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  1. 1. Gastrointestinal Assessment<br />Physical Exam<br />1<br />
  2. 2. Health History and Clinical Manifestations<br />1. Complete history focusing on GI dysfunction.<br /><ul><li>Pain - major symptom of GI disease
  3. 3. Note the character, duration, pattern, frequency, location, distribution and time of the pain.
  4. 4. Aggravating factors – meals, rest, defecation, and vascular disorders may directly affect the pain
  5. 5. Indigestion - upper abdominal discomfort or distress associated with eating.
  6. 6. Most common symptom of patients with GI dysfunction.
  7. 7. Gastric peristaltic movements may or may not relieve the pain
  8. 8. Can result form disturbed nervous system control of the GI tract or elsewhere in the body
  9. 9. Fatty foods tend to cause discomfort as well as coarse vegetable and highly seasoned foods.</li></li></ul><li>
  10. 10. Health History and Clinical Manifestations<br /><ul><li>Intestinal gas – accumulation of gas in the GI tract.
  11. 11. May result to belching or flatulence
  12. 12. Complain of bloating, distention or being “full of gas”
  13. 13. Excessive flatulence – maybe symptom of gallbladder disease or food intolerance.
  14. 14. Nausea and vomiting - Another major symptom of GI disease.
  15. 15. Vomiting (emesis) is usually preceded by nausea
  16. 16. Can be triggered by odors, activity or food intake.
  17. 17. Vomitus may vary in color and content
  18. 18. May contain undigested food particles or blood (hematemesis)
  19. 19. When vomiting occurs soon after hemorrhage – bright red
  20. 20. If blood has been retained in the stomach – coffee-ground appearance because of digestive enzymes
  21. 21. Hematemesis – Vomiting of blood</li></li></ul><li>Health History and Clinical Manifestations<br /><ul><li>Changes in bowel habits – a signal of colon disease</li></ul>Diarrhea – abnormal increase in frequency and liquidity of the stool or daily stool weight or volume.<br /><ul><li>Occurs when contents move so rapidly through the intestine and colon with inadequate time for absorption of GI contents.
  22. 22. Sometimes associated with abdominal pain or cramping and nausea and vomiting</li></li></ul><li>Health History and Clinical Manifestations<br />Constipation – decrease in the frequency of stool or stools that are hard, dry and smaller volume than normal.<br />- May be associated with anal discomfort and rectal bleeding<br /><ul><li>Stool characteristics
  23. 23. Normally light to dark brown
  24. 24. Indigestion of certain foods and medications can change the appearance of stool.</li></li></ul><li>Foods and Medications That Alter Stool Color<br />COLOR<br />Dark brown<br />Green<br />Red<br />Dark red or brown<br />Yellow<br />Black<br />Milky white<br />ALTERING SUBSTANCES<br />Meat protein<br />Spinach<br />Carrots and beets<br />Cocoa<br />Senna<br />Bismuth,iron,licorice & charcoal<br />Barium <br />
  25. 25. Health History and Clinical Manifestations<br /><ul><li>Blood in the stool
  26. 26. Melena – black tarry stool is produced if blood is shed into the upper GI tract.
  27. 27. Blood entering the lower portion of the GIT or passing rapidly through it will appear bright or dark red.
  28. 28. Lower rectal or anal bleeding if there is streaking of blood on the surface of the stool or noted on toilet tissue</li></li></ul><li>Health History and Clinical Manifestations<br /><ul><li>Other Common abnormalities in stool characteristics
  29. 29. Bulky, greasy, foamy stools foul in odor, gray with a silvery sheen.
  30. 30. Light gray or clay-colored stool-caused by absence of urobilin
  31. 31. Stool with mucus threads or pus
  32. 32. Small, dry, rock-hard mass called scybala, streaked with blood from rectal trauma
  33. 33. Loose, watery stool that may or may not be streaked with blood.</li></li></ul><li>Health History and Clinical Manifestations<br />Previous GI disease<br />Past and current medication use<br />Previous treatment or surgery<br />Dietary history<br />Use of tobacco and alcohol – type and amount<br />Changes in appetite or eating patterns<br />Unexplained weight gain or loss over the past year<br />Psychosocial factors – Stress and anxiety<br />Spiritual factors -Religion<br />Cultural factors – Beliefs and Tradition<br />
  34. 34. sequence<br />Inspection<br />Auscultation<br />Percussion<br />Palpation <br />11<br />
  35. 35. PHYSICAL ASSESSMENT<br />Mouth<br /><ul><li>Inspection of the mouth, tongue, buccal mucosa, teeth and gums
  36. 36. Ulcers, nodules, swellling, discoloration and inflammation are noted
  37. 37. Dentures should be removed.</li></li></ul><li>
  38. 38. PHYSICAL ASSESSMENT<br />2. Abdomen<br /> a. Inspection - note for skin changes and scars from previous surgery, contour and symmetry, localized bulging, distention or peristaltic waves.<br /> b. Auscultation - notes the character, location and frequency of bowel sounds.<br /> - Assess bowel sounds in all four quadrants using the diaphragm of the stethoscope (high pitched and gurgling sounds)<br /> - Bowel sounds (Borborygmi sound)<br /> NORMAL – Sounds heard every 5-20 seconds<br /> HYPOACTIVE – 1-2 sounds in 2 minutes<br /> HYPERACTIVE – 5-6 sounds heard in less than 30 seconds<br /> ABSENT – no sound in 3-5 minutes<br />
  39. 39.
  40. 40. PHYSICAL ASSESSMENT<br /> c. Palpation <br /> > Light palpation may identify areas of tenderness or swelling<br /> > Deep palpation may identify masses in any four quadrants.<br /> > Identify direct and rebound tenderness…HOW?<br /> > Identify findings in relation to surface landmarks (xiphoid process, costal margins, ASIS, symphysis pubis) and four quadrants (RUQ,RLQ,LUQ,LLQ)<br /> d. Percussion - Note for tympany or dullness<br />
  41. 41. PHYSICAL ASSESSMENT<br />3. Anus and Perineal Area<br /> > Inspect and palpate areas of excoriation or rash, fissures or fistula openings or external hemorrhoids<br /> > Digital rectal examination may note areas of tenderness or mass.<br />
  42. 42. DIAGNOSTIC ASSESSMENT<br />Blood Tests<br />Stool Tests<br />Breath Tests<br />Abdominal Ultrasonography<br />DNA Testing<br />Imaging Studies<br />Computed Tomography (CT) Scan<br />Magnetic Resonance Imaging (MRI)<br />Scintigraphy<br />Endoscopic Procedures<br />Manometry and Electrophysiologic Studies<br />Gastric Analysis, Gastric Acid Stimulation Test and pH Monitoring<br />Laparoscopy (Peritoneoscopy)<br />
  43. 43. GENERAL NURSING INTERVENTIONS FOR PATIENTS HAVING GI DIAGNOSTIC ASSESSMENT<br />Provide general information about a healthy diet and nutritional factors that can cause GI disturbances<br />Providing information about the test and the activities required of the patient<br />Alleviating anxiety<br />Help patient cope with discomfort<br />Encourage family members to offer emotional support to patient during the test<br />Assess for adequate hydration before, during and immediately after the procedure and provide education about maintenance of hydration<br />
  44. 44. DIAGNOSTIC ASSESSMENT<br />Blood Tests<br /><ul><li>CBC, CEA, Liver function tests, serum cholesterol, and triglycerides
  45. 45. May reveal alterations in basal metabolic function and severity of a disorder</li></ul>Stool Tests<br /><ul><li>Inspect specimen for consistency and color, occult blood (Hematest), fecal urobilinogen, fat, nitrogen, parasites, pathogens, food residues and other substances.
  46. 46. Quantitative 24-72-hour collections must be kept refrigerated until taken to the laboratory
  47. 47. What stool test is most frequently used in cancer screening programs and for early cancer detection?</li></li></ul><li>DIAGNOSTIC ASSESSMENT<br /><ul><li>False positive HEMATEST may result if patient eat
  48. 48. Rare meat, liver, poultry, turnips, broccoli, cauliflower, melons, salmon, sardines or horseradish within 7 days before testing
  49. 49. Medications: aspirin, ibuprofen, indomethacin, colchicine, corticosteroids, cancer chemotherapeutic agents and anticoagulants
  50. 50. False negative result: ingestion of Vit. C supplements or food</li></li></ul><li>DIAGNOSTIC ASSESSMENT<br /><ul><li>Other occult blood tests that yield more specific and more sensitive readings include:
  51. 51. Hematest II SENSA
  52. 52. HemoQuant</li></ul> OTHER TESTS:<br /><ul><li>Immunologic tests are more specific to human hemoglobin
  53. 53. Hemoporphyrin assays detect the broadest range of blood derivatives
  54. 54. Immunochemical test using antihuman antibodies that are extremely sensitive to human hemoglobin are available.</li></li></ul><li>DIAGNOSTIC ASSESSMENT<br />Breath Tests<br /><ul><li>Hydrogen breath test – evaluate carbohydrate absorption and diagnosis of bacterial overgrowth in the intestine and short bowel syndrome.
  55. 55. Determines the amount of hydrogen expelled in the breath after it has been produced in the colon and absorbed into the blood.
  56. 56. Urea breath test – detect presence of Helicobacter pylori which causes peptic ulcer disease.</li></li></ul><li>4. Abdominal Ultrasonography<br /><ul><li>Noninvasive diagnostic technique which uses high-frequency sound waves.
  57. 57. Used to indicate the size and configuration of abdominal structures.
  58. 58. Useful in detection of cholelithiasis, cholecystitis, and appendicitis and acute colonic diverticulitis.
  59. 59. Advantages: No ionizing radiation, no noticeable side effects, relatively inexpensive.
  60. 60. Disadvantage: It cannot be used to examine structures that lie behind bony tissue….
  61. 61. Endoscopic ultrasonography – gives direct imaging of a target area.
  62. 62. Nursing Interventions:
  63. 63. Patients fasts for 8-12 hours before the test
  64. 64. If gallbladder studies is to be done, patient should be fat-free the evening before the test
  65. 65. If barium studies are to be performed, nurse should make sure they are scheduled after this test…..why?</li></li></ul><li>5. DNA Testing – Pre clinical diagnosis to identify persons who are at risk for certain GI disorders (gastric cancer, lactose deficiency, inflammatory bowel disease, colon cancer).<br />6. Imaging Studies<br />X-ray and contrast studies <br /> Upper GI series or barium swallow<br />> Double contrast studies – administration of thick barium suspension followed by tablets that release carbon dioxide in the presence of water. (Early superficial neoplasms are identified)<br />> Enteroclysis – a double contrast study of the entire small intestine by infusing continuously of 500-1000ml of thin barium sulfate suspension followed by methylcellulose and observed through fluoroscopy. Up to 6 hours. For diagnosis of Partial small-bowel obstructions or diverticula.<br />
  66. 66. 7. Upper GI series or Barium Swallow<br />Nursing Interventions<br /><ul><li>Patient need to maintain low-residue diet for several days before the test.
  67. 67. NPO after midnight before the test.
  68. 68. Physician may prescribe laxative
  69. 69. Discourage smoking on the morning before the examination
  70. 70. Withholds all medications
  71. 71. Follow up care after the procedure, fluids must be increased, monitor patient’s stool color, laxative or enema may be needed.</li></li></ul><li>8. Lower Gastrointestinal Tract Study<br /><ul><li>Barium Enema
  72. 72. Barium is instilled rectally to visualize the lower GI tract.
  73. 73. To detect presence of polyps, tumors and other lesions of small intestine and demonstrate abnormal anatomy or malfunction of the bowel.
  74. 74. Takes about 15-30 minutes
  75. 75. Double contrast studies – barium enema with instillation of air.</li></li></ul><li>
  76. 76. Lower Gastrointestinal Tract Study<br />Nursing Interventions:<br /><ul><li>Emptying and cleansing the lower bowel.
  77. 77. Low residue diet 1-2 days before the test
  78. 78. Clear liquid diet and laxative the evening before
  79. 79. NPO after midnight
  80. 80. Cleansing enemas until returns are clear the following morning
  81. 81. Barium enemas should be scheduled before any upper GI studies.
  82. 82. Contraindications: Signs of perforations or obstruction, GI bleeding prohibit the use of laxatives and enemas
  83. 83. Administers enema or laxative after test to facilitate barium removal, Increase fluid intake.</li></li></ul><li>9. Computed Tomography (CT) Scans<br /><ul><li>Provides cross-sectional images of abdominal organs and structures. Multiple x-ray images are taken for many different angles.</li></ul>Nursing Interventions:<br /><ul><li>Patient should not eat or drink for 6-8 hours before the test.
  84. 84. Physician may prescribe an IV or oral contrast agent. Dye allergy history should be asked.
  85. 85. Barium studies should be performed after CT scanning.</li></li></ul><li>10. Magnetic Resonance Imaging (MRI)<br /><ul><li>Noninvasive technique that uses magnetic fields and radio waves to produce an image of the area being studied.
  86. 86. Useful in evaluating abdominal soft tissues as well as blood vessels, abscesses, fistulas, neoplasms, and other sources of bleeding.
  87. 87. Contraindications: patients with permanent pacemakers, artificial heart valves and defibrillators, implanted insulin pumps or implanted transcutaneous electrical nerve stimulation devices, with internal metal devices (aneurysm clips) or intraocular metallic fragments.
  88. 88. Nursing Interventions:
  89. 89. Patient should not eat or drink for 6-8 hours before the test.
  90. 90. Remove all jewelry and other metals
  91. 91. Warn patients on the close-fitting scanners which may induce feelings of claustrophobia and the machine will make a knocking sound during the procedure.</li></li></ul><li>11. Scintigraphy (Radionuclide imaging)<br /><ul><li>Use radioactive isotopes (technitium,iodine and indium) to reveal displaced anatomic structures, changes in organ size and presence of neoplasms, cysts or abscesses.
  92. 92. Scintigraphic scanning measure the uptake of tagged red blood cells and leukocytes which will define areas of inflammation, abscess, blood loss.
  93. 93. A sample of blood is removed, mixed with a radioactive substance and reinjected into the patient.
  94. 94. Abnormal concentrations of blood cells are detected at 24 and 48 hours intervals</li></li></ul><li>12. Gastrointestinal Motility Studies<br /><ul><li>Used to assess gastric emptying and colonic transit time.
  95. 95. After meal, patient is positioned under a scintiscanner and measures the passage of radioactive substance out of the stomach.
  96. 96. For evaluation of diabetic gastroparesis and dumping syndrome, chronic constipation and obstructive defecation syndrome
  97. 97. Abdominal x-rays are taken every 24 hours until all markers are passed
  98. 98. The process takes 4-5 days but in severe constipation may take as long as 10 days.
  99. 99. If with chronic diarrhea, may be evaluated at 8-hour intervals. </li></li></ul><li>13. Endoscopic Procedures<br />Fibroscopy/ Esophagogastroduodenoscopy<br />Anoscopy<br />Proctoscopy<br />Sigmoidoscopy<br />Colonoscopy<br />Small-bowel enteroscopy<br />Endoscopy through ostomy<br />
  100. 100. Gastroscopy<br />
  101. 101. ENDOSCOPIC PROCEDURESEGD<br />After the patient is sedated, the endoscope is lubricated with a water-soluble lubricant and passed smoothly and slowly along the back of the mouth and down into the esophagus.<br />Biopsy forceps to obtain tissue specimens or cytology brushes to obtain cells for microscopic study can be passed through the scope.<br />Patients may experience nausea, choking or gagging.<br />
  102. 102. ENDOSCOPIC PROCEDURESEGD<br />Use of oral anesthetics and moderate sedation makes it important to monitor and maintain the oral airway during the after the procedure.<br />Monitor oxygen saturation by means of pulse oximeters, and supplemental oxygen may be administered if necessary<br />
  103. 103. ENDOSCOPIC PROCEDURESEGD: Nursing Interventions<br />The patient should not eat or drink for 6 to 12 hours before the examination.<br />Help the patient spray or gargle with a local anesthetic.<br />Administer a sedative such as midazolam intravenously just before the scope is introduced.<br />The nurse may also administer atropine to decrease secretion, and glucagon to relax smooth muscle.<br />
  104. 104. ENDOSCOPIC PROCEDURESEGD: Nursing Interventions<br />Position the patient on the left side to facilitate saliva drainage and provide easy access for the endoscope.<br />Instruct the patient not to eat or drink until the gag reflex returns.<br />Place the patient in the Simms position until he or she is awake, and then place the patient in the semi-Fowler’s position until ready for discharge<br />
  105. 105. ENDOSCOPIC PROCEDURESEGD: Nursing Interventions<br />After gastroscopy, observe for signs of perforation: bleeding, unusual dysphagia, fever.<br />Monitor the pulse and blood pressure for changes that can occur with sedation.<br />Test the gag reflex. <br />Relieve minor throat discomfort by giving lozenges, saline gargle and oral analgesics<br />
  106. 106. Colonoscopy<br />
  107. 107. Fiberoptic Colonoscopy<br />Direct visual inspection of the colon to the cecum.<br />Used commonly as a diagnostic and screening device.<br />Tissue biopsies can be obtained as needed, and polyps can be removed and evaluated.<br />May also be used to evaluate diarrhea of unknown cause, occult bleeding, or anemia<br />
  108. 108. Fiberoptic Colonoscopy<br />Usually performed while the patient is lying on the left side with the legs drawn up toward the chest.<br />Discomfort may result from instillation of air to expand the colon or from insertion and moving of the scope.<br />Potential complications include cardiac dysrhythmias and respiratory depression resulting from the medications administered, vasovagal reactions and circulatory overload or hypotension as a result of under- or over hydration.<br />
  109. 109. Fiberoptic Colonoscopy<br />Adequate colon cleansing provides optimal visualization and decreases the time needed for the procedure.<br />Patient should limit the intake of liquids for 24 to 72 hours before the examination.<br />Prescribe laxatives for two nights before the examination and a Fleet’s or saline enema until the return runs clear on the morning of the test.<br />Clear liquid diet starting at noon the day before the procedure.<br />
  110. 110. Fiberoptic Colonoscopy<br />Patient ingests lavage solutions orally at intervals over 3 to 4 hours.<br />Cardiopulmonary clearance prior to test for patients with known or suspected cardiac and pulmonary conditions, and in patients over the age of 40 years.<br />NSAIDs, aspirin, ticlopidine and pentoxifylline must be discontinued before the test and for 2 weeks after the procedure.<br />Informed consent must be obtained. <br />
  111. 111. Fiberoptic Colonoscopy<br />NPO after midnight before the test.<br />Monitor for changes in oxygen saturation, vital signs, color and temperature of the skin, level of consciousness, abdominal distention, vagal response and pain intensity during the test.<br />After the procedure, patients who were sedated are maintained on bed rest until fully alert.<br />Abdominal cramps are common as a result of increased peristalsis stimulated by air insufflated into the bowel during the procedure<br />
  112. 112. Fiberoptic Colonoscopy<br />Immediately after the procedure, observe the patient for signs and symptoms of bowel perforation.<br />If midazolam was used, the nurse should explain its amnesic effect; it is important to provide written instructions, because the patient may be unable to recall verbal information.<br />Instruct the patient to report any bleeding to the physician.<br />
  113. 113. Flexible Fiberoptic Sigmoidoscopy<br />
  114. 114. Anoscopy, Proctoscopy and Sigmoidoscopy<br />Visualize the lower portion of the colon to evaluate rectal bleeding, acute or chronic diarrhea, or change in bowel patterns, and to observe for ulceration, fissures, abscesses, tumors, polyps, or other pathologic processes.<br />Rigid or flexible fiberoptic scopes can be used.<br />Anoscopes are rigid scopes that are used to examine the anus and lower rectum.<br />Proctoscopes and sigmoidoscopes are rigid scopes used to inspect the rectum and sigmoid colon.<br />
  115. 115. Anoscopy, Proctoscopy and Sigmoidoscopy<br />For rigid scopes, the patient assumes the knee-chest position at the edge of the bed or examining table.<br />Keep the patient informed about the progress of the examination and to explain that the pressure exerted by the instrument will create the urge to have bowel movement.<br />
  116. 116. Anoscopy, Proctoscopy and Sigmoidoscopy<br />For flexible scope procedures, the patient assumes a comfortable position on the left side, with the right leg bent and placed amteriorly.<br />It is important to keep the patient informed throughout the examination and to explain the sensations associated with the examination.<br />These examinations require only limited bowel preparation, including a warm tap water or Fleet’s enema until returns are clear.<br />
  117. 117. Anoscopy, Proctoscopy and Sigmoidoscopy<br />Dietary restrictions usually are not necessary, and sedation usually is not required.<br />Monitor the vital signs, skin color and temperature, pain tolerance and vagal response during the procedure.<br />After the procedure, the nurse monitors the patient for rectal bleeding and signs of intestinal perforation.<br />On completion of the examination, the patient can resume regular activities and dietary practices.<br />
  118. 118. DIAGNOSTIC ASSESSMENT<br /> Manometry and Electrophysiologic Studies.<br /> Gastric Analysis, Gastric Acid Stimulation Test and pH Monitoring<br /> Laparoscopy (Peritoneoscopy)<br />
  119. 119. Gastrointestinal Assessment<br />Laboratory Procedures<br />54<br />
  120. 120. 55<br />Foods and Medications<br />Color<br />Altering Substance<br />Dark brown<br />Meat protein<br />Green<br />Spinach<br />Red<br />Carrots and beets<br />Dark red or brown<br />Cocoa<br />Yellow<br />Senna<br />Black<br />Bismuth, iron, licorice and charcoal<br />Milky white<br />Barium<br />Health History and Clinical Manifestations<br />
  121. 121. COMMON LABORATORY PROCEDURES<br />FECALYSIS<br />Examination of stool consistency, color and the presence of occult blood.<br />Special tests for fat, nitrogen, parasites, ova, pathogens and others<br />56<br />
  122. 122. COMMON LABORATORY PROCEDURES<br />FECALYSIS: Occult Blood Testing<br />Instruct the patient to adhere to a 3-day meatless diet<br />No intake of NSAIDS, aspirin and anti-coagulant<br />Screening test for colonic cancer<br />57<br />
  123. 123. COMMON LABORATORY PROCEDURES<br />Upper GIT study: barium swallow<br />Examines the upper GI tract<br />Barium sulfate is usually used as contrast<br />58<br />
  124. 124. COMMON LABORATORY PROCEDURES<br />Upper GIT study: barium swallow<br />Pre-test: NPO post-midnight<br />Post-test: increase pt fluid intake, instruct that stools will turn white, monitor for obstruction, laxative is also ordered<br />59<br />
  125. 125. 60<br />
  126. 126. 61<br />
  127. 127. COMMON LABORATORY PROCEDURES<br />Lower GIT study: barium enema<br />Examines the lower GI tract<br />Pre-test: Clear liquid diet and laxatives, NPO post-midnight, cleansing enema prior to the test<br />62<br />
  128. 128. COMMON LABORATORY PROCEDURES<br />Lower GIT study: barium enema<br />Post-test: Laxative is ordered, increase patient fluid intake, instruct that stools will turn white, monitor for obstruction<br />63<br />
  129. 129. 9/19/2011<br />64<br />
  130. 130. COMMON LABORATORY PROCEDURES<br />Gastric analysis<br />Aspiration of gastric juice to measure pH, appearance, volume and contents<br />Pre-test: NPO 8 hours, avoidance of stimulants, drugs and smoking<br />Post-test: resume normal activities<br />65<br />
  131. 131. COMMON LABORATORY PROCEDURES<br /> EGD<br />(esophagogastroduodenoscopy)<br />Visualization of the upper GIT by endoscope<br />Pre-test: ensure consent, NPO 8 hours, pre-medications like atropine and anxiolytics<br />66<br />
  132. 132. 67<br />
  133. 133. COMMON LABORATORY PROCEDURES<br />EGD<br />esophagogastroduodenoscopy<br />Intra-test: position : LEFT lateral to facilitate salivary drainage and easy access<br />68<br />
  134. 134. COMMON LABORATORY PROCEDURES<br />EGD (esophagogastroduodenoscopy)<br />Post-test: NPO until gag reflex returns, place patient in SIMS position until he awakens, monitor for complications, saline gargles for mild oral discomfort<br />69<br />
  135. 135. COMMON LABORATORY PROCEDURES<br />Lower GI- scopy<br />Use of endoscope to visualize the anus, rectum, sigmoid and colon<br />Pre-test: consent, NPO 8 hours, cleansing enema until return is clear<br />70<br />
  136. 136. 71<br />
  137. 137. COMMON LABORATORY PROCEDURES<br />Lower GI- scopy<br />Intra-test: position is LEFT lateral, right leg is bent and placed anteriorly<br />Post-test: bed rest, monitor for complications like bleeding and perforation<br />72<br />
  138. 138. 9/19/2011<br />73<br />
  139. 139. COMMON LABORATORY PROCEDURES<br />Cholecystography<br />Examination of the gallbladder to detect stones, its ability to concentrate, store and release the bile<br />Pre-test: ensure consent, ask allergies to iodine, seafood and dyes; contrast medium is administered the night prior, NPO after contrast administration<br />9/19/2011<br />74<br />
  140. 140. COMMON LABORATORY PROCEDURES<br />Cholecystography<br />Post-test: Advise that dysuria is common as the dye is excreted in the urine, resume normal activities<br />75<br />
  141. 141. COMMON LABORATORY PROCEDURES<br />Paracentesis<br />Removal of peritoneal fluid for analysis<br />76<br />
  142. 142. COMMON LABORATORY PROCEDURES<br />Paracentesis<br />Pre-test: ensure consent, instruct to VOID and empty bladder, measure abdominal girth<br />77<br />
  143. 143. COMMON LABORATORY PROCEDURES<br />Paracentesis<br />Intra-test:Upright on the edge of the bed, back supported and feet resting on a foot stool<br />78<br />
  144. 144. DIAGNOSTIC EVALUATION: Computed Tomography<br />Provides cross-sectional images of abdominal organs and structures.<br />The patient should not eat or drink for 8 hours before the test.<br />The practitioner may prescribe an intravenous or oral contrast agent.<br />Obtain a history and ask about allergies.<br />Should be performed before barium studies.<br />79<br />
  145. 145. DIAGNOSTIC EVALUATION: Computed Tomography<br />80<br />
  146. 146. DIAGNOSTIC EVALUATION: MRI<br />Used in gastroenterology to supplement ultrasonography and CT scanning.<br />Noninvasive technique that uses magnetic fields and radio waves to produce an image of the area being studied.<br />Physiologic artifacts of heartbeat, respiration and peristalsis may create a less-than-clear image.<br />81<br />
  147. 147. DIAGNOSTIC EVALUATION: MRI<br />The patient should not eat or drink for 8 hours before the test.<br />The patient must remove all jewelry and other metals.<br />Warn patients that the close-fitting scanners used in many MRI facilities may induce feelings of claustrophobia and that the machine will make a knocking sound during the procedure.<br />82<br />
  148. 148. DIAGNOSTIC EVALUATION: MRI<br />83<br />
  149. 149. COMMON LABORATORY PROCEDURES<br />Liver biopsy<br />Pretest<br />Consent<br />NPO<br />Check for the bleeding parameters<br />84<br />
  150. 150. COMMON LABORATORY PROCEDURES<br />Liver biopsy<br />Intratest<br />Position: Semi fowler’s LEFT lateral to expose right side of abdomen<br />85<br />
  151. 151. COMMON LABORATORY PROCEDURES<br />Liver biopsy<br />Post-test: position on RIGHT lateral with pillow underneath, monitor VS and complications like bleeding, perforation. Instruct to avoid lifting objects for 1 week<br />86<br />
  152. 152. The NURSING PROCESS in GIT Disorders<br />Assessment<br />Health history Nursing History<br />PE<br />Laboratory procedures<br />87<br />
  153. 153. GASTRIC GAVAGE: Nursing Intervention<br />Gastric gavage is the introduction of liquid feedings directly into the stomach.<br />Purpose:<br />Effective in persons who have difficulty in swallowing, prolonged unconsciousness, or anorexia.<br />Useful when there is oral or esophageal obstruction or trauma.<br />Life-saving in one who is debilitated or who has had surgery on some part of the GIT that does not permit normal ingestion of food.<br />
  154. 154. GASTRIC GAVAGE: Nursing Intervention<br />Avenues:<br />Nasogastric/orogastric<br />Esophagotomy – a stoma (temporary or permanent) may be created at one of several sites along the esophagus.<br />Gastrostomy<br />Jejunostomy<br />
  155. 155. GASTRIC GAVAGE: Nursing Intervention<br />Feeding Methods:<br />Gravity<br />Drip-regulated (a Murphy drip is connected by tubing to a receptacle or Kelly flask) which hangs on an IV pole.<br />Motor pump<br />
  156. 156. GASTRIC GAVAGE: Nursing Intervention<br />Continuous Nursing Assessment<br />Recognize that even though nutritional deficits are corrected, some other problems may arise.<br />Cleanse all containers and tubings thoroughly.<br />Aspirate the tubing prior to feeding to verify that the tube is inside the patient’s stomach.<br />Avoid air bubbles in the system.<br />Provide oral and nasal hygiene before and after orogastric and nasogastric feedings for comfort or prevent infection.<br />
  157. 157. GASTRIC GAVAGE: Nursing Intervention<br />Continuous Nursing Assessment<br />Follow each feeding with water to flush tubing for cleansing and to promote fluid balance.<br />Monitor patient for signs of fluid and electrolyte imbalance.<br />Record amount of feeding and water; indicate patient’s participation and acceptance.<br />
  158. 158. GASTRIC GAVAGE: Nursing Intervention<br />Patient Education<br />Since tube should be changed every 2 to 3 days, the patient may be taught how to do it.<br />The patient should learn how to feed himself.<br />Skin requires special care.<br />
  159. 159. Total Parenteral Nutrition (TPN)<br /><ul><li>Intravenous administration of a hypertonic solution of glucose, nitrogen and other nutrients to achieve tissue synthesis and anabolism. Lipids may be given as a supplement.
  160. 160. Provides 3,000 – 4,000 calories per day.</li></li></ul><li>TPN/ PPN<br /><ul><li>IV Hyperalimentation
  161. 161. Method of supplying nutrients to the body via IV route
  162. 162. Goal: to improve nutritional status, promote weight gain & enhance healing process</li></ul>Indications:<br /><ul><li> Severe burns, malnutrition, sepsis, cancer, paralytic ileus, bowel obstruction, anorexia nervosa, acute pancreatitis, bowel surgery
  163. 163. Solution: 25% glucose and synthetic amino acids
  164. 164. Site: Subclavian vein going to SVC</li></li></ul><li>Complications:<br /><ul><li>Pneumothorax
  165. 165. Air embolism
  166. 166. Clotted line
  167. 167. Displacement
  168. 168. Sepsis
  169. 169. Hyperglycemia
  170. 170. Fluid overload
  171. 171. Rebound hypoglycemia</li></ul>NURSING ALERT!<br /><ul><li> Continous uniform infusion in 24-hour period
  172. 172. Weigh daily
  173. 173. Prevent infection
  174. 174. Change dressings aseptically twice a week
  175. 175. Infusion rate NOT too fast nor too slow</li></li></ul><li> Indication for use:<br /><ul><li> Inability of the gastrointestinal tract to absorb nutrients adequately.
  176. 176. Inability to take food by mouth
  177. 177. Excessive nutritional needs that cannot be met by the usual methods
  178. 178. *1000 cc D5W provides only 200 calories and no protein; adult energy requirements can reach 2,500 to 3,000 calories in some situations such as burns</li></li></ul><li><ul><li>Nursing Intervention
  179. 179. CXR immediately after subclavian line insertion
  180. 180. Assess weight, baseline electrolytes, blood glucose, zinc and copper levels before treatment begins
  181. 181. Maintain aseptic technique during dressing changes
  182. 182. Maintain infusion rate
  183. 183. Monitor for complications</li></ul> - Infection - Pneumothorax during insertion<br /> - Hypoglycemia - Zinc deficiency<br /> - Hyperglycemia - Fluid overload<br /> - Air embolism - Hyperglycemic, hyperosmolar <br /> nonketotic coma<br />
  184. 184.                                                     <br />                                                    <br />                                                    <br />Ileostomy stoma<br /><ul><li>Protrudes so that the liquid stool does not burn the skin.
  185. 185. Located on the right hand side of the tummy.
  186. 186. Colostomy stoma
  187. 187. Note how it is flusher with the skin
  188. 188. Located on the left hand side of the tummy</li></li></ul><li>Colostomy and Ileostomy<br />Nursing Intervention<br /><ul><li>Preoperative Care</li></ul> - Emotional support<br /> - Client-teaching concerning impending surgery ileostomy/ colostomy<br /><ul><li>Postoperative Care</li></ul> - General postoperative care<br /> - Psychological support<br /> - Observe stoma, surrounding tissues, and type of excretion<br /> - Teach client of self care<br /> * Type of equipment to use and how<br /> * Skin care<br /> * Diet<br /> * Irrigation<br />
  189. 189. Colostomy Care<br />Assess every shift for 3 days post op<br />Normal stoma: pink<br />Abnormal: cyanotic; dusky color, black/brown<br />Initially it protrudes 1 inch outward<br />Check bowel sounds q 4<br />Begins functioning after 48 hrs<br />Avoid gasforming foods/ high fiber<br />
  190. 190. Colostomy Care<br />Stoma irrigations: 500-1000ml of warm or tepid water<br />Nsg. Alert :Prior to 1st irrigation, insert gloved finger to note direction of stoma<br />Hang bag 12-14 inches above the stoma<br />Lubricate and insert 3-4 inches<br />Infuse for 15 mins<br />Expect return after 15-20 mins<br />
  191. 191. The ABDOMINAL examination<br />The sequence to follow is:<br />Inspection<br />Auscultation<br />Percussion<br />Palpation<br />103<br />
  192. 192. Most Common GIT Symptom<br />Abdominal Pain<br />Major symptom of GI disease.<br />Character<br />Duration<br />Pattern<br />Frequency<br />Location<br />Distribution of referred pain<br />Time of the pain<br />Is it?<br />Medical Abdomen?<br />Surgical Abdomen?<br />When to refer?<br />104<br />
  193. 193. Indigestion<br />Upper abdominal discomfort or distress associated with eating.<br />Most common symptom of patients with GI dysfunction.<br />Fatty foods tend to cause the most discomfort.<br />Coarse vegetables and highly seasoned foods can also cause considerable distress.<br />105<br />
  194. 194. Intestinal Gas<br />The accumulation of gas in the GIT may result in belching or flatulence.<br />Patients often complain of bloating, distention, or “being full of gas.”<br />106<br />
  195. 195. Nausea and Vomiting<br />Vomiting is usually preceded by nausea, which can be triggered by odors, activity, or food intake.<br />Emesis, or vomitus, may vary in color and content.<br />Hematemesis refers to bloody vomitus.<br />107<br />
  196. 196. Change in Bowel Habits and Stool Characteristics<br />These may signal colon disease.<br />Diarrhea (abnormal increase in the frequency and liquidity of the stool or in daily stool weight or volume) occurs when the contents move so rapidly through the intestine and colon.<br />Constipation (decrease in the frequency of stool, or stools that are hard, dry, and of smaller volume than normal) may be associated with anal discomfort and rectal bleeding.<br />108<br />
  197. 197. Change in Bowel Habits and Stool Characteristics<br />Stool is normally light to dark brown.<br />Ingestion of certain foods and medications, as well as the presence of blood, can change the appearance of stool.<br />Bulky, greasy, foamy stools that are foul in odor; stool color is gray with a silvery sheen (fat malabsorption).<br />Light gray or clay-colored stool (absence of urobilin).<br />Mucus threads or pus in stools (infection).<br />109<br />
  198. 198. Change in Bowel Habits and Stool Characteristics<br />Scybala (small, dry, rock-hard masses) often seen in narrowing of the colonic lumen.<br />Loose, watery stool that may or may not be streaked with blood (inflammatory conditions).<br />110<br />
  199. 199. PHYSICAL ASSESSMENT<br />Assessment of the mouth, abdomen and rectum.<br />Mouth, tongue, buccal mucosa, teeth and gums are inspected, and ulcers, nodules, swelling, discoloration, and inflammation are noted.<br />Patients with dentures should remove them during this part of the examination to allow good visualization.<br />111<br />
  200. 200. PHYSICAL ASSESSMENT: The Abdomen<br />Patient lies supine with knees flexed slightly for inspection, auscultation, palpation and percussion.<br />The nurse performs inspection first, noting skin changes and scars from previous surgery.<br />It is also important to note the contour and symmetry of the abdomen, to identify any localized bulging, distention, or peristaltic waves.<br />112<br />
  201. 201. Abdominal Assessment: Auscultation<br />Character, location and frequency of bowel sounds.<br />Assess bowel sounds in all four quadrants using the diaphragm of the stethoscope.<br />Categorize and document frequency of bowel sounds into normal (5 to 6/min), hypoactive (1 sound/min), hyperactive (5 to 6 sounds in less than 30 seconds), or absent (no sound in 3 to 5 minutes).<br />113<br />
  202. 202. Abdominal Assessment: Percussion and Palpation<br />Tympany or dullness.<br />Light palpation for identifying areas of tenderness or swelling.<br />Deep palpation to identify masses in all four quadrants.<br />If any area of discomfort is identified, the nurse can assess for rebound tenderness.<br />114<br />