Your SlideShare is downloading. ×
Nursing Care of Patients with Alterations in the GI tract
Upcoming SlideShare
Loading in...5

Thanks for flagging this SlideShare!

Oops! An error has occurred.

Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Nursing Care of Patients with Alterations in the GI tract


Published on

1 Comment
  • Slide 54. I was under the impression that Duodenal ulcers are relieved with food. Gastric Ulcers are aggravated by food.
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

No notes for slide
  • This is a child.***Acquired umbilical hernia may be seen if patient is 50 pounds above ideal body weight**With complaint of abd pain, nausea, vomiting and hypoactive BS consider intestinal obstruction
  • Minimally invasive commonly used**Will have an NG tube post-op—usually dark brown (old blood) for first 8 hours—just document**Keep head of bed elevated 30 degrees in the immediate post-op periodPost opSoft foods for one week, stay on antireflux meds, no driving, report fever > 101, nausea vomiting or bloating. Walk daily **otify provider if develops signs of a cold**Gas bloat is common—avoid gasy foods and eat small frequent meals.
  • A Colostomy is when only part of the large intestine is removed whereas an Ileostomy involves the removal of the whole of the large intestine and often the rectum as well. The distinguishing feature between a colostomy and an ileostomy is that in a colostomy, the stoma is made out of the large bowel and the stoma is therefore a little bigger than for an ileostomy where the stoma is made from the small intestine. Both colostomies and ileostomies can either be permanent or temporary. A Urostomy is when the bladder is bypassed or removed
  • Historically, the standard operation for ulcerative colitis has been removal of the entire colon, rectum, and anus. This operation is called a proctocolectomy (Illustration A) and may be performed in one or more stages. It cures the disease and removes all risk of developing cancer in the colon or rectum. However, this operation requires creation of a Brooke ileostomy (bringing the end of the remaining bowel through the abdomen wall, Illustration B) and chronic use of an appliance on the abdominal wall to collect waste from the bowel
  • Transcript

    • 1. Nursing Care of Patients with Alterations in the GI tract
      C. Cummings RN,EdD
    • 2. A & P of GI system
    • 3. GI tract
      Hollow muscular tube, lumen surrounded by 4 tissue layers:
      Mucosa- innermost, thin layer of smooth muscle and exocrine cells
      Submucosa- connective tissue
      Muscularis- smooth muscle
      Serosa- outermost, connective tissue
    • 4. GI tract
      Secretion- secretes HCL acid, digestive enzymes
      Digestion- mechanical and chemical, food is broken down to chyme
      Absorption- from GI tract to blood supply
    • 5. GI tract
      Nerve Supply
      Intrinsic stimulation by myenteric plexus in smooth muscle and submucosa plexus in inner layer
      Autonomic system- Parasympathetic stimulation by vagus nerve, connects with intrinsic system
      Vagus-stimulates motor and secretory activity and relaxes spinchters
      Sympathetic system- thoracic and lumbar splanchnic nerves slows movement, inhibits secretions and contracts spinchters
    • 6. Nerves of GI tract
    • 7. Mouth
      Mastication, taste, begin movement
      Glands produce 1 L of saliva/day
      Saliva contains mucin and salivary amylase with begins to break down CHO
      Oral preparatory phase- food is softened, made into a “bolus” and tongue moves to the back of the mouth
      Oral phase- tongue presses bolus against hard palate, elevates the larynx and forces the food bolus to the pharynx, triggering swallowing
      Pharyngeal phase- soft palate elevates and seals nasal cavity, inhibits respirations and allows esophagus to open
      Esophageal phase- is when bolus enter at cricopharyngeal juncture, peristalsis now takes food to the stomach
      All this takes about 10 seconds !
    • 8. Esophagus
      Canal about 10 in long, passes through the center of the diaphragm
      Upper end is the upper esophageal sphincter, at rest it is closed to prevent air from entering the esophagus
      Lower end is the lower esophageal sphincter, it sits at the gastroesophageal junction, at rest it is closed to prevent reflux of gastric contents, this is where GERD occurs
      Function- to propel food and fluids and prevent reflux
      Mucous is secreted to move the food along
      Cardiac sphincter of the stomach opens to allow the food to enter
    • 9. Stomach
      Digestive and endocrine organ, in midline and LUQ
      Four regions:
      Cardia- narrow part that is distal to the gastroesophageal junction
      Fundus- left above the GE junction
      Body or corpus- largest area
      Antrum- pylorus, is the distal portion and is separated from the duodenum by the pyloric sphincter, prevents backflow from the duodenum
      Surface is covered in rugae or folds and have smooth muscle for motility
      Has intrinsic and extrinsic nerves
    • 10. Stomach
      • Function:
      • 11. Parietal cells secrete HCL acid and intrinsic factor, which absorbs B 12, without it, what anemia can occur?
      • 12. Chief cells secrete Pepsinogenpepsin
      • 13. Cephalic phase- sight, smell and taste of food, regulated by vagus, begin secretory and contractile activity
      • 14. Gastric phase- G cells in the antrum secrete gastrin, which causes HCL and pepsinogen to be released. HCL changes pepsinogen to pepsin, which digest proteins. Mucous and Bicarb are secreted to protect the stomach wall
      • 15. Intestinal phase- chyme produced empties into the duodenum and causes distention, this produces secretin, which stops the acid production and gastric motility !
    • Stomach
    • 16. Small Intestine
      Longest portion of the GI tract, 16-19 ft.
      Made up of 3 sections:
      Duodenum- first 12” and is attached to the pylorus. The CVD and pancreatic duct join to form the ampulla of Vater and empty into the duodenum at the duodenal papilla. This surrounded by a muscle, called the Sphincter of Oddi
      Jejunum- middle 8 ft portion
      Ileum- last 8-12 ft. The ileocecal valve separates the ileum form the cecum of the large intestine
      Inner lining is made up of intestinal villi and folds of mucosa and submucosa for digestion.
    • 17. Small Intestine
      3 main functions:
      Movement- mixing and peristalsis
      Moves chyme by segmental contractions and mixes with enzymes
      Digestion- enzymes produced by the intestinal cells make:
      Enterokinase, peptidases, lactase, maltase and sucrase
      Help to digest, CHO, proteins and lipids
      Absorption- absorbs most of the nutrients from food, takes 3-10 hours for the contents to pass through
      Major organ for absorption
    • 18. Small intestine
    • 19. Large Intestine
      Ileocecal valve to the anus, 5-6’, lined with columnar epithelium tha thas absorptive and mucous cells.
      Cecum- is the beginning, dilated pouch like structure, appendix is attached to the base
      Colon has 4 divisions:
      Ascending, transverse, descending and sigmoid
      Rectum- last 6-8” to the sphincter muscles and anus
    • 20. Large Intestine
      Movement- segmental contractions, to allow time for the water and electrolytes to be absorbed
      Absorption- absorbs most of water and electrolytes, reduces fluid volume of chyme and creates a more solid mass for elimination
      Elimination- 3-4 strong peristaltic contraction /day triggered by colonic distention in proximal large intestine to propel contents to rectum, until urge to defecate.
    • 21. Nursing Assessment
      Family history- GI disorders, cancer
      Personal history- what kinds of things?
      Diet history- anorexia, dyspepsia- what is that? What should you question them on for diet history?
      Health history- diarrhea, constipation, # and color of stools, change in wt. or appetite
      Abdominal pain-
      P- precipitating
      Q-quality- how intense, severe, type
      R-region or radiation
      S- severity scale- 0-10
      T-timing- when did it first occur, duration and frequency
    • 22. Physical Assessment
      Inspection- skin, symmetry, rashes, lesions, scars
      Auscultation- all four quadrants, normally heard in 5-15 seconds, normal, hypoactive or hyperactive, listen 1 full minute. What is borborygmus? Why would bruits be heard? Why would there not be bowel sounds heard?
      Percussion- tympanic- air filled, dull- organ
      Palpation- light and deep palpation, masses, tenderness, look for guarding
    • 23. Lab tests
      CBC- anemia
      Oncofetal antigens- CA19-9 and CEA, used to monitor for cancer in the GI tract
      Ca- decreased in malabsorption
      K – decreased with vomiting, diarrhea
      Xylose absorption- decreased indicates possible malabsorption in the small intesting
      Stool for Occult blood
      Stool for ova and parasite- infection
      Stool for fecal fat- increased with Crohn’s disease and malabsorption
    • 24. Radiology
      Abdominal films- air in bowel and masses
      Upper GI and small bowel- pharynx to duodenojejunal junction, barium swallow and SBFT
      NPO 8 hours before, drink barium, then lie, stand and turn in multiple directions to view movement of barium
      SBFT- drink more barium and view passage
      After drink fluids to pass barium
      Barium enema
      Large intestine, done for obstructions, masses, not done is perforated colon or fistulas
      Only clear liquids for 12-24 hours prior, NPO, given bowel prep like Golytely
      Insert rectal catheter with a balloon and give 500-1500 ml of barium and hold
      Can be uncomfortable, must take a laxative after
    • 25. UGI exam
    • 26. Diagnostic Tests
      EGD- esophagogastroduodenoscopy
      Visualize esophagus to duodenum, NPO prior, given versed and fentanyl, maybe cetacaine to inhibit gag reflex, pass tube and visualize structures, can take biopsies
      Gag reflex may not return for 1-2 hours after, so no eating or drinking until then
      Colonoscopy- large bowel, take biopsies and remove polyps, have a bowel prep prior, given versed and fentanyl prior; Capsule enteroscopy is now done to visualize, apply a data recorder to the abdomen and the patient swallows the capsule
      Proctosigmoidoscopy- like colonoscopy, only a rigid tube, less invasive and does not require the cleansing of the colonoscopy
    • 27. Colonoscopy
    • 28. Case Study
      72 year old male admitted with chest pain and nausea. He states that he awakens in the night with pain in his chest and nausea.
      What would you do first to evaluate his condition?
      What diseases could he have?
      What kind of lab work would you like to obtain?
      What past medical history do you need?
    • 29. Case Study
      Your patient starts to have hematemesis.
      What does this mean?
      Is this life-threatening?
      What interventions should be done?
      What could have caused this condition?
    • 30. Case Study
      It is determined that your patient can be treated non-surgically. What medications would be given? (should have 3)
      What type of teaching would be done for prevention?
      If he needed surgery, what could have been done?
    • 31. Esophageal Problems
      GERD- gastroesophageal reflux disease
      Reflux causes esophageal mucosa to be irritated by the effects of gastric and duodenal contents, results in inflammation
      Inappropriate relaxation of the LES, sphincter tone is decreased
      Irritation from refluxed material
      Delayed gastric emptying, gastric volume or intra-abdominal pressure is increased
      Abnormal esophageal clearance
    • 32. GERD
      Refluxed material has a pH of 1.5-2, whereas the esophagus normally has a pH of 6-8 erosive esophagitis, once inflammed, the mucosa can’t eliminate the material as quickly. This leads to increased blood flow and more erosion. Gastric acid and Pepsin cause the tissue injury.
      Can lead to Barrett’s epithelium- thicker, but can be cancerous, can also cause hemorrhage, aspiration pneumonia, asthma, laryngitis and dental deterioration.
    • 33. GERD
    • 34. GERD
      Physical Manifestations:
      Dyspepsia- heartburn, substernal or retrosternal burning that moves up and down in wavelike fashion, pain may radiate to neck or jaw or back, worsens when bends over, strains or lies on their back, occurs after meals and last 1-2 hours, helped by fluids and staying upright
      Regurgitation- food entering throat without nausea, watch for cough, hoarseness or wheezing
      Hypersalivation- water brash in response to reflux, fluid without sour or bitter taste
    • 35. GERD
      Physical Manifestations
      Dysphagia and Odynophagia- difficulty swallowing, esophagus may be narrowed by inflammation or tumor, odynophagia- means what?
      Chronic cough, mostly at night
      Atypical chest pain
      Belching and flatulence or bloating
      Endoscopy, 24 hour ambulatory pH monitoring- pass a small tube into esophagus and monitor pH levels
    • 36. GERD
      Nursing Diagnoses:
      What diagnoses would apply to these patients?
      Diet therapy- what type of dietary modifications would be appropriate?
      Certain foods decrease LES pressure- chocolate, fat and mints. Also, smoking and alcohol decrease
      Spicy foods irritate the esophagus and Carbonated can increase gastric pressure
    • 37. GERD
      Lifestyle changes:
      How should they sleep?
      What things increase intra-abdominal pressure?
      Drug therapy:
      Goal is to inhibit gastric acid secretion, accelerate gastric emptying and protect the gastric mucosa
      Elevate the pH and deactivate pepsin, good for heartburn, take 1 hour before and 2-3 hr after a meal
      Name 2 antacids.
    • 38. GERD
      Drug therapy:
      Histamine Receptor Antagonists
      Decrease acid, help promote healing of the esophagus
      Name 2 common ones sold OTC (generic ends in “dine”)
      Proton Pump Inhibitors
      Main treatment for GERD, long acting inhibition of gastric acid secretions by inhibiting protom pump of parietal cell, can reduce by 90%/ day
      Name 2 proton pump inhibitors (generic ends in “zole”)
    • 39. GERD
      Other therapies:
      Consider medications that may lower LES pressure- oral contraceptives, anticholinergics, sedative, tranquilizers, B-adrenergic agonists, nitrates and Ca channel blockers
      Prokinetic drugs- for emptying and peristalsis- metoclopramide (reglan)
      Enteryx procedure- spongy material in LES to tighten it Stretta procedure- radiofrequency energy through needles to inhibit the vagus nerve
      Laparoscopic Nissen Fundoplication
      Angelchik esophageal antireflux- anchors the LES in the abdomen to increase sphincter pressure
    • 40. Hiatal Hernia
      Protrusion of stomach through the esophagus
      Sliding or Rolling hernias
      Symptoms are similar to GERD patient
      Nonsurgical management is like GERD
      Lap Nissen Fundoplication- reinforces the LES, wraps a portion of the stomach around the distal esophagus to anchor it
      Post op- risk for bleeding, infection and respiratory complications
      Have an NGT, begin PO once BS return
      Watch for gas-bloat syndrome and air swallowing
    • 41.
    • 42.
    • 43.
    • 44.
    • 45. Nursing Diagnosis: GERD
      Impaired Nutrition: less than body requirements
      What things can be done to improve their intake and decrease pain?
      What would be the expected outcomes?
      How would you monitor their progress?
      Acute Pain r/t irritation of the esophagus
      What interventions can be performed?
      Risk for aspiration r/t reflux of gastric contents
      How can you determine that this does not occur?
    • 46. Peptic Ulcer Disease
      Mucosal lesion of the stomach or duodenum
      Peptic can be gastric or duodenal
      PUD- gastric mucosal defenses become impaired and they can no longer protect the epithelium from acid and pepsin
      Three main types of ulcers:
    • 47. Peptic Ulcers
    • 48. Gastric Ulcers
      Gastric mucosa is protected by mucous and bicarbonate that maintain a normal pH on the gastric tissue and protects it from acid
      Gastromucosal prostaglandins increase the barrier’s resistance to ulceration by producing mucous
      Integrity is improved by a rich blood supply to the mucosa
      If there is a break in the mucosal barrier, HCL acid damages the epithelium. Gastric ulcers result from back-diffusion of acid or dysfunction of the pyloric sphincter.
    • 49. Gastric Ulcers
      If the pyloric sphincter doesn’t function, bile backs up into the stomach, produces H+ ion back diffusion and  mucosal inflammation
      Toxic agents and bile destroy the lipid plasma membrane of the mucosa. Delayed gastric emptying also affects. What drug can be given to improve emptying?
      Gastric Ulcers are deep and penetrating and usually are in the lesser curvature of the stomach, near the pylorus
    • 50. Duodenal Ulcers
      Occur in the first portion of the duodenum.
      Deep lesions that penetrate through the mucosa and submucosa into the muscle layer. The floor of the ulcer consists of a necrotic area on granulation tissue and surrounded by fibrosis
      High gastric acid secretion, pH levels are low for long periods
      Protein rich meals, calcium and vagal excitation stimulate acid secretion
      Hypersecretion, rapid emptying of food from stomach reduces the buffering effect of food and delivers a large acid bolus to the duodenum
      Inhibitory secretory mechanisms and pancreatic secretion may be insufficient to control the acid
      Many patients have H. pylori infection. H. pylori produces urease changes urea to ammonia, H+ ions released contribute to damage
    • 51.
    • 52. Stress Ulcers
      Acute gastric mucosal lesions occurring after and acute medical crisis or trauma
      Associated with head injury, major surgery, burns, respiratory failure, shock and sepsis
      Bleeding is the principle manifestation
      Multifocal areas often in the proximal portion of the stomach and duodenum
      Usually elevated HCL acid levels and hospital stay longer than 11 days
    • 53. Complications of Ulcers
      15-25% of patients with PUD, most serious complication
      Most often with gastric ulcers and elderly
      After initial bleed, 40% have a recurrence if untreated, especially if H. pylori untreated and no H2 antagonist
      Have Hematemesis- bleeding at or above the duodenojejunal junction
      Smaller amounts of bleeding are seen as melena, more often seen in duodenal ulcers, stool may appear black.
    • 54. Complications of Ulcers
      Gastric or duodenal may perforate or bleed
      Stomach or duodenal contents can leak into the abdomen, acid peptic juice, bile and pancreatic juice empty through the anterior wall of the stomach into the peritoneal cavity
      Sudden, sharp pain in midepigastric region and spread over the abdomen
      Amount of pain correlates with the amount and type of GI contents spilled
      Abdomen is tender, rigid and boardlike, go into a fetal position to decrease tension of abdomen
      Chemical peritonitis, bacterial septicemia and hypovolemic shock follow paralytic ileus and possible death
    • 55. Perforated ulcer
    • 56. Complications of Ulcers
      Pyloric obstruction
      Small number of patients, vomiting caused by stasis and gastric dilation
      Obstruction occurs at the pylorus and is caused by scarring, edema, and/or inflammation
      Gastric outlet obstruction abdominal bloating, nausea and vomiting
      May go into metabolic alkalosis from loss of large quantities of acid gastric juice (H+ and Cl-)
      Hypokalemia may result from the vomiting
    • 57. Complications of Ulcers
      Intractable disease
      Disease may recur throughout life, stressors, inability to adhere to therapy, no longer responds to management
      Use of NSAID’s- break down the mucosal barrier and disrupt the protection by COX inhibition. Cause the depletion of prostaglandins, have a high rate of recurrence
      Drugs such as Theophylline, corticosteroids and caffeine stimulate HCL acid production
      H pylori infection is transmitted person to person
      50% of people with PUD have a first or second line relative with PUD, usually the same type of ulcer
    • 58. Physical Manifestations
      Epigastric tenderness, midline between the umbilicus and xiphoid process
      May begin as hyperactive BS, then diminish if perforation
      Dyspepsia- discomfort around the epigastrium, sharp, burning or gnawing
      Gastric- occurs in upper epigastrium with localization to the left of the midline and may be relieved by food
      Duodenal- located to the right of the epigastrium, occurs 90 min to 3 hours after eating and awaken at night, may be aggravated by spicy foods, onions, alcohol, caffeine and ASA, NSAIDS
    • 59. Physical Manifestations
      Vomiting may occur
      Appetite is maintained, unless pyloric obstruction occurs
      Fluid volume deficit, if bleeding, take orthostatic BPs
      Watch for Hematemesis and melena
      Monitor H & H
      Dx- barium swallow and EGD
      Test for H. pylori is IgG serologic testing and urea breath testing
    • 60. Nursing Diagnoses
      Name 5 diagnoses r/t PUD
      What would be an expected outcome for this disorder?
    • 61. Nursing Interventions
      Drug Therapy
      Goals: Provide pain relief, eradicate H. pylori, heal ulcerations, prevent recurrence
      Eliminate H. pylori- triple treatment:
      Bismuth product (pepto-bismol) or a a proton pump inhibitor and two antibiotics (metronidazole (Flagyl) and tetracycline or amoxicillin)
      May have to take medications 4 x’s/day for 14 days and often they don’t complete the series
    • 62. Nursing Interventions
      Drug therapy:
      Hyposecretory drugs- reduce gastric acid secretions
      Antisecretory agents- proton pump inhibitors, “zole” ending, suppress H, K-ATP ase enzyme system of gastric acid production, can be given IV or PO
      H2 receptor antagonists- block histamine-stimulated gastric secretions, “dine” ending
      Prostaglandin analogues- reduce gastric acid secretion and enhance gastric mucosal resistance to tissue injury, Misoprostol (Cytotec) helps prevent NSAID induced ulcers, does cause uterine contraction and can not be given to pregnant women
    • 63. Nursing Interventions
      Buffer gastric acid and prevent formation of pepsin, heal duodenal ulcers
      Aluminum hydroxides and magnesium hydroxide, may affect those with renal impairment
      Take 2 hours after meals to reduce the H+ion load
      Calcium carbonate (TUMS) is an antacid, but it triggers gastrin release and causes a rebound acid secretion
      Antacids can interact with other drugs- tetracycline, dilantin, also may have a high sodium content
      Mucosal Barrier fortifiers- sucralfate (Carafate) supplies a protect coating by forming a complex with proteins, binds with bile acids and pepsin, should be given on an empty stomach and not within 1 hour of eating or taking antacids
    • 64. Nursing Interventions
      Diet therapy
      Bland diet may help to relieve symptoms
      Food may help to neutralize acids, rebound may follow when more acid is released
      Avoid foods that stimulate gastric acid release
      They are??
      Yoga for stress relief, herbals, such as licorice and vitamins may help
    • 65. Gastrointestinal Bleeding
      What would be a nursing diagnosis for GI Bleeding?
      What would be the expected outcome and how would you know that this was met?
    • 66. GI bleeding
    • 67. Gastrointestinal Bleeding
      Hypovolemia Management
      Monitor vital signs and I&O, assess for bleeding and vomiting, monitor CBC
      Fluid and electrolyte replacement is necessary, usually NSS or LR, may give PRBC’s or FFP
      Watch for signs of shock, what are they??
      Bleeding reduction
      Monitor labs, insert and NGT to decompress the stomach, give an H2 blocker, may need gastric lavage, what is that??
    • 68. Nursing Interventions for GI bleeding
      Endoscopic therapy
      EGD, can do:
      cautery on the bleeding sites
      inject a sclerosing agent with diluted epipherine
      Laser therapy
      Clip the bleeding vessel
      Somastatin Analogue- Sandostatin may be used to suppress gastric acid secretion on parietal and chief cells, vasoconstricts the splanchnic arteries which reduce hemorrhage
    • 69. Surgical management of GI bleeding
      MIG- minimally invasive gastrectomy- laproscopic to remove chronic gastric ulcer or treat hemorrhage, make several small incisions, may partially remove the stomach and/or vagotomy to control acid secretion
      Gastroenterostomy- creates a passage between the body of the stomach and jejunum, reduces motor activity in the pyloroduodenal area, diverts acid, a vagotomy may be done with it to decrease secretion. Can do truncal, selective or proximal. Billroth I- connect to duodenum, Billroth II connects to jejunum
      Pyloroplasty- widens the exit of the pylorus and empties the stomach
    • 70. Billroth 1
    • 71. Postop care for GI surgery
      NGT management
      Monitor for complications of:
      Dumping syndrome- vasomotor symptoms, rapid emptying of gastric contents into the small intestine, shifts fluid into the gut and cause abdominal distention, 30 min after eating have vertigo, tachycardia, syncope, sweating, pallor, palpitations. 90 min later have excessive amount of insulin released, this dizziness, palpitations, diaphoresis and confusion
      Should eat smaller amounts, take less liquid with food, high protein and fat, low CHO diet, sandostatin may be given and pectin with food
    • 72. Postop Care of GI surgery
      Reflux gastropathy- bile reflux, when pylorus is bypassed, bile in stomach and have abdominal discomfort and vomiting
      Delayed gastric emptying- usually resolves in 1 week, edema at the anastomosis or adhesions may occur, hypokalemia, hypoproteinemia and hyponatremia may also cause
      Afferent loop syndrome- duodenal loop is partially obstructed, pancreatic and biliary secretions fill the intestinal loop, it becomes distended painful contractions, bloating and pain 20-60 min after eating
    • 73. Post op GI surgery
      Recurrent ulceration- occurs in 5% of patients, may have ulcers at the anastomosis
      Nutritional management:
      Deficiencies of B12, folic acid and iron
      Impaired Ca metabolism and reduced absorption of Ca and vitamin D
      Shortage of intrinsic factor, r/t the resection and rapid emptying of the food
       pernicious anemia- weak, anemic, atrophic glossitis- beefy shiny tongue
      Give back B12 and folic acid
    • 74. Pernicious anemia
    • 75. Irritable Bowel Syndrome
      Chronic GI disorder, with chronic or recurrent diarrhea, constipation, abdominal pain and bloating
      Spastic colon, impairment of the motor/sensory function diarrhea alternating with constipation
      Usually begin as a young adult
      Stress, anxiety and familial factors may predispose patient
    • 76. IBS
      History of bowel pattern
      Manning criteria- abdominal pain relieved by defection, abdominal distention, sensation of incomplete evacuation of stool, presence of mucus with the stool
      Pain in LLQ and cramps, may be tenderness and air in bowels
      Dx- flexible sigmoidoscopy or colonoscopy if >40
      Barium enema
    • 77. IBS
      Diet therapy- limit caffeine, alcohol, beverages with sorbitol, take in fiber and bulk, 30-40 gm/day
      Drug therapy:
      Bulk forming laxatives (Metamucil)
      antidiarrheals (loperamide)
      anticholinergics (bentyl)
      antidepressants (elavil)
      5-HT4 agonists(Zelnorm) for prokinetic activity, imitates serotonin to stimulate peristalsis
      Stress management- relaxation techniques
    • 78. Nursing Diagnoses
      Constipation r/t low residue diet and stress
      What can be done to manage this?
      Diarrhea r/t increased motility of intestines
      How can this be corrected or treated?
      What can be done to correct constipation and impaction?
      What role may analgesics play in constipation?
    • 79. Colorectal Cancer
      95% are adenocarcinomas, most come from adenomatous polyps
      2/3 occur in rectosigmoid region
      Can metastasize through blood and lymph, liver most common site with 15-30% spread there, can also go to the lungs, brain, bones and adrenals
      May form fistulas into bladder and vagina
      Genetics- autosomal dominant disorder- familial adenomatous polyposis only 1%, 100% malignant, usually starting at age 20. Also, hereditary nonpolyposis colorectal cancer- autosomal dominant, 10% of cancers, develop by age 45
    • 80. Colorectal cancer
      75% have no known cause
      Age is a risk factor
      Dietary- decreased bowel emptying time, foods with carcinogens- red meat, fatty food, fried meats and fish, concentrated sweets
      High fat diet increases bile acid secretion and anaerobic bacteria
      Irritable bowel diseases
      Third most common malignancy
    • 81. Colorectal Cancer
    • 82. Colorectal cancer
      Rectal bleeding, anemia and change in stool
      Gas pains, cramping or incomplete evacuation
      Hematochezia- bright red blood when in rectum
      Tumors can grow large when in upper abdomen, mostly liquid stool, more pain when in lower
      Tests- stool for occult blood, CEA, barium enema, CT of abdomen
      Colonoscopy or sigmoidoscopy
    • 83. Colorectal cancer
      Nursing Diagnoses- Name 4 diagnoses, associated with colorectal cancer
      What would be the expected outcomes?
    • 84. Colorectal cancer
      Nonsurgical management:
      Duke’s staging classification
      A- tumor has penetrated into, but not through the bowel wall
      B- tumor has penetrated through the bowel wall
      C-tumor has penetrated through the bowel wall and there is lymph node involvement
      D- tumor has metastasized to distant sites
      Radiation therapy
      Drug therapy-chemotherapy IV 5-FU and leucovorin, side effects are diarrhea, mucositis, leucopenia and mouth ulcers
      Eloxatin, Camptosar, Avastin are also being used, along with monoclonal antibodies- cetuximab
    • 85. Colorectal cancer
      Surgical management:
      Colon resection- removal of tumor and lymph nodes
      Colectomy- colon removal
      Abdominal perineal resection- removes sigmoid colon, rectum and anus, colostomy is performed
      Colostomies may be ascending, descending, sigmoid, transverse or double barreled
      Stool returned depends on the site of the colostomy
    • 86. Colostomy
    • 87. Colorectal cancer
      Postoperative Care:
      Colostomy management
      What types of nursing diagnoses may accompany this procedure?
      How should the stoma appear?
      Report any bleeding, breakdown of the sutures from the wall and signs of ischemia or necrosis
      Wound care management- JP drains, monitor for infection
      Fluid volume deficit and electrolyte imbalance
    • 88. Colorectal cancer
      Colostomy care- what kinds of things should be covered?
      Dietary measures to control stool and gas, what would they be?
      Psychological adjustment to the colostomy, what diagnosis relates to this?
      Grief and family coping- what resources may be needed?
      Genetic testing if familial type
    • 89. Intestinal Obstruction
      Partial or complete
      Mechanical- bowel is physically obstructed by adhesions, tumors
      Nonmechanical- paralytic ileus or adynamic ileus, neuromuscular distrubance- slow movement or backup
      Contents accumulate at or above the obstruction distention, peristalsis increases to aid movement, stimulates more secretions more distention edema of the bowel, increased capillary permeability
    • 90. Intestinal Obstruction
      Plasma leaks into the peritoneal cavity and trapped fluid decreases the absorption of fluid and electrolytes into the vascular space reduced blood volume and electrolyte imbalances, can  hypovolemic shock
      Can also lead to metabolic alkalosis if high and there is a loss of gastric acid, if low, metabolic acidosis occurs with the loss of alkaline fluids
      Bacterial peritonitis and septic shock can also occur from the release of endotoxins
    • 91. Intestinal obstruction
    • 92.
    • 93. Intestinal Obstruction
      Adhesions account for 45-60%, r/t scar tissue
      Intussusception- telescoping bowel and volvulus- twisting of the bowel
      Paralytic ileus- decreased peristalsis from trauma, toxin or autonomic, can result from surgery, MI’s, rib fracture, pneumonia, peritonitis and vascular insufficiency from heart failure or shock
    • 94. Intestinal Obstruction
      History of symptoms and occurrence
      Abdominal pain and cramping
      Obstipation, vomiting with brown and foul smelling
      Borborygni above the obstruction, then absent
      Abdominal distention and tympanic abdomen
      Abdominal films and CT of abdomen
      WBC elevated in some cases
    • 95. Intestinal Obstruction
      Nonsurgical management:
      NGT to decompress to LCS
      Nasointestinal tubes- Miller-Abbott, mercury balloons and migrate down the intestine by peristalsis, don’t irrigate with fluid- it will increase edema at the obstruction
      Fluid and electrolyte replacement- NPO, give NSS or LR, replace K
      Pain control- not normally given opioids, mask pain and peritonitis
      Antibiotics if suspect perforation
      Surgical management:
      Exploratory laparotomy
    • 96. Case Study
      24 year old female admitted with frequent bloody diarrhea stools, weight loss and anemia.
      What do you suspect?
      What labwork should you do?
      What treatment may be needed?
    • 97. Case Study
      Your patient tells you that the diarrhea has been occurring for months.
      How do you differentiate between U.C. and Crohn’s disease?
      What may be her treatment options?
    • 98. Case Study
      How do you help your patient decide about a colostomy?
      If she does want a colostomy, what type of teaching needs to be done?
    • 99. Chronic Inflammatory Bowel Disease
      Ulcerative Colitis and Crohn’s
      Ulcerative Colitis:
      Remissions and exacerbations
      Loose stools with blood and mucous 10-20/day
      Poor absorption of nutrients and thickening of the colon wall
      Abdominal distention and cramping
      Complications are: hemorrhage, perforation, fistulas and nutritional deficiencies
      May be familial tendency, inflammation r/t response to normal flora
    • 100. Ulcerative Colitis
    • 101. Chronic Inflammatory Bowel Disease
      Crohn’s disease
      Terminal ileum, patching involvement through all layers of the bowel
      Deep fissures and ulcers occur
      5-8 loose stools/day, rarely bloody
      Complications are:
      Fistulas, nutritional deficiencies
      Cause is thought to be mycobacterium paratuberculosis, genetic predisposition
    • 102. Crohn’s Disease
      Crohn's story
    • 103. Ulcerative Colitis
      Abdominal pain, bloody diarrhea, tenesmus- uncontrolled straining
      Dx- barium enema
      Nursing Diagnoses:
      Diarrhea r/t inflammation of the bowel
      Acute and chronic pain
      Imbalance nutrition: less than body requirements
      Disturbed body image
    • 104. Ulcerative Colitis
      Diarrhea management-
      Drugs- salicylate compounds- Sulfasalazine (Azulfidine) inhibits prostaglandins to reduce inflammation, also use Asacol, Pentasa
      Corticosteroids- Prednisone to decrease edema
      Immunosuppressive- cyclosporine
      Monoclonal antibody- Remicade neutralizes the activity of tumor necrosis factor and prevents toxic megacolon
    • 105. Ulcerative Colitis
      Diet therapy:
      NPO at first, then TPN, may have low fiber or low residue, what foods would be included?
      Surgical management:
      Total Proctocolectomy with permanent Ileostomy
      Total colectomy with a continent ileostomy
      Total colectomy with ileoanal anastomosis and ileoanal reservoir or pouch
      Postop- teaching for ostomy, pain control and monitoring for GI bleeding and fluid volume deficit
    • 106.
    • 107.
    • 108. Crohn’s Disease
      Aggravated by bacterial infection, inflammation and smoking
      History of fever, abdominal pain and loose stools, weight loss
      Steatorrhea is common- fatty stools
      Fistulas may occur between bladder and vagina
      Drug therapy- same as UC, except may take metronidazole if fistulas and imuran as an immunosuppressant
      Diet therapy- may be on TPN, supplements like ensure, vivonex
    • 109. Crohn’s Disease
      Monitor for fistulas- infections, skin problems, malnutrition, fluid and electrolyte imbalances
      Fluid and electrolyte therapy- what would this entail?
      Name one antidiarrheal.
      Surgical management:
      Bowel resections
      Fistula repairs
      Ileostomies may also be required to rest the bowel or repair damaged areas.