Chapters 46-52 (Gastrointestinal Diagnostic Procedures, Gastrointestinal Therapeutic Procedures, Esophageal disorders, Peptic Ulcer, Gastritis, Noninflammatory Bowel Disease, Cholecystitis, Cholelithiasis)

Labs for liver function

Liver function tests are
aspartate aminotransferase (AST)
alanine aminotransferase (ALT)
Alkaline phosphatase (ALP)
Bilirubin
Albumin
What are the values

Fecal occult blood test and stool indications

Fecal occult blood tests should be done annually beginning at age 50
ulcer, colitis, cancer C diff, parasites (Giardia lamblia)
? GI bleeding
? Unexplained diarrhea

Fecal occult blood test Nursing actions

three samples, restrict red meats and anticoagulants (heparin, warfin, exoxprin), can be mailed.

Endoscopies like Colonoscopy, EGD are for

ulcers, GI bleeding Polyps, tumors

Colonoscopy

NPO after midnight, Golytely, sedation, left side knees to chest

Sigmoidoscopy

no sedation, golytely, npc at midnight, left side

EGD

NPO 6-8 hours, remove dentures, left side lying

Hemorrhage s/s?
Nursing actions?

Bleeding, cool and clammy skin, hypotension, tachycardia, dizziness, and tachypnea
Monitor diagnostic test results (particularly Hgb and Hct).

Gastrointestinal series Upper

AKA **Radiographic (x ray)
Upper GI imaging is done by having the client
drink a radiopaque liquid (barium). For small bowel follow-through, barium is traced through the small

Gastrointestinal series Nursing actions

? Inform the client about food and fluid restrictions and avoiding smoking or chewing gum (increases peristalsis).
After
increase fluids
Instruct the client that stools will be white for 24 to 72 hr until barium clears. The client should report abdominal fullness, pain, or delay in return to brown stool.

Enteral feedings are for patient who

? Inability to eat due to a medical condition (comatose, intubated)
? Pathologies that cause difficulty swallowing or increase risk of aspiration (stroke, advanced Parkinson's disease, multiple sclerosis)

Enteral feedings: Overfeeding complication. What are the nursing actions?

? Check residual(fluid remain in the stomach) every 4 to 6 hr.
? Follow protocol for slowing or withholding feedings
for excess residual volumes. Many facilities hold for residual volumes of 100 to 200 mL and then restart at a lower rate after a period of rest.
? Check pump for proper operation and ensure feeding infused at correct rate.

Total parenteral nutrition (TPN)

Hypertonic Intravenous solution.
Complete nutrition
High concentration dextrose 20-50%
TPN administration is usually through a central line, such as a tunneled triple lumen catheter or a single- or double-lumen peripherally inserted central (PICC) line.

Partial parenteral nutrition or peripheral parenteral nutrition (PPN)

is less hypertonic, intended for
short-term use, and administered in a large peripheral vein. Usual dextrose concentration is 10% or less. Risks include phlebitis.

Someone who present signs TPN should have

? Weight loss greater than 10% of body weight and NPO or unable to eat or drink for more than 5 days
Hypermetabolic state

TPN Pre-Nursing Actions

? Determine the client's readiness for TPN.
**? Obtain daily laboratory values, including electrolytes.
Solutions are customized for each client according to daily laboratory results.**

TPN Nursing Actions

! Never abruptly stop TPN. Speeding up/slowing down the rate is contraindicated. An abrupt rate change can alter blood glucose levels significantly.
?Vitals every 4-8
? Change tubing and solution bag (even if not empty)
every 24 hr. NEVER put meds or IV bolus through TPN line
? A filter is added to the tubing to collect particles from
the solution.
? Check capillary glucose every 4 to 6 hr for at least the first 24 hr.
*
? Keep dextrose 10% in water at the bedside in case the solution is unexpectedly ruined or the next bag is not available. This will minimize the risk of hypoglycemia with abrupt changes in dextrose concentrations.
.**
? Do not use the line for other IV bolus solutions
(prevents contamination and interruption of the
flow rate).
? Do not add anything to the solution due to risks of
contamination and incompatibility.
? Use sterile procedures, including a mask,
when changing the central line dressing (per facility procedure).

TPN: Air embolism

Pressure changes can during tubing changes can lead to air embolism (dyspnea, chest pain, anxiety, hypoxia)
? Clamp the catheter immediately and place the client on his left side in Trendelenburg position to trap air. Administer oxygen and notify the provider so trapped air can be aspirated.

TPN: Infection NURSING ACTIONS

From concentrated glucose (is a medium) for bacteria
? Observe the central line insertion site for local infection (erythema, tenderness, exudate).
? Change the sterile dressing on a central line per protocol (typically every 48 to 72 hr).
? Change IV tubing per protocol (typically every 24 hr).
? Observe the client for manifestations of systemic infection (fever, increased WBC, chills, malaise).
**
Do not use TPN line for other IV bolus fluids and medications (repeated access increases the risk for infection).
*

Paracentesis is?
Indication?

performed by inserting a needle or trocar through the abdominal wall into the peritoneal cavity. The therapeutic goal is relief of *
abdominal ascites pressure
*
? Usually preformed with ultrasound as a
safety precaution.
? Once drained, ascitic fluid can be sent for
laboratory culture.

Abdominal ascites

? Ascites is an abnormal accumulation of protein-rich fluid in the abdominal cavity most often caused by cirrhosis of the liver. The result is increased abdominal girth and distention.
? Respiratory distress is the determining factor in the use of a paracentesis to treat ascites, and in the evaluation of treatment effectiveness.

Paracentesis nursing actions

? Have the client void, or insert an indwelling
urinary catheter.
? Position the client in an upright position
? Review baseline vital signs, *
record weight, and measure abdominal girth
h**
? Administer sedation as prescribed.

Bariatric surgeries?

Gastroplasty, intestinal bypass, vertical banded, adjustable banded

Bariatric surgeries. Nursing actions

Bariatric surgeries are a treatment for morbid obesity when other weight control methods have failed.
Nursing actions-
? Resume fluids as prescribed. The first fluids can
be restricted to 30 mL and increased in frequency
and volume.
? Provide six small meals a day when the client can resume oral nutrients. Observe for indications of *
dumping syndrome
e** (cramps, diarrhea, tachycardia, dizziness, fatigue).

Indication a client needs a NG tube

Bowel Obstruction
? Vomiting
? Bowel sounds absent (paralytic ileus) or hyperactive and high-pitched (obstruction)
? Intermittent, colicky abdominal pain and distention
? Hiccups

NG tube POSTPROCEDURE

? Monitor tube for displacement (decrease in drainage, increased nausea, vomiting, distention).
? Assess bowel sounds and abdominal girth; return
of flatus.

NG Tube nursing actions

? Assess NG tube patency and placement. Irrigate every
4 hr, or as prescribed.
? Clamp during ambulation
? Provide oral hygiene every 2 hr.
? Monitor vital signs, skin integrity, weight, and I&O.

Ostomies?

Illeostomy opening from ileum. Liquid
Colostomy opening large intestine. Firm

Illeostomy is for
Colostomy is for

Patients who's entire colon must be removed (Crohn's disease)
Patients needing a partial bowl removal (Diverticulitis, cancer)

Ostomies Nursing actions

Fit the ostomy appliance based on the following.
? Type and location of the ostomy
? Visual acuity and manual dexterity of the client
? Assess peristomal skin integrity and appearance of the
stoma. The stoma should appear pink and moist.
? Apply skin barriers and creams (adhesive paste) to peristomal skin and allow to dry before applying a
new appliance.
? Empty the ostomy bag when it is one-fourth to one-half
full of drainage.

Ostomies: Foods that decrease gas?
Foods to avoid?

Yogurt, crackers, and toast can be ingested to decrease gas.
Avoid high-fiber foods for the first 2 months after surgery, chew food well, increase fluid intake

Stomal ischemia/necrosis

Stomal appearance should normally be pink or red and moist.
? Signs of stomal ischemia are pale pink or bluish purple
color and dry appearance.
? If the stoma appears black or purple in color, this
indicates a serious impairment of blood flow and requires immediate intervention.

GERD is

GERD is a common condition characterized by gastric content and enzyme backflow into the esophagus.

Untreated Gerd leads to

adenocarcinoma

How to prevent GERD/Risk factors

? Obesity
? Older age
? Smoking
? Foods that relax the LES include fatty and fried foods, chocolate, caffeinated beverages (coffee), peppermint, spicy foods, tomatoes, citrus fruits, and alcohol
? Increased abdominal pressure from obesity, pregnancy, bending at the waist, ascites, or tight clothing at
the waist

Gastroesophageal reflux disease (GERD) s/s

? Classic report of dyspepsia after eating an offending food or fluid, and regurgitation
? Pain that worsens with position (bending, straining,
laying down)
? Throat irritation (chronic cough, laryngitis),
hypersalivation, bitter taste in mouth (caused by
regurgitation). Chronic GERD can lead to dysphagia (difficulty swallowing)
? Pain is relieved (almost immediately) by drinking water, sitting upright, or taking antacids.

GERD DIAGNOSTIC PROCEDURES: Esophagogastroduodenoscopy (EGD)

? EGD is done under moderate sedation to observe for tissue damage and to dilate strictures in the esophagus.
?EGD allows visualization of the esophagus, revealing esophagitis or Barrett's epithelium (premalignant cells).
? make sure gag reflex returns

Antacids

Aluminum hydroxide
Instruct the client to take antacids when acid secretion is the highest (1 to 3 hr after eating and at bedtime), and to separate from other medications by at least 1 hr.

Proton pump inhibitors (PPIs) end in?
For? Side effects?

-zole
Pantoprazole, omeprazole, esomeprazole, rabeprazole, and lansoprazole reduce gastric acid.
NURSING CONSIDERATIONS
? Monitor for electrolyte imbalances and hypoglycemia in clients who have diabetes mellitus.
? Long-term use has been related to the development of community-acquired pneumonia and Clostridium difficile infections.
CLIENT EDUCATION: Long-term use of PPIs places the client at risk for fractures, especially in older adults.

Histamine2 receptor antagonists end in?

Ranitidine, famotidine, and nizatidine reduce the secretion of acid.
NURSING CONSIDERATIONS: Use cautiously in clients who have kidney disease.
CLIENT EDUCATION
? Take with meals and at bedtime.
? Separate dosages from antacids (1 hr before or after
taking antacid).
? Instruct clients to notify the provider of obvious or occult GI bleeding (coffee-ground emesis).

Metoclopramide hydrochloride Reglan

Metoclopramide increases the motility of the esophagus and stomach.
NURSING CONSIDERATIONS: Monitor the client taking metoclopramide for extrapyramidal (Movement complications) side effects.
CLIENT EDUCATION: Instruct the client to report abnormal, involuntary movement.

GERD: Fundoplication (Presurgical education)

?Diet- avoid offending foods, large meals, and eating before bedtime.
?Remain up right after eating
?Avoid tight fit clothing
**? Elevate the head of the bed 15.2 to 20.3 cm (6 to 8 in)
with blocks.**
? Sleep on the right side.

Esophageal varices?
Risk factor

Esophageal varices are swollen, fragile blood vessels
? Portal hypertension (elevated blood pressure in veins that carry blood from the intestines to the liver)
? Alcoholic Cirrhosis
? Hepatits

Esophageal varices s/s

Bleeding
? Shock
? Hypotension
? Tachycardia
? Cool clammy skin

Esophageal varices labs

Liver function test (portal hypertension bleeding
Hg and Hct low = anemia

Esophageal varices Diagnostic procedure

endoscopy

Therapeutic procedures

sclerotherapy/ vatical band ligation
Transjugular Intrahepatic portal-systemic shunt (TIPS)
Esophagogastric balloon tamponade

Esophageal varices: Nursing actions

IV large bore needle
Hct
Overt/ Occult bleeding
prepare for blood transfusion

Peptic Ulcer Disease

A peptic ulcer is an erosion of the mucosal
lining of the stomach, esophagus, or duodenum.

Peptic Ulcer Disease includes

gastric ulcers, duodenal ulcers, stress ulcers

Peptic Ulcer Disease can cause

*
Peritonitis
*
Perforation that extends through all the layers of the stomach or duodenum can cause peritonitis.

Peptic Ulcer Disease Risk factors/Labs/ Diagnostic test

? Helicobacter pylori (H. pylori) infection
? NSAID/ Corticosteroid use
? stress
? alcohol
? Zollinger-ellison syndrome
?Gastric samples, C 13 Urea breath testing (NPO, drinks carbon, breaths, Two collections) Stool sample tests for Helicobacter pylori (H. pylori) infection
EGD

Peptic Ulcer Disease s/s

? Dyspepsia (Indigestion): heartburn, bloating, nausea, and vomiting (vomiting is rare but can be caused by a gastric outlet obstruction). Can be perceived as uncomfortable fullness or hunger.
? Dull, gnawing pain or burning sensation at the midepigastrium or the back
? Bloody emesis (hematemesis) or stools (melena)
? Weight loss

*
GASTRIC ULCER s/s
*

? Pain most commonly occurs 30 to 60 min after a meal
? Less often pain at night (30% to 40% of clients)
? Pain exacerbated by ingestion of food
? Malnourishment
? Hematemesis (vomiting of blood)

*
DUODENAL ULCER s/s
*

because duodenal comes after the stomach
? Pain occurs 1.5 to 3 hr after a meal.
? Awakening with pain during the night
? Pain relieved by ingestion of food or antacid
? Well?nourished
? Melena (dark sticky feces)

Peptic Ulcer Disease Antibiotics

Metronidazole, amoxicillin, clarithromycin, and tetracycline eliminate H. pylori infection.
CLIENT EDUCATION: Instruct the client to complete a full course of medication.

Sucralfate

Coats the ulcer and protects it from the actions of pepsin and acid.
? Administer on an empty stomach 1 hr before meals and at bedtime.

Peptic Ulcer Disease: Dumping syndrome. Client education.

A shift of fluid to the abdomen is triggered by rapid gastric emptying or high-carbohydrate ingestion. The rapid release of metabolic peptides following ingestion of a food bolus causes dumping syndrome.
? Gastrojejunostomy poses the greatest risk for dumping syndrome
? Lying down after a meal slows the movement of food within the intestines.
? Limit the amount of fluid ingested at one time.
? Eliminate liquids with meals, for 1 hr prior to, and
following a meal.
? Consume a high-protein, high-fat, low-fiber, and low-
to moderate-carbohydrate diet.
? Avoid milk and sugars (sweets, fruit juice, sweetened fruit, milk shakes, honey, syrup, jelly).
? Consume small, frequent meals rather than large meals.

Gastritis is?
Can cause

Inflammation of the lining the stomach
*
Pernicious anemia
* damage to cells, the client will need B12 injections

Gastritis Risk factors?

? Family member who has H. pylori infection
? Family history of gastritis
? Prolonged use of NSAIDs, corticosteroids (stops
prostaglandin synthesis)
? Excessive alcohol use
? Bile reflux disease
? Advanced age
? Radiation therapy
? Smoking
? Caffeine
? Excessive stress
? Exposure to contaminated food or water

Gastritis? s/s?

? Upper abdominal pain or burning can increase or decrease after eating
? Abdominal bloating or distention
? Hematemesis (bloody emesis) and stools that test positive for occult blood
? Nausea and vomiting

Gastritis DIAGNOSTIC PROCEDURES?

Upper endoscopy/ Radiographic!

Gastritis Nursing Care?

? Monitor for findings of anemia (tachycardia,
hypotension, fatigue, shortness of breath, pallor, feeling lightheaded or dizzy, chest pain).
? Provide small, frequent meals and encourage the client to eat slowly.
? Advise the client to avoid alcohol, caffeine, and foods
that can cause gastric irritation.

Misoprostol (Cytotec)

Reduces gastric acid secretion
? Advise clients to use contraceptives.
? Advise clients not to take if there is a chance of
becoming pregnant.
? Advise clients to take with food to reduce gastric effects.

Complication with Gastritis-Pernicious anemia

? Insufficient vitamin B12 can lead to pernicious anemia
NURSING ACTIONS: Instruct the client of the need for
monthly vitamin B12 injections.

Bowel Hernia is?
Incisional hernias is?
When is surgery necessary

Bowel herniation is the displacement of the bowel through a weakness of the abdominal muscle into other areas of the abdominal cavity.
Incisional hernias can occur as a postsurgical complication due to inadequate healing of the incisional site from malnutrition, infection, or obesity.
A hernia that cannot be moved back into place with gentle palpation is considered irreducible and requires immediate surgical evaluation.

Hernia nursing actions

If the hernia does not require surgery, instruct the client to wear a truss pad with hernia belt during waking hours to prevent the abdominal contents from bulging into the hernia sac. Inspect skin under the pad daily.

Hernia nursing post op ed

? Instruct the client to avoid increased intra-abdominal pressure for 2 to 3 weeks (avoid coughing, straining, and lifting objects greater than 10 lb).
? Instruct the client to apply ice as prescribed and inspect and report redness or swelling at the incisional site.
? Instruct the client to prevent constipation by increasing dietary fiber and fluids.
? Instruct the client to rest for several days and return to work when recommended by the surgeon, usually 1 to 2 weeks postoperatively.

Irritable bowel syndrome (IBS)
Diagnostic test are looking for?

Changes in bowel function (chronic diarrhea, constipation, bloating, and/or abdominal pain).
*
the presence of mucus in the stool
*

Irritable bowel syndrome (IBS): Disease prevention

? Avoid foods that trigger exacerbation, such as dairy, wheat, corn, fried foods, alcohol, spicy foods, and aspartame.
? Avoid alcoholic and caffeinated beverages, and other fluids containing fructose and sorbitol.
? Consume 2 to 3 L fluid per day from food and fluid sources.
? Increase fiber intake (approximately 30 to 40 g/day).

Irritable bowel syndrome (IBS): Nursing actions

? Review strategies to reduce stress.
? Instruct the client to limit the intake of irritating agents
(gas-forming foods, caffeine, alcohol).
? Encourage a diet high in fiber and fluids.
? Instruct client to keep a food diary to record intake and
bowel patterns (to adjust diet to prevent exacerbations).

Bowel obstructions: Risk factors

? Postsurgical adhesions are often the cause of small bowel obstructions.
?Diverticulitis
?Tumors
?Fecal impaction

Small Bowel obstructions: S/s

? Profuse, sudden projectile vomiting with fecal odor

Large Bowel obstructions: S/s

? Diarrhea or ribbon-like stools around an impaction

Bowel obstructions (BOTH) s/s

? Obstipation: the inability to pass a stool and/or flatus for more than 8 hr despite feeling the urge to defecate
Abdominal distention
? High-pitched bowel sounds above site of obstruction
(borborygmi) with hypoactive bowel sounds below, or overall hypoactive; absent bowel sounds later in process

Inflammatory Bowl Diseases (IBD)

Acute:
Appendicitis
Peritonitis
Gastroenteritis
Chronic:
Ulcerative colitis
Crohn's disease
Diverticulitis

Paralytic Ileus is

Non mechanical bowel obstruction decreased peristalsis secondary

Ulcerative colitis is? S/S?

Edema and inflammation primarily in the rectum and rectosigmoid colon. Mucosa and submucosa become hyperemic (increase in blood flow) may abscess
? Abdominal pain/cramping: *
often left-lower quadrant pain
n**
? Anorexia and weight loss
? Fever
? *
Diarrhea: up to 15 to 20 liquid stools/day
y**
? Stools can contain mucus, blood, or pus.
? Abdominal distention, tenderness, and/or firmness
upon palpation
? High-pitched bowel sounds
? *
Rectal bleeding
g**

Crohn's disease is s/s?

Inflammation and ulceration of the gastrointestinal tract, often at the distal ileum.
*
Lesions are sporadic.
* Fistulas are common.
? Abdominal pain/cramping: *
often right-lower quadrant pain
n**
? Anorexia and weight loss
? Fever
? *
Diarrhea: five loose stools/day with mucus or pus
s**
? Abdominal distention, tenderness and/or firmness
upon palpation
? High-pitched bowel sounds
? *
Steatorrhea (fat in stool)
)**

Diverticulitis? s/s?

inflammation of the diverticula hernia in the intestinal wall
? Acute onset of abdominal pain often in *
left-lower quadrant
t**
? Nausea and vomiting
? Fever
? Chills
? Tachycardia

Ulcerative colitis & Crohn's disease LABS

Serum albumin: Decreased
Hematocrit and hemoglobin: Decreased
Everything else increased

Ulcerative colitis & Crohn's disease Nursing actions

? Instruct the client to seek emergency care for indications of bowel obstruction or perforation (fever, severe abdominal pain, vomiting).
? NPO status
? Educate the client to eat high-protein, high-calories, low-fiber foods.
? Instruct the client to avoid caffeine and alcohol, and to take a multivitamin that contains iron.
? Advise the client that small frequent meals can reduce the occurrence of manifestations.
? Inform the client that dietary supplements that
are high in protein and low in fiber (elemental and semi-elemental products, canned nutrition beverages) can be used.
**
? Monitor for electrolyte imbalance, especially !potassium!. Diarrhea can cause a loss of fluids and electrolytes.
.***

Diverticulitis Nursing Actions

*
? Educate the client to consume a clear liquid diet until manifestations subside. The client can progress to a low-fiber diet as tolerated.
.**
? Instruct the client to add fiber to the diet once solid foods are tolerated without other manifestations. The client should slowly advance to a high-fiber diet as tolerated when inflammation resolves.
? Teach the client to avoid seeds or indigestible material, which can block diverticulum (nuts, popcorn, seeds).
? Instruct client to avoid foods or drinks that can irritate
the bowel. (Avoid alcohol. Limit fat to 30% of daily
calorie intake.)

Immunosuppressants mostly end in -rine

MEDICATIONS
? Cyclosporine
? Methotrexate
? Azathioprine
? Mercaptopurine
? Teach clients to avoid crowds and other chances of exposures to infectious diseases and to report evidence of infection.
? Advise the client to monitor for indications of bleeding, bruising, or infection.
? Monitor for pancreatitis and neutropenia.
? Can take up to 6 months to see therapeutic effects.

Peritonitis is? S/s?

? A life threatening inflammation of the peritoneum and lining of the abdominal cavity.
Rigid, board-like abdomen (hallmark indication)
? Abdominal distention
? Nausea, vomiting
? Rebound tenderness
? Tachycardia
? Fever

Peritonitis Nursing Care

? Place the client in Fowler's or semi-Fowler's position to promote drainage of peritoneal fluid and improve lung expansion.
? Monitor respiratory status and administer oxygen as prescribed. Turn, cough, deep breathe. Provide mechanical ventilation if needed.
? Maintain and monitor nasogastric suction.
? Keep the client NPO.

What lab findings indicates that the GI tract is digesting and absorbing blood?

Elevated BUN
An elevated BUN is an indication of GI bleeding