Gastrointestinal Nursing

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  • hi sir mark can you please send me a copy of this to be use as a review material? thank you .. kindly send it to me in my email add d.toysoldier22@mail.com. God bless
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Gastrointestinal Nursing

  1. 1. Medical and Surgical NursingGastro-intestinal DisorderPrepared: Mark Fredderick Abejo RN, MAN MEDICAL AND SURGICAL NURSING Gastrointestinal System Lecturer: Mark Fredderick R. Abejo RN,MAN ______________________________________________________________________________________________ OVERVIEW OF THE STRUCTURE AND FUNCTION OF THE GASTROINTESTINAL TRACT II. MIDDLE ALIMENTARY CANAL (Absorption) A. 2nd half of duodenumI. UPPER ALIMENTARY CANAL (Digestion) B. Jejunum A. Mouth initial phase of digestion C. Ileum B. Pharynx D. 1st half of ascending colon C. Esophagus D. Stomach  complete digestion E. First half of duodenum  digestionMS 1 Abejo
  2. 2. Medical and Surgical NursingGastro-intestinal DisorderPrepared: Mark Fredderick Abejo RN, MAN  Better to have mumps at an early stage, preferably before puberty  may lead toIII. LOWER ALIMENTARY CANAL (Elimination) sterility A. 2nd half of ascending colon 3. Provide a general liquid to soft diet B. Transverse colon 4. Apply cold compress or ice pack at affected site C. Descending colon 5. Prevent complications D. Sigmoid colon  Cervicitis, oophoritis, vaginitis E. Rectum  MeningitisIV. ACCESSORY ORGANS  Orchitis  sterility A. Salivary glands – produces 1.2-1.5 L of saliva per day 1. Parotid – below and in front the ear II. APPENDECITIS – Inflammation of the vermiform appendix 2. Sublingual (located at the R. iliac region, produces WBC during fetal life) 3. Submandibular B. Vermiform appendix C. Liver – largest gland, occupies most of R hypochondriac region 1. Glison’s capsule – covers liver, transparent, brown 2. Liver lobules – functional site D. Gall bladder E. Pancreas Small intestines – initial phase of absorption Large intestines – absorption of vitamin K and complete phase of absorption Tears: lacrimal gland  lacrimal duct  lacrimal sac  punctae  nasolacrimal glandI. PAROTITIS (Endemic mumps) – inflammation of the parotid gland A. PREDISPOSING FACTORS 1. Microbial invasion 2. FECALITHS – undigested food particles (tomato, guava seeds) 3. intestinal obstruction B. SIGNS AND SYMPTOMS 1. (+) Rebound tenderness 2. Low grade fever, anorexia, nausea and vomiting 3. Pain at r iliac region 4. Diarrhea/constipation A. ETIOLOGIC AGENT 5. Tachycardia d/t pain 1. Paramyxovirus virus C. DIAGNOSTICS B. SIGNS AND SYMPTOMS 1. CBC – mild leukocytosis 1. Swollen parotid gland 2. PE – (+) rebound tenderness 2. Earache / otalgia 3. Urinalysis – (+) acetone) 3. Dysphagia 4. Fever, chills, anorexia, generalized body malaise D. NURSING MANAGEMENT PRE-OP 1. Secure informed consent C. NURSING MANAGEMENT 2. Routinary nursing care 1. Strict isolation  NPO 2. Meds as ordered  Skin preparation  Antipyretics  Avoid enema  may lead to rupture  Antibiotics  to prevent secondary infection 3. Administer medications as ordered  GENTIAN VIOLET HAS NO COOLING  antipyretics EFFECT! Cooling effect may be caused  antibiotics by vinegar!MS 2 Abejo
  3. 3. Medical and Surgical NursingGastro-intestinal DisorderPrepared: Mark Fredderick Abejo RN, MAN  NO ANALGESICS! May mask pain which A. PREDISPOSING FACTORS indicates impending rupture 1. Alcoholism 4. Monitor IO VS and Bowel sounds 2. Malnutrition 5. Avoid heat application  rupture 3. Viruses 6. Maintain patent IV line 4. Toxicity  Carbon tetrachloride E. NURSING MANAGEMENT POST-OP 5. Use of hepatotoxic agent 1. If (+) penrose drain (indicates rupture) – place patient on affected site for drainage 2. If (-), position is based on pt. comfort 3. Administer medications as ordered  Analgesics  Antibiotics  Antipyretics PRN 4. Maintain patent IV line 5. Monitor VS IO and bowel sounds (N=borborygmi)Complications: PERITONITIS AND SEPTICEMIAMC BURNEY’S POINT – incision site for appendectomy B. SIGNS AND SYMPTOMS 1. Early  Weakness and fatigueIII. LIVER CIRRHOSIS (Laennec’s cirrhosis) – loss of  Anorexia architectural design of liver leading to fat necrosis and  Nausea and vomiting scarring; can lead to liver cancer  Tea-colored urine, clay-colored stool  Decreased sexual urge  Amenorrhea  Dyspepsia – indigestion  Hepatomegaly  Jaundice  Urticaria/pruritus  Loss of pubic/axillary hair 2. Late signs  Hematologic changes  Anemia  Leucopenia  Bleeding tendencies  Endocrine changes  Spider angiomas/ telangiectasis  Caput medusae (Varicose veins radiating from the umbilicus)  Palmar erythema  Gynecomastia  GIT changes  Ascites  Bleeding esophageal varices d/t portal HPN  Neuro changes  Hepatic encephalopathy  Early  Asterixis (flapping hand tremors)MS 3 Abejo
  4. 4. Medical and Surgical NursingGastro-intestinal DisorderPrepared: Mark Fredderick Abejo RN, MAN  Late  headache, dizziness, confusion, irritability, fetor hepaticus, (ammonia-like breath), decreased LOC  hepatic coma C. DIAGNOSTICS 1. Liver enzymes  SGPT (ALT) elevated  SGOT (AST) elevated 2. Serum cholesterol  Ammonia elevated 3. Indirect bilirubin / Unconjugated bilirubin elevated 4. CBC low 5. PTT prolonged 6. Hepatic UTZ – fat necrosis of liver lobules D. NURSING MANAGEMENT A. PREDISPOSING FACTORS (na di hamak naman na 1. Enforce CBR wala nito si Rico Yan) 2. Monitor strictly VS and IO 1. Chronic alcoholism 3. Weigh pt daily and assess for pitting edema 2. Hepatobiliary disorders 4. Measure abdominal girth and notify physician 3. Drugs: 5. Restrict Na and fluids  Thiazide diuretics - Etacrynic acid Ano daw? 6. Diet high in CHO, moderate in fat, decreased  OCPs CHON, increased vitamins and minerals  Pentamide HCl (Pentam) – for AIDS 7. Meticulous skin care 4. Metabolic disturbances 8. Prevent complications  Hyperlipidemia  Ascites  Hyperparathyroidism  Administer medications as ordered 5. Obesity  Loop diuretics (Furosemide) 6. Diet: high in saturated fats  Assist in abdominal paracentesis (empty the bladder pre-op) B. S/Sx  Bleeding esophageal varices 1. Severe abdominal pain radiating from the back (left  Administer meds as ordered upper quadrant), chest and flank area accompanied  Vitamin K by DOB and aggravated by eating (so dapat naka  Pitressin (to conserve fluids) TPN to, uhm, usually an infusion vamine glucose or lipofundin, kung may pera ang patient eh di  Institute NGT decompression by gastric Nutripak; remember to keep all lines securely taped lavage (ice/cold saline solution) to prevent embolism)  Assist in mechanical decompression – insertion of sengstaken-blakemore catheter 2. Shallow respirations 3. Tachycardia and palpitations, hypertension ( 3-lumen catheter)  decompress 4. Anorexia, N&V, dyspepsia esophageal veins prevents bleeding 5. Decreased bowel sounds  Hepatic Encephalopathy 6. (+) Cullen’s sign – ecchymoses around umbilicus  Assist in mechanical ventilation and (+) Grey-turner’s spots  ecchymoses at the  Monitor VS, NVS flank area; both are indications of hemorrhage  Maintain side rails  Administer medications as ordered C. DIAGNOSTICS  Lactulose  for ammonia excretion 1. Serum amylase (very toxic to the body) and lipase elevated 2. Serum Ca low (hypocalcemia)PANCREAS D. NURSING MANAGEMENTBoth an endocrine (islets of Langerhans) and exocrine gland 1. Administer meds as ordered(Acinar cells)  Narcotic analgesics  Meperidine HCl (Demerol)  RespiratoryIV. PANCREATITIS – an acute or chronic inflammation of the Depression pancreas leading to pancreatic edema, necrosis and  DO NOT GIVE MORPHINE  can hemorrhage d/t autodigestion; idiopathic; TRYPSIN – kills cause spasm of the sphincter of Oddi pancreas  Smooth muscle relaxation  Papanarine HCl  Vasodilators  NTG  Antacids (Maalox)  H2 receptor antagonistMS 4 Abejo
  5. 5. Medical and Surgical NursingGastro-intestinal DisorderPrepared: Mark Fredderick Abejo RN, MAN  Ranitidine (Zantac) A. PREDISPOSING FACTORS  Decrease pancreatic stimulation 1. High risk group: women  Calcium gluconate 2. Obesity  Phosphate binders 3. Post-menopausal women undergoing estrogen  Amphogel therapy 2. Withhold food and fluids (need to rest the GIT) 4. Diet high in saturated fats  Nursing goal: rest the Git 5. Sedentary lifestyle  Upon d/c: high CHO and CHON, low fat 6. Neoplasm 3. Assist in TPN or hyperalimentation 7. Obstruction  Complications of TPN  Infection (so maintain strict asepsis) B. SIGNS AND SYMPTOMS  Air embolism 1. Severe abdominal pain (RUQ) radiating from the  Hyperglycemia back and chest that usually occurs at night  Hyponatremia 2. Fatty intolerance (pain after ingestion of high fat 4. Instruct pt to assume comfortable position meals) characterized by: Anorexia, nausea and  Fetal position (knee-chest position) vomiting 5. Prevent complications 3. Tea-colored urine and steatorrhea  Chronic hemorrhagic pancreatitis  Shock C. DIAGNOSTICS  Septicemia 1. Gallbladder series (Oral cholecystogram) – confirm 6. Stress management presence of gallstones  DBE, biofeedback 2. Serum lipase elevated 3. Indirect bilirubin elevatedV. CHOLECYSTITIS/CHOLELITHIASIS – inflammation of 4. Alkaline phosphatase elevated the gallbladder with gallstone formation 5. Transaminases elevated D. NURSING MGT 1. Narcotic analgesics  Meperidine HCl (Demerol) 2. Anticholinergic agents  Atropine sulfate 3. Anti-emetics  Metoclopramide (Plasil)  Phenergan 4. Diet low in fat, high CHON and CHO 5. Meticulous skin care 6. Assist in surgery: Cholecystectomy  Post-op: maintain patency of tube drain (t-tube)  Monitor for infections STOMACH  J-shaped structure  Widest section of alimentary canal especially p.c. A. Parts 1. Antrum 2. Fundus 3. Pylorus B. Valves - prevents reflux 1. cardiac – between esophagus and stomach 2. pyloric – stomach and duodenum  projectile vomiting  olive shaped belly C. Cells 1. Chief cells or zymogenic cells  Gastric amylase – digests CHO  Gastric lipase – digests fats  Pepsin – proteins  Rennin – milk and milk products 2. Parietal/augentaffin/oxyntic cells  Produces intrinsic factors  reabsorption of B12 (cyanocobalamin)  maturation of RBCsMS 5 Abejo
  6. 6. Medical and Surgical NursingGastro-intestinal DisorderPrepared: Mark Fredderick Abejo RN, MAN 10. Microbial invasion (Helicobacter pylori)  Produces HCl acid with pH of 1-2  aids in  Metronidazole digestion  SE: photosensitivity 3. Endocrine cells  Etampicillin  Secretes gastrin  stimulates HCl Acid secretion C. TYPESD. FUNCTIONS 1. Severity 1. Mechanical and chemical digestion  Acute ulcers – submucosal 2. Storage of food  Chronic ulcers – deeper underlying tissues; (+)  CHO and CHON – 1-2 hours scar formation  Fats – 2-3 hours 2. Location  Stress (Critically-ill patients)  Curling’s ulcer  Burns and trauma  hypovolemia V. PEPTIC ULCER DISEASE – erosion/excoriation of GIT ischemia  decreased resistance submucosa/mucosal lining d/t of mucosal barrier to HCl acid  Hypersecretion of acid – pepsin secretion  Decreased resistance of mucosal barrier to HCl  Cushing’s ulcer acid secretion (neutralizes acidity)  Head trauma  CVA/Stroke  increased vagal stimulation  hyperacidity  ulceration  Gastric  Duodenal Differences Gastric Ulcer Duodenal Ulcer (90%) Location Antrum Duodenal bulb Pain 30 mins-1hour p.c. 2-3 hours p.c. 12mn-3am pain Pain location Epigastrium Mid-epigastrium Pain Gaseous and burning, not Cramping and burping, character relieved by food and relieved by food and antacids antacids Gastric acid Normal Increased secretion Weight Loss Gain Hemorrhage Hematemesis Melena Complication Hemorrhage, stomach Perforation s cancer High risk 60 y.o above 20 y.o above D. DIAGNOSTICS 1. Endoscopy 2. (+) Stool occult blood 3. Gastric analysis reveals A. INCIDENCE RATE  Normal gastric acid secretion if gastric 1. Men  Increased gastric acid secretion if duodenal 2. Aggressive 4. Upper GI series – confirms ulceration B. PREDISPOSING FACTORS E. NURSING MANAGEMENT (Diet, Drugs, Surgery) 1. Heredity 1. Bland diet  non-irritating, non-spicy 2. Emotional stress  Avoid beverages and foods high in caffeine or 3. Smoking  vasoconstriction  gastric ischemia milk and milk containing products 4. Alcoholism  release of histamine  parietal cells 2. Admin meds as ordered to secrete gastrin  Antacids 5. Irregular diet  ACA – aluminum containing antacids 6. Rapid eating 7. Ulcerogenic drugs  Aluminum OH gel (Ampho gel)  Aspirin  SE: constipation, hyperphosphatemia,  Ibuprofen hypoparathyroidism  Indomethacin (SE:corneal cloudiness)  MAD – magnesium containing antacids  Steroids  Milk of magnesia  NSAIDs  SE: diarrhea 8. Foods or beverages rich in caffeine  Mg + Al preparations (Maalox)  less SE 9. Gastrin producing tumors  H2 receptor antagonists  Gastrinoma  Zollinger-Ellison’s SyndromeMS 6 Abejo
  7. 7. Medical and Surgical NursingGastro-intestinal DisorderPrepared: Mark Fredderick Abejo RN, MAN  Vagotomy (severe vagus nerve) and  Cimetidine (Tagamet) – antagonizes oral pyloroplasty  for drainage anti-coagulant, more SEs  Decrease vagal stimulation  decrease  Ranitidine (Zantac) – most common, HCl acid secretion  prevent hemorrhage fewer SE  Famotidine (Pepsid)  Give antacids and Cimetidine ONE HOUR APART  decreased antacid absorption and vise versa  Instruct client to avoid smoking because it decreases effectiveness of drug  Cytoprotective agents  Sucralfate (Carafate)  provides a paste- like substance that coats the mucosal lining  Cytotec (Misoprostol)  causes severe spasm (abortifacient)  uterine cramping  bleeding  Anticholinergic/Anti-spasmodic agents  Atropine  Propanthelene sulfate (Probanthene)  Sedatives, tranquilizers 3. Assist in surgical procedure: subtotal gastrectomy  Billroth I (removal of 1/3 of stomach)  Gastroduodenostomy  gastric stump to the duodenum F. NURSING MANAGEMENT POST OP 1. Monitor NGT output that includes:  Immediately after post-op  bright red  32-46 hours  greenish in color  48h  dark red  because of influence of HCl acid 2. Administer medications as ordered  Antimicrobials  Narcotic analgesics  Anti-emetics 3. Maintain a patent IV line 4. Monitor VS, IO, Bowel Sounds 5. Prevent complication  Hemorrhage  shock  Paralytic Ileus – most common type of complication in all abdominal surgery  Peritonitis  Billroth II  Septicemia  Gastrojejunostomy  gastric stump to  Hypokalemia jejunum  Pernicious anemia  Removal of ½ to ¾ of the stomach,  DUMPING SYNDROME (Billroth II) – rapid duodenal valve and anastomosis of gastric emptying of hypertonic food solutions; chyme stump to jejunum – food and HCl acid from stomach to jejunum  Complic: DUMPING SYNDROME with resultant hypovolemia  dizziness, diaphoresis, palpitation, tachycardia, diarrhea, weakness  Nursing management for dumping syndrome:  Provide fluids BEFORE meals  Avoid fluids/chilled solutions  Provide a small frequent feeding or 6 equal divided feeding  Diet low in CHO and sugar moderate CHON and fats  Instruct pt to lie flat on bed 15-30 minutes after each feedingMS 7 Abejo
  8. 8. Medical and Surgical NursingGastro-intestinal DisorderPrepared: Mark Fredderick Abejo RN, MANVI. DIVERTICULUM – outpouching of the intestinal mucosa particularly the sigmoid colon; DIVERTICULOSIS – multiple diverticulum; DIVERTICULITIS – inflammation of diverticula A. PREDISPOSING FACTORS 1. High risk: female 2. Congenital weakness of muscular fibers of intestines 3. Obesity 4. Stress 5. Diet: decrease in roughage B. SIGNS AND SYMPTOMS 1. Intermittent pain at LLQ and tenderness at the rectosigmoid area 2. Alternate bouts of diarrhea/constipation with blood and mucosa 3. Decreased hematocrit/hemoglobin  amnesia C. DIAGNOSTICS 1. Barium Enema – reveals inflammatory process 2. Decreased hematocrit/hemoglobin (d/t diarrhea) D. NURSING MANAGEMENT 1. Administer medications as ordered.  Bulk laxatives  Anti-cholinergics  Atropine Sulfate  Propanthelene Bromide  Antibiotics for infection 2. Provide dietary intake:  Diverticulosis – high roughage/fiber with no seeds  Diverticulitis – low fiber diet 3. Assist in surgical procedure  Bowel resection: removal of diseased portion of the bowel and creation of colostomy.MS 8 Abejo

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