Medical-Surgical Nursing Gastrointestinal System

Anatomy and Structure of Gastrointestinal System

I. Upper alimentary canal - function for digestion a. Mouth b. Pharynx (throat) c. Esophagus d. Stomach e. 1st half of duodenum II. Middle Alimentary canal Function: for absorption - Complete absorption large intestine a. 2nd half of duodenum b. Jejunum c. Ileum d. 1st half of ascending colon III. Lower Alimentary Canal Function: elimination a. 2nd half of ascending colon b. Transverse c. Descending colon d. Sigmoid e. Rectum IV. Accessory Organ a. Salivary gland b. Verniform appendix c. Liver d. Pancreas auto digestion e. Gallbladder storage of bile Salivary Glands 1. Parotid below & front of ear 2. Sublingual 3. Submaxillary Produces saliva for mechanical digestion 1200 -1500 ml/day - saliva produced

GASTROINTESTINAL SYMPTOMS
1. 2. 3. 4. 5. Nausea and Vomiting Bloating Constipation Diarrhea Abdominal Pain

Disorders of the Gastrointestinal Tract PAROTITIS

mumps inflammation of parotid gland -Paramyxo virus Signs and Symptoms 1. Fever, chills anorexia, gen body malaise 2. Swelling of parotid gland 3. Dysphagia 4. Ear ache otalgia Mode of transmission: Direct transmission & droplet nuclei Incubation period: 14 21 days

Period of communicability 1 week before swelling & immediately when swelling begins. Nursing Management 1. CBR 2. Strict isolation 3. Meds: analgesic Antipyretic Antibiotics to prevent 2 complications 4. Alternate warm & cold compress at affected part 5. Gen liquid to soft diet 6. Complications a. Women cervicitis, vaginitis, oophoritis b. Both sexes meningitis & encephalitis/ reason why antibiotics is needed c. Men orchitis might lead to sterility if it occur during / after puberty

APENDICITIS
inflamation of verniform appendix Predisposing factor 1. Microbial infection 2. Feacalith undigested food particles tomato seeds, guava seeds 3. Intestinal obstruction Signs and Symptoms 1. Pathognomonic sign: (+) rebound tenderness 2. Low grade fever, anorexia, n/v 3. Diarrhea / & or constipation 4. Pain at Rt iliac region 5. Late sign due pain tachycardia Diagnosis 1. CBC mild leukocytosis increase WBC 2. PE (+) rebound tenderness (flex Rt leg, palpate Rt iliac area rebound) 3. Urinalysis Treatment - appendectomy 24 45 Nursing Management 1. Consent 2. Routinary nursing measures: a.) Skin prep b.) NPO c.) Avoid enema lead to rupture of appendix 3. Meds: Antipyretic Antibiotics *Dont give analgesic will mask pain - Presence of pain means appendix has not ruptured. 4. Avoid heat application will rupture appendix. 5. Monitor VS, I&O bowel sound Nursing Management:Post op 1. If (+) to Pendrose drain indicates rupture of appendix Position- affected side to drain 2. Meds: analgesic due post op pain Antibiotics, Antipyretics PRN 3. Monitor VS, I&O, bowel sound 4. Maintain patent IV line 5. Complications- peritonitis, septicemia

LIVER CIRRHOSIS
- lost of architectural design of liver leading to fat necrosis & scarring Early sign hepatic encephalopathy

Asterixis flapping hand tremors Late signs headache, restlessness, disorientation, decrease LOC hepatic coma. Nursing priority assist in mechanical ventilation Predisposing factor: Decrease Laennacs cirrhosis caused by alcoholism 1. Chronic alcoholism 2. Malnutrition decreaseVit B, thiamin - main cause 3. Virus 4. Toxicity- eg. Carbon tetrachloride 5. Use of hepatotoxic agents Signs and Symptoms Early signs: a.) Weakness, fatigue b.) Anorexia, n/v c.) Stomatitis d.) Urine tea color Stool clay color e.) Amenorrhea f.) Decrease sexual urge g.) Loss of pubic, axilla hair h.) Hepatomegaly i.) Jaundice j.) Pruritus or urticaria Late signs 1.Hematological changes all blood cells decrease 1. Leukopenia- decrease 2. Thrombocytopenia- decrease 3. Anemia- decrease 2.Endocrine changes 1. Spider angiomas, Gynecomastia 2. Caput medusate, Palmar errythema 3.GIT changes 1. Ascitis, bleeding esophageal varices due to portal HPN 4.Neurological changes: Hepatic encephalopathy - ammonia (cerebral toxin) Late signs: Headache Fetor hepaticus Confusion Restlessness Decrease LOC Hepatic coma Diagnosis 1,Liver enzymes- increase SGPT (ALT) SGOT (AST) 2.Serum cholesterol & ammonia increase 3.Indirect bilirubin increase 4.CBC - pancytopenia 5.PTT prolonged 6.Hepatic ultrasonogram fat necrosis of liver lobules Nursing Management 1. CBR 2. Restrict Na! 3. Monitor VS, I&O 4. With pt daily & assess pitting edema 5. Measure abdominal girth daily notify MD Early signs: asterexis(flapping hand tremors)

6. 7. 8.

Meticulous skin care Diet increase CHO, vit & minerals. Moderate fats. Decrease CHON Well balanced diet Complications: a.) Ascites fluid in peritoneal cavity Nursing Management 1. Meds: Loop diuretics 10 15 min effect 2. Assist in abdominal paracentesis - aspiration of fluid - Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted b.) Bleeding esophageal varices - Dilation of esophageal veins 1. Meds: Vit K Pitrisin or Vasopresin (IM) 2. NGT decompression- lavage - Give before lavage ice or cold saline solution - Monitor NGT output 3. Assist in mechanical decompression - Insertion of sengstaken-blackemore tube - 3 lumen typed catheter - Scissors at bedside to deflate balloon. Hepatic encephalopathy 1. Assist in mechanical ventilation due coma 2. Monitor VS, neuro check 3. Siderails due restless 4. Meds Laxatives to excrete ammonia

c.)

HEPATITIS
-Inflammation & infection of the liver Hepatitis A Hepa A virus 25 days 2 weeks before onset of jaundice Hepatitis B Hepa B virus 120 days Later part of the incubation period, acute stage Contaminated blood, plasma or semen, placental transmission, contaminated syringe

Causative agent Incubation period Period of communicability

Mode of transmission

ingestion of contaminated water, sexual transmission from oral intercourse

Signs and Symptoms 1. Headache, vomiting 2. Generalized aching 3. Right upper quadrant pain 4. Icteric sclera 5. Generalized jaundice 6. White or gray-colored stool 7. Low-grade fever, sore throat, nasal discharge 8. Dark-colored urine after 3-7 days Nursing Management 1. Maintain a high-caloric diet 2. Strict hand washing & isolation technique 3. Cool bath to reduce discomfort from pruritus 4. Complication: Hepatic coma

PANCREATITIS
acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto digestion. Bleeding of pancreas - Cullens sign at umbilicus

Predisposing factors 1. Chronic alcoholism 2. Hepatobilary disease 3. Obesity 4. Hyperlipidemia 5. Hyperparathyroidism 6. Drugs Thiazide diuretics, pills Pentamidine HCL (Pentam) 7. Diet increase saturated fats Signs and Symptoms 1. Severe Left epigastric pain radiates from back & flank area Aggravated by eating, with DOB 2. Nausea/Vomiting 3. Tachycardia 4. Palpitation due to pain 5. Dyspepsia indigestion 6. Decrease bowel sounds 7. (+) Cullens sign - ecchymosis of umbilicus hemorrhage 8. (+) Grey Turners spots ecchymosis of flank area 9. Hypocalcemia Diagnosis 1. 2. 3. Serum amylase & lipase increase Urine lipase increase Serum Ca decrease

Nursing Management 1. Administer Medications as ordered a.) Narcotic analgesic - Meperidine Hcl (Demerol) Dont give Morphine SO4 will cause spasm of sphincter. b.) Smooth muscle relaxant/ anti cholinergic - Ex. Papavarine Hcl Prophantheline Bromide (Profanthene) c.) Vasodilator NTG d.) Antacid Maalox e.) H2 receptor antagonist - Ranitidin (Zantac) f.) Ca gluconate 2. Withold food & fluid because it aggravates pain 3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation Complications of TPN 1. Infection 2. Embolism 3. Hyperglycemia 4. Institute stress Management technique a.) Deep Breathing Exercise b.) Biofeedback 5. Assist in comfortable position - Knee chest or fetal like position 6. If pt. can tolerate food, give increase CHO, decrease fats, and increase CHON Complications -Chronic hemorrhagic Pancreatitis

CHOLECYSTITIS/ CHOLELITHIASIS
inflammation of gallbladder with gallstone formation. Predisposing factor 1. High risk women 40 years old 2. Post menopausal women undergoing estrogen therapy 3. Obesity 4. Sedentary lifestyle 5. Hyperlipidemia 6. Neoplasm

Signs and Symptoms 1. Severe Right abdominal pain (after eating fatty food). Occurring especially at night 2. Fatty intolerance 3. Anorexia 4. Nausea/vomiting 5. Jaundice 6. Pruritus 7. Easy bruising 8. Tea colored urine 9. Steatorrhea Diagnosis 1. Oral cholecystogram (or gallbladder series)- confirms presence of stones Nursing Management 1. Administer Medications as ordered a.) Narcotic analgesic - Meperdipine Hcl Demerol b.) Anti cholinergic - Atropine SO4 c.) Anti emetic -Phenergan Phenothiazide with anti emetic properties 2. Diet increase CHO, moderate CHON, decrease fats 3. Meticulous skin care 4. Surgery: Cholecystectomy Nursing Management Post Cholecystectomy -Maintain patency of T-tube intact & prevent infection

PEPTIC ULCER DISEASE

excoriation / erosion of submucosa & mucosal lining due to: a.) Hypercecretion of acid pepsin b.) Decrease resistance to mucosal barrier Incidence Rate: 1. Men 40 55 yrs old 2. Aggressive persons Predisposing factors 1. Hereditary 2. Emotional 3. Smoking vasoconstriction GIT ischemia 4. Alcoholism stimulates release of histamine = Parietal cell release Hcl acid = ulceration 5. Caffeine tea, soda, chocolate 6. Irregular diet 7. Rapid eating 8. Ulcerogenic drugs NSAIDS, aspirin, steroids, indomethacin, ibuprofen Indomethacin - S/E corneal cloudiness. Needs annual eye check up. 9. Gastrin producing tumor or gastrinoma Zollinger Ellisons sign 10. Microbial invasion helicobacter pylori. Metromidazole (Flagyl)

Types of ulcers Ascending to severity 1. Acute affects submucosal lining 2. Chronic affects underlying tissue heals & forms a scar According to location 1. Stress ulcer 2. Gastric ulcer 3. Duodenal ulcer most common Stress ulcers common among eritically ill clients

2 Types GASTRIC ULCER Intrum or lesser curvature -30 min 1 hr after eating - epigastrium - gaseous & burning - not usually relieved by food & antacid Normal gastric acid secretion common hematemeis Wt loss a. stomach cause b. hemorrhage 60 years old DUODENAL ULCER Duodenal bulb -2-3 hrs after eating - mid epigastrium - cramping & burning - usually relieved by food & antacid - 12 MN 3am pain Increased gastric acid secretion Not common Melena Wt gain a. perforation 20 years old

SITE PAIN

HYPERSECRETION VOMITING HEMORRHAGE WT COMPLICATIONS HIGH RISK Diagnosis 1. 2. 3. 4.

Endoscopic exam Stool from occult blood Gastric analysis GI series confirms presence of ulceration

Nursing Management 1. Diet bland, non irritating, non spicy 2. Avoid caffeine & milk/ milk products 3. Administer meds as ordered a.) Antacids b.) H2 receptor antagonist 1. Ranitidine (Zantac) 2. Cimetidine (Tagamet) 3. Tamotidine (Pepcid) Avoid smoking decrease effectiveness of drug c.) Cytoprotective agents 1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach 2. Cytotec d.) Sedatives/ Tranquilizers - Valium, lithium e.)Anticholinergics 1. Atropine SO4 2. Prophantheline Bromide (Profanthene) 4.Surgery: subtotal gastrectomy - Partial removal of stomach Billroth I (Gastroduodenostomy) -Removal of of stomach & anastomoses of gastric stump to the duodenum. Billroth II (Gastrojejunostomy) - removal of -3/4 of stomach & duodenal bulb & anastomostoses of gastric stump to jejunum.

Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first. Nursing Management 1. Monitor NGT output a.) Immediately post op should be bright red b.) Within 36- 42h output is yellow green c.) After 42h output is dark red 2. Administer meds: a.) Analgesic b.) Antibiotic c.) Antiemetics 3. Maintain patent IV line 4. VS, I&O & bowel sounds 5. Complications: a.) Hemorrhage hypovolemic shock Late signs anuria b.) Peritonitis c.) Paralytic ileus most feared

d.) e.) f.)

Hypokalemia Thromobphlebitis Pernicious anemia hypovolemia.

Dumping syndrome common complication rapid gastric emptying of hypertonic food solutions CHYME leading to
Signs of Dumping syndrome: 1. Dizziness 2. Diaphoresis 3. Diarrhea 4. Palpitations Nursing Management 1. Avoid fluids in chilled solutions 2. Small frequent feeding s-6 equally divided feedings 3. Diet decrease CHO, moderate fats & CHON 4. Flat on bed 15 -30 minutes after q feeding

Hiatal Hernia
-protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm Two major kinds a. sliding hiatul hernia b. rolling (or paraesophageal) hiatul hernia Signs and Symptoms 1. dull pains in the chest 2. shortness of breath 3. heart palpitations 4. swallowed food "balling up" and causing discomfort in lower esophagus until it passes on to stomach Risk Factors 1. Heavy lifting or bending over 2. Frequent or hard coughing 3. Hard sneezing 4. Pregnancy and delivery 5. Violent vomiting 6. Straining with constipation 7. Obesity (extra weight pushes down on the abdomen increasing the pressure) 8. Use of the sitting position for defecation 9. Heredity 10. Smoking 11. Drug use, such as cocaine 12. Stress 13. Diaphragm weakness Nursing Intervention 1. 2. 3. Prepare the patient for diagnostic tests, as needed. Administer prescribed antacids and other medications To reduce intra-abdominal pressure and prevent aspiration, have the patient sleep in a reverse Trendelenburg position with the head of the bed elevated. 4. Assess the patients response to treatment. 5. Observe for complications, especially significant bleeding, pulmonary aspiration, or incarceration or streangulation of the herniated stomach portion. 6. After endoscopy, watch for signs of perforation such as falling blood pressure, rapid pulse, shock, and sudden pain caused by endoscope. 7. To enhance compliance, teach the patient about the disorder. Explain significant symptoms, diagnostic tests, and prescribed treatments. 8. Review prescribed medications, explaining their desired actions and possible adverse effects. 9. Teach the patient dietary changes to reduce reflux. 10. Encourage the patient to delay lying down for 2 hours after eating.