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GI Linton Ch38 Powerpoint 2

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  • 1.
    • Learn to see things backwards, inside out and upside down
    • John Heider
  • 2. DIGESTIVE TRACT DISORDERS: NURSING ASSESSMENT OF THE DIGESTIVE TRACT Linton p.733 Mrs.Powell GI PP2 CHAPTER 38
  • 3. Nursing Assessment
    • Health History and Physical Examination
    • SUBJECTIVE DATA :
    • HEALTH HISTORY
    • 1. CHIEF COMPLAINT and HISTORY OF PRESENT ILLNESS
        • RN performs initial assessment, LPN contributes
        • Detailed description of present illness
    • What types of questions do we ask? ???
  • 4. Chief Complaint—Questions
    • Where it is
    • How it feels
    • Aggravating and alleviating factors
    • Timing
    • Severity
    • Useful data for associated symptoms
    • Perception by the patient of the problem
  • 5. COMMON SYMPTOMS OF ABDOMINAL DISEASE
    • Pain
    • Nausea / Vomiting
    • Change in appetite
    • Change in bowel habits
    • Rectal bleeding
    • Jaundice
    • Abdominal distention
    • Mass
  • 6. SOME PAIN QUESTIONS TO CONSIDER
      • Onset and duration
        • Sudden, gradual, persistent, or intermittent
      • Character
        • Dull, sharp, burning, stabbing, aching
        • Location
        • Radiation, superficial, deep, changing
      • Associated symptoms
        • N/V/D, change in abdominal girth, belching
  • 7. MORE PAIN QUESTIONS
    • What makes the pain better?
      • Belching, eating, vomiting, change in position
    • What makes the pain worse?
  • 8. Health History (cont)
    • 2. PAST MEDICAL HISTORY
      • Chronic/serious illnesses/infections: diabetes, hepatitis, anemia
      • History of GI diseases i.e. peptic ulcers, CA, Crohn’s disease, colitis
      • Previous GI surgeries
  • 9. PAST MEDICAL HX (CONT)
    • MEDICATIONS:
    • Ask about medication use such as NSAIDs, aspirin, vitamins, laxatives, enemas, or antacids
      • Carefully note meds that can cause bleeding or irritation of the GI tract i.e. NSAID, aspirin
    • Assess pt knowledge of side effects to identify education needs
      • Regular use of laxatives can cause dependence
      • Educate on normal bowel patterns
    • OTC medications, herbal / natural products
  • 10. MEDICATIONS (CONT’D)
    • Clostridium Dificile
      • Recent hospitalizations or antibiotic use -> risk factor for C. Dificile
      • Can cause diarrhea, colitis, dehydration, colonic perforation, death
      • S/S diarrhea, nausea, anorexia, abd tenderness, pain
      • Pts with + C. dificile require isolation
      • Hand washing
      • Can be carried on hands, nails, rings, shoes
  • 11. Health History (cont)
    • 3. FAMILY HISTORY—some conditions are hereditary
    • 4. Review of Systems
      • Pt general health state
      • S/S
      • Normal bowel pattern; changes in bowel habits
      • Unexplained weight loss/ gain
      • S/S of disease i.e. bloody/ tarry stools, rectal bleeding, stomach / abdominal pain
  • 12. HEALTH HISTORY (cont)
      • N/V, abdominal distention, gas
      • Work activities and work setting
      • Exposure to liver toxic substances
      • Use of alcohol
      • Recent blood transfusions/ products, dental procedures, body piercing, tattooing, IV injection with contaminated needle
      • Fatigue, stressors
  • 13. HEALTH HISTORY (CONT)
    • 5. FUNCTIONAL ASSESSMENT
    • Nutrition, activity, stressors
      • Diet History:
      • Usual foods and fluids
      • Allergies/ intolerance
      • Appetite patterns
      • Swallowing difficulty
      • Nutritional herbal supplements
    • Effect of chief complaint on usual functioning
  • 14. Cultural Influences
    • Many cultures have special dietary practices and restrictions
  • 15. Objective Data
    • Physical Exam
      • Height, Weight, Vital Signs, Body Mass Index
        • Should be normal
        • BMI should be 18.5-24.9
      • Oral Cavity
        • Moist, pink, teeth intact, proper fitting dentures
        • No lesions, inflammation, tenderness, discoloration,odor
      • Abdomen
        • Contour, shape, skin, bowel sounds
  • 16. Objective Data (cont’d)
    • Inspection
    • Auscultation
    • Percussion
    • Palpation
    • (goal is to prevent palpation from changing other assessment findings)
  • 17. Physical Assessment
    • Preparation
      • Gather equipment—examination gown, drape, examination light, gloves, stethoscope, skin-marking pen, ruler, tape measure
      • Wash your hands
      • Explain the procedure to the client
      • Ask the client to void--
      • Be sure the room is warm and draft free with proper lighting
  • 18. Physical Assessment
    • REMEMBER:
    • Ensure client privacy
    • Use universal precautions
    • Determine if abd pain is present before proceeding and examine painful area last
    • Inspection, auscultation, percussion, palpation
    • Visualize underlying structures before proceeding
    • Have client relax abd muscles by taking several deep breaths
    • Observe for nonverbal signs of pain or discomfort (facial grimacing, legs flexed at knees/hips, abd guarding w/ hands)
    • Stand on right side of client to conserve energy (liver, spleen, and right kidney assessed from clients right side)
  • 19. Inspection
    • Place client in supine position with arms at sides
    • Place small pillow under clients head and knees
    • Drape examination gown over chest, exposing abdomen
    • Place drape at symphisis pubis, covering pelvic area and legs
    • Map the abdomen-imaginary horizontal and vertical lines delineating abdominal quadrants
    • Visualize underlying structures
  • 20. Inspection (cont)
    • Note condition of skin and contour
    • Contour: Flat, rounded (convex), Sunken (concave), Distended (protuberant)
      • Distention, tumors, hernia, previous surgeries
    • Umbilicus—center of abdomen, clean and free of inflammation
    • Note abdominal pulsations and peristalsis—may be visible in thin persons or may indicate an abdominal aortic aneurysm
    • Wounds, tubes, ostomy device
  • 21. Inspection (cont)
    • Scars, striae (stretch marks), bruising, caput medusae (bluish purple swollen vein pattern extending from navel), spider angiomas, petechiae
    • Visible masses, movement, or peristalsis
    • Jaundice (icterus)—yellowing of skin and sclerae (liver and GB disease, or RBC disorders)—elevated bilirubin
  • 22.   Abdominal Auscultation
  • 23. Auscultation
    • Clockwise from RUQ
    • 2 minutes per quadrant
    • Press lightly, listen for soft clicks and gurgles every 5-15 seconds (5-30X per minute)
    • Peristalsis moves air and fluid through GI tract: normal, hyperactive, hypoactive, absent
  • 24. Bowel Sounds
    • Hyperactive—rapid, high pitched, and loud—may occur with hunger or gastroenteritis
    • Hypoactive—infrequent—may occur with paralytic ileus or after abd surgery
    • Absent—no sounds after listening for a full 5 minutes
    • Bowel obstruction—high pitched, tinkling sound proximal to obstruction and absent distal to obstruction
    • Vascular sounds or bruits (swooshing) over aorta normally not present
  • 25. Percussion/Palpation
    • Percussion: Produces sound that identifies density of organs beneath and is performed by the physician or advanced nurse practitioner
    • Palpation: Light palpation concludes the phys assessment. Painful areas palpated last.
      • Note muscle tension, rigidity, masses or expressions of pain
      • Deep palpation done only by physicians and highly skilled nurses (nurse practitioners)
    • Abdominal Girth-mark made so subsequent measurements taken at the same location
    • Rebound tenderness--? appendicitis
  • 26. Rectum and Anus
    • Inspect perianal skin for color, rashes, lesions, hemorrhoids
    • You may be asked to assist the examiner with the rectal exam
  • 27. D IAGNOSTIC TESTS
    • Use Standard precautions when obtaining specimens of body fluids, substances, or blood
  • 28. Radiographic Tests
    • Linton p. 736-737
    • Flat Plate o f t he Abdome n
      • organs, tumors, obstructions, strictures
      • Hospital gown with no metal
      • Avoid during pregnancy
    • Upper gastrointestinal series (barium swallow), small bowel series, barium enema
  • 29. Upper GI Series
      • Upper GI Series (Barium Swallow)
      • Radiographs of the esophagus, stomach, duodenum
      • oral liquid radiopaque constrast medium (barium) and x-rays
      • detect strictures, ulcers, tumors, polyps, hiatal hernias, motility problems
      • Clear liquid dinner, then NPO until test (no smoking, no gum—can stimulate gastric motility)
  • 30. Upper GI (cont)
    • Pt drinks barium and Xrays taken at specific intervals to visualize outline of organs and note passage of barium through GI tract
    • Procedure may take several hours
    • Laxative given afterward to help expel barium and prevent constipation or barium impaction
    • Drink 12 8-oz glasses of water per day for several days
    • Stool monitored, will look white X2-3 days
    • Complication: constipation with distention= barium impaction
  • 31.  
  • 32. Small Bowel Series
    • Detects abnormalities of small intestine
    • Pt drinks contrast; Films taken at 20-30 min intervals
    • Preparation same as UGI
  • 33. Lower GI Series
    • BARIUM ENEMA
    • Visualize position, movements and filling of colon
    • Detects tumors, diverticula, stenosis, obstructions, inflammation, ulcerative colitis, and polyps
    • Low residue or clear liquid diet X2 days
  • 34. Lower GI (Barium enema)
    • Laxatives, bowel-cleansing solutions (GoLYTELY) and enemas evening before
    • GoLYTELY chilled and drunk full strength—8 oz every 10 min for a total of 4L
    • Watery diarrhea X5 hours
    • Clear liquids in am or NPO after midnight
    • Lower GI contraindicated if active inflammatory disease, suspected perforation or obstruction, active GI bleeding
  • 35. Barium enema (cont)
    • Barium instilled rectally and xrays taken
    • Cramping and urge to have a BM
    • Slow deep breaths and tighten anal sphincter
    • Stools monitored after to ensure barium is passed
    • Monitor for constipation
    • Increase fluids and laxative might be ordered
    • Instructions: report abd pain, bloating, absence of stool, or rectal bleeding
  • 36. Endoscopy
    • Tube and fiberoptic system
    • View structures, remove polyps, biopsy specimens, coagulate bleeding sites
    • Must have consent
      • Esophagoscopy
      • Gastroscopy
      • Gastroduodenoscopy
    • Esophagogastroduodenoscopy [EGD]
    • Endoscopic Retrograde Cholangiopancreatography (ERCP)
      • Lower Gastrointestinal Endoscopy
      • Colonoscopy
      • Proctoscopy
      • Sigmoidoscopy
  • 37.  
  • 38.  
  • 39. Esophagogastroduodenoscopy
    • EGD visualizes esophagus, stomach, and duodenum
    • Inflammation, cancer, bleeding, injury, infection
    • Consent, preop checklist
    • NPO 8-12 hrs (prevent aspiration)
    • Sedatives diazepam (Valium) and midazolam (Versed)
    • May be given atropine sulfate to dry oral secretions
    • Local anesthetic spray or gargle inhibits gag reflex
    • Placed on left side, tube passed orally down GI tract
  • 40. EGD (cont)
    • Photos or video
    • Specimens obtained
    • Afterward: VS, pt remains on side to prevent aspiration until sedation and anesthetic wear off
    • NPO until gag reflex returns (4hrs)
    • S/S perforation: bleeding, fever, dysphagia, pain—in various areas depending on site of perforation, cyanosis
    • Sore throat for a few days
  • 41.  
  • 42.  
  • 43.  
  • 44. G astroscopy
  • 45. Endoscopic Retrograde Cholangiopancreatography
    • ERCP visualize liver, GB, and pancreas
    • Direct viewing and use of contrast
    • Endoscope passed into duodenum and dye injected—outlines pancreatic and bile ducts
    • NPO night before, Iodine allergies
    • Lab studies i.e. Prothrombin time
    • Remove dentures
  • 46. Endoscopic Retrograde Cholangiopancreatography
  • 47. ERCP (cont)
    • Afterward note RUQ pain, fever, chills—infection
    • Hypotension, tachycardia, increasing RUQ pain, n/v—perforation or onset of pancreatitis
  • 48. Lower GI Endoscopy
    • Proctosigmoidoscopy—examination of distal sigmoid colon, rectum and colon using rigid or flexible endoscope
      • Detects ulcerations, punctures, lacerations, tumors, hemorrhoids, polyps, fissures, fistulas, abscesses
      • Annual exam for 40+
      • Lower bowel must be clean
  • 49. Proctosigmoidoscopy
    • Clear liquids X24hrs; laxative night before
    • Warm tap water enema or Fleet morning of
    • No bowel prep if bleeding, severe diarrhea
    • Position left lateral knee-to-chest (straightens sigmoid colon)
    • Rigid proctoscope for rectum
    • Flexible scope above rectosigmoid junction
  • 50. Proctosigmoidoscopy
    • Biopsy specimens, polyps removed
    • Cauterization to prevent/stop bleeding
    • After procedure rest in supine position to avoid orthostatic hypotension
    • Pain and flatus from instilled air
    • Observe for signs of perforation
  • 51. Colonoscopy
    • Visualization of lining of large intestine w/ flexible endoscope
    • Biopsy, polyps removed
    • Liquid diet 24hrs before; NPO after midnight
    • Bowel Prep i.e. GoLYTELY night before
    • Laxative, suppository (Dulcolax) or enema may be needed
  • 52. Colonoscopy (cont)
    • Conscious sedation i.e. Versed—relax and ease pain
    • Left side with knees bent
    • Air instilled into colon to help visualize (pressure/discomfort)
    • Encourage relaxation/deep breathing
    • VS; Watch for vasovagal response (Hypotension and bradycardia)
    • Monitor until stable; hemorrhage or severe pain
    • Flatus and cramping for several hours
    • Blood may be present in stool if biopsy
  • 53.  
  • 54.  
  • 55.  
  • 56.  
  • 57. Gastric Analysis
    • Measures stomach secretions
    • Duodenal ulcer, gastric carcinoma, pyloric or duodenal obstruction, pernicious anemia
    • Basal cell secretion test
      • Avoid drugs that interfere w/ acid secretion
      • NPO after midnight
      • NG tube inserted and syringe used to suction
      • Wall suction; contents q15min X1 hr
      • pH and amount of gastric acid
      • Too much HCL—peptic ulcer; too little—CA or pernicious anemia
  • 58. Gastric Analysis (cont)
    • Gastric Acid stimulation test
      • Measures amount of gastric acid for 1 hr after SQ injection of histamine drug
      • If abnormal results radiographic tests or endoscopy done
    • Tubeless gastric analysis detects presence of HCL
      • Stimulant and dye administered
      • Dye reacts if HCL present and appears in urine in 2 hrs
  • 59. Occult Blood Test
    • Detects blood not visible with naked eye in vomitus, gastric secretions, and stool
    • Small sample placed on special paper and treated with a chemical
    • Observe for specific color change
    • 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)
  • 60. Stool Tests
    • Blood
    • Bile
    • Pathogenic organisms
    • Parasite ova (eggs)
    • Fecal fat
    • White blood cell count