Case Study

Group 5
SITUATION: J.V. is an 87-year old female client who is admitted
to a medical nursing unit from a local nursing home. She had
surgery for abdominal adhesion 4 weeks ago and is now
passing blood-streaked stools. J.V. also reports that her
stomach hurts, especially during the nights. “It feels like
someone is burning a hole inside me”. J.V. states that she lives
alone in a retirement department building. Last week, a close
friend and neighbor visited J.V. at the nursing home and
reported news of death of 2 residents of the apartment
building who were mutual friends.
A. What additional data should be the
nurse collect for a thorough G.I. System
Assessment of J.V.?
• The nurse should collect additional data from JV, the ff.:
– V/S
– Amount, frequency and duration - Blood-Streaked Stool
– Stress and Fatigue caused by the death of two close friends
– Oral Fluid Volume
– Grimace facial expression
– Guarding behavior in the abdominal area
– Changes of duration of sleep
– Changes in Food Intake
– Diaphoresis
– Urinary output and color
– Alcohol or Drug Abuse
– Bowel Sounds
– Area and level of pain
– Previous GI surgery and illnesses
B.
J.V. is scheduled to have an upper G.I.
and sound bowel series the next day.
What does the nurse do and prepare
J.V. for these diagnostic studies? Revise
a teaching and writing plan for J.V.
What is it?
An upper GI and small
bowel series is a set of
x-rays taken to examine
the esophagus,
stomach, and small
intestine.
Procedure: An upper GI and small bowel series is done in a
medical office or hospital radiology department.
1. An injection of a medication that will temporarily slow bowel
movement, so structures can be more easily seen on the x-
rays.
2. Before the x-rays are taken, you must drink 16 - 20 ounces
of a millkshake-like drink that contains a substance called
barium. An x-ray method called fluoroscopy tracks how
the barium moves through your esophagus, stomach, and
small intestine. Pictures are taken with you in a variety of
positions. You may be sitting or standing.
3. The test usually takes around 3 hours. However, in some
cases, it may take up to 6 hours to complete.
4. A GI series may include this test or a barium enema.
Nursing Considerations:
1. Identify the client and explain the procedure.
2. Tell the client that the test should be done after other x-ray
procedures, because the barium that remains in the body may
block details in other imaging tests.
3. Tell the client to change her diet for 2 or 3 days before the test.
Usually, you can not eat for period of time before the test.
4. The nurse should tell the patient not to eat the evening before
the exam.
5. Tell the client to continue medications she can take by mouth.
6. Instruct the patient to remove all jewelry before the test.
 WRITING PLAN/
TEACHING PLAN:
Objectives: At the end of 30-minute J.V. will be
able to:
1. Understand the importance of changing diet
before and after the test.
2. Keep the proper medication to be taken.
3. Distinguish/describe the effects of the test
before and after.
4. Learn the nursing considerations to be made
through the nurse.
6. Adapt the changes to be experienced.
7. Learn stress-reduction technique applicable to
her such as music therapy, massage therapy,
Benson’s Relaxation Technique
 WRITING PLAN/
TEACHING PLAN:
1. Give health teachings about barium and
importance to the test.
2. Adminitster proper medication and teach
why it is important before the test.
3. Ask the patient about his expectations
regarding the test.
4. Do the nursing considerations.
5. Accept the client’s feelings.
6. Tell the patient that the procedure will
last for about 20-30 minutes.
7. Practice techniques to reduce the client’s
stress.
C. J.V. is unable to tolerate solution,
becomes nauseated and vomits. Her
physicians orders that an
esophagogastroduodenoscopy (EGD)
be done.
Upper GI Fibroscopy, sometimes called EGD
(esophagogastroduodenoscopy), is a visual examination of the upper
intestinal tract using a lighted, flexible fiber optic or video
endoscope. The upper gastrointestinal tract begins with the mouth
and continues with the esophagus (food tube) which carries food to
the stomach. The J-shaped stomach secretes a potent acid and
churns food into small particles. The food then enters the duodenum,
or small bowel, where bile from the liver and digestive juices from
the pancreas mixes with it to help the digestive process.
Alternative Testing
• Alternative tests to upper GI endoscopy
include a barium x-ray and ultrasound
(sonogram) to study the organs in the upper
abdomen. Study of the stools, blood and
stomach juice can provide indirect
information about a gastrointestinal
condition. These exams, however, do not
allow for a direct viewing of the esophagus,
stomach and duodenum, removing of polyps
or taking of biopsies.
Equipment
• The PEF-V uses a simultaneous-multicolor CCD at the scope tip to produce
images that are color-consistent, moiré-free and clearer than ever from
Olympus. The PEF-V’s slim 5.3mm tip diameter allows for easy insertion -
without sedation - and a large 2mm channel to accommodate a variety of
endotherapy accessories, the PEF-V is the all-in-one solution you've been
looking for. GE Inspection Technologies provides high-resolution articulating
flexible fiberscopes, featuring densely-packed, 7-micron diameter imaging
fibers to reveal more detail than other scopes, in diameters as small as 2.4
mm.
• The flexible fibroscope is a remarkable piece of equipment that can be
directed and moved around the many bends in the gastrointestinal tract.
Endoscopes now come in two types. The original pure fiberoptic instrument
has a flexible bundle of glass fibers that collect the lighted image at one
end and transfer the image to the eye piece. The newer video firbroscope
have a tiny, optically sensitive computer chip at the end. Electronic signals
are then transmitted up the scope to the computer which then displays the
image on a large video screen. An open channel in these scopes allows
other instruments to be passed through in order to take tissue samples,
remove polyps and perform other exams.
The flexible fibroscope is a remarkable piece of
equipment that can be directed and moved
around the many bends in the gastrointestinal
tract. Endoscopes now come in two types. The
original pure fiberoptic instrument has a flexible
bundle of glass fibers that collect the lighted
image at one end and transfer the image to the
eye piece. The newer video firbroscope have a
tiny, optically sensitive computer chip at the
end. Electronic signals are then transmitted up
the scope to the computer which then displays
the image on a large video screen. An open
channel in these scopes allows other instruments
to be passed through in order to take tissue
samples, remove polyps and perform other
exams.
What additional preparation is to do before this procedure can be
performed on J.V.?
Before
• Ask the patient to sign the informed consent.
• Tell the patient to stop aspirin and other blood-thinning
medications several days before the test.
• For the best possible examination, the stomach must be
completely empty, so you should have nothing to eat or drink
(including water from 11 p.m. on the evening before the
examination or for at least six hours before its performance.  Your
doctor will be more specific about the time to begin fasting,
depending on the time of day that your EGD is scheduled.
• Be sure to let your doctor know if you are allergic to any drugs.
• A companion must accompany you to the examination because
you will be given an injection to help you relax. 
• It will make you drowsy so you will need some-one to take you
home. You will not be allowed to drive after the procedure. Even
though you may not feel tired, judgment and reflexes may not be
normal. 
• Bring the X-rays, they may be very important for comparison and
localization of abnormalities. 
The Procedure
• The patient should be in the left lateral position to facilitate clearance of
pulmonary secretions and provide smooth entry of scope.
• Upper GI endoscopy is usually performed on an outpatient basis.
• The throat is often anesthetized by a spray or liquid. Intravenous
sedation is usually given to relax the patient, deaden the gag reflex and
cause short-term amnesia.
• For some individuals who can relax on their own and whose gagging can
be controlled, the exam is done without intravenous medications.
• The endoscope is then gently inserted into the upper esophagus.
• The patient can breathe easily throughout the exam.
• Other instruments can be passed through the endoscope to perform
additional procedures if necessary.
• A biopsy can be done in which a small tissue specimen is obtained for
microscopic analysis.
• A polyp or tumor can be removed using a thin wire snare and
electrocautery (electrical heat).
• The exam takes from 15 to 30 minutes, after which the patient is taken
to the recovery area.
• There is no pain with the procedure and patients seldom remember much
about it.
After
• A temporary, mild throat irritation sometimes
occurs after the exam.
• Risk is excessive bleeding, especially with
removal of a large polyp.
• In extremely rare instances, a perforation, or
tear, in the esophagus or stomach wall can
occur. These complications may require
hospitalization and, rarely, surgery.
• A diagnostic error or oversight may occur.
Due to the mild sedation, the patient should
not drive or operate machinery following the
exam. For this reason, someone else should
be available to drive the patient home.
D.
Following the EGD, JV is returned to her room by stretcher. The nurse assesses
J.V. and transfer to bed. What position should J.V. is assessed to assume?
What assessment should the nurse initially perform? Why?

The patient may be placed in a semi-Fowler’s or a High Fowler’s

Position for comfort and improved respiratory exchanged.
The nurse should assess for the ff:
• Level of Consciousness
• ® To plan an appropriate intervention.
• Vital Signs
• ® To assess the patient for any alterations.
• Oxygen Saturation
• ® To measure of how much oxygen the blood is carrying as a percentage
of the maximum it could carry.
• Observe for s/s of perforation (pain, bleeding, unusual difficulty swallowing,
temperature)
• ® To assess if there is a disease process such diseases duodenal ulcer or
stomach cancer.
• Gag reflex
• ® To know if the patient can drink water.
• ® To prevent aspiration.
• Position
• ® For comfort and improved respiratory function.
• Instruct not to drive for 10-12 hrs. post
• ® To avoid unwanted injury.
E.
While, the nurse is assessing her, J.V. asked some
water to drink because she said “my mouth is so
dry and that my tongue is sticky”. What should
the nurse do?
The nurse should not give water instead moisturize
the lips. And it is advisable to give water until
the local anesthetic has worn off which may last
for 2-4 hours and the gag reflex has returned.
To test if the gag reflex has returned, a spoon
can be placed on the back of the tongue for a
few seconds with light pressure to observe if the
patient gags. After the patient’s gag has
returned, lozenges, saline gargle, and oral
analgesics may be offered to relieve minor
throat discomfort.
 Bibliography
Sources:
• Nurse’s Pocket Guide (11th Edition) by Marilynn E.
Doenges, Mary Frances Moorhouse, and Alice C. Geissler-
Murr
• Home Health Nursing: Assessment and Care Planning by
Karen Monks, MSN, RN
• Ambulatory Surgical Nursing 2nd Edition by Nancy Berden,
Donna M. DeFazo Quinn, Denise O’Brien, Brenda S. Gregory
Daves
• Brunner and Suddarth’s Textbook of Medical-Surgical
Nursing (11th Edition) by Suzanne C. Smeltzer, Brenda G.
Bare, Janice L. Hinkle, and Kerry H. Cheever
• Nursing Care Plans Edition 7 by Marilyn E. Doenges, Mary
Frances Moorhouse and Alice C. Murr