowel must be clean </li></ul></ul>
  43. 49. Proctosigmoidoscopy <ul><li>Clear liquids X24hrs; laxative night before </li></ul><ul><li>Warm tap water enema or Fleet morning of </li></ul><ul><li>No bowel prep if bleeding, severe diarrhea </li></ul><ul><li>Position left lateral knee-to-chest (straightens sigmoid colon) </li></ul><ul><li>Rigid proctoscope for rectum </li></ul><ul><li>Flexible scope above rectosigmoid junction </li></ul>
  44. 50. Proctosigmoidoscopy <ul><li>Biopsy specimens, polyps removed </li></ul><ul><li>Cauterization to prevent/stop bleeding </li></ul><ul><li>After procedure rest in supine position to avoid orthostatic hypotension </li></ul><ul><li>Pain and flatus from instilled air </li></ul><ul><li>Observe for signs of perforation </li></ul>
  45. 51. Colonoscopy <ul><li>Visualization of lining of large intestine w/ flexible endoscope </li></ul><ul><li>Biopsy, polyps removed </li></ul><ul><li>Liquid diet 24hrs before; NPO after midnight </li></ul><ul><li>Bowel Prep i.e. GoLYTELY night before </li></ul><ul><li>Laxative, suppository (Dulcolax) or enema may be needed </li></ul>
  46. 52. Colonoscopy (cont) <ul><li>Conscious sedation i.e. Versed—relax and ease pain </li></ul><ul><li>Left side with knees bent </li></ul><ul><li>Air instilled into colon to help visualize (pressure/discomfort) </li></ul><ul><li>Encourage relaxation/deep breathing </li></ul><ul><li>VS; Watch for vasovagal response (Hypotension and bradycardia) </li></ul><ul><li>Monitor until stable; hemorrhage or severe pain </li></ul><ul><li>Flatus and cramping for several hours </li></ul><ul><li>Blood may be present in stool if biopsy </li></ul>
  47. 57. Gastric Analysis <ul><li>Measures stomach secretions </li></ul><ul><li>Duodenal ulcer, gastric carcinoma, pyloric or duodenal obstruction, pernicious anemia </li></ul><ul><li>Basal cell secretion test </li></ul><ul><ul><li>Avoid drugs that interfere w/ acid secretion </li></ul></ul><ul><ul><li>NPO after midnight </li></ul></ul><ul><ul><li>NG tube inserted and syringe used to suction </li></ul></ul><ul><ul><li>Wall suction; contents q15min X1 hr </li></ul></ul><ul><ul><li>pH and amount of gastric acid </li></ul></ul><ul><ul><li>Too much HCL—peptic ulcer; too little—CA or pernicious anemia </li></ul></ul>
  48. 58. Gastric Analysis (cont) <ul><li>Gastric Acid stimulation test </li></ul><ul><ul><li>Measures amount of gastric acid for 1 hr after SQ injection of histamine drug </li></ul></ul><ul><ul><li>If abnormal results radiographic tests or endoscopy done </li></ul></ul><ul><li>Tubeless gastric analysis detects presence of HCL </li></ul><ul><ul><li>Stimulant and dye administered </li></ul></ul><ul><ul><li>Dye reacts if HCL present and appears in urine in 2 hrs </li></ul></ul>
  49. 59. Occult Blood Test <ul><li>Detects blood not visible with naked eye in vomitus, gastric secretions, and stool </li></ul><ul><li>Small sample placed on special paper and treated with a chemical </li></ul><ul><li>Observe for specific color change </li></ul><ul><li>False positive results can occur with bleeding gums following a dental procedure; ingestion of red meat within 3 days before testing; ingestion of fish, turnips, or horseradish; certain medications (anticoagulants, NSAIDS, steroids, aspirin, large doses of iron) </li></ul>
  50. 60. Stool Tests <ul><li>Blood </li></ul><ul><li>Bile </li></ul><ul><li>Pathogenic organisms </li></ul><ul><li>Parasite ova (eggs) </li></ul><ul><li>Fecal fat </li></ul><ul><li>White blood cell count </li></ul>