GI part I and II

GI Assessment History

Health history, Current concerns, Nutritional status evaluation., Social, medical, surgical history, Consider age related changes

GI age related changes and care

decreased bile production, pancreatic issues (low lipase), decrease hepatic cells (low metabolism of medication), peristalsis, decrease enzyme production, dysphagia, (want to increase fiber and fluid intake)

Unrecognized dysphagia

is a common problem among nursing home residents and can lead to malnutrition, dehydration, and aspiration pneumonia!

RUQ

liver, gallbladder, duodenums, pancreas, ascending colon, transverse colon

LUP

liver, spleen, stomach, jejunums, pancreas, descending colon, Transverse colon

RLQ

cecum, appendix, ileum, ascending colon

LLQ

sigmoid colon, descending colon

Physical Assessment Oral Cavity

saliva production, lesion, dentures

Abdominal assessment

Inspection, Auscultation, Percussion , Palpation

assessment Stool characteristics and color

white (fat, bile duct obstruction ), red (lower GI bleed), black (upper gi bleed),

Inspection of an ostomy

pink moist, raised, illlum more liquid

Abdominal trauma

Cullen’s sign and Turner’s or Grey Turner’s sign

Cullen’s sign

periumbilical brushing, intrabdominal or retroperitoneal bleed

Turner’s or Grey Turner’s sign

flank brushing, retroperitoneal bleeding (aorta, pancreas, colon, kidney)

CT scan (with or without contrast—PO and/or IV)

NPO 2-4 hours before, Check contrast, iodine and shellfish allergies!, Fluids after to eliminate dye, Check creatinine before the dye, Glucophage (Metformin) should be held for several days pre-scan and potentially post scan.

Glucophage (Metformin) held because

rental function, lactric acidosis concer, up to 48hr hold

Barium Studies

NPO 8-12 hours, Possibly clear liquids, enemas prior to barium enema, No opioids/anticholinergics within 24 hrs if possible, FLUIDS!!!!, possible laxative post procedure, Stool chalky white 24-72 hours post procedure

GI diagnostics

CT scan, Barium Studies, Endoscopic Studies

Patient Preparation Endoscopic Studies

NPO time varies from 6-12 hours Bowel prep likely prior to colonoscopy

Bowel prep colonoscopy

Liquids 12-24 hrs

Bowel prep colonoscopy Medications

Golytely, Magnesium citrate, Enemas

Golytely

half gallon, drink 1 glass q4hr, cold is palatable, be close bathroom, electrolytes, mix and chill, may be given NGT, NO PO med within 1 hr of starting, diabetic may need reduce meds

Golytely pain and bloating

wait 15-20mins

Magnesium citrate

1-1 ½ , plently water after, well tolerated

Enemas

to empty completely eee

Endoscopic Studies

Stop NSAIDs, antiplatelet drugs and anticoagulants possibly, Permit, sedation, remove dentures/partials for upper endoscopy

Endoscopic Post-procedure Care

Safety measures while patient wakens from sedation, Monitor VS frequently, monitor for signs of perforation (PAIN! Elevated HR, Decreased BP, Fever) Patient should not drive home

Upper endoscopy

Sore throat, hoarse post procedure several days , NPO until return of gag reflex

Endoscopic Retrograde Cholangiopancreatogram (ERCP)

looks at esophagus stomach duodenum and common bile duct

Endoscopic Retrograde Cholangiopancreatogram (ERCP) Watch for

signs of post-procedure pancreatitis (Pain URQ) nausea, vomiting,

Lower endoscopy

Teach patient fullness, cramping, flatus for several hours is normal, severe pain and/or heavy bleeding should be reported immediately, Fluids OK when alert and after flatus

Lower endoscopy If polyps removed

Antibiotics, patient teaching – some bleeding expected report infection signs (fever and foul drainage), follow up is important

Fecal Occult Blood Testing (FOBT)

Can be collected by health care professionals or patients (in the home setting). AKA hemoccult or guaiac testing.

Fecal Occult Blood Testing (FOBT) Teaching

Avoid NSAIDs and ASA for a week prior (false positive possible), Avoid more than 250 mg of vitamin C daily for a week (can cause a false negative result), Avoid red meat for three days prior (potential false positive), Collection method

Common GI Complications

GI Bleeding, Bowel Obstruction, Peritonitis,

GI Bleeding

Bleeding anywhere along the gi tract, multiple etiologies (esophageal varices, ulcers, cancers and more). May be a “slow” bleed, with gradual manifestations, or a hemorrhage—a medical emergency ! ! !

GI Bleeding Potential Assessment Alterations

poor perfusion, pale, melena, hematochezia (red or maroon frank or occult), coffee grounds, abdominal pain, UOP decrease VS

Patient Care with GI Bleeding

ABC’s always come first!, Supplemental oxygen possibly. Monitoring vital signs, monitor for signs of shock

with GI Bleeding Replacement of lost volume

Isotonic fluids. PRBC’s, FFP (if indicated by coagulation studies)

PRBC’s gauge

20g pink

GI Bleeding Monitor fluid volume status, how?

UOP, weight blood pressure, blood pressure

GI Bleeding Monitoring labs, which ones?

RBC, H/H, CBC, Elytes, FOBT, BUN (can be elevated with GI bleed) Creatine (more specific to kidney function), Liver functions, ABGs, coagulation studies

GI Bleeding Patient Care Possible NGT

gastric lauge possible if suspect upper GI bleed

GI Bleeding Patient Care NPO Status

scope testing surgery

GI Bleeding Patient Care Preparation for

endoscopy or surgery

GI Bleeding Patient Care PPI Medication

reduces gastric acid protrctive if inflammation, stress ulcers

Small Bowel Obstruction

There are mechanical and non-mechanical forms of bowel obstruction.

Mechanical obstruction

involves blockage of the bowel by anything that physically occludes the bowel lumen (tumor, barium, food, disease processes, bowel anomalies, e.g.).

Non-mechanical obstruction (paralytic ileus)

involves a failure of peristalsis.

factors increase risk for ileus

Abdominal or pelvic surgery, Stress response, Immobility or reduced activity level, Medications (opioids, CCB, Anticholinergics) Decreased volume

decrease patient’s risk of ileus

laxatives, catch early, reduce stress, hydration, ambulation, reduce pain meds

assessment alterations with ileus

Distention, bloating, pain, nausea,

ileus Patient Care

Ambulation, Limit narcotics, NPO, Possible NGT to low intermittent suction (LIS), IV fluids to maintain hydration

ileus Medications

options include laxatives, cholinergic drugs, Metoclopramide (Reglan), enemas, MOM

Metoclopramide (Reglan) How does it work?

prokinetic, decrease input of dopamine and serotonin to CTZ in brain,

Metoclopramide (Reglan) Patient Care implications

risk for tardive dyskinesia, (STOP med and tell HCP), not for pt with mechanical obstruction risk for perfusion

Mechanical Obstruction Pathophysiology

Secretions, Distension, Increased Peristalsis, Inflammation/edema, Leaking of fluids, Hypovolemia, e-lyte and pH imbalances

Mechanical Obstruction Potential for

Renal insufficiency, peritonitis, bacteremia, perforation, sepsis, septic shock and death.

Mechanical Obstruction Assessment

Symptoms like non-mechanical (ileus), Nausea and Vomiting likely, Bowel sounds abnormal (Hyperactive then silent and Peristalsis increased at first) Distension, Fluid and e-lyte changes

Patient Care with Mechanical Small Bowel Obstruction

NPO, NGT to low intermittent suction (LIS), IV fluids and monitor fluid volume status, Pain management with caution, Nausea management, Possible preparation for surgery

Mechanical Small Bowel Obstruction Monitor for

bowel perforation or peritonitis

Signs of bowel perforation

Increased pain. Tachycardia, Fever, Changes in abdominal assessment

Signs of peritonitis

Go obstruction signs, poor perfusion signs, distension, increased pain, so full it puts pressure on vessels and organs, reduced breathing ability (pressure on the diaphragm) (potential for metabolic acidosis)

peritonitis potential for

abdominal compartment syndrome

Peritonitis

A life threatening, acute inflammation of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity.

Peritonitis potential etiologic factors

ruptured appendix or peptic ulcer, bowel obstruction, ruptured gallbladder, etc.

Signs of Peritonitis

“Acute abdomen” (rigid, board-like, distended, exquisitely tender to light palpation), Nausea and vomiting, Fever, Diminished bowel sounds, Dehydration signs, Shortness of breath.

peritonitis Shortness of breath. Why?

diaphragm pushed up from pressure

How to respond if patient has signs of peritonitis?

Quick Assessment with Vital Signs & UOP, Report to HCP, Be alert for signs of sepsis

signs of peritonitis Anticipate

Labs, IVF, ABX, Surgery

Gastroesophageal Reflux Disease (GERD)

Backflow of gi contents into the esophagus!! Ouch !!! (pH of gastric acid ~ 1.5-3.5)

Gastroesophageal Reflux Disease (GERD) Can be caused by

Decreased tone/increased relaxation of the lower esophageal sphincter (LES), Increased gastric volume, Increased intra-abdominal pressure, Delayed gastric emptying

Factors that contribute to decreased LES pressure, thus allowing transient or chronic reflux

Physiologic alterations, Over eating, Obesity, Pregnancy, Ascites, Tight clothing, Some medications, Some foods, Nicotine and Alcohol, NGT

GERD complications

Can lead to esophageal stricture, Esophageal ulceration (possible hemorrhage), Aspiration pneumonia, Linked to adult –onset asthma, laryngitis, dental deterioration, Barrett’s epithelium- premalignant

GERD Clinical Manifestations

Regurgitation, Dyspepsia, Water brash, Eructation, flatulence or bloating, Nausea, Globus, Dysphagia and odynophagia, Chest pain, Respiratory symptoms

GI and Cardiac symptoms

are similar. Assess, collaborate with the health care provider. EKG if needed. Treat as cardiac until ruled out

How would cardiac symptoms be different from GI?

have some L arm or jaw pain

GERD Patient Care Measures Diet modifications

Eat slowly, chew thoroughly, 4-6 small meals, no late day eating, Nothing that decreases LES pressure, Avoid most juices (apple OK), Possibly reduce fluid intake with meals

GERD Patient Care Measures Lifestyle changes

HOB elevated, No tight clothes, Weight loss if appropriate, No smoking, No Alcohol

GERD Patient Care Measures

Endoscopic therapies, surgery

GERD Medications

Antacids, H2 Blockers, Proton pump inhibitors, Pro-kinetic meds

Antacids ex

Tums, Mylanta e.g.

Antacids How do they work?

increase gastric acid pH

Antacids Patient care and teaching

1-3 hrs after meals and at bedtime, Follow with glass of water, Do not take other PO meds within 1-2 hrs of antacid

Histamine receptor antagonists (H2 Blockers) Examples

Cimetidine (Tagamet), Famotidine (Pepcid), Nizatidine (Axid), Ranitidine (Zantac)

H2 Blockers How do they work?

Reduce gastric acid production

H2 Blockers Patient care and teaching

Available PO and IV, OTC and RX, Slow IV push, Cimetidine inhibits CYP 450 enzymes

Proton pump inhibitors Examples

Esomeprazole (Nexium), Pantoprazole (Protonix), Lansoprazole (Prevacid)

PPI How do they work?

Powerful inhibition of gastric acid production

PPI Patient care and teaching

PO and IV available, OTC and Rx, Slow IVP or infusion

PPI Concern with long term use

Hypergastrinemia with DC, Pneumonia, C. Diff infection, Fractures (Calcium absorption decrease), Hypomagnesemia, B12 and iron deficiency

Hiatal Hernia

A portion of the stomach protrudes upward through the LES and the esophageal hiatus and into the esophagus.

Hernia causes

weaken diaphragm too much pressure, lifting something heavy

Type I, Sliding hernias (95% of cases)

Big concern . . . reflux and its’ ramifications! Potential for Barrett’s esophagus

Type II, Rolling hernias

Reflux usually not a big issue (LES remains below the diaphragm) , Risk of volvulus, obstruction and strangulation is high!!!

Volvulus

intestine twist

Clinical Manifestations hernias

Symptoms associated with GERD, Iron deficiency anemia potential

Unique manifestations with rolling type hernias

Reflux less likely, Fullness, breathlessness after eating, Suffocating feeling, Chest pain, Increased symptoms when lying flat

hernia Patient Care Measures

just like management of GERD, plus avoid straining and activities that increase intra-abdominal pressure.

Why do you want to avoid activities that increase intra-abdominal pressure with hernias ?

want to prevent strangulation