Week 13 - care of the pt with GI problems

GERD - what is it

acidic gastric contents overwhelm esophageal defence causing inflammation and irritation

• the most common upper GI disease

• chronic syndrome - reflux of stomach acid into lower esophageal

clinical manifestations of GERD

• hiatal hernia - most common

• incompetent lower esophageal sphincter

• dec. esophageal clearance

• dec. gastric emptying

• obestiy

• pregnant

• smoking

• alc./caffine

GERD - cues

• heartburn - pyrosis (burning in lower sternum into throat and jaw)

• dyspepsia - indegestion (pain upper abd)

• regurgitation - (hot, bitter sour mouth)

• hypersalivation

• non cardiac chest pain

• resp. symptoms - wheeze, cough, dyspnea, hoarsness, sore throat, choking

GERD lifestyle mods - pt./ caregiver teachings

• avoid alc., caffine, smoking

• upright position 2-3 hrs after eating

• avoid tight clothing/ bending over after eating

• avoid eating 3hrs before bed

• HOB inc. 4-6in

• weight reduction

• meds

GERD nutrition

• avoid foods that dec. left esophageal sphincter pressure

• avoid irritating foods

• avoid milk before bed

• encourage small frequent meals and fluids between meals

• dont lie down 30 mins following food

• elevate HOB 30deg at night

• avoid caffine/gas forming drinks

• avoid - smoking, chocolate, peppermint, caffine, tomato products and orange juice

GERD - gerontological considerations

concerns with home meds

• meds can dec. LES pressure (nitrates, CCBs, antidepressants)

• med induced enophagitis (NSAIDs and K)

• first sign - esophageal bleeding or aspiration

Peptic Ulcer Dz - what is it

erosion of GI mucosa from digestive action of HCL acid and Pepsin

• susceptible areas - LES, stomach, duodenum

• types: acute, chronic, gastric or duodenal

PUD - risk factors

• Aspirin adn NSAIDS - main cause

• high ETOh intake

• stress

• H.pylori infxn

• smoking

• other meds - corticoisteroids, SSRIs, anticoagulants

PUD cue - gastric PUD

epigastric discomfort 1-2 hrs after eating a meal

• burning or gasous pain

• food may make worses

• perforation cna be first sympt.

PUD cues - Duodenal PUD

burning or cramplike pain in midepigastric or back

• occurs 2-5 hrs after meal

• bloating, N/V, feelings of fullness

PUD - diagnostic studies - EGD - flexible endoscope

most accurate for presence and location

• direct visuals

• can collect h.pylori specimens

• used to monitor healing progress

PUD diagnostic studies - noninvasive h.pylori

• serology

• stool test

• breath test

PUD diagnostic studies - LABs

CBC, liver enzymes, serum amylase

stool - blood or melena check

PUD treatment

goal - dec. gastric acidity, inc. mucousal defense

• adequate rest

• no smoking

• no alcohol

• stress management

• diet changes

• pain management

• NO nsaids or aspirin for 4-6 wks

  • eondscopic eval. 3-6 months after

PUD med therapy

• reduce gastric acid secretion - PPI, H2 blockers

• elim. h.pylor - abx, PPI

  • pt. edu. - adhere to meds, report blood in vomit or stool

PUD med therapy - Cytoprotective drug therapy: sucralfate

• works best in low pH (acidic) dont take within 30 mins of taking antacid

• take on empty stomach 1hr before meal

  • dont take within 30 mins of other med

complications of PUD - Hemmorrhage

the most common complication

• usually duodenal

• upper GI bleed - cause VS changes (dec. BP, inc. HR), inc. amount/redness of aspirate

• management - EGD - first line within 24hrs of bleeding

complications of PUD - Perforation

the most lethal

• GI contents spill into peritoneal cavity

• causes sudden, severe ABD pain that radiates to back and shoulders, rigid abd, absent bowel sounds, NV, shallow resp. inc. pulse but weak, no relief

not treated - peritonitis occurs 6-12hrs

management

• NGT and gastric decompression

• IV fluids and blood

• Central line, PA catheter, ECG urinary catheter

small ones are self healing

large one req. surgery to close and suction of peritoneal cavity

Complications of PUD - Gastric outlet obstruction

edema, inflammation, pylorospasm, scar tissue cause block and distal stomach and duodenum

• stomach fills cause discomfrot, pain, worse at end of day, visible dilation

• belching, vomit, may give relief,

management

• decompress with NGT, PPI or H2, F&E replace, surgery, balloon dilation

PUD gerontological considerations

• inc. morbidity/mortality

• frequent NSAID use

• first symp. - GI bleed, dec. HGB/HCT

chole

cholecyst

bile and gallbladder

lithiasis

stone

itis

inflammation

docho

common bile duct

cholelithiasis

stones in the gall bladder from cholesterol, bile satl and calcium imblanace

• supersaturated w/ cholesterol

• percipitation into stones is most commonly cholesterol

• dec. bile flow

cholelithiasis - risk factors

• immonbility

• pregnancy

• inflammatory or obstructive lesions of billiary sys

• stones may stay in gallbladder or move to cystic or common bile ducts

  • most move to small intestine

  • migration causes pain

  • bile stasis = cholesistitis

  • stone location determines treatment plan

Cholecystitis - what is it

inflammation or infxn of gall bladder

• obstructed from gall stone, bile cant escape

• confined to mucousa lining or entire wall

• gall bladder = etematou, hyperemic

• may distend w/ bile or pus

• cystic duct may become occluded

cholelithiasis/cholesystitis manifestations

• indigestion

• tenderness in RUQ that radiates to back

• acute, colicky pain/spasms

• NV

• intolerance to fatty foods

• restless

• tachycardia

• diaphoresis

• fever/chills

• total obstruct - jaundice, amber urine, clay colored stool, steatorrhea

cholelethiasis/cholecystitis diagnostics

most common - Ultrasound

HIDA scan (cholescintigraphy)

MRCP

ERCP - need NPO 8hrs before, can remove stones from duct, takes bile sample.

cholelithiasis/cholecystitis labs

• WBC (inc)

• direct and indirect billiruben (Inc)

• urinary billiruben (inc)

• alkaline phosphate, ALT, AST (poss. inc)

• sreum amylase and lipase

cholelithiasis/cholecystitis complications

• infxn - gengerous GB, subphrenic abcess, rupture

• Common bile duct obstruction: jaundice, inc LFT

• pancreatic ampula obstruct: inc. amylase, lipase

cholelthiasis/cholecystitis treatment

• NPO

• Meds - pain control, abx, antiemetics, IV F&E, itching from bile (choestyramine), anticholinergics

• gastric decopression - NG tube

• ERCP w/ sphincterotomy

• Extracorpoeral shock wave lithotripsy

• surger - laproscopic cholecystectomy, open cholecysectomy

cholelethiasis/cholecystitis treatment - laprascopic cholecysectomy

• treatment of choice

• remove through 1-4 puncture holes

• minimum post-op pain

• discharge same/next day

• main complication - injury to bile duct

• stones in bile duct - additional surgery for remove CBD stones

cholelithiasis/cholcysectomy - open cholecystectomy

• removal through right subcostal incision

• often w/ suspected/confirmed gallbladder cancer

• pts. w/ cirrhosis

• pregnant - 3rd trimester

• t-tube may be insert in CBD - ensure patency, allow excess bile drain

• possible JP drain

Nursing management after cholecystectomy

monitor complications

• laproscopic - shoulder pain from phrenic nerve irritation and diaphragm from CO2

  • lateral or sims position for comfort

  • make sure pts moving

• infxn

• bleeding

• bile leak - abd pain, NV, fever, distended abd, post-cholecystectomy synd.

• bile duct injury/perforation of intesitine

• periotnitis

cholelethiasis/cholecystitis - pt. edu.

• pain manage - opiods, NSAIDs

• encourage TCDB, IS

• encourage ambulation

• look for jaundice

• treat NV

  • NG tube decompression

  • hydration

  • antiemetic

Pt education after cholecystectomy

• clear liquids first advance through diet slowly as tolerated

• smaller meals

• fat intake - dependent on tolerance

• take fat soluble vitamins

• incisions

acute pancreatitis - what is it

acute inflammation of pancreas

• d/t spill of pancreatic enzymes into surroudn tissue = autodigestion/severe pain

• 2 causes: gall bladder dz, heavy ETOH use

acute pancreatitis cues

• pain - epigastric, radiate to back left flank/shoulder, worse when lie down/eating, worse after eat ETOH or fat

• NV, low grade fever, leukocytosis, hypotension, tachycardia

• dec. breath sounds

• severe gen. jaundice

• paralytic illeus

• crackles in lungs - severe

• warm, moist skin

acute pancreatitis complications - Pseudocyst

accumulation fluid, pancreatic enzymes, tissue debris, inflammatory exudates at wall of pancreas

• abd pain, palpable mass, NV, anorexia

• resolves spontaneously, may rupture

acute pancreatitis complications - abscess

pseudocysts infxd cuasing excessive necrosis in tissue

• may rupture, perforate into adjacent organs

• upper abd pain, abd mass, leukocytosis, high fever

• prompt surgery to prevent sepsis

acute pancreatitis - daignostics

• blood tests - lipase, amaylase (also): enzymes, triglycerides, glucose biliruben, calcium

• abd ultrasound

• X-ray

• CT scan w/ contrast

• ERCP - endoscopy x X-ray

Acute pancreatitis - nursing goals

• relieve pain

• prevent/alleviate shock

• reduce pancreatic secretions

• correct fluid and electrolyte imbalances

• monitor pulmonary involvment

• prevent/treat infxns

• remove cause if possible

pancreatitis - nursing care

• rest pancreas - NPO, NG tube suction

• diet - start with clear after no pain, then low fat diet

• avoid caffine/ETOH

• small, frequent, high carb meals

• no smoking

• pain management

• surgical intervention - if worsens only

• keep sidelying, fetal, HOB elevated, leaning forward

• monitor BG

• monitor hydration

• TCDB/IS

Acute pancreatitis meds

NO DRUGS CURE THIS

• IV F&E

• pain meds

• antacids, abx, antiemetics, antispasmodics, anticholinergics,

• PPI

• pancreatic enzymes - aid digestion

• O2 sat >95%

• Total parenteral nutrition

• if stones - ERCP needed

appendecitis - what is it

inflammation of the appendix

• most common emergent abd surgery

• common ages 10-30

• obstruct of lumen = distention, venous engorgement, mucus and bactseria accumulation causing infxn, perforation and periotonitis

appendicities - labs and diagnostics

• CBC w/ differential

• UA

• CT scan

• US/MRI

appendicites - assessment: subjective

• dull periumbilical pain, anorexia NV, localizes to RLQ in days

• persistent pain at RLQ (mcburneys point)

• pain in RLQ when LLQ palpated (rosvings sign)

• localized tender, rebounding

• inc. pain w/ cough, sneeze, deep breaths, ambulation

appendecitis - assessment - objective

• s/sx of dehydration, dec. perfusion, shock

• low grade fever

• abd: rigid, tender, gaurding

• bowel sounds: dec., absent

appendicities - assessment: older adults

• less pain

• slight fever

• right illiac fossa discomfort

appendicitis - pre and post op care - preop

• non op management more common - Fluid and ABX

• admin IV fluids

• prevent complications - prevent NPO, monitor VS, antiemetycs, antipyretics,

• position fro pain relief - list still, right leg flexed

appendicitis - pre and post op care - postop

• ABC assessment

• early ambulation - advance diet as tolerated

• IV antibiotics if ruptured

appendicitis - potential complications - perferated appendix and peritonitis

oragans perforated spill contents into cavitys cause inflammed, infxd peritoneum

• abd pain - most common sign

• universal signs - tenderness over area involved or entire abd

• also - rebiound tenderness, muslce rigidity, spasms, peritoneal irritation, distention, fever, tachycardia, NV, altered bowel habits

peitonitis potential complications - data collection

• CBC, WBC count, h/h, CMP

• paracentesis - analyze fluid for blood, pus, bile, bacteria, fungus, amylase

• abd Xray, CT, peritoneoscopy

peritonitis complications

• hypovolemic shock

• sepsis

• intrabd abscess

• paralytic illeus

• ARDS

• ABD compartment syndrome

peritonitis management - preop

preop - NPO, NG suction, IV fluids, ABX, analgesia, antiemetics,

• keep knees flexed

• fowlers or semifowlers

• monitor VS, I&O, VTE prophylaxis and O2

peritonitis management - durign surgery

locate source, drain purulent fluid, remove damaged organ

peritonitis management - Postop

• NPO

• IV fluids

• NG suction

• Blood

• parenteral nutrition

• ABX

• sedatives

• opiods

• antiemetics

diverticula

saccular dilation, outpouching of mucosa in colon

diverticulosis

• multiple noninflammed diverticula

  • needs high fiber diet

diverticulitis

one or more inflammed diverticula

• needs low fiber diet

diverticulosis/diverticulitis

• common in older adults but inc. in middle age

• in left descending colon

• develop where blood vessels pass through muscles

diverticulosis/ diverticulitis - causes

genetic and environmental factors

• mainly: constipation, lack of dietary fibers

• others: obesity, inactvity, smoking, excess alcohol use, NSAID use

diverticulosis/diverticulitis - potential complications

• erosion of bowel wall

• perforation

• abscess

• fistula

• bleeding

diverticulosis - nursing assessment and data

usually asymptomatic

• sigmoidoscopy, colonoscopy

• Abd pain, bloating, flatulence, changes in bowel habtis, bleeding, diverticulitis

diverticulitis - nusing assessment and data

• acute pain: LLQ

• distention

• dec./absent bowel sounds

• NV

• syst. symp. of infxn

• fever

• cna perforate

  • older adults: afib, normal WBC, abd tender

diverticulosis/diverticulitis - data collection

• CT scan, oral contrast

• fecal occult blood

• CBC w/ differnetial

• blood cultures

• UA

• rare barium enemia

  • abd/chest xray

medical management of DIverticulitis

• diet changes

• med - abx, pain

• rest

• oral fluids

• sepsis management

surgical management of diverticulitis

• complicated

• IV ABX

• CT guided percutaneous drainage

• resection/multiple stage resection

• temporary colostomy (hartmann procedure)

post op care of diverticulitis

• ABCs

• NGT

• promote bowel motility - diet, ambulation, hydration

• TCDB

• ostomy care - assess for perfusion, stool, blood, bowel sounds, nausea, tolerating diet flatus, stool

• emotional support

• ostomy edu

Bowel obstructions

blockage prevents normal flow of contents

fluid build up above obstruction

• cause abd distention, edematous bowel, F&E shift

below obstruction - overgrow bacteria, inc bowel permeability = bacterial peritonitis

• causes - adhesion, hernia, vovulus, instussception, tumors, diverticulitis

INterventions of blocakge - consevative

• strict NPO, Ng tube suciton, IV fluids, IV antibiotics,

• promote bowel movement

• await return of bowel fxn

• rebound tenderness indicate perforation

• severe obstruction = perforation

interventions of blockage - surgical interventions

if not resolvoing

• exploratroy laporotomy - bowel ressection - possibly ostomy creation

• post op nursing considerations

• assess - bowel sounds, pause NG suction