Nursing of Adult Patients with

Medical & Surgical Conditions

Gastrointestinal

Disorders

Part I

Laboratory & Diagnostic Examinations

• Upper GI Series– Rationale

• Series of radiographs of the lower esophagus, stomach, and duodenum using barium sulfate as the medium contrast

– Nursing Interventions• NPO after midnight• Ensure pt. Expels barium

– increase fluid intake– Milk of Magnesia

• Gastric Analysis– Rationale

• Aspiration of stomach contents to determine the amount of acid produced gy the parietal cells in the stomach, estimate acid secretory capacity for intrinsic factor

– Nursing Interventions• No anticholinergic medications for 24 hours before the test

• NPO after midnight

• No smoking

• Esophagogastroduodenoscopy (EGD)– Rationale

• Direct visualization of the upper GI tract by means of a long, fiberoptic, flexible scope

• Assess for disease, remove abnormalities, dilate strictures

– Nursing Interventions• NPO after midnight• Informed consent• IV sedative as ordered• Do not allow pt. to eat or drink until

gag reflex returns (2-4 hrs)• Assess for s/s of perforation (pain,

bleeding)

• Barium Swallow– Rationale

• Through study of the esophagus using barium contrast

• Assess for anatomical abnormalities

• Use Gastrografin if perforation is suspected– water soluble and easily absorbed

– Nursing Interventions• NPO after midnight

• Ensure pt. expels barium– increase fluids

– Milk of Magnesia

• Bernstein Test– Rationale

• Reproduces the symptoms of gastroesophageal reflux

• Differentiates esophageal pain from angina

• Tube is inserted to the lower esophagus and hydrochloric acid is inserted

– Nursing Interventions• NPO for 8 hours prior to test

• Hold any antacids and analgesics

• No sedation (pt must describe the pain)

• Stool for Occult Blood– Rationale

• Detect hidden blood in the stool

• May be caused from tumors, ulcerations, and inflammation

– Nursing Interventions• Stool should be free of urine, toilet paper, etc.

• Sigmoidoscopy– Rationale

• Visualization of the anus, rectum, and sigmoid colon

• May obtain biopsies, remove polyps, or specimens of ulcerations

– Nursing Interventions• Informed consent

• Enemas the evening before and/or the morning of the exam

• Observe for s/s of perforation (pain, bleeding)

• Barium Enema– Rationale

• Series of radiographs of the colon using barium contrast

• Assess for presence of polyps, tumors, and diverticula

– Nursing Interventions• Administer cathartics

– Magnesium citrate

• Cleansing enema the evening before and/or the morning of the exam

• Ensure pt. expels barium– Increase fluids

– Milk of Magnesia

• Colonoscopy– Rationale

• Visualization of the colon from anus to cecum• Detection of neoplasms, inflammations, ulcerations,

and bleeding• Biopsies can be obtained and small tumors removed

– Nursing Interventions• Informed consent• Clear liquid diet 1-3 days prior to exam• NPO 8 hours before exam• Administer cathartic

– GoLYTELY

• Enemas as ordered• IV sedative as ordered

• Stool Culture and Sensitivity; Stool for Ova and Parasites– Rationale

• Stool examined for bacteria, ova, and parasites

– Nursing Interventions• Use only normal saline enemas if required to obtain

specimen

• Take to lab within 30 minutes

• Flat Plate of the Abdomen– Rationale

• Group of radiographic studies on the abdomen of pts. suspected of bowel obstruction, paralytic ileus, perforation, or abcess

– Nursing Interventions• Schedule before any barium studies

Dental Plaque and Caries

• Etiology/Pathophysiology– Erosive process that results from the action of

bacteria on carbohydrates in the mouth, which produces acids that dissolve tooth enamel

Dental Plaque and Caries

• Cause– Presence of plaque– Strength of acids and ability of saliva to

neutralize them– Length of time acids are in contact with the

teeth– Susceptibility of tooth to decay

Dental Plaque and Caries

• Treatment– Removal of affected area and replace with

dental material

Candidiasis

• Etiology/Pathophysiology– Infection caused by a species of Candida,

usually Candida albicans– Fungus normally present in the mouth,

intestine, vagina, and on the skin– Also refered to as thrush and moniliasis

Candidiasis• Signs and Symptoms

– Small white patches on the mucous membrane of the mouth

– Thick white discharge from the vagina

Candidiasis

• Treatment– Nystatin

• oral suspension

• vaginal tablets

– Half strength hydrogen peroxide/saline mouth wash

– Ketoconazole oral tablets– Meticulous handwashing

Carcinoma of the Oral Cavity

• Etiology/Pathophysiology– Malignant lesions on the lips, oral cavity, tongue, or

the pharynx– Usually squamous cell epitheliomas

• grow rapidly and metastasize quickly

Carcinoma of the Oral Cavity

• Signs and Symptoms– Leukoplakia

• white, firmly attached patch

on the mouth or tongue

mucosa

– Roughened area on the tongue– Difficulty chewing, swallowing, or speaking– Edema, numbness, or loss of feeling in the

mouth– Earache, faceache, and toothache become

constant

Carcinoma of the Oral Cavity

• Treatment– Stage I

• Surgery or radiaiton

– Stage II & III• Both surgery and radiation

– Stage IV• palative

Carcinoma of the Esophagus

• Etiology/pathophysiology– Malignant epithelial neoplasm that has invaded

the esophagus• 90% are squamous cell carcinoma associated with

alcohol intake and tobacco use• 6% are adenocarcinomas associated with reflux

esophagitis• Other causes are environmental carcinogens,

nutritional deficiencies, chronic irritation, and mucosal damage

Carcinoma of the Esophagus

• Signs & Symptoms– Progressive dysphagia over a six month period– Sensation of food sticking in throat

Carcinoma of the Esophagus• Treatment

– Radiation• May be curative or pallative• Complication

– Fistula formation may cause aspiration

– Surgery• may be palliative, increase longevity, or curative• Types of Surgical Procedures

– Esophagogastrectomy: remove a portion of the esophagus and stomach

– Esophagogastrostomy: remove a portion of the esophagus with anastomosis to the stomach

– Esophagoenterostomy: remove the esophagus with anastomosis to the colon

– Gastrostomy: insertion of a feeding tube into the stomach through the abdominal wall

Esophagoenterostomy

Esophagogastrostomy

Achalasia

• Etiology/Pathophysiology– Inability of the cardiac sphincter of the stomach to relax– Also called cardiospasm– Possible causes: nerve degeneration, esophageal dilation,

and hypertrophy

Achalasia

• Signs and Symptoms– Dysphagia– Regurgitaion of food– Substernal chest pain– Loss of weight– Poor skin turgor– Weakness

Achalasia

• Treatment– Medications

• Anticholinergics, nitrates, and calcium channel blockers

– Dilation of cardiac sphincter• Balloon is inflated and remains in place for 1 minute; 1-2

times

– Surgery• Cardiomyectomy

– Incision of the muscular layer

Acute Gastritis

• Etiology/Pathophysiology– Inflammation of the lining of the stomach– May be associated to alcoholism, smoking, and

stressful physical problems– Usually a single occurance, resolving when

offending agent is removed

Acute Gastritis

• Signs and Symptoms– Fever– Epigastric pain– Nausea– Vomiting– Headache– Coating of the tongue– Loss of appetite

Acute Gastritis

• Treatment– Antiemetics

• Compazine

• Tigan

– Antacids & Tagamet or Zantac

– Antibiotics

– IV fluids

– NG tube and administration of blood, if bleeding

– NPO until s/s subside

Peptic Ulcers

• Gastric Ulcers & Duodenal Ulcers– Ulcerations of the mucous membrane or

deeperstructures of the GI tract– Most commonly occur in the stomach and

duodenum– Result of acid and pepsin imbalances

• Excess of gastric acid or

• Decrease in protection from acid and pepsin

– H.pylori• Bacterium found in 70% of pts. with gastric ulcers

and 95% of pts. with duodenal ulcers

Peptic Ulcers (Gastric)

• Etiology/Pathophysiology– Most common site is the distal half of the

stomach– Risk factors:

• Irregular diet

• Genetic predisposition

• Excessive use of salicylates

• Use of tobacco

• H.pylori

– Gastric mucosa is damaged, acid is secreted, mucosa errosion occurs, and an ulcer develops

Peptic Ulcers (Duodenal)

• Etiology/Pathophysiolosy– Excessive production or release of gastrin– Increased sensitivity to gastrin– Decreased ability to buffer the acid secretions– Risk factors:

• H.pylori• NSAID’s• Smoking• Coffee

Peptic Ulcers (Gastric & Duodenal)

• Signs & Symptoms– Pain

• Dull, burning, boring, or gnawing

• Epigastric

• Occurs between meals with gastric ulcers

• Duodenal ulcer pain may awaken pt. at night

– Dyspepsia• Nausea, eructation, and distention

– Hematemesis

– Melena

Peptic Ulcers (Gastric & Duodenal)

• Treatment– Antacids

• Neutralize or reduce the acidity of the stomach– Maalox, Gaviscon, Rolaids, Tums, Mylanta, Riopan

– Histamine H2 Receptor Blockers • Decrease acid secretion by blocking the histamine H2 receptors

– Tagamet, Zantac, Pepcid, and Axid

– Proton Pump Inhibitor• Antisecretory agent ot inhibit secrtion of gastrin by the parietal

cells of the stomach– Prilosec, Losec, and Prevacid

Peptic Ulcers (Gastric & Duodenal)

– Mucosal Healing Agents• Heal ulcers without antisecretory properties

• Adhere to the proteins in the ulcer base– Carafate and Cytotec

– Antibiotics• Eradicates H.Pylori

– Flagyl, tetracycline, amoxicillin, and Biaxin

– Usually combined with some of the other medications

Peptic Ulcers (Gastric & Duodenal)

• Diet– High in fat and carbohydrates– Low in protein and milk products– Small frequent meals– Limit coffee, tobacco, alcohol, and aspirin use

Peptic Ulcers (Gastric & Duodenal)

• Surgery– Antrectomy

• Removal of entire antrum(gastric producing portion of the lower stomach)

– Gastrodudodenostomy (Billroth I)• Fundus of the stomach is directly anastomosed to the

duodenum

– Gastrojejunostomy (Billroth II)• Duodenum is closed, and the fundus of the stomach is

anastomosed into the jejunum

Billroth Procedures

Peptic Ulcers (Gastric & Duodenal)

– Total Gastrectomy• Removal of the entire stomach

– Vagotomy• Removal of the vagal

innervation to the fundus

• Decreases acid production

– Pyloroplasty• Surgical enlargement of the

pylorus to provide drainage of the gastric contents

Peptic Ulcers (Gastric & Duodenal)

• Complications– Dumping Syndrome

• Rapid gastric emptying causing distention of the duodenum or jejunum produced by a bolus of hypertonic food

• Increased intestinal motility and peristalsis and changes in blood glucose levels

• Diaphoresis, nausea, vomiting, epigastric pain, explosive diarrhea, borborygmi (noises from gas), and dyspepsia

Peptic Ulcers (Gastric & Duodenal)

– Dumping Syndrome• Treatment

– Six small meals a day

– Diet high in protein and fat, low in carbohydrates

– No fluids during meals

– Anticholenergics

– Lying down for approximately 1 hour after meals

Peptic Ulcers (Gastric & Duodenal)

– Pernicious Anemia• Caused by a deficiency of the intrinisic factor

– Aids in absorption of Vitamin B12

• Treatment

• Vitamin B12 Injections

– Iron Deficiency Anemia• Caused by impaired absorption in the duodenum and jejunum

as a result of rapid gastric emptying

• Treatment– Oral iron replacement

» Ferrous sulfate

Cancer of the Stomach• Etiology/Pathophysiology

– Most commonly adenocarcinoma– Primary location is the pyloric area– Risk Factors:

• History of polyps• Pernicious anemia• Hypochlorhydria• Gastrectomy• Chronic gastritis• Gastric ulcer• Diet high in salt, perservatives, and carbohydrates• Diet low in fresh fruits and vegetables

Cancer of the Stomach• Signs & Symptoms

– Early stages may be asymptomatic

– Vague epigastric discomfort or indigestion

– Postparandial fullness

– Ulcer-like pain that does not respond to therapy

– Anorexia

– Weakness

– Weight loss

– Blood in stools

– Hematemesis

– Vomiting after fluids and meals

Cancer of the Stomach• Treatment

– Surgery• Partial or total gastric resection• Post-Op Complications

– Dehiscence» Separation of wound edges

– Evisceration» Viscera protrudes through the wound» Caused by coughing, straining, malnutrition, obesity,

and infection» Nursing Interventions: Pt. should remain quite and

calm, position with knees bent and semi-fowlers postion, cover eviseration with a warm sterile saline soaked dressing

– Chemotherapy– Chemotherapy and radiation

Infection of the Intestines• Etiology/Pathophysiology

– Invasion of the alimentary canal by pathogenic microorganisms

– Most commonly enters through the mouth on food or water

– Person to person contact– Fecal-Oral transmission

• due to poor handwashing

– Long-term antibiotic therapy can cause an overgrowth of the normal intestinal flora (c.difficile)

Infection of the Intestines

• Signs & Symptoms– Diarrhea

• May contain blood and mucus

– Rectal urgency

– Tenesmus• Ineffective and painful straining with defecation

– Nausea & vomiting

– Abdominal cramping

– Fever

Infection of the Intestines

• Treatment– Antibiotics

• Stool postive for leukocytes

– Fluid and electrolyte replacement• Oral or IV

– Kaopectate• Increase stool consistency

– Pepto-Bismol• Decrease intestinal secretions and decrease diarrhea

Irritable Bowel Syndrome• Etiology/Pathophysiology

– Episodes of alteration in bowel function– Low pain threshold to intestinal distention

caused by abnormal intestinal sensory neural circuitry

– May be associated with psychological problems– Spastic and uncoordinated muscle contractions

of the colon, usually due to excessively course or highly seasoned foods

Irritable Bowel Syndrome

• Signs & Symptoms– Abdominal pain

• Relieved after bowel movement

– Frequent bowel movements– Sense of incomplete evacuation– Flatulance– Constipation and/or diarrhea

Irritable Bowel Syndrome• Treatment

– Diet and Bulking Agents• Increase dietary fiber

• Administer fiber agents

• Avoid food which cause exacerbation

– Medications• Anticholinergics

– Relieve abdominal cramps

• Milk of Magnesia, fiber, or mineral oil for constipation

• Opioids for diarrhea

• Antianxiety drugs for panic attacks