9/20/2012

Disorders of the Mouth

DISORDERS OF THE GASTROINTESTINAL SYSTEM

STOMATITIS
DEFINITION Inflammation of the oral cavity TYPES OF STOMATITIS 1) Primary APHTHOUS STOMATITIS or canker sores MOST COMMON TYPE 2) Secondary Candidiasis or oral thrush may be due to overgrowth of normal flora

9/20/2012

9/20/2012

ACTINIC CHEILITIS
Irritation of lips associated with scaling, crusty, fissure; white overgrowth of horny layer of epidermis (hyperkeratosis) Considered a premalignant squamous cell skin cancer

HERPES SIMPLEX 1 (cold sore or fever blister)

Singular or clustered painful vesicles that may rupture Very contagious

9/20/2012

CHANCRE
Reddened circumscribed lesion that ulcerates and become crusted

LEUKOPLAKIA
White patches; may be hyperkeratotic; usually in buccal mucosa; usually painless Common among tobacco users May progress to cancer

9/20/2012

HAIRY LEUKOPLAKIA
White patches with rough hair-like projections; typically found on lateral border of the tongue Often seen in HIV+

LICHEN PLANUS
White papules at the intersection of a network of interlacing lesions; usually ulcerated and painful

9/20/2012

CANDIDIASIS (Moniliasis/thrush)
Cheesy white plaque that looks like milk curds; when rubbed off, it leaves an erythematous and often bleeding base. Candida Albicans fungus DM, antibiotic therapy, immunosuppression

APHTHOUS STOMATITIS (canker sore)

Shallow ulcer with a white or yellow center and red border; seen on the inner side of the lip and cheek or on the tongue

9/20/2012

NICOTINE STOMATITIS (Smokers patch)

Begins as a stomatitis Over time the tongue and mouth become covered with a creamy, thick, white mucous membrane, which may slough, leaving a beefy red base

KRYTHOPLAKIA
Red patch on the oral membrane

9/20/2012

Kaposis sarcoma
Appears first on the oral mucosa as a red, purple, or blue lesion; may be singular or multiple; may be flat or raised

ETIOLOGY Infection e.g. herpes zoster or cytomegalovirus Allergy to coffee, potatoes, cheese, nuts, citrus fruits, and gluten Vitamin deficiency e.g. Vitamin B, folate, zinc, and iron Systemic disease e.g. HIV, chronic renal failure, inflammatory bowel disease Irritants e.g. tobacco and alcohol Chemotherapy Radiation
16

9/20/2012

Inflammation and denudation of oral mucosa ulceration

infection

bleeding

pain

17

CLINICAL MANIFESTATIONS CANKER SORES whitish gray center and erythematous ring Whitish plaque-like lesion, appears red and sore when wiped away COMMON IF WITH CANDIDIASIS Dysphagia Dry or hot sensation on area of lesions Elevation of temperature RARE
18

9/20/2012

LABORATORY ASSESSMENT COMPLETE BLOOD COUNT may reveal INFECTION CYTOLOGIC CULTURE and GRAM STAIN TESTING to identify the CAUSATIVE MICROORGANISM

19

NURSING CARE Provide ORAL CARE EVERY 2 HOURS and twice at night Use SOFT-BRISTLED TOOTHBRUSH OR FOAM SWABS to stimulate gums and clean the oral cavity Use SODIUM BICARBONATE solution (baking soda), WARM SALINE or HYDROGEN PEROXIDE in rinsing the mouth Avoid COMMERCIAL MOUTHWASHES Provide SOFT, BLAND and NONACIDIC foods Apply TOPICAL ANALGESICS or ANESTHETICS as prescribed
20

10

9/20/2012

DRUG THERAPY

TYPE OF
STOMATITIS General

DRUG

CONSIDERATIONS

Herpes Simplex

TetracyUSUAL DOSE 250 mg/10 ml cline Syrup for 10 days INSTRUCTION rinse for 2 minutes then swallow USUAL DOSE 5 mg/kg for 1 hour IV Acyclovir Q 8H (Zovirax) Nystatin USUAL DOSE 600,000 units (Mycostatin) QID oral suspension

INSTRUCTION make sure client has no renal problem

Fungal

21

ANTI-INFLAMMATORY AGENTS AND IMMUNE MODULATORS Triamcinolone in Benzocaine Dexamethasone Levamisole Amlexanox Thalidomide (Im)

22

11

9/20/2012

SYMPTOMATIC TOPICAL AGENTS FOR PAIN Benzocaine Camphor phenol 15 ml 2% viscous Lidocaine gargle of mouthwash every 3 hours (maximum of 8 doses per day)

Disorders of the Esophagus

DISORDERS OF THE GASTROINTESTINAL SYSTEM

12

9/20/2012

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

DESCRIPTION BACKWARD FLOW (reflux) of gastrointestinal contents into the esophagus MOST COMMON upper GI disorder Common in PEOPLE OVER AGE 45 Considered a disease process when is excessive and causes undesirable symptoms such as pain and respiratory distress

25

26

13

9/20/2012

CAUSE INAPPROPRIATE RELAXATION of lower esophageal sphincter or inability of the LES to close fully PREDISPOSING FACTORS Ingestion of LARGE MEALS Conditions associated with DECREASED GASTRIC EMPTYING Recumbent or SUPINE positioning Insertion of nasogastric tube (NGT) INCREASED INTRAABDOMINAL and INTRAGASTRIC PRESSURE e.g. pregnancy, wearing of tight belts, 27 obesity, bending over, ascites

FACTORS THAT RELAX LOWER ESOPHAGEAL SPHINCTER TONE Fatty foods , Chocolate Caffeinated beverages Citrus fruits, tomatoes and tomato products Peppermint, spearmint Alcohol Nicotine in cigarette smoke High levels of estrogen and progesterone Medications e.g. calcium channel blockers ( calcibloc), anticholinergic drugs (ASO4)
28

14

9/20/2012

Increased intraabdominal pressure

Decreased LES sphincter tone

Inappropriate relaxation of the LES

Regurgitation

Reflux of GI contents
Irritation of esophageal mucosa Inflammation Narrowing of esophageal lumen

Dyspepsia

Hypersalivation

Esophagitis Dysphagia and Odynophagia

29

ASSESSMENT SUBJECTIVE DATA HEARTBURN suggests reflux DYSPHAGIA suggests narrowing of lumen

30

15

9/20/2012

OBJECTIVE DATA Dyspepsia MOST COMMON SYMPTOM; occurs 3060 minutes after meals and with reclining position Regurgitation with sour or bitter taste Hypersalivation Dysphagia Odynophagia sharp substernal pain on swallowing Eructation (belching) Pyrosis burning sensation in the esophagus Chronic cough Aspiration pneumonia Respiratory distress
31

DIAGNOSTIC TESTS 24-hour ambulatory esophageal pH monitoring most accurate method ; allows for observation of the frequency of reflux episodes and their associated symtoms Upper endoscopy Esophageal manometry

32

16

9/20/2012

MANAGEMENT

DIET THERAPY Avoid CAFFEINATED AND CARBONATED foods Avoid SPICY and ACIDIC FOODS SMALL FREQUENT FEEDINGS (4-6 small meals) Avoid foods 3 hours before going to bed

33

LIFESTYLE CHANGES ELEVATE HEAD OF THE BED 6-8 inches for sleep DO NOT LIE DOWN 3-4 hours after eating Avoid NICOTINE and ALCOHOL LOSE WEIGHT if the patient is obese Avoid CONSTRICTIVE CLOTHING, STRAINING or BENDING OVER
34

17

9/20/2012

DRUG THERAPY ANTACIDS GENERIC NAME: Aluminum or Magnesium Hydroxide BRAND NAMES: Maalox Mylanta INDICATION: management of heartburn ACTION: elevates gastric pH and deactivates pepsin SIDE EFFECTS: constipation and diarrhea CLIENT INSTRUCTIONS: take the antacid 1 hour before and 2-3 hours after meals 35

HISTAMINE RECEPTOR ANTAGONISTS DRUG NAMES: famotidine (Pepcid) ranitidine (Zantac) cimetidine (Tagamet) nizatidine (Axid) INDICATION: management of heartburn ACTION: suppresses secretion of gastric acid by blocking the histamine receptor sites DRUG INTERACTION: CIMETIDINE may have significant interactions with WARFARIN, THEOPHYLLINE, PHENYTOIN, NIFEDIPINE and PROPANOLOL

36

18

9/20/2012

PROTON PUMP INHIBITORS DRUG NAMES: omeprazole (Priolosec) lansoprazole (Prevacid) rabeprazole (Aciphex) pantoprazole (Protonix) esomeprazole (Nexium) INDICATION: management of heartburn ACTION: inhibits gastric acid secretion by blocking enzymes associated with the final stage of acid production CLIENT INSTRUCTIONS: should be taken 30-60 minutes before meals

37

OTHER DRUGS METOCLOPRAMIDE (Plasil) ( GI stimulant) ACTION increase rate of gastric emptying and relaxation of the pyloric sphicter ADVERSE EFFECTS fatigue, anxiety, ataxia and hallucinations

19

9/20/2012

SURGICAL MANAGEMENT

LAPAROSCOPIC NISSEN FUNDOPLICATION (LNF) WRAPPING and ANCHORING a portion of the stomach fundus around the lower esophageal sphincter

39

NURSING CARE AFTER SURGERY Elevate head of the bed at least 30 degrees to lower the diaphragm and facilitate lung expansion Facilitate insertion of NGT to prevent excessive tightening of the fundoplication Monitor drainage of NGT (should be normal yellowish green within the first 8 hours after surgery) Check placement every 4-8 hours Avoid alcohol, caffeinated and carbonated foods Monitor for dysphagia (sign that fundoplication is too tight) Monitor for gas bloat syndrome Administer simethicone 80 mg QID for excessive gas 40

20

9/20/2012

ENDOSCOPIC THERAPIES STRETTA PROCEDURE PURPOSE to INHIBIT THE ACTIVITY of the vagus nerve use of radiofrequency energy through needles to induce THERMAL BURN in the gastroesophageal junction; tiny lesions occur initially and as it heals ,it tightens the tissues and increases muscle mass at the LES Lasts 45 minutes ; recovery time is 1-2 days ENTERYX PROCEDURE PURPOSE to TIGHTEN the lower esophageal sphincter INJECTION OF SOFT, SPONGY PERMANENT IMPLANT 41 made of liquid polymeric material into the LES muscle

42

21

9/20/2012

43

PATIENT CARE AFTER ENDOSCOPIC THERAPIES

Maintain on CLEAR LIQUIDS for 24 hours After the DAY 1 shift to SOFT DIET such as custard, pureed vegetables, mashed potatoes Avoid NSAIDs and ASPIRIN for 10 days Give LIQUID MEDICATIONS as much as possible Avoid NGT INSERTION for at least 1 month Watch out for CHEST or ABDOMINAL PAIN, BLEEDING, DYPHAGIA, SHORTNESS OF BREATH, NAUSEA or VOMITING
44

22

9/20/2012

HIATAL HERNIA
ETIOLOGY
Portion of the stomach protruding through a hiatus (opening) in the diaphragm into the thoracic cavity result from a congenital weakness of the diaphragm or from injury, pregnancy, or obesity Function of the cardiac sphincter is lost, gastric juices enter the esophagus causing inflammation

23

9/20/2012

B. CLINICAL FINDINGS:

1. Subjective:
substernal burning pain fullness after eating dyspepsia in the recumbent position nocturnal dyspnea.

2. Objective:
GI series and endoscopy

C. THERAPEUTIC INTERVENTIONS: Small, frequent, bland feedings. Pharmacologic management:

Antacids antisecretory agents antiemetics, especially those that promote gastric emptying

Surgical repair (done infrequently) Fundoplication

24

9/20/2012

FUNDOPLICATION
the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter: Whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. This prevents the reflux of gastric acid (in GERD). The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia, in which the fundus slides up through the enlarged esophageal hiatus of thediaphragm.

NURSING CARE: Teach the client and family about the dietary regimen Encourage attempts at weight loss Avoid constricting clothing and heavy lifting Encourage the client to sit up for at least 1 hour after eating Encourage the client to eat slowly and avoid drinking fluids with meals to limit the volume in the stomach

25

9/20/2012

ACHALASIA
a disorder in which the lower esophageal sphincter does not relax when food passes down the esophagus to the stomach. As a result, the esophagus becomes distended and filled with food, and food passes into the stomach very slowly. often associated with chest pain during eating, weight loss, and regurgitation of food. The lower esophagus becomes distended as food and liquid are unable to pass into the stomach.

MANAGEMENT
Eat slowly and to drink fluids with meals Calcium channel blockers and nitrates (to decrease esophageal pressure and improve swallowing) Injection of botulinum toxin (Botox) Pneumatic dialtion Esophagomyotomy

26

9/20/2012

SPECIAL NUTRITIONAL MODALITIES

27

9/20/2012

Enteral Feeding Defined

Enteral feeding is the term used when nourishment is put directly into the stomach or intestines by a method other than chewing or swallowing.

When to Use Enteral Feeding?

If no weight gain for 3 months ( less for infants and young children) Indicators of fat or muscle mass has decreased or are below 5th percentile Oral feeds providing less than 80% of required calories or not meeting fluid needs Caregiver spending more than 4-6 hrs a day feeding Oral-motor skills prevent adequate intake Risk of aspiration

28

9/20/2012

When to use ..
A.I.D.S. Burns Cancer Oro-motor anomalies Anorexia nervosa Many short term uses

Types of Enteral Feeding

Nasogastric NG Tube short term use advantage- no surgery required disadvantages discomfort, in infants can decrease the suck/swallow reflex must be positioned correctly

Very seldom used for our clients

29

9/20/2012

Nasogastric tube

Nasogastric tube

30

9/20/2012

Nasogastric tube
One of the nostrils nasopharynx tract alimentary tract

Nasogastric tube
Traditional large-bore nasogastric tube Larger than 12 Fr in diameter, firm E.g. Levin tube, single lumen E.g. Salem sump tube, double lumen Will cause pharyngitis, tracheal-oesophageal erosion Advantage: easy to aspirate the gastric content, aspiration Small- bore tube Smaller than 12 Fr in diameter, softer More flexible,less irritating Need to check the correct placement as migrate easily

31

9/20/2012

Fr Unit (French unit)

A unit for denoting the size of catheter or other tubular instruments, each unit being roughly equivalent to 0.3mm in diameter 18French (Fr) indicates a diameter of 6mm

What does it for?

Levin tube

Salem sump tube

32

9/20/2012

It acts as a air vent To prevent build up of suction pressure in the tube To avoid damage to gastric mucosa
Levin tube

Salem sump tube

Nasogastric tube
For clients who have intact gag and cough reflexes To provide nutrition To prevent nausea, vomiting and gastric distention following surgery To remove stomach contents for laboratory analysis To lavage (wash) the stomach in cases of poisoning or overdose of medications

33

9/20/2012

Nasoenteric tube
A longer tube (at least 40 inches for an adult) Nostril to upper small intestine Requires special trained nurses or physicians for this procedure For client who are at risks for aspiration Decreased level of consciouness Poor cough or gag reflexes Endotracheal intubation Recent extubation Inability to cooperate with the procedure Restlessness or agitation

How to confirm the tube is in-situ?

Aspiration of visually recognizable gastrointestinal secretion Auscultation of air insufflated through the tube pH testing of aspirates Observing for coughing and choking Testing the ability to speak Observing for bubbling when the tip of the tube is held under water X-ray

34

9/20/2012

Gastronomy Tube Sites

Percutaneous endoscopic gastrostomy(PEG)

Percutaneous endoscopic gastrostomy (PEG) A technique for the endoscopic insertion of a gastrostomy feeding tube, for the purpose of providing enteral feeding

35

9/20/2012

Percutaneous endoscopic gastrostomy(PEG

Percutaneous endoscopic jejunostomy (PEJ) A technique for the endoscopic insertion of a feeding tube through a PEG Tubing and into jejunum, for the purpose of providing enteral feeding (Kozier)

G-Tube Feeds
Well suited for longterm Enteral feeding. More comfortable, do not irritate nasal passage, esophagus or trachea, cause facial skin irritation or interfere with breathing. Stable more physiologic, allowing some continued oral eating.

36

9/20/2012

G-Tube Disadvantages
the surgery required to place the tube possible skin irritation or infection around the site slight risk of intraabdominal leakage resulting in peritonitis. Of special concern is the child with poor gastric emptying and or severe reflux or intractable vomiting.

G-Tubes
Button G tubes are at skin level and easily hidden under clothing. G tubes generally use a large-bore tube which allows a more viscous feeding and decreased risk of tube occlusion.

37

9/20/2012

Jejunal Tube feeding

Tube feeding directly into the jejunum ( middle section of the small intestine) Used for severe gastric reflux or a high risk of aspiration. The jejunal tube bypasses the stomach decreasing the risk of gastric reflux and aspiration

J-Tube Feeds
Disadvantages: Difficult to position, and may dislodge or relocate Must be checked often by ex-ray Require continuous drip and slower feeding time. Grater risk of formula intolerance and nausea, diarrhea Formulas more expensive

38

9/20/2012

Continuous Drip
Gravity Drip less expensive than pump Infusion Pump provides consistent, uniform amount of formula

Administration of Nourishment
Bolus Feeding
delivered 4-8 x a day directly into stomach each feed lasts 15 minutes more convenient less expensive not always easily tolerated or digested allows for supplemental feeds in the event of undernourished

Continuous Drip By gravity or Infusion Pump feeding may be delivered without interruption for an unlimited period of time each day Commonly used for 8-10 hours during the night with bolus supplements during the day good for extremely malnourished

39

9/20/2012

Continuous Drip Pump

Several types of pumps exist, some have back packs and battery packs and are more easily transported. Kangaroo Brand

Kangaroo Pump

40

9/20/2012

Formula
Disease - Specific have fibre milk -based blends contain electrolytes
TRADE NAMES NutriSource Pediasure Enercal Ensure Suplena Resource

Complications Common
Gas, bloating, pain and discomfort Aspiration reflux Inability to tolerate particular formula Nausea , Vomiting Diarrhea Constipation child pulls tube out Inappropriate Mixes can cause dehydration or electrolyte imbalances clogged tubes Leakage of gastric contents Bleeding around the stoma Infection of stoma Scar tissue build up

41

9/20/2012

When The Tube needs changing or if Johnny pulls it out!

Dont panic! 1.Have extra sets on hand for this purpose and one at school. 2. Make sure balloon in new set works by injecting sterile saline into the port .

Changing a g tube....
3. Draw out saline from existing tube, Drain it completely. 4.Hold the button area down. 5. Put sterile gauze around the area keeping child flat and tummy muscles loose.

42

9/20/2012

Changing the G tube

6. Begin pulling gently on the tube, lifting it out of place. No rush. 7. If you meet with resistance, try withdrawing more saline from balloon. Sometimes air and or blood come out with the tube.

Changing continued.
8. With sterile Gauze wipe the area, dab the actual hole, remove excess blood or fluid. 9. Gently insert the new GTube into the opening. 10. Fill the balloon slowly with saline.

43

9/20/2012

Finished!!
Make sure to double check the syringe and that the saline has not gone back into the syringe...

Summary Enteral Feeding

For under or malnourished individuals Can be inserted into stomach or jejunum Formula is either a supplement to the diet or the only form of nutrition the person receives. Each system is person specific. A strict protocol is followed know your client! Eating is essential for all of us!!!!!!!!

44

9/20/2012

Disorders of the Stomach and Small Intestine

DISORDERS OF THE GASTROINTESTINAL SYSTEM

GASTRITIS
Inflammation of the stomach mucosa

CLASSIFICATION Acute includes erosive gastritis and stress ulcers Chronic includes non-erosive gastritis
Types of chronic gastritis

Type A inflammation of the glands in the fundus and body Type B inflammation of the glands from fundus to antrum Atrophic diffuse inflammation and destruction of deeply located glands
90

45

9/20/2012

91

92

46

9/20/2012

ETIOLOGY

ACUTE GASTRITIS

CHRONIC GASTRITIS

Local irritants (drugs, alcohol, corrosive substances) Bacterial invasion by salmonella, E. Coli and H. Pylori)

May occur due to bile acid reflux (complication of gastrojejunal surgery or peptic ulcer disease) Chronic use of irritants

93

PATHOPHYSIOLOGY
Irritants Bacteria

Mucosal injury HCl diffuses into mucosa Erosion of GI lining Atrophy of GI glands and mucosa

Decreased acid secretion

Decreased intrinsic factor

Decreased vitamin B12 absorption

Pernicious anemia

94

47

9/20/2012

95

96

48

9/20/2012

97

ASSESSMENT ACUTE GASTRITIS rapid onset of epigastric pain Pain not relieved by food Anorexia Nausea and vomiting Dyspepsia gastric hemorrhage hematemesis CHRONIC GASTRITIS

vague epigastric pain pain relieved by food anorexia nausea and vomiting intolerance of fatty or spicy foods pernicious anemia

98

49

9/20/2012

DIAGNOSTIC TEST Esophagogastroduodenoscopy with biopsy

99

DRUG THERAPY H2 Receptor Antagonists Antacids Proton Pump Inhibitors Vitamin B12 (if there is pernicious anemia) Triple Therapy (if there is H. Pylori in biopsy) 1) 1 Bismuth subsalicylates or proton pump inhibitor (omeprazole) 2) 1 Antibiotic (metronidazole) 3) 1 Antibiotic (tetracycline, clarithromycin, amoxicillin) DRUGS TO AVOID aspirin, ibuprofen

100

50

9/20/2012

DIET THERAPY Instruct client to limit intake of foods and spices that cause distress e.g. Tea, cola, chocolate, mustard, pepper and hot spices Instruct client to avoid alcohol and tobacco Give soft, bland diet and smaller, more frequent meals STRESS REDUCTION Progressive muscle relaxation Cutaneous stimulation Guided imagery Distraction

101

SURGICAL MANAGEMENT Partial gastrectomy Pyloroplasty Vagotomy Total gastrectomy

102

51

9/20/2012

103

104

52

9/20/2012

105

PEPTIC ULCER DISEASE

ulceration of the gastric mucosa, duodenum and rarely the lower esophagus and jejunum TYPES 1. Gastric Ulcers 2. Duodenal Ulcers 3. Stress Ulcers

106

53

9/20/2012

108

54

9/20/2012

109

Parameter Age Gender Blood group

Gastric Ulcer Usually 50 years or older Male/Female ratio 1:1 No differentiation

Duodenal Ulcer Usually 50 years or older Male/Female ratio 1:1 Most often type O

General Nourishment
Stomach acid production Clinical course

May be malnourished
Normal secretion or hyposecretion Healing and recurrence

Usually well nourished

Hypersecretion Healing and recurrence

Pain

Occurs 30-60 minutes Occurs 1.5-3 hours after a after meal; at night rarely meal; at night 1-2 am
110

55

9/20/2012

Pain Quality

Accentuated by ingestion of food

Healing with appropriate therapy Hematemesis more common than melena Perhaps in less than 10%

Relieved by ingestion of food

Healing with appropriate therapy Melena more common that hematemesis Rare

Response to treatment Hemorrhage

Malignant change Recurrence

Tends to heal and recurs 60% recurrence in the often in the same location same year
111

PREDISPOSING FACTORS Stress Irregular hurried meals Smoking and alcoholism Caffeinated, fatty, spicy, acidic foods Ulcerogenic medications Aspirin, NSAIDs, Steroids GI disorders Gastritis, Zollinger-Ellison Syndrome Type A personality Type O blood

112

56

9/20/2012

PATHOPHYSIOLOGY Stress Stimulants Increased gastric glands activity Increased HCl and Pepsin (mucosal aggressor) Caffeine or Nicotine

Decreased blood flow

Decreased mucus (mucosal protector

Mucosal irritation and ulceration PEPTIC ULCER DISEASE

113

COMPLICATIONS Hemorrhage Perforation Pyloric Obstruction Intractable Disease

114

57

9/20/2012

ASSESSMENT HISTORY Alcohol and tobacco use Use of corticosteroids, aspirin and NSAIDs CLINICAL MANIFESTATIONS Epigastric tenderness Rigid, boardlike abdomen with rebound tenderness Diminishing hyperactive bowel sounds Dyspepsia Vomiting
115

DIAGNOSTIC TESTS Low hemoglobin and hematocrit Positive fecal occult blood test Barium examination Esophagogastroduodenoscopy (most accurate) Elevated Immunoglobulin G antibodies (suggest H. Pylori infection) Fecalysis

116

58

9/20/2012

DRUG THERAPY TRIPLE THERAPY (most successful regimen) 1) Bismuth compound or proton-pump inhibitor (omeprazole) 2) Metronidazole 3) Tetracyline or Clarithromycin and Amoxicillin HYPOSECRETORY DRUGS 1) Histamine Receptor Antagonists 2) Proton Pump Inhibitors 3) Prostaglandin Analogues
117

PROSTAGLANDIN ANALOGUES MISOPROSTOL (CYTOTEC) gastric secretion and resistance of mucosa to injury CONTRAINDICATION: pregnancy MUCOSAL BARRIER FORTIFIERS SUCRALFATE (CARAFATE) ACTION: forms a seal over the ulcer, protecting it from irritation INSTRUCTION: take 1 hour before meals and at bedtime SIDE EFFECT: constipation
118

59

9/20/2012

DIET THERAPY Bland diet Small frequent feedings (6 small meals/day) Avoid caffeine-containing foods (coffee, tea or cola) Avoid tobacco and alcohol

119

MANAGEMENT FOR HYPOVOLEMIA Monitor vital signs, intake and output Monitor serum electrolytes to determine need for replacement Administer ISOTONIC SOLUTIONS (NSS or lactated Ringers) Perform BLOOD TRANSFUSION as prescribed to expand blood volume If there is active bleeding, administer FRESH FROZEN PLASMA

120

60

9/20/2012

MANAGEMENT FOR BLEEDING Monitor for the following: signs of SHOCK (hypotension, chills, palpitations, diaphoresis, weak thready pulse) Occult blood hematocrit, hemoglobin and coagulation studies Perform GASTRIC DECOMPRESSION OR LAVAGE AVOID NSAIDS to minimize GI bleeding

121

ENDOSCOPIC THERAPY GOAL: promote blood clot formation METHODS OF ENDOSCOPIC THERAPY (1) THERMAL CONTACT heater probe or multielectrocoagulation (2) Inject bleeding site with diluted EPINEPHRINE (3) Laser therapy (4) Mechanical clip

122

61

9/20/2012

CLIENT PREPARATION Administer SEDATIVES e.g. midazolam and meperidine Place on NPO 6 hours prior the procedure CARE AFTER THE PROCEDURE Resume diet once gag reflex is present

123

MANAGEMENT FOR PERFORATION Replace lost fluids, blood and electrolytes Administer of antibiotics Place on NPO Gastric lavage or decompression Monitor for signs of septic shock (fever, pain, tachycardia, lethargy or anxiety)

124

62

9/20/2012

125

SURGICAL MANAGEMENT FOR OBSTRUCTION Gastroduodenostomy (Billroth I) Gastrojejunostomy (Billroth II) Partial Gastrectomy Pyloroplasty CLIENT PREPARATION Insert NGT connected to suction to remove secretions and empty the stomach

126

63

9/20/2012

127

128

64

9/20/2012

POST-OPERATIVE CARE Monitor placement, patency and drainage of NGT Monitor for DUMPING SYNDROME

129

65

9/20/2012

SIGNS AND SYMPTOMS OF DUMPING SYNDROME EARLY SIGNS (within 30 minutes after feeding) LATE SIGNS
(90 minutes-3 hours after feeding)

Vertigo Tachycardia Syncope Sweating Pallor Desire to lie down

Dizziness Light-headedness Palpitations Diaphoresis Confusion

131

MANAGEMENT FOR DUMPING SYNDROME Small frequent feeding Do not take fluids with meals Advise high-protein, high-fat, low-to-moderate carbohydrate diet Administer pectin to prevent the syndrome

132

66

9/20/2012

GASTROENTERITIS
Inflammation of the mucous membranes of the stomach and the intestinal tract CLASSIC MANIFESTATION increase in the frequency and water content of the stools or vomiting TYPES VIRAL caused by norwalk virus or rotavirus BACTERIAL caused by E. Coli, campylobacter enteritis or shigellosis

133

134

67

9/20/2012

PATHOPHYSIOLOGY Microorganisms Irritation of GI tract Inflammation of GI tract Increased GI motility Decreased absorption of water Decreased digestion and absorption

Increased defecation of soft watery stool Dehydration and malnutrition

135

ASSESSMENT Nausea and vomiting (first 2 days of illness) Diarrhea Myalgia Headache Malaise Abdominal tenderness

136

68

9/20/2012

SIGNS OF DEHYDRATION Poor skin turgor Dry mucous membranes Hypotension Oliguria

Parameter Duration of Diarrhea Stool

Viral 24-48 hours Watery

Campylobacter 20-30 defecation for 7 days Watery Foul-smelling Some blood None Yes

E. Coli 10 days

Shigella 5 days

Watery Watery Some blood Some blood Some mucus Some mucus None None Yes None

White blood cells Red blood cells

None None

138

69

9/20/2012

MANAGEMENT FLUID REPLACEMENT Monitor vital signs, I and O and weight (1 kg weight loss is equivalent to 1 L loss) Administer HYPOTONIC IV FLUIDS (0.45% NaCl) Oral Rehydration Salts (Oresol) If with HYPOKALEMIA Incorporate potassium supplements Observe standard precautions

139

DIET THERAPY IF NOT ACTIVELY VOMITING clear liquids with electrolytes IF VOMITING NPO IF TREATED crackers, toast and jelly IF IMPROVING bland diet AVOID caffeine

140

70

9/20/2012

DRUG THERAPY LOPERAMIDE (IMODIUM) to inhibit peristalsis BISMUTH SUBSALICYLATES (PEPTO-BISMUL) to reduce watery volume of stool ( suppresses H. Pylori and assist in healing of mucosal lesions) ANTIBIOTICS NORFLOXACIN OR CIPROFLOXACIN If caused by bacteria TRIMETHOPRIM - SULFAMETHOXAZOLE (BACTRIM)

141

SKIN CARE Avoid toilet paper and harsh soap Use warm water and absorbent cotton Apply cream, oil or gel to excoriated skin Provide witch hazel compress and sitz bath

142

71

9/20/2012

Disorders of the Lower GI Tract

DISORDERS OF THE GASTROINTESTINAL SYSTEM

INFLAMMATORY BOWEL DISEASES

ULCERATIVE COLITIS chronic inflammatory process affecting the mucosa and submucosa of the SIGMOID COLON and RECTUM CROHNS DISEASE (REGIONAL ENTERITIS) subacute or chronic inflammatory bowel disease affecting segmental areas along the ENTIRE WALL OF THE GI TRACT; most commonly noted at within the TERMINAL ILEUM

144

72

9/20/2012

146

73

9/20/2012

PARAMETER Other Name Location Cause

ULCERATIVE COLITIS None Rectum/lower colon Unknown Familial Jewish Emotional stress autoimmune 15-40 years old

CROHNS DISEASE Regional Enteritis Distal Ileum/ascending colon Unknown Jewish race Environmental

Age

20-30 years old 40-60 years old 50-80 y/o moderate Stool with pus and mucus Severe

Bleeding

Severe Stool with pus, mucus and blood Mild

Perianal Involvement

147

Parameter Rectal Involvement

Ulcerative Colitis 100%

Crohns Disease 20%

Diarrhea Abdominal pain Weight loss Interventions

20-30 watery stool/day Yes

Yes Diet Total parenteral nutrition Steroids Azulfidine Ileostomy or Proctosigmoidoscopy

5-6 soft stool/day yes

Yes TPN Azulfidine(steroids,sulfon amide) Ileostomy or Colectomy ** recurrence is common
148

74

9/20/2012

PATHOPHYSIOLOGY OF ULCERATIVE COLITIS AND CROHNS DISEASE Inflammation of the intestinal mucosa Ulceration surface epithelium Abscess formation

Poor absorption of vital nutrients Stool containing blood and mucus Thickening of the colon wall Fibrosis and retraction of the bowel

149

CLINICAL MANIFESTATIONS
PARAMETER FEVER FOOD INTOLERANCE WEIGHT LOSS FREQUENCY OF BM STOOL ABDOMINAL PAIN OTHER SIGNS ULCERATIVE COLITIS Low-grade Intolerance to dairy, spicy and greasy foods Yes 10-20/day Bloody Cramping ( LLQ) Tenesmus , urgency Anorexia Fatigue Rebound tenderness (RLQ) CROHNS DISEASE Low-grade none Yes 5-6/day Loose Periumbilical & RLQ Steatorrhea

75

9/20/2012

DRUG THERAPY 1. SALICYLATE COMPOUNDS Drug Name Sulfasalazine (Azulfidine) Indication Management of ulcerative colitis Action inhibit prostaglandin synthesis to reduce inflammation Adverse effects leukopenia and anemia Client Instructions (1) take the drug with a full glass of water (2) take the drug after meals to prevent GI discomfort
151

2. ORAL OR INTRAVENOUS CORTICOSTEROIDS Drug Name Prednisone Indication to reduce inflammation Adverse Effects hyperglycemia, osteoporosis, peptic ulcer disease, increased risk for infection 3. IMMUNOSUPPRESIVE DRUGS Should be given in combination with steroids to be effective Drug Name cyclosporine, mercaptopurine Indication to reduce inflammation Adverse Effects thrombocytopenia, leukopenia, anemia, renal failure, infection, headache, stomatitis, hepatotoxicity
152

76

9/20/2012

4. ANTI-DIARRHEAL DRUGS diphenoxylate HCl, atropine sulfate (lomotil), loperamide (imodium) 5. INFLIXIMAB (REMICADE) given for refractory disease or for toxic megacolon an immunoglobulin G that neutralizes activity of tumour necrosis factor

153

DIET THERAPY If client has severe symptoms: NPO Total Parenteral Nutrition (TPN)

154

77

9/20/2012

Avoid: Whole-wheat grains Nuts fresh fruits and vegetables lactose containing foods caffeinated beverages Pepper Alcohol smoking

COMPLEMENTARY AND ALTERNATIVE THERAPIES Vitamin C Biofeedback Hypnosis Yoga Acupuncture

156

78

9/20/2012

SURGICAL MANAGEMENT INDICATIONS FOR SURGERY Bowel perforation Toxic megacolon Hemorrhage Colon cancer Failure of conventional treatment

157

TOTAL PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY Terminal ileum is pulled through the abdominal wall and forms a stoma or ostomy
PRE-OPERATIVE CARE Administer oral or parenteral antibiotic such as neomycin sulfate (Mycifradin) as a bowel antiseptic Administer laxative or enema

158

79

9/20/2012

POST-OPERATIVE CARE Monitor color, odor, consistency of ileostomy output (effluent) Instruct client to report any foul or unpleasant odor (it may indicate intestinal blockage or infection) Instruct the client to wear pouch system at all times Apply skin barrier to prevent irritation and injury to the skin

159

TOTAL COLECTOMY WITH CONTINENT ILEOSTOMY Alternative to traditional ileostomy with external pouch Creation of an internal reservoir called a Kocks ileostomy or ileal reservoir to be drained periodically

Post-Operative Care Monitor character and quality of effluent Teach the client to drain stoma when sensation of fullness is felt Apply a small dressing to keep stoma moist
160

80

9/20/2012

TOTAL COLECTOMY WITH ILEOANAL ANASTOMOSIS Removal of the colon and rectum with anastomosis of the ileum and the anal canal

161

162

81

9/20/2012

163

164

82

9/20/2012

165

DISCHARGE INSTRUCTIONS FOR CLIENTS WITH ILEOSTOMY SKIN CARE Use pectin-based skin barrier to protect skin from irritation Use skin sealants and ostomy skin creams Monitor skin for irritation POUCH CARE Empty pouch when it is 1/3 full Change pouch at intervals such as before meals, before bedtime, before walking at morning, 2-4 hours after meals Change pouch system every 3-7 days

166

83

9/20/2012

DIET Chew food thoroughly Be cautious in taking high-fiber and high-cellulose foods such as popcorn, peanuts, coconut, string beans, shrimp and lobster, rice, skinned vegetables (tomatoes, corn and peas) MEDICATIONS Avoid taking enteric-coated and capsule medications Do not take laxative or enema Contact physician if no stool has passed in 6-12 hours
167

DANGER SIGNS Drastic increase or decrease in effluent Stomal swelling, abdominal cramping, distention, and absence of drainage INTERVENTIONS FOR DANGER SIGNS Remove pouch Lie down and assume knee-chest position Begin abdominal massage Apply moist towels to the abdomen Drink hot tea Contact health care provider

168

84

9/20/2012

IRRITABLE BOWEL SYNDROME

Also known as SPASTIC BOWEL OR MUCUS COLITIS Different from ulcerative colitis because there is no inflammation or ulceration present

RISK FACTORS Emotional stress or anxiety, depression Diverticulitis Intolerance to gastric stimulants such as caffeine or spicy foods or lactose Diet high in fats Smoking and alcohol
CAUSE : UNKNOWN
169

INCIDENCE Common among women, Caucasians and Jewish population

PATHOPHYSIOLOGY AND CLINICAL MANIFESTATIONS
Emotional stress Anxiety Diverticulitis Stimulants Alteration in gastric motility Constipation Diarrhea

Abdominal cramps (relieved by defecation) Bloating Anorexia Fatigue Headache

170

85

9/20/2012

DIAGNOSTIC TESTS Contrast studies Barium enema Colonoscopy Manometry and electromyography- to study intraluminal pressure changes that generated spasticity

NURSING INTERVENTIONS Administer anti-diarrheals, antispasmodics, bulk-forming laxatives as ordered Encourage high-fiber diet and avoid fatty and gas forming foods (carbonated beverages, cauliflower or beans) Instruct client to avoid alcohol and tobacco Encourage to increase oral fluids intake but should not be taken with meals because it can result to distention. Instruct on lifestyle changes (regular exercise, adequate rest periods, stress management) Anticholinergics and Ca channel blockers

172

86

9/20/2012

DIVERTICULOSIS AND DIVERTICULITIS

TWO FORMS OF DIVERTICULAR DISEASE (1) DIVERTICULOSIS asymptomatic multiple out-pouching of the intestinal mucosa WITHOUT INFLAMMATION (2) DIVERTICULITIS symptomatic multiple out-pouching of the intestinal mucosa WITH INFLAMMATION; causes retention of hardened stool; 20% of patients with diverticulosis results to diverticulitis.

INCIDENCE More common in older adults More prevalent in men

173

174

87

9/20/2012

175

Acute diverticulitis occurs when a section of colon reveals acute inflammation (hyperemia, swelling) of the serosa and pericolic fat.

A section of colon reveals numerous diverticula which protrude from the edge of the taenia coli (*). The colon is cut in cross section revealing the diverticuli (contain feces) and the empty colonic lumen.

88

9/20/2012

89

9/20/2012

PREDISPOSING FACTORS Diet low in fiber Diet high in refined carbohydrates COMPLICATIONS Bowel perforation and peritonitis Bowel obstruction Hemorrhage Shock

179

PATHOPHYSIOLOGY
High intraluminal pressure Low volume in the colon Decreased muscle tone

Colon herniates to the muscular wall ( diverticulum)

Bowel contents dislodged and decompose at the diverticulum

Peritonitis

Abscess develops Perforation Inflammation ( diverticulum)

Arterial bleeding

Erosion of blood vessels

90

9/20/2012

ASSESSMENT Acute onset of crampy abdominal pain in the left lower quadrant Abdominal distention Low-grade fever Chronic constipation with intervals of diarrhea Occult bleeding Nausea and vomiting Leukocytosis

181

DIAGNOSTIC TESTS Barium enema and colonoscopy (contraindicated if there is diverticulitis due to the danger of perforation) Complete blood count increase ESR and WBC Urinalysis CT Scan procedure of choice & can reveal abscess

182

91

9/20/2012

NURSING INTERVENTIONS Instruct client to eat high-fiber foods Encourage to increase fluids Administer bulk laxatives and anticholinergics as prescribed Encourage client to lose weight and avoid activities that increase intra-abdominal pressure such as straining at stool (valsalva maneuver), vomiting, lifting, bending, lifting or tight clothing SURGICAL MANAGEMENT Colon resection with temporary colostomy
183

APPENDICITIS
Inflammation of the vermiform appendix More common in males 10-30 years of age ETIOLOGY Obstruction by fecal impaction, kinking of the appendix, parasites or infections Low fiber diet High intake of refined carbohydrates

184

92

9/20/2012

PATHOPHYSIOLOGY

Inflammation Increased intraluminal pressure Lymphoid swelling Decreased venous drainage Thrombosis Bacterial invasion

Abscess
Gangrene Perforation within 24 hours Peritonitis
186

93

9/20/2012

ASSESSMENT Acute abdominal pain at RLQ or McBurneys point (halfway between the umbilicus and the anterior iliac crest) Anorexia, nausea and vomiting Rigid and guarded abdomen Blumberg sign (rebound tenderness) Fever (temperature of 38-38.5 C) Psoas Sign (lateral position with right hip flexion) Decreased or absent bowel sounds

187

DIAGNOSTIC TESTS WBC Count Leukocytosis: WBC above10,000/mm3 Perforation: suggested if WBC is above 20,000/mm3 Ultrasound may reveal enlarged appendix Barium Enema or CT Scan Ordered if symptoms are recurrent or prolonged May reveal presence of fecalith

188

94

9/20/2012

MANAGEMENT Maintain patient on NPO for possible admission Administer IV fluids as prescribed to prevent fluids and electrolyets imbalance Maintain patient in semi-Fowlers position to prevent upward spread of infection DO NOT GIVE LAXATIVE NOR ENEMA to prevent perforation of the appendix DO NOT APPLY LOCAL HEAT to prevent inflammation and perforation; instead apply COLD HEAT
189

SURGICAL MANAGEMENT LAPAROSCOPY A small incision in the umbilicus is made and a small endoscope is used to visualize the appendix If diagnosis is not definitive LAPAROTOMY An open approach in which large abdominal incision is made

190

95

9/20/2012

191

192

96

9/20/2012

193

APPENDECTOMY Removal of the inflamed appendix Guided with laparoscopy Done with spinal anesthesia NURSING CARE AFTER APPENDECTOMY Maintain client flat on bed for 6-8 hours Monitor for return of sensation in the lower extremities Maintain on NPO until peristalsis returns Instruct client to ambulate after 24 hours Tell the client that he can resume normal activities within 2-4 weeks
194

97

9/20/2012

PERITONITIS
Inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera TYPES OF PERITONITIS 1. PRIMARY acute bacterial infection resulting from contamination of the peritoneum through the vascular system May occur from tuberculosis, cirrhosis and ascites 2. SECONDARY bacterial invasion resulting from acute bacterial abdominal disorder May occur from gangrenous bowel, visceral perforation, bile leakage, blunt or penetrating trauma(gunshot 195 wound)

196

98

9/20/2012

Spillage of chemical to peritoneum

Inflammation Abscess Initially - hypermotility Decrease motility

bacterial proliferation fluid shift to peritoneal cavity

Intestinal obstruction Paralytic ileus Bowel distention sec. to trapped gas and fluid

Hypovolemia Electroyte imbalance Dehydration shock

Increasing CHON,WBC, cellular debri and blood

197

CLINICAL MANIFESTATIONS RIGID, BOARDLIKE ABDOMEN (CLASSIC SIGN) Abdominal pain diffuse and become localized near the site of inflammation. Distended abdomen Nausea, anorexia and vomiting Diminishing bowel sounds Inability to pass flatus or feces Rebound tenderness in the abdomen High fever Dehydration Oliguria Hiccups
198

99

9/20/2012

DIAGNOSTIC ASSESSMENT
ELEVATED WBC: 20,000/MM3 Hgb and Hct may be low Altered levels of K+, Na +. Cl Abdominal x-ray may show free air and fluid in the peritoneum CT Scan or ultrasound - changes in abdominal organs Peritoneal Lavage may reveal the following WBC: 500/ml RBC: 50,000/ml Gram stain: (+) bacteria Culture reveals: E.coli, klebsiella, proteus, pseudomonas If untreated can result to septic shock and death
199

MANAGEMENT Administration of the following as prescribed IV fluids to replace lost fluids (isotonic) Broad spectrum antibiotics Oxygen if there is dyspnea due to ascites Analgesics (meperidine or morphine) Antiemetics (metoclopramide) Monitor daily weight, intake and output to monitor fluid status Side lying with knees flexed to lessen pain NGT insertion to decompress the stomach and intestine Maintain client on NPO
200

100

9/20/2012

SURGICAL MANAGEMENT Abdominal surgery guided by exploratory laparotomy Appendectomy if there is appendicitis Colon resection with or without colostomy if there is bowel perforation

201

NURSING CARE AFTER SURGERY Maintain patient in SEMI-FOWLERS POSITION to promote drainage of peritoneal contents and allow adequate lung expansion Perform PERITONEAL IRRIGATION as prescribed Check for presence of abdominal distention or pain (suggetive of irrigant retention) Assess incision,dressing and drains Instruct client to AVOID LIFTING for at least 6 weeks COMPLICATIONS - Sepsis- major cause of death - Wound evisceration and dehiscence ( sudden occurrence of serous sanguinous wound drainage

101

9/20/2012

HEMORRHOIDS
dilated and painful veins in the rectum, anal canal, inside or outside the anal sphincter CLASSIFICATIONS Internal hemorrhoids ABOVE the anal sphincter External hemorrhoids BELOW the anal sphincter

203

204

102

9/20/2012

RISK FACTORS Familial tendency Straining at stool Prolonged sitting or standing Pregnancy , prolonged labor Obesity Portal hypertension Anal intercourse Colon malignancy

205

PATHOPHYSIOLOGY

Chronic straining, frequent defecation

Weakening of tissue supporting the veins

No adequate connective tissue & muscle support,

Veins will be displaced from their normal position

Veins dilate , fill with blood

103

9/20/2012

ASSESSMENT Bleeding with defecation of hard stool and pain due to stretching and irritation of mucosa External hemorhoids- extreme pain due to thrombosis and edema ; appear reddish blue lump Internal hemorrhoids- not usually painful, until it bleeds & prolapse when enlarged ; some protrudes during defecation and retracts after defecation
DIAGNOSTIC TESTS Digital rectal examination Sigmoidoscopy Colonoscopy rules out colorectal CA
207

NURSING INTERVENTIONS Instruct client on the importance of HIGH-FIBER DIET and INCREASED FLUID INTAKE Instruct client to take STOOL SOFTENERS and use ointments such as dibucaine, anti-inflammatories, or astringents ( medication that causes contraction or constriction of tisuues) Apply ICE PACKS for several hours followed by warm packs
208

104

9/20/2012

SURGICAL MANAGEMENT HEMMORHOIDECTOMY- removal of hemorrhoid

Internal and external packing secured by a T-binder

Cryosurgery application of extreme low temperature to destroy or remove diseased tissue(prolonged wound healing) Rubber band ligation- internal hemorrhoids ( anoscope & small rubber band)

209

PREOPERATIVE CARE Advise low residue diet Administer stool softeners NURSING CARE AFTER HEMORRHOIDECTOMY Watch out for bleeding Place the client in PRONE OR SIDE-LYING POSITION Administer analgesics as prescribed Administer stool softeners Offer warm Sitz baths 3-4 times a day
210

105

9/20/2012

Disorders Involving the Accessory Organs

DISORDERS OF THE GASTROINTESTINAL SYSTEM

106

9/20/2012

Gallbladder
located in the right upper quadrant major function is storage and concentration of bile contracts during digestion to force bile ( into the duodenum the sphincter of Oddi which keeps the ampulla of vater closed releases bile in the presence of cholecystokinin, pancreozymin and parasympathetic stimulation

CHOLELITHIASIS and CHOLECYSTITIS

CHOLELITHIASIS STONE FORMATION in the in the gallbladder and accessory ducts CHOLEDOCHOLITHIASIS- stone formed at the CBD CHOLECYSTITIS INFLAMMATION of the gallbladder

RISK FACTORS: 5Fs Female gender Fat (Obesity) Fair (Caucasian) Forty (age) Fertile (multigravida; use of contraceptive pills)

214

107

9/20/2012

108

9/20/2012

217

109

9/20/2012

PATHOPHYSIOLOGY

High Fat diet Gallstone formation (Cholelithiasis)

, ,

Obstruction Decreased fat emulsification Bile stasis Increased serum bilirubin

GB becomes Decreased bile inflammed, flow to colon swollen,disten Jaundice, urticaria, steatorrhea ded with bile Tea-colored urine Clay-colored stool Altered fat-soluble ( absence of bile 219 vitamin absorption pigment)

SIGNS AND SYMPTOMS CAUSE fat emulsification EFFECTS/MANIFESTATIONS Fat intolerance (belching,nausea,RUQ pain) Anorexia Nausea and vomiting Weight loss Gaseous eructation Flatulence Steatorrhea Pain (Right Upper Quadrant) may radiate to right shoulder and back- biliary colic Fever Leukocytosis
220

Inflammation

110

9/20/2012

bile flow to colon

Steatorrhea Clay- colored stool vitamin K absorption

serum bilirubin

Slight jJaundice Pruritus Tea-colored urine

221

DIAGNOSTIC TESTS Ultrasonography Dx procedure of choice. Accurate,can be used even if pt liver dysfunction and jaundice. 95% stone detection Oral cholecystography ( gallbladder imaging) IV cholangiogram Prolonged Prothrombin time Complete blood count - leukocytosis
222

111

9/20/2012

TYPES OF CHOLECYSTOGRAPHY 1) ORAL done 10 HOURS after administration of contrast medium 2) INTRAVENOUS done 10 MINUTES after administration of contrast medium

223

ORAL CHOLECYSTOGRAPHY radiographic examination of the gallbladder PURPOSES OF ORAL CHOLECYSTOGRAPHY 1) To detect gallstones 2) Assess the ability of the gallbladder to fill, concentrate and store a dyelike, iodine based radiopaque contrast medium.

224

112

9/20/2012

NURSING CONSIDERATIONS 1) ASSESS FOR ALLERGIES to iodine, seafood, or contrast media 2) Administer contrast medium 10-12 hours before x-ray study 3) Instruct patient to remain NPO AFTER TAKING THE CONTRAST medium to prevent contraction and emptying of the gallbladder 3) DEFER THE PROCEDURE IF PATIENT IS JAUNDICED!!!

PREPARING A PATIENT FOR CHOLECYSTOGRAPHY Instruct to have FAT FREE DINNER Place patient on NPO 2 HOURS BEFORE the test
PREPARING A PATIENT FOR CHOLANGIOGRAPHY ASSESS FOR ALLERGY TO IODINE!!! Instruct to drink ample amount of fluids after the procedure to promote excretion of dye Instruct that a burning sensation and nausea can occur during dye administration.
226

113

9/20/2012

NURSING CARE AFTER CHOLANGIOGRAPHY Check for HYPERSENSITIVITY REACTION Instruct client that excretion of dye would cause BURNING SENSATION during urination

227

NURSING INTERVENTIONS Administer MEPERIDINE HCL (drug of choice) as prescribed for pain relief AVOID ADMINISTERING MORPHINE!!! it may cause spasm of the sphincter of Oddi Use BAKING SODA or CALAMINE-CONTAINING LOTIONS for pruritus Encourage LOW-FAT DIET Administer BILE SALTS such as Chenodeoxycholic acid or Ursodioxycholic acid (UDCA)

228

114

9/20/2012

SURGICAL MANAGEMENT Cholecystectomy PREOPERATIVE NURSING CARE Administer IV fluids to replace electrolytes Administer vitamin K injection, especially if prothrombin time is prolonged

229

POSTOPERATIVE NURSING CARE Place patient in SEMI-FOWLERS POSITION to promote lung expansion NGT DECOMPRESSION to prevent gastric distention LOW-FAT DIET for 2-3 months Encourage ambulation after 24 hours Encourage to resume normal activities within 2-3 days Monitor T-Tube if common bile duct exploration was done

230

115

9/20/2012

T-TUBE INSERTION Purpose to DRAIN BILE Drainage Characteristics It should be BROWNISH RED for the first 24 hours It should be 300-500 ML for the first 24 hours Nursing Responsibilities Place drainage bottle AT THE LEVEL OF THE INCISION
231

232

116

9/20/2012

Pancreas
Large elongated accessory organ of digestion secretes bicarbonate and pancreatic enzymes aiding in the process of digestion (exocrine function- amylase,lipase,trypsin) contains the islets of Langerhans composed of beta cell secreting insulin and alpha cells secreting glucagon

117

9/20/2012

PANCREATITIS
Inflammation of the pancreas CAUSE is unknown; linked with autodigestion
TYPES (1)Acute vary from mild, self-limiting disorder to severe, fatal and does not respond to any treatment. - edema and inflammation confined to the pancreas (2) Chronic RISK FACTORS Alcohol abuse MEDICATIONS: Antihypertensives, diuretics, antimicrobials, immunosuppresives, oral contraceptives GI DISORDERS: Biliary obstruction and intestinal diseases

235

236

118

9/20/2012

PATHOPHYSIOLOGY Disruption of pancreatic ducts Pancreatic enzymes spill into pancreatic tissues Autodigestion Inflammation Necrosis

237

ASSESSMENT
ACUTE PANCREATITIS SEVERE, CONTINUOUS left upper quadrant pain radiating to the back CHRONIC PANCREATITIS HEAVY, GNAWING, OCCASIONAL BURNING OR CRAMPY left upper quadrant abdominal pain malabsorption and weight loss Pain not relieved by vomiting Flexion of the spine Low-grade fever and leukocytosis mild jaundice with dark urine and steatorrhea diabetes mellitus

Pain aggravated by eating

238

119

9/20/2012

DIAGNOSTIC TESTS Elevated serum and urinary amylase, serum lipase, serum bilirubin, alkaline phosphatase, and sedimentation rate White blood cell count Fecal fat determinations Blood and urine glucose

239

NURSING INTERVENTIONS Administer MEPERIDINE HCL (DEMEROL) as ordered AVOID MORPHINE SULFATE!!! Place client on NPO DURING ACUTE PHASE bland, LOW-FAT DIET; avoid alcohol NGT DECOMPRESSION insertion to remove gastrin and prevent further stimulation of the pancreas Administer CALCIUM SUPPLEMENTS (WITH VITAMIN D) if there is hypocalcemia Administer INSULIN as ordered if there is hyperglycemia
240

120

9/20/2012

LIVER CIRRHOSIS
Irreversible chronic inflammatory disease characterized by massive degeneration and destruction of hepatocytes resulting in a disorganized lobular pattern of regeneration TYPES/CAUSES (1) LAENNECS caused by ALCOHOLISM or hepatotoxic drugs (2) POST-NECROTIC caused by viral HEPATITIS or industrial hepatotoxins (3) BILIARY caused by BILIARY PROBLEMS (4) CARDIAC caused by CONGESTIVE HEART FAILURE (CHF)
241

PATHOPHYSIOLOGY

Chronic inflammation Destruction of hepatocytes

Fibrosis and scarring

Obstruction of blood flow Portal hypertension
242

121

9/20/2012

ASSESSMENT vitamin K absorption bleeding tendencies glycogen stores hypoglycemia serum albumin hydrostatic pressure edema and ascites bilirubin metabolism hyperbilirubinemia jaundice Portal hypertension esophageal varices, hepatomegaly ADH hyponatremia serum ammonia hepatic encephalopathy

243

244

122

9/20/2012

DIAGNOSTIC TESTS LIVER BIOPSY (definitive test) Abdominal x-ray Ct scan Endoscopy Elevated Aspartate Aminotrasferase (AST)(SGOT) 4.819U/L, Alanine Aminotrasferase (ALT)(SGPT) 2.4-17 U/L, bilirubin TB- 0-0.9mg/dL Prolonged prothrombin time (PT) 12-16 seconds Decreased serum albumin CBC reveals anemia Serum ammonia = 150-250mg/dL 245

PREPARING A PATIENT FOR ULTRASOUND OF THE LIVER Place patient on NPO 8-12 hours before the procedure Administer laxative a night before the test Maintain adequate hydration

246

123

9/20/2012

PREPARING A PATIENT FOR LIVER BIOPSY Place patient on NPO 2-4 hours before the test ADMINISTER VITAMIN K Monitor prothrombin time Position patient in LEFT LATERAL POSITION with pillow under right shoulder Instruct to HOLD BREATH 5-10 seconds during needle insertion

NURSING CARE AFTER LIVER BIOPSY Turn the patient to sides q4 hours Place on bed rest for 24 hours Monitor for signs of bleeding

248

124

9/20/2012

NURSING INTERVENTIONS Place client on BED REST with bathroom privileges Offer LOW-PROTEIN, HIGH CARBOHYDRATES and vitamins (ADEK, B-complex), LOW SODIUM RESTRICT AMOUNT OF ORAL FLUIDS and eliminate alcohol intake Provide meticulous skin care Monitor weight, intake and output and ABDOMINAL GIRTH Assist in paracentesis if necessary Monitor for bleeding of esophageal varices Perform tap water or NSS enema Avoid giving aspirin (causes bleeding) and sedatives (hepatotoxic)

249

MEDICATIONS FOR A PATIENT WITH CIRRHOSIS (1) ANTACID to prevent GI bleeding (2) SPIRONOLACTONE (Potassium-sparing diuretic) diuretic of choice to manage ascites; does not cause hypokalemia (3) FUROSEMIDE diuretic given if patient has hyperkalemia after prolonged use of spironolactone (4) VITAMIN K prevents bleeding tendencies (5) INTRAVENOUS ALBUMIN to manage ascites and edema (6) DUPHALAC (Lactulose) reduces levels of ammonia (7) NEOMYCIN SULFATE reduce colonic bacteria responsible for ammonia formation 250

125

9/20/2012

PREVENTION OF BLEEDING OF ESOPHAGEAL VARICES Avoid Valsalva maneuver Avoid bending or stooping Avoid hot spicy foods Avoid lifting heavy objects

251

INTERVENTIONS FOR BLEEDING ESOPHAGEAL VARICES Place patient in SEMI-FOWLERS POSITION to prevent aspiration Suction the mouth Perform gastric lavage with tap water Insert SENGSTAKEN-BLAKEMORE TUBE Administer IV fluids, blood transfusion as ordered Administer VASOPRESSIN to constrict splanchnic arteries
252

126

9/20/2012

253

PREPARING A PATIENT FOR PARACENTESIS Ask to empty bladder to prevent puncture Check serum protein studies Place patient in sitting or upright position NURSING CARE AFTER PARACENTESIS Check urine output Watch out for board-like abdomen (sign of PERITONITIS) Monitor for signs of hypovolemic shock
254

127

9/20/2012

255

Nutritional Disorders

DISORDERS OF THE GASTROINTESTINAL SYSTEM

128

9/20/2012

MALABSORPTION SYNDROME
Impaired absorption or digestion of nutrients COMPLICATION Malnutrition RISK FACTORS Impaired digestion resulting from surgery, deficiency of digested enzymes Impaired absorption resulting from genetic disorders, small bowel disease, drug therapy and short bowel syndrome
257

PATHOPHYSIOLOGY Gastric surgery intrinsic factor vitamin B12 absorption pernicious anemia Intestinal surgery malabsorption of bile salts, vitamins and nutrients Bile salts deficiency malabsorption of fats and fat-soluble vitamins Lactase deficiency malabsorption of carbohydrates Pancreatic Insufficiency malabsorption of carbohydrates, proteins, fats and vitamin B12
258

129

9/20/2012

SIGNS AND SYMPTOMS Increased number of daily bowel movements Weight loss without decrease in oral intake Decreased serum levels of vitamins, minerals, albumin or total protein Signs of vitamin deficiencies (bruising, anemia or bone pain) or protein loss (edema)

259

NURSING INTERVENTIONS Administer enzyme replacements, vitamins, minerals, antidiarrheal agents, anticholinergics, anti-inflammatory medications, as ordered Institute dietary therapy to avoid or control symptoms (lactose or gluten-free foods) and to supplement deficiencies (high-protein or low-fat foods) Advise patient to eat small frequent feedings to prevent dumping syndrome Monitor nutrient intake
260

130

9/20/2012

MALNUTRITION
Also known as UNDERNUTRITION FORMS Marasmus calorie malnutrition Kwashiorkor protein malnutrition Marasmic-Kwashiokor combined protein and calorie malnutrition

261

ETIOLOGY Inadequate nutrient intake e.g. anorexia nervosa Increased nutrient losses e.g. vomiting, diarrhea Increased nutrient requirements e.g. hospitalization

131

9/20/2012

PATHOPHYSIOLOGY

Inadequate nutrient intake

Protein catabolism exceeds protein intake and synthesis

Negative nitrogen balance

Decreased muscle mass

Weight loss

Weakness

263

ASSESSMENT SUBJECTIVE DATA Anorexia Decreased food intake Activity intolerance Intolerance to cold Recurrent infection

264

132

9/20/2012

OBJECTIVE DATA Leanness and cachexia (muscle wasting) Lethargy Edema Dry, flaking skin and various types of dermatitis Poor wound healing

265

LABORATORY AND DIAGNOSTIC ASSESSMENT

Diagnostic Test Hemoglobin Hematocrit Values Clinical Implication High Low High Low Hemoconcentration or dehydration Anemia, hemorrhage, hemodilution Dehydration or hemoconcentration Anemia, hemorrhage, excessive fluid

Serum albumin

Low

Kwashiorkor
Malnutrition Malnutrition Malabsorption, liver disease, pernicious anemia, terminal cancer or sepsis
266

Thyroxine-binding Low prealbumin Transferrin Serum Cholesterol Low Low

133

9/20/2012

NURSING INTERVENTIONS ascertain clients food preferences collaborate with physician, dietitian and nutritionist about clients nutritional needs provide high calorie, high-protein foods e.g. milkshakes, cheese, crackers make feeding schedule of 6 small meals/day provide pureed or dental soft diet for edentulous (toothless) patients provide quiet environment conducive for eating weigh patient regularly ensure that the client wears properly fitted dentures

267

DRUG THERAPY Cyproheptadine (Periactin) an antihistamine prescribed to patients who are underweight and with eating disorders Megestrol acetate (Megace) an antineoplastic drug that can increase appetite in clients with cachexia Multivitamins MEDICAL MANAGEMENT Enteral Nutrition Parenteral Nutrition
268

134

9/20/2012

OVERWEIGHT & OBESITY

DEFINITION OF TERMS Overweight increase in body weight for height compared with a reference standard or 10% greater than the ideal body weight (IBW) Obesity excess amount of body fat and an increase of at least 20% greater than the ideal body weight; Morbid Obesity weight that is 100% more than the IBW or BMI of greater than 40
269

COMPLICATIONS OF OBESITY Diabetes mellitus Hypertension Hyperlipidemia Coronary Artery Disease (CAD) Obstructive sleep apnea Obesity hypoventilation syndrome Depression Urinary incontinence Cholelithiasis Chronic back pain Early osteoarthritis Decreased wound healing
270

135

9/20/2012

CAUSES OF OBESITY Familial and genetic factors High-fat and high-cholesterol diet (trans-fat containing foods such as commercial cookies, snack foods, and French fries) Physical inactivity Intake of drugs that can cause weight gain corticosteroids estrogens and certain progestins nonsteroidal anti-inflammatory drugs antidepressants and other psychoactive drugs antihypertensives antiepileptic drugs certain oral hypoglycemics

271

ASSESSMENT SUBJECTIVE DATA economic status usual food intake eating behavior cultural background attitude toward food appetite chronic diseases medications physical activity family history of obesity
272

136

9/20/2012

OBJECTIVE DATA weight is 10% or more above the ideal body weight pendulous breasts abdominal apron erectile dysfunction

273

NON-SURGICAL MANAGEMENT Diet Programs Diet Therapy Exercise Program Drug Therapy Behavioral Treatment Complementary and Alternative Therapies SURGICAL MANAGEMENT liposuction panniculectomy bariatric surgery
274

137

9/20/2012

DIET PROGRAM CONSIDERATIONS

Fasting
Very-LowCalorie Diets

Does not produce permanent benefits Can cause severe ketosis

Provide 200-800 calories/day; Protein-sparing Requires cardiac evaluation and health supervision Needs supplementation with vitamins and mineral Should be complemented with exercise Provide 1200 calories/day Proteins, fats and carbohydrates are taken sparingly Restriction of 1 or more nutrients e.g. lowcarbohydrate Examples are South Beach or Atkins diet Nutritionally inadequate Examples are grapefruit diet
275

Balanced LowEnergy Unbalanced Low-Energy Novelty Diets

138