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  • 1. GASTROINTESTINAL DISORDERS C Washington RN, MSNEd
  • 2. Relationship of GI System to Other Systems
    • Neurological
    • Parasympathetic nervous system increases peristalasis
    • Sympathetic nervous system decreases peristalsis
    • Many cranial nerves are essential for eating
    • Spinal cord probems may affect bowel & bladder control
  • 3. Relationship of GI System to Other System
    • Endocrine
    • Thyroid regulates metabolism
    • Pancreas is an endocrine organ producing insulin, glucagons, and digestive enzymes
  • 4. Relationship of GI System to Other System
    • Respiratory
    • A distended abdomen can impringe on respiratory structures
    • Chronic lung disease with
    • overinflation of lungs can
    • push diaphragm farther
    • into abdomen
  • 5. Relationship of GI System to Other System
    • Cardiovascular
    • CV system transports nutrients and wastes
    • Abdominal aorta is located in the abdominal cavity
    • Right sided heart problem can result in fluid accumulation in abdomen (ascites)
  • 6. Relationship of GI System to Other Systems
    • Muscular
    • Abdominal muscles protect and support abdominal contents
    • Skeletal
    • Osteoporesis and arthritis are complications of ulcerative colitis
  • 7. Relationship of GI System to Other Systems
    • Integumentary
    • Skin-color changes such as jaundice may indicate liver disease
    • Nutritional deficits or
    • malabsorption problems
    • can affect growth of skin,
    • hair & nails
  • 8. Relationship of GI System to Other Systems
    • Digestive
    • Digestive system is found in adominal cavity
    • Problems with digestive system may affect other abdominal structures
  • 9. Relationship of GI System to Other Systems
    • Urinary
    • Urinary structures are located in the abdomen
    • Problems with the urinary system may affect other abdominal structures
    • Lymphatic
    • The spleen is a lymphatic structure
    • Reproductive
    • Pregnancy displaces abdominal contents
  • 10. GI Assessment
    • Ask about
    • Weight changes
    • Diet
    • Fevers
    • Dizziness
    • Inspect:
    • Orientation, facial expression
    • Posture
    • Nutritional status
    • Measure:
    • Ht, wt, vital signs
  • 11. GI Assessment
    • Integumentary:
    • Ask about
    • Changes in skin, hair, & nails
    • Rashes, itching, lesions
    • Inspect
    • Skin, hair & nails for changes in color & texture, lesions, and edema/ascites
    • Palpate:
    • Skin turgor
  • 12. GI Assessment
    • Head & Neck: Ask about
    • Thyroid disease, neck masses, recent infections
    • Eyes: Ask about
    • Vision changes
    • Inspect: Neck masses
    • Palpate: Thyroid gland, lymph nodes
    • Inspect eyes: edema,
    • color of sclera, retinal
    • changes
  • 13. GI Assessment Assessment
    • Ear, Nose, & Throat:
    • Ask about
    • Trouble swallowing
    • Sore throat
    • Dizziness
    • Last dental exam
    • Inspect: mouth, throat,
    • teeth
    • Test:
    • Cranial nerves 1, 7, 9, 10, 12
  • 14. GI Assessment
    • Respiratory: Ask about
    • Breathing problems
    • SOB
    • History of COPD
    • Measure:
    • Respiratory rate & depth
    • Auscultate:
    • Breath sounds
  • 15. GI Assessment
    • Cardiovascular:
    • Ask about history of
    • CVD
    • HTN
    • CHF
    • Palpate:
    • Pulses: check for thrills, edema
    • Auscultate:
    • Heart sounds
  • 16. GI Assessment
    • Genitourinary:
    • Ask about
    • Color of urine
    • Urinary burning, frequency, hesitancy
    • Inspect:
    • Color of urine, external genitalia for lesions or discharge
    • Palpate:
    • Bladder for distention, kidneys, prostate
    • CVA tenderness
  • 17. GI Assessment
    • Reproductive:
    • Ask about
    • History of STDs
    • Women: LMP, vaginal discharge
    • Men: Prostate problems, Penile discharge
    • Women
    • Pelvic exam
    • Men
    • Rectal exam
  • 18. GI Assessment
    • Musculoskeletal:
    • Ask about
    • History of fractures
    • Joint pain
    • Weakness
    • Inspect
    • Spinal curves, joints, ROM
    • Palpate
    • Muscle strength
  • 19. GI Assessment
    • Neurological:
    • Ask about
    • Alcohol use
    • Numbness
    • Back problems
    • Loss of bowel/bladder control
    • Test:
    • Sensation
    • DTR
  • 20. GI Assessment
    • Endocrine:
    • Ask about
    • History of diabetes
    • Thyroid problems
    • Lymphatic/Hematologic
    • Ask about
    • Food Allergies
    • Infection
    • Sickle Cell Anemia
    • Palpate:
    • Lymph nodes, spleen
  • 21. GI: Key Terms
    • Borborygmus
    • Dumping symdrome
    • Dyspepsia
    • Gastroparesis
    • Hematemesis
    • Helicobacter pylori
    • Intussusception
    • leukoplakia
  • 22. GI: Key Terms
    • McBurney’s point
    • Melena
    • Peritonitis
    • Pyrosis
    • Rebound tenderness
    • Steatorrhea
    • Volvulus obstruction
    • Lavage/gavage
  • 23. GI System Assessment: Health History
    • Description of present
    • illness or chief complaint
    • Onset, course, duration
    • Location
    • Alleviating or precipitating factors
  • 24. GI System Assessment: Health History
    • Risk Factors
    • Low fiber diet
    • Smoking
    • Alcohol consumption
    • Inactivity
    • Stress
    • Familial predisposition to Gi disorders
  • 25. Assessment of GI System
    • Pain
    • Location, quality,duration
    • Abdomen, epigastric, indigestion
    • Before or after meals
    • Alleviated by position changes, OTC med, home remedies
  • 26. Assesment of GI System
    • Examination of abdomen
    • Color, contour, distention, previous scars
    • Bowel sounds
    • Tympany or dullness
    • Tenderness or masses
    • Elimination pattern
    • Constipation
    • Diarrhea
    • rectal bleeding
    • laxative use
  • 27. Assessment of GI System
    • Nutritional issues
    • Loss of appetite
    • Anorexia
    • Intake and output
    • Difficulty swallowing
    • Nausea & vomiting
  • 28. Assessment of GI System
    • Associated
    • manifestations or
    • complaints
    • Flatus
    • Bleching
    • Heartburn
    • Dark urine
    • Jaundice
    • Excessive wt gain or loss
  • 29. Critical Thinking Challenge
    • 50 yr old female c/o RUQ abd pain/cramping x 2 days
    • Travels extensively with job
    • Eats at restaurants several times weekly
    • Symptoms began 1-2 hrs after eating dinner of fried or spicy foods.
  • 30. Critical Thinking Challenge
    • About what specific areas of the history should you seek further information or clarification?
    • What physical assessment findings would you be most likely to find during the abdominal examination
  • 31. Physical Exam
    • Imperative that the nurse takes a systematic approach to the examination
    • Order is inspection, auscultation, percussion and palpation
  • 32. Inspection
    • Watch the patient first
      • Guarding of abdomen, posture, movement, scars
      • Inspect oral mucosa, tongue, pharynx, soft palate, uvula, tonsils and anterior and posterior pillars
      • Inspect abdomen, ask about any scars
  • 33. Auscultation
    • Listen in all 4 quadrants for 2-5 minutes each
    • Assess aorta and renal arteries
  • 34. Palpation
    • Should start with the mouth and throat area
    • Palpate abdomen in a systematic pattern, from light palpation to deeper palpation
    • Palpate the liver, spleen, kidneys, and aorta
  • 35. Physical Assessment
    • Work with the client prior to starting to find a comfortable position
  • 36. Physical Assessment
    • Have the patient tilt their head back slightly and then have the patient say “ahhh.”
      • Allows for inspection of the uvula, tonsils, soft palate and anterior and posterior pillars
  • 37. Physical Assessment
    • While inspecting the abdomen
      • Look at the contour of the abdomen both obliquely and straight on prior to touching
      • Look for masses, fluid waves or changed in contour
      • Look for scars and readdress any questions from the history to assist the patient in recalling further information
  • 38. Auscultation
    • A ticklish patient may not tolerate the touch of the stethoscope
      • Have the patient place the stethoscope where the nurse directs
    • Check bowel sounds in all 4 quadrants for 2-5 minutes
  • 39. Auscultation
    • Figure 44.6 Sites for vascular sounds.
  • 40. Palpation
    • Palpate the abdomen in a systematic pattern
    • Move from light palpation to deeper palpation
  • 41. Palpation
    • In patients who are sensitive, even light palpation will cause muscle resistance. In this case attempt to assist the patient to relax by having them bend their knees, or have the patient place their hand under the nurses and then press down
  • 42. Palpation
    • In clients with a complaint of abdominal pain, palpation of the area the patient has identified as painful should be done last
    • Palpate the liver edge, spleen, right and left kidneys
  • 43. Palpation
    • Figure 44.9 Palpation of kidneys. Source: Cheryl Wraa
  • 44. Physical Examination Findings
    • Rebound tenderness: greater when pressure is released than applied
    • A reliable sign of peritoneal inflammation
      • Gently press into the abdomen and then release pressure
      • Start away from painful area and work it
  • 45. Physical Examination Findings
    • Murphy’s sign: positive with inflammation of the gallbladder
      • Stand on the right side of the bed
      • Place a hand flat on the abdomen, fingertips just below right costal margin
      • Have the patient gently inhale
      • As the liver and gallbladder descend into the fingertips, pain will be present where there is inflammation
  • 46. Diagnostic Blood & Urine Test
    • Stomach
    • Helicobacter pylori
    • Biliary system
    • Total bilirubin
    • Alkaline phosphatase
    • Pancreas
    • Amylase
    • Lipase
    • Calcium
  • 47. Diagnostic Blood & Urine Test
    • Urine
    • Bilirubin
    • Amylase
    • Urobilinogen
    • Intestine
    • Total protein
    • Lactose tolerance test
  • 48. Radiologic Tests
    • UGI series
    • Barium enema
    • Ultrasonography
    • Computed Tomography
    • Radionuclide imaging
    • Cholecystography
    • Cholangiography
    • Gastric analysis
    • Schilling test
    • EGD
    • ERCP
    • Colonscopy
  • 49. Barium Swallow Series
    • Detects abnormalities of
    • the esophagus, stomach,
    • and/or small intestines
    • NPO MN
    • No smoking, chewing, or eating before procedure
    • Post-procedure
    • Increase fluids
    • Laxative
    • Monitor stools for chalky-white appearance as barium is eliminated
  • 50. Barium Enema Study
    • Examines large intestine
    • Rectal insertion of barium enema
    • Cl liq diet
    • Laxative
    • NPO MN
    • Cleansing enema in am
    • Post-Procedure
    • Increase fluids
    • Laxative
    • Monitor stools for barium
    • Notify MD if no BM in 48 hrs
  • 51. Critical Thinking Challenge
    • A patient underwent an UGI series 2 days ago and is scheduled for a barium enema today.
    • What assessment data does the nurse need to obtain before sending the patient to radiology?
  • 52. Endoscopic Studies: Lower GI
    • Colonscopy
    • Visualize lining of small intestine
    • Biopsies
    • Polypectomies
    • Anoscopy
    • Examine anal canal
    • Sigmoidoscopy
    • Examine rectum
    • Sigmoid colon
    • Biopsies
    • polypectomies
  • 53. Endoscopic Studies: Lower GI Nursing Interventions
    • Preparation
    • Clear liquid diet
    • Osmotic laxative (fleets phospho soda/Golytely)
    • NPO MN
    • Versed IV for conscious sedation
    • Post-procedure
    • Bedrest until alert
    • Monitor for perforation, bleeding
  • 54. Critical Thinking Challenge
    • 55 yr old male scheduled for a colonoscopy
    • “ My aunt died of colon cancer 5 yrs ago
    • He is very worried about the procedure
    • States he is not sure his wife will be able to leave work to pick him up after the test.
  • 55. Critical Thinking Challenge
    • What should you respond to his comments about his worries and his aunt’s death?
    • What would you tell him about what he can expect during the procedure?
    • What discharge instructions will he need after the procedure is finished?
  • 56. Critical Thinking Challenge
    • When can you discharge him?
    • Will he be able to drive home alone?
    • Why or why not
  • 57. Endoscopic Studies: Upper GI
    • EGD
    • Visualize gastric wall, spincters, doudenum
    • Tissue biopsies
    • NPO MN
    • Versed conscious sedation
    • Post-Procedure
    • Bedrest until alert
    • Monitor for perforation
    • NPO until gag reflex returns
    • Observe for dysphagia
  • 58. Analysis of GI Secretions
    • Stool analysis
    • fecal urobilinogen, nitrates, bacteria, parasites
    • Inspect stool for color, consistency, occult blood
    • Do not refrigerate
    • Send specimen promptly to lab
  • 59. Analysis of GI Secretions
    • Gastric Analysis
    • NGT to aspirate gastric contents
    • Measures amt of acid secreted in stomach
    • NPO MN
    • Antacids & H2-receptor antagonist stopped 24-48 hrs prior
    • Avoid smoking/chewing tobacco 6 hrs before
  • 60. Analysis of GI Secretions
    • Gastric Analysis: Used to diagnose
    • Pernicious anemia-lack of stomach acid
    • Zollinger-Ellison Syndrome-high levels of gastrin produced, excess hydrochloric acid
    • Pre/post acid suppressing therapy to eval adequacy of drug dose
  • 61. Evaluation of the Gallbladder
    • Cholecystogram
    • Examines gallbladder
    • Dx liver, gallbladder disorders (gallstones & tumors)
    • Check for allergy
    • High-fat diet lunch, low fat dinner
    • 12 hrs prior take contrast medium tablets
    • NPO
  • 62. Evaluation of the Liver
    • Percutaneous Transhepatic Cholangiogram
    • X-rays bile ducts inside & outside liver
    • Contrast medium injected into bowel ducts
    • Dx blockage causing juandice and pancreatitis
    • Check for allergy
  • 63. Evaluation of the Liver
    • Percutaneous Transhepatic Cholangiogram
    • Post-procedure: monitor
    • Bleeding
    • Infection (sepsis)
    • Inflammation of the bile ducts
  • 64. Diagnostic Procedures
    • Abdominal X-ray
    • KUB
    • Flat plate
    • Assess urinary system
    • Blockage of intestines
    • Assist in diagnosis of:
    • abd pain
    • Distention
    • unexplained nausea
  • 65. Liver Biopsy
    • Supine or left lateral position
    • Performed under fluoroscopy
    • Informed consent
    • Check PT, PTT, INR, platelet count
    • NPO MN
    • Post-procedure
    • Right side 1-2 hrs
    • Monitor bleeding, pneumothorax, infection
  • 66. Paracentesis
    • Removal of abdominal fluid in peritoneum
    • Treat new onset ascites/ascites unknown reason
    • Ascites: c/o fever, painful abd distension, peritoneal irritation, hypotension, encephalopathy, sepsis, difficulty breathing
    • Malignant ascites
    • Peritoneal dialysis with suspected peritonitis
  • 67. Paracentesis
    • Prep
    • Informed consent
    • Void prior to procedure
    • Measure weight
    • Measure abd girth
    • Post
    • Measure weight
    • Measure abd girth
    • Supine 2-4 hours
    • Observe for hypovolemia, shock, infection
  • 68. Liver Function Test
    • Alkaline phosphatase: tumor marker
    • Prothrombin time: prolonged
    • Blood ammonia: assess protein by products
    • Elevated in liver disease (SGOT, SGPT, LDH, AST, ALT)
    • Cholesterol: increase with liver damage/decreased with liver damage
    • Bilirubin: monitor jaundice
  • 69. Gastrointestinal Intubation
    • NGT=decompress stomach
    • Salem sump=continous or intermittent suction-prevents trauma to stomach lining
    • Miller-Abbot=intestinal suction-reposition hourly for movement in intestines
    • Sengstaken-Blakemore=treatment of esophageal varices (ICU-rebleeding, pneumonia, respiratory obstruction)
  • 70. NGT Feeding/Suction
    • Feeding
    • Assess placement before feeding & q 4 hrs with continous feeding
    • Semi-fowler’s
    • Check residual: hold feeding if over 100ml
    • Nose & mouth care
  • 71. NGT Feeding/Suction
    • Suction
    • Drain stomach contents
    • Should see a decrease in volume of drainage
  • 72. Feeding Tubes
    • Gastrostomt/Jejunostomy
    • tube
    • Sutured in place
    • Skin care important
    • Long term feeding
    • Percutaneous Endoscopic
    • Gastrostomy (PEG)
    • No need to check placement
    • Long term feeding
    • Preferred over GT because of ease of insertion and care
  • 73. Total Parental Nutrition (TPN)
    • IV administration hyperosmotic solution
    • 3-6 times osmolarity of blood
    • Glucose
    • Nitrogen
    • Lipids
    • Electrolytes
    • Other nutrients
  • 74. Total Parental Nutrition (TPN)
    • Used when nutrition can’t be met by enteral route
    • Central line (for rapid dilution & blood flow)
    • GI disorders
    • Disorders that impair absorption of nutrients
    • GI tract dysfunction
  • 75. Total Parental Nutrition
    • CXR immediately after central line insertion
    • Assess wt, electrolytes, blood glucose
    • Maintain sterile technique during dressing changes
    • Maintain infusion rate-don’t increase or decrease without order (hyper/hypoglycemia
  • 76. Total Parental Nutrition
    • Weight daily
    • Change all tubings/filter daily
    • Follow protocol for discontinuing TPN
    • Turn off TPN 1 full minute before drawing all labs
    • Ensure safe medication administration with regard to compatibility
  • 77. Total Parental Nutrition
    • Monitor for complications
    • Infection-change filter/tubing every bottle
    • Hypoglycemia or hyperglycemia-BS q 4 hrs
    • If behind admin rate don’t attempt to catch up
    • Fluid overload
  • 78. Total Parental Nutrition
    • Air embolism-never open subclavian central line to air (less change with PICC line and multi lumen setups
    • Pneumothorax during insertion of central line
  • 79. GI Health Problems
    • Gastroesophageal reflux disease (GERD)
    • Peptic ulcer disease
    • Hiatal hernia
    • Crohn’s disease
    • Ulcerative colitis
    • Diverticular disease
    • Intestional obstruction
    • Appendicitis
    • Peritonitis
    • Neoplasms of GI tract

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