care of patients with gastrointestinal problems

1. Care of patients with Gastrointestinal Problems Nursing 1930 Brendalyn Browner Muriel Mitchell

3. GI Focused Assessment Physical Vital Signs Height and Weight Lab and diagnostic test results Emesis ,amount, color, consistency Stool,amount, color, consistency, odor. Oral Assessment Abdominal Assessment Rectal Assessment

4. COMMON “GI OFFENDERS” Caffeine (coffee, tea, cola) Dairy products Chocolate Pepper (black and green) Alcohol Spicy foods Tobacco Drugs

5. Abdominal Assessment Inspection Auscultation Diaphragm (Bowel sounds) Bell (Vascular sounds, bruits) Percussion Palpation

6. GI Charting Exercise Document an assessment of the mouth in a person with normal findings.

7. EFFECTS OF AGINGPhysiologic Changes in the GI Tract Mouth Teeth loosen, reduced circulation to gums, teeth darken and fracture Decreased output of salivary glands Decreased stimulation of taste buds Stomach Atrophy of gastric mucosa Decreased secretion of hydrochloric acid Decreased bile secretion Decreased muscle tone and strength

13. Common Causes of Bleeding in the GI Tract Esophagus Inflammation (esophagitis) Tear (Mallory-Weiss syndrome) Cancer Stomach Ulcers Inflammation (gastritis) Cancer Small Intestines Duodenal ulcer Inflammation (Crohn’s disease) Large Intestines and Rectum Hemorrhoids, infections, inflammation (ulcerative colitis) Colorectal polyps, colorectal cancer Diverticular disease

14. GastroesophagealREFLUX DISEASE (GERD) Physiological Contributing Factors: Incompetent lower esophageal sphincter Irritant effects of reflux Abnormal esophageal clearance Delayed gastric emptying

15. GastroesophagealREFLUX DISEASE (GERD) Common Signs and Symptoms: Heartburn Regurgitation Retrosternal Burning Pain (epigastrium, neck, throat)

16. GastroesophagealREFLUX DISEASE (GERD) Management and Treatment: Lifestyle modification measures Antacids, H2 antagonists, proton-pump inhibitor, carafate, prokinetic agents (reglan) Surgical Intervention Nissen Fundoplication

17. GastroesophagealREFLUX DISEASE (GERD) Pharmacology Antacids H2 Antagonist Proton Pump Inhibitors (Bid) Prilosec Prevacid Protonix Nexium Aciphex Pro-Motility Agents (Qid) Reglan

18. GastroesophagealREFLUX DISEASE (GERD) Lifestyle Modifications: Avoid fried and fatty foods, garlic and onions Avoid chocolate, caffeine and alcohol Avoid citrus fruits and juices, tomato products and pepper Reduce food portions, eat 2-3 hours before bedtime Lose excess weight, avoid tight clothing Raise the head of your bed with 6-inch blocks

19. GastroesophagealREFLUX DISEASE (GERD) Nursing Interventions and Patient Education: Offer emotional support Reinforce lifestyle modifications Teach about prescribed medications Advise patient to sit or stand when taking pills, tablets or capsules and follow with at least 100mL of liquid

21. PEPTIC ULCER DISEASE DUODENAL (80%) Increased gastric secretion, between meals, after meals, during night. Twice as many parietal cells. Pain 2-3 hours after meal. Relieved by food. Peak age 35-45 yrs May cause weight gain Hemorrhage, perforation, outlet obstruction, intractability GASTRIC Decreased gastric acid secretion. 2/3 as many parietal cells. Pain 1/2-1 hour after eating. Not relieved by food. More likely to be malignant Peak age 50-60 yrs May cause weight loss Hemorrhage, perforation, obstruction

22. CASE STUDY

23. Peptic Ulcer Disease: DRUG THERAPY Antacids ( Decrease gastric acidity) Histamine (H2 ) Receptor Antagonists (Inhibit HCL secretion) Proton Pump Inhibitors (Suppress gastric acid secretion) Cytoprotective Agent (carafate) GI Stimulant (Reglan) Triple Drug Therapy H. Pylori Therapy Proton Pump Inhibitor (Prilosec) Antibiotic Pink Bismuth

24. Peptic Ulcer Disease:COMPLICATIONS HEMORRHAGE PERFORATION PYLORIC OBSTRUCTION INTRACTABILITY

25. Peptic Ulcer Disease Signs of Complications Signs of Bleeding Dizziness Paleness Bloody, black or tarry stools Coffee ground vomitus Sweating and/or chills Restlessness/anxiety Signs of Perforation Severe pain in the stomach, shoulders or both A rigid, boardlike abdomen A flushed sweaty sensation Fever and dizziness

28. GI JEOPARDY Clients with resection of the ileum are susceptible to this vitamin deficiency

29. Peptic Ulcer Disease: POST-OP COMPLICATIONS Dumping Syndrome Vitamin B12 Deficiency Leaking from suture line Shock and Hemorrhage Dehiscence Evisceration

30. SYMPTOMS: ( Weakness, faintness, dizziness, flushing, palpitations, gastric fullness,nausea, cramping pains, diarrhea) TREATMENT: (Teach the patient to eat meals low in simple carbohydrates, Hi in protein and moderate in fat, eat small frequent meals, lie down after eating, fluids only between meals. Sedatives, antispasmodics, surgery)

31. Peptic Ulcer Disease:Nursing Interventions and Patient Teaching Alleviate Pain Ensure Adequate Nutrition Avoid Fluid Volume Deficit I&O Decrease diarrhea Monitor for bleeding (emesis, stool) Monitor hemoglobin, hematocrit and electrolytes Monitor NG tube drainage Monitor for S&S of complications Hemorrhage, shock, perforation, gastric outlet obstruction Implement measures to reduce stress Patient teaching related to disease, treatment and procedures

32. Peptic Ulcer Disease:Nursing Diagnoses: Pain R/T Increased Secretion of Gastric Acid Diarrhea R/T Gastrointestinal Bleeding Altered Nutrition: Less Than Body Requirements R/T Nausea, Vomiting or Pain or more than body requirements R/T…….. Fluid Volume Deficit R/T Gastrointestinal Bleeding Knowledge Deficit R/T Management and Treatment of Peptic Ulcer Disease

33. Peptic Ulcer Disease: Outcome-Based Evaluation Pain Free Vital Signs Stable Fluid Volume Maintained Enjoys Meals Without Pain Reports No Weight Loss Complies With Treatment Regimen Can Describe Peptic Ulcer Disease, its Treatment and Complications

34. INFLAMMATORY BOWEL DISEASE CROHNS DISEASE Affects any part of the GI tract, all parts of the bowel Diarrhea, non-bloody,mucous and pus, less than 5/day Not cured by surgery ULCERATIVE COLITIS Affects colon and rectum Severe bloody diarrhea with mucus and pus 15-20 stools per day Can be cured with surgery, colectomy and ileostomy

35. INFLAMMATORY BOWEL DISEASE (Con’t) CROHNS DISEASE Regional ileitis, Regional enteritis, Crohns Colitis Most often seen in terminal ileum, jejunum, colon, but can occur anywhere in bowel Complications of Crohns can occur outside the bowel, i.e.,arthritis, Inflammatory disorders of the eye, gallstones ULCERATIVE COLITIS Usually begins in rectum and sigmoid colon, involves mucosa and submucosa Complications include hemorrhage, fistulas, obstruction, strictures perianal/perirectal abscesses, toxic megacolon, colon cancer

36. GI JEOPARDY Increased values of this laboratory test finding is normal during fetal life but may indicate colorectal cancer or inflammatory bowel disease in adults.

37. AMINOSALICYLICS (contain 5-aminosalicyclic acid or 5-ASA) Sulfasalazine is an anti-inflammatory, olsalazine, mesalamine or balsalazide maybe used in patients allergic to sulfa SULFASALAZINE (azulfadine) sulfa and aspirin like compound, anti-inflammatory, anti-bacterial TOPICAL 5-ASA (Rowasa suppositories or enemas) distal colitis CORTICOSTEROIDS anti-inflammatory, (IV, PO or enema) Immunomodulators azathioprine and 6-mercapto-purine (6-MP) used for patients who do not respond to 5-ASA or corticoids takes 6-months to see benefits METRONIDAZOLE (Flagyl) anti-bacterial LOPERAMIDE (Imodium) antidiarrheal BULK AGENTS(Metamucil) To absorb fluid from colon and add bulk INFIXIMAB (Remicade) ( New Drug) a monoclonal antibody with serious side effects INFLAMMATORY BOWEL DISEASE: DRUG THERAPY

38. Inflammatory Bowel DiseaseNursing Diagnoses Diarrhea R\T inflamed intestinal mucosa Altered nutrition: Less than body requirements R\T diarrhea and malabsorption Pain R\T inflamed bowel Risk for ineffective individual coping R\T exacerbations of the disease

39. INFLAMMATORY BOWEL DISEASE Nursing Dx = Diarrhea R/T ……… Nursing Interventions Administer medications Note # and appearance of stools Monitor I&O Monitor lab values Make sure pt is near restroom or has bedpan near Provide perianal care, wipes, topical anesthetics Empty bedpan immediately Use room deodorizer Diet as ordered or TPN Monitor for potential complications, i.e. F&E imbalance,obstruction, abscess, etc.

40. INFLAMMATORY BOWEL DISEASE Outcome-Based Evaluation The Patient: Reports decrease in # of stools Has less pain and cramping Maintains fluid balance Moves toward optimum nutrition Copes successfully with diagnosis Understands disease

42. APPENDICITIS Signs and Symptoms may be abrupt! Characterized by pain around the umbilicus but may be generalized abdominal pain Rebound tenderness Low grade temp,vomiting, nausea, constipation Ruptured Appendix

43. APPENDICITISTreatment and Nursing Intervention No Medical Management Surgery ASAP to prevent rupture Nursing Interventions NPO until surgery Bedrest Apply ice pack for comfort, NEVER HEAT! Never give an enema unless ordered by MD Administer pain med only after diagnosis is made

44. APPENDICITISNursing Diagnosis, Outcome-Based Evaluation NURSING DIAGNOSES: Pain R\T Inflammation Outcomes = client describes decreased postoperative pain Risk for fluid volume deficit R\T vomiting Outcomes = client maintains fluid and electrolyte balance Risk for Infection Outcomes = client will receive prompt treatment to prevent rupture, client will not develop infection

45. PERITONITISInflammation of the peritoneal membrane Caused by leakage of content from abdominal organs into the abdominal cavity May be caused by appendicitis, perforated ulcer, diverticulitis, bowel perforations, acute salpingitis, trauma, CAPD S&s= pain, rigid abdomen,rebound tenderness, paralytic ileus, increased temp, pulse, WBC Massive doses of antibiotics initiated early to prevent death from Sepsis

47. GI JEOPARDY The single most important factor in nutrient deficiencies in the United States

49. STATISTICS:COLON AND RECTAL CANCER The American Cancer Society Reports: Colorectal cancer is the third most common type of cancer in both men and women. It predicts 57, 100 deaths from colon cancer in 2003. 105, 500 new cases of colon cancer and 42, 000 new cases of rectal cancer will be diagnosed in 2003. The 5-year survival rate is 90% for people whose cancer is treated in the early stages but only 37% are found in the early stage. Spread to nearby organs or lymph nodes, survival rate is 65% Spread to distant part of the body (liver, lungs), survival rate is only 9%.

50. What is Colorectal Cancer? Cancer develops when cells in a part of the body grow and divide out of control. Colorectal cancer is a disease in which abnormal or malignant cells form in the tissues of the colon, rectum or anus. Most colorectal cancers begin as polyps or adenomas. These polyps may slowly change to cancer after 5-10 years

51. Types of Colorectal Cancers 95% are Adenocarcinomas Less Common Types Are: Carcinoid Tumors - develop from hormone producing cells of the intestines. Gastrointestinal Stromal Tumors – develop in the connective tissue and muscle layers in the wall of the colon and rectum. Lymphomas - are cancers of the immune system cells, usually develop in the lymph nodes but may start in the colon or rectum

52. RISK FACTORS:Colorectal Cancer Family History Familial adenomatous polyposis (FAP) Hereditary nonpolyposis colorectal cancer (HNPCC) Ethnic Background Jews of Eastern European decent Personal History of: Colorectal cancer Intestinal polyps Inflammatory bowel disease Aging Diet Physical Inactivity Obesity Diabetes 30-40% increased chance of developing colon cancer Smoking Alcohol

53. Possible Signs/SymptomsColorectal Cancer Change in bowel habits Blood in stool Diarrhea, constipation Feeling of incomplete evacuation of bowel Narrow stools General abdominal discomfort Frequent gas, bloating, fullness, cramps Weight loss Constant tiredness Vomiting

54. TREATMENT OPTIONS: Colorectal Cancer SURGERY Resection/Anastomosis Ostomies CHEMOTHERPY RADIATION THERAPY BIOLOGICAL THERAPY Treatment to stimulate the immune system to fight cancer, also called immunotherapy

56. Care of the patient/client with an Ostomy Before surgery After surgery Check the stoma and the skin around it daily during your assessment. A healthy stoma should be shiny, moist and a deep rich red. Monitor the output and stool consistency Pouching and skin care Patient Teaching: Medications Diet modification Irrigations

57. GI JEOPARDY Ostomy clients may want to avoid this alcoholic beverage because of excessive odor

59. GI VIDEOS ( In the Library, Non-Print Section) “ Basics of ileostomy care” (N278) “Basics of Colostomy Care” (N280) “Enteral Feeding” (N279) “Peptic Ulcers” (N277)