Liquid diet for 12 to 24 hr before procedure, NPO for 6 to 8 hr before procedure
Bowel cleansing routine
Assessment of vital signs every 15 min
If polypectomy or tissue biopsy, blood possible in stool
Endoscopic examination of the rectum and sigmoid colon
Liquid diet 24 hr before procedure
Cleansing enema, laxative
Position client on left side in the knee-chest posture.
Mild gas pain and flatulence from air instilled into the rectum during the examination
If biopsy was done, a small amount of bleeding possible
Measurement of the hydrochloric acid and pepsin content for evaluation of aggressive gastric and duodenal disorders (Zollinger-Ellison syndrome)
Basal gastric secretion and gastric acid stimulation test
NPO for 12 hr before test
Nasogastric tube insertion
To remove gas and fluids from the stomach or intestines (decompression).
To diagnose GI motility and to obtain gastric secretions for analysis.
To relieve and treat obstructions or bleeding within the GI tract.
Gastrointestinal Intubation cont……
To provide a means for nutrition ( gavage feeding), hydration, and medication when the oral route is not possible or is contraindicated.
To promote healing after esophageal, gastric, or intestinal surgery by preventing distension of the GI tract and strain on the suture lines .
Gastrointestinal Intubation cont….
To remove toxic toxic substances (lavage) that have been ingested either accidentally or intentionally and to provide for irrigation.
General Nursing Care
Assessing tube placement must be assessed after insertion and maintenance. Assessing tube placement is essential to prevent complications or death from incorrect tube placement.
Nasogastric tube placement must be assessed after insertion and then intermittently to ensure that it is in the correct position and not in the lungs (most common), esophagus, pleural space, or brain.
Interventions for Clients with Oral Cavity Problems
Painful, single or multiple ulcerations of the oral mucosa that appear as inflammation and denudation of the oral mucosa, impairing the protective lining of the mouth
Dry, painful mouth, open ulcerations, predisposing the client to infection
Commonly found on the buccal mucosa, soft palate, oropharyngeal mucosa, and lateral and ventral areas of the tongue
If candidiasis, white plaquelike lesions on the tongue; when wiped away, red sore tissue appears
Soft-bristled toothbrush or disposable foam swabs to stimulate gums and clean the oral cavity are recommended.
Frequent rinsing of the mouth with solution, not commercial mouthwash
Mouth care every 2 hr and twice during the night, if stomatitis is not controlled
Antibiotics such as tetracycline syrup and minocycline (swish and swallow)
Antifungals such as nystatin oral suspension (swish and swallow)
Intravenous acyclovir for immunocompromised clients with herpes simplex stomatitis
Drug Therapy (Continued)
Anti-inflammatory agents and immune modulators
Symptomatic topical agents such as gargle or mouthwash
Slowly developing changes in the oral mucous membranes characterized by thickened, white, firmly attached patches that are slightly raised and sharply circumscribed.
Most common oral lesion among adults
Oral hairy leukoplakia is an early manifestation of HIV infection and is highly correlated with the progression from HIV to AIDS.
Red, velvety mucosal lesions on the surface of the oral mucosa
Higher degree of malignant transformation in erythroplakia than in leukoplakia
Commonly found on the floor of the mouth, tongue, palate, and mandibular mucosa
Squamous Cell Carcinoma
Most common oral malignancy: can be found on the lips, tongue, buccal mucosa, and oropharynx
Highly associated with aging, tobacco use, and alcohol ingestion
Tumor, node, metastasis classification system for tumors of the lips and oral cavity
Basal Cell Carcinoma
Occurs primarily on the lips
Lesion is asymptomatic and resembles a raised scab; evolves into ulcer with a raised pearly border
Aggressively involves the skin of the face, but does not metastasize
Major etiologic factor is exposure to sunlight
Malignant lesion arising in blood vessels
Raised purple nodule or plaque
Found on the hard palate, gums, tongue, or tonsils
Most often associated with AIDS
Risk for Ineffective Airway Clearance
Excessive tumor involvement and tenacious secretions can inhibit airway patency.
Nursing measures for maintaining airway patency is primary focus.
Assessment should focus on client’s dyspnea, inability to cough effectively, or inability to swallow.
Decannulation accomplished after postoperative edema resolves
Impaired Oral Mucous Membrane
Oral cavity lesions can be treated by surgical excision, by nonsurgical treatments such as radiation or chemotherapy, or by a combination of treatments (multimodal therapy)
Maintaining airway patency
Protecting the operative area
Inflammation of a salivary gland, caused by infectious agents, irradiation, or immunologic disorders
Application of warm compresses
Massage of the gland
Use of saliva substitute
Use of sialagogues
Xerostomia results in very dry mouth caused by severe reduction in the flow of saliva.
Little can be done during the course of radiation, but frequent sips of water and frequent mouth care, especially before meals, are the most effective interventions.
Postirradiation Sialadenitis (Continued)
Saliva substitutes can be used after the course of radiation therapy is complete.
Salivary Gland Tumors
Relatively rare among oral tumors
Often associated with radiation of the head and neck areas
Assessment: ability to wrinkle brow, raise eyebrows, squeeze eyes shut, wrinkle nose, pucker lips, puff out cheeks, and grimace or smile
Treatment of choice: surgical excision of the parotid gland
Interventions for Clients with Esophageal Problems
Gastroesophageal Reflux Disease
Occurs as a result of the backward flow (reflux) of gastrointestinal contents into the esophagus
Reflux esophagitis characterized by acute symptoms of inflammation
Gastroesophageal Reflux Disease (Continued)
Esophageal reflux occurs when gastric volume or intra-abdominal pressure is elevated, the sphincter tone of the lower esophageal sphincter is decreased, or it is inappropriately relaxed.
Hypersalivation or water brash
Dysphagia and odynophagia
Others manifestations: chronic cough, asthma, atypical chest pain, eructation (belching), flatulence, bloating, after eating, nausea and vomiting
24-hr ambulatory pH monitoring
Lifestyle changes: elevate head of bed 6 in. for sleep, sleep in left lateral decubitus position; stop smoking and alcohol consumption; reduce weight; wear nonbinding clothing; refrain from lifting heavy objects, straining, or working in a bent-over posture
Antacids elevate the level of the gastric contents.
Uterine contraction is a significant adverse effect of misoprostol.
Antacids buffer gastric acid and prevent the formation of pepsin; they are effective in accelerating the healing of duodenal ulcers.
The most widely used preparations are mixtures of aluminum hydroxide and magnesium hydroxide, such as Mylanta or Maalox.
For optimal effect, take about 2 hr after meals.
Antacids can interact with certain drugs and interfere with their effectiveness.
Mucosal Barrier Fortifiers
Sucralfate (Carafate) is a sulfonated disaccharide that forms complexes with proteins at the base of a peptic ulcer; this protective coat prevents further digestive action of both acid and pepsin.
Mucosal Barrier Fortifiers (Continued)
Sucralfate binds bile acids and pepsins, reducing injury from these substances.
The main side effect of sucralfate is constipation.
Diet therapy may be directed toward neutralizing acid and reducing hypermotility.
A bland, nonirritating diet is recommended during the acute symptomatic phase.
Avoid bedtime snacks.
Avoid alcohol and tobacco.
Complementary and Alternative Therapies
Kundalini yoga techniques are being studied to see how they can help manage gastrointestinal disorders.
Certain herbs are thought to heal inflamed tissue and increase blood flow to the gastric mucosa.
Other substances include zinc, vitamin C, essential fatty acids, acidophilus, vitamins E and A, and glutamine.
Potential for Gastrointestinal Bleeding
Monitoring and early recognition of complications (critical to the successful management of PUD).
Preventing and/or managing bleeding, perforation, and gastric outlet obstruction.
Possible surgical treatment.
Monitor vital signs and observe for fluid loss from bleeding and vomiting.
Monitor serum electrolytes.
Insert two large-bore peripheral IV catheters to replace both fluids and blood lost.
Hypovolemia Management (Continued)
Volume replacement with isotonic crystalloid solutions should be started immediately.
Blood products may be ordered to expand volume and correct abnormalities in the CBC.
Orthostatic hypotension is common in clients with decreased fluid volume.
Bleeding Reduction: Gastrointestinal
Endoscopic therapy can assist in achieving hemostasis.
Acid-suppressive agents are used to stabilize the clot by raising the pH level of gastric contents.
Upper gastrointestinal bleeding may require the health care provider to insert nasogastric tube.
Saline lavage requires the insertion of a large-bore nasogastric tube.
Perforation is managed by immediately replacing fluid, blood, and electrolytes.
Keeping the client NPO
Pyloric obstruction related to edema, and spasm generally responds to medical therapy.
Preoperative care: insertion of a nasogastric tube.
A simple gastroenterostomy permits neutralization of gastric acid.
Surgical Management (Continued)
Vagotomy eliminates the acid-secreting stimulus to gastric cells and decreases the response of parietal cells.
Pyloroplasty facilitates emptying of stomach contents.
Monitor the nasogastric tube.
Monitor for postoperative complications:
Dumping syndrome (constellation of vasomotor symptoms after eating)
Postoperative Care (Continued)
Delayed gastric emptying (usually resolved within 1 week)
Afferent loop syndrome may occur after a Billroth II resection.
Recurrent ulceration occurs in about 5% of clients.
Deficiencies of vitamin B 12 , folic acid, and iron; impaired calcium metabolism; and reduced absorption of calcium and vitamin D develop as a result of partial removal of the stomach.
These problems are caused by a shortage of intrinsic factor.
Monitor CBC for signs of megaloblastic anemia and leukopenia.
Zollinger-Ellison syndrome is manifested by upper gastrointestinal tract ulceration, increased gastric acid secretion, and the presence of a non–beta cell islet tumor of the pancreas, called a gastrinoma.
Clients may complain of peptic ulcer disease symptoms and may have diarrhea and/or steatorrhea.
The aim of therapy is to suppress acid secretion to control the client’s symptoms.
Drugs of choice are:
If medical therapy fails, a vagotomy and pyloroplasty to supplement pharmacologic means of controlling hypersecretion may be performed.
Gastric carcinoma refers to malignant neoplasms in the stomach.
Clinical manifestations: early gastric cancer may be asymptomatic, but indigestion and abdominal discomfort are the most common symptoms.
Gastric Carcinoma (Continued)
Signs of distant metastasis include:
Sister Mary Joseph nodes
The role of chemotherapy in gastric cancer remains uncertain.
The use of this treatment is limited because the disease is often widely disseminated.
Preoperative care is similar to that provided for general anesthesia and abdominal surgery.
Operative procedures include subtotal and total gastrectomy.
Surgical Management (Continued)
Interventions for Clients with Malnutrition and Obesity
Nutritional Standards to Promote Health
Dietary recommendations, food guide pyramids for adequate nutrition
Nutritional assessment includes:
Measurement of height and weight
Assessment of body fat (body mass index)
Marasmus calorie malnutrition, in which body fat and protein are wasted, serum proteins are often preserved
Other laboratory tests
Imbalanced Nutrition: Less Than Body Requirements
Partial enteral nutrition
Total enteral nutrition
Candidates for total enteral nutrition
Types of enteral products for nutrients
Methods of administration of total enteral nutrition