NURS 220 - GI & Hepatic Disease

Hunter College NURS 22000 - GI/Hepatic Disease

What is the difference between nausea and vomiting?

-Nausea: subjective feeling of discomfort in the epigastric area with the urge to vomit; can occur without vomiting; often accompanied by anorexia (lack of appetite, NOT anorexia nervosa) -Vomiting: forceful ejection of partially digested food and secretions; the vomited material is called emesis

What are causes of nausea and vomiting?

GI disorders or infections, CNS disorders (including motion sickness), cardiovascular problems (e.g. MI), pregnancy, endocrine/metabolic disorders (diabetes, renal failure), side effects of medications, anesthesia or chemotherapy, psychologic factors, food (food poisoning)

What are clinical manifestations of nausea and vomiting?

-Anorexia and weight loss -Prolonged vomiting: dehydration, fluid and electrolyte imbalances, metabolic alkalosis or acidosis, decreased plasma volume, circulatory failure -Altered LOC: risk for pulmonary aspiration -> aspiration pneumonia

What acid-base imbalances can vomiting cause?

-Metabolic alkalosis (most common): loss of gastric hydrochloric acid (HCl) -Metabolic acidosis (less common): when small intestine contents are vomited, bicarbonate is lost

What ABG result would you expect in a patient who has been vomiting persistently for 3 days?

pH 7.6; PaCO2 30; HCO3- 40 -> metabolic alkalosis (high pH, high HCO3-) from loss of gastric HCl

How should you position a vomiting patient with an altered level of consciousness?

Rescue position: left lateral recumbent (side-lying) to protect the airway and prevent aspiration; if alert, semi-Fowler's

What do the colors and characteristics of emesis indicate?

-Bright red: active bleeding (Mallory-Weiss tear, varices, ulcer, cancer) -Coffee-ground: old blood that sat in the GI tract; acid breaks down the heme so it turns dark brown -> gastric bleeding -Blood doesn't always come from the GI tract (e.g. swallowed blood from a nosebleed)

What is the difference between regurgitation and projectile vomiting?

-Regurgitation: effortless; partially digested food slowly comes up from the stomach; rarely preceded by retching or vomiting -Projectile: forceful expulsion WITHOUT nausea; common with brain and spinal cord tumors (and gastric outlet obstruction)

What are nursing interventions for nausea and vomiting (acute care)?

-NPO -IV fluids -NG tube (may be connected to suction for decompression) -Monitor I&O (no point measuring one without the other), vital signs (watch for low BP, high HR), assess for dehydration (mucous membranes, skin turgor) -Psychosocial and environmental comfort -Aspiration precautions: semi-Fowler's or side-lying

A patient's NG tube drains 500 mL in 8 hours with an order to 'replace mL for mL' with D5 1/2NS. What do you give?

500 mL of D5 1/2NS; whatever volume comes out is replaced with the same volume of the ordered IV fluid

What antiemetic was emphasized for nausea and vomiting?

Ondansetron (Zofran), PO or IV; IV relieves nausea within about 10-15 minutes. But you must still find and treat the underlying cause, or the nausea and vomiting return when the drug wears off

What labs should be checked in a patient with nausea and vomiting?

BUN and creatinine (kidney function and hydration) and electrolytes: sodium, potassium, calcium, magnesium

What is the nutrition therapy progression after nausea and vomiting?

IV fluids until oral intake tolerated -> clear liquids (sips of water every 15-20 min) -> full liquids -> soft/bland, high carb, low fat -> normal diet based on needs (e.g. diabetic, cardiac); eat slowly, avoid overdistention, dietary consult as needed

What is the difference between a clear and full liquid diet?

-Clear liquid: liquids you can see through: water, apple juice, tea, broth, gelatin (Jell-O counts); coffee is NOT clear -Full liquid: still liquid but not see-through, e.g. milk, orange juice

Why should carbonated beverages (e.g. ginger ale) be avoided after nausea and vomiting?

Carbonation causes gastric distension, which can bring on nausea and vomiting; give non-carbonated, room-temperature beverages (warm tea) and dry toast, crackers, gelatin

What is gastroesophageal reflux disease (GERD)?

A chronic syndrome of mucosal damage due to reflux of stomach acid into the lower esophagus; most common upper GI problem in adults (~20-25% of US adults)

What is the primary factor causing GERD?

An incompetent lower esophageal sphincter (LES), the anti-reflux barrier between the esophagus and stomach; when weakened it doesn't close completely and allows food, fluid and acid to reflux. Lying down right after eating puts pressure on the LES and weakens it over time

What factors contribute to GERD?

Certain foods, obesity, smoking, hiatal hernia, stress (increases acid); medication-induced esophagitis from NSAIDs and potassium (K+)

What is the most common symptom of GERD?

Heartburn (pyrosis): burning, tight sensation under the lower sternum that may spread to the throat or jaw; recent onset in an older adult needs medical evaluation

How do you tell GERD pain apart from cardiac (angina) pain?

GERD pain is relieved by antacids (Tums, Maalox); cardiac pain is not and needs a nitrate. Always rule out a cardiac cause first

What are other manifestations of GERD besides heartburn?

-Dyspepsia: pain or discomfort in the upper abdomen -Regurgitation: hot, bitter, or sour liquid in the mouth or throat -Sore throat, hoarseness, choking sensation

What are complications of GERD?

-Esophagitis: ulcerations -> scar tissue, stricture (narrowing), dysphagia -Barrett's esophagus: metaplasia of cells -> increased risk for esophageal cancer -Respiratory: cough, bronchospasm, laryngospasm, cricopharyngeal spasm; aspiration -> asthma, chronic bronchitis, pneumonia -Dental erosion from acid

What is Barrett's esophagus?

Metaplasia (one cell type replaced by another) of the esophageal lining from chronic reflux; high risk for esophageal cancer

What is GERD-induced asthma and how is it treated?

Microaspiration of acid (pH ~4-5) into the airway causes wheezing, SOB and cough that look like regular asthma; it resolves by treating the GERD with acid suppression

What lifestyle changes are taught for GERD?

Low fat, small meals; no alcohol, caffeine or smoking; avoid acidic and spicy foods; sit upright 2-3 hours after meals; HOB at least 30 degrees; reduce stress; weight management and exercise

What are the most common and effective drugs for GERD?

-Proton pump inhibitors (PPIs): shut off proton pumps in the stomach lining to decrease acid production (e.g. Nexium) -H2 receptor blockers: block histamine-2 receptors to decrease acid secretion (e.g. Pepcid) -Other: antacids, cholinergics, cytoprotective drugs, prokinetics

When is surgery used for GERD?

Last resort; most patients manage GERD themselves with OTC drugs and diet. Surgery to tighten the LES is done only after lifestyle changes, medications and H. pylori testing fail

Which statement shows GERD diet teaching was effective?

"I will use herbal teas instead of caffeinated drinks."

What is H. pylori and how is it spread?

A bacteria easily spread person to person, especially among people in the same household; most infected people have no symptoms. Major cause of GERD, peptic ulcer disease, and gastric cancer

(T/F) Untreated H. pylori can keep GERD and ulcers from healing no matter how many acid-reducing drugs are given

True; the infection must be treated with antibiotics or symptoms keep coming back

How is H. pylori diagnosed?

-Endoscopy with biopsy of the gastric/duodenal lining (invasive, needs sedation) -Breath test: patient blows into a tube; easier and has replaced biopsy

How is H. pylori treated?

Antibiotics for at least 14 days along with a PPI (and H2 blocker): penicillin; if allergic, metronidazole; or bismuth alone or combined with tetracycline and metronidazole. Resistant strains need two antibiotics. Key teaching: take the ENTIRE course

What is peptic ulcer disease (PUD)?

Erosion of the GI mucosa from hydrochloric acid (HCl) and pepsin; ulcers can only develop in an acidic environment: lower esophagus, stomach, duodenum, and post-op gastrojejunal anastomosis

How are peptic ulcers classified?

By degree and duration of mucosal involvement and by location (gastric or duodenal) -Acute: superficial erosion, minimal inflammation -Chronic: erosion of the muscular wall with fibrous tissue; present continuously for months or on and off throughout life (more common)

What are characteristics of gastric ulcers?

-Usually in the antrum -More common in females older than 50 -Risk factors: H. pylori, NSAIDs, bile reflux -Increased obstruction, increased mortality, high recurrence -More likely than duodenal ulcers to cause hemorrhage, perforation and obstruction

What are characteristics of duodenal ulcers?

-Most common type (~80%) -1 to 2 cm -Most common age 35-45 -Etiology: H. pylori; high HCl secretion -High risk: COPD, cirrhosis, pancreatitis, hyperparathyroidism, Zollinger-Ellison syndrome, chronic renal failure -Occur, disappear, recur (endless cycle unless H. pylori is treated)

What factors increase the risk of peptic ulcers?

H. pylori, NSAIDs, aspirin, increased HCl production, caffeine, alcohol, smoking, carbonation, and milk

(T/F) Milk relieves peptic ulcer pain

False; milk actually increases acid secretion, it is not an antacid

What are manifestations of a gastric ulcer?

Burning or gaseous epigastric pain (can be high enough to be mistaken for chest pain) 1-2 hours after a meal; food may worsen the pain; perforation may be the first symptom in some patients

What are manifestations of a duodenal ulcer?

Burning or cramplike pain in the midepigastrium or back 2-5 hours after a meal (food takes longer to reach the duodenum); eating relieves the pain

What symptoms do both gastric and duodenal ulcers share?

Bloating, nausea, vomiting, early feeling of fullness; may be silent, especially in older adults and those taking NSAIDs

What are the three major complications of PUD?

All three are emergencies (more common with gastric ulcers): -Hemorrhage: most common; especially duodenal -Perforation: most lethal -Gastric outlet obstruction

What are manifestations of a perforated ulcer?

GI contents spill into the peritoneal cavity -> peritonitis -> sepsis: -Sudden, severe abdominal pain radiating to the back and shoulders; no relief with food or antacids -Rigid, boardlike abdomen; absent bowel sounds -Nausea and vomiting; shallow respirations; weak, rapid pulse; signs of hypovolemic shock -Intensity proportional to amount and duration of spillage

What is gastric outlet obstruction?

Obstruction in the distal stomach and duodenum; pain worsens over the day as the stomach fills and dilates; key finding is projectile vomiting, plus dehydration, distended abdomen, loss of appetite

What is the most reliable test to determine the presence, location, and healing of an ulcer?

Endoscopy; ulcers can take up to 3 months to heal

What drugs must be stopped in a patient with a peptic ulcer?

Aspirin and NSAIDs (irritate gastric mucosa; aspirin is an antiplatelet and increases bleeding); stop for at least 1-2 months

What is the drug therapy for PUD?

-Reduce gastric acid: PPIs and H2 receptor blockers (sometimes both) -Eliminate H. pylori: antibiotics + PPI for 14 days -Teach adherence, drug side effects, and to report recurrence of pain or blood in vomitus or stool -Goals: adherence, no symptoms, complete healing, lifestyle changes to prevent recurrence

How are PUD complications (hemorrhage, perforation, obstruction) managed?

-Endoscopy to stop bleeding; surgery for perforation or obstruction -ICU with frequent vital signs -IV PPIs or H2 blockers, IV antibiotics -IV fluids to correct fluid and electrolytes -NG tube to suction (decompress stomach, prevent projectile vomiting)

What is dumping syndrome?

The stomach can no longer control passage of chyme, so a large hypertonic bolus enters the small intestine and pulls fluid into the bowel -> decreased plasma volume, bowel distention, and rapid transit within 15-30 minutes of eating

What are manifestations of dumping syndrome?

Weakness, sweating, palpitations, dizziness, cramping, borborygmi (hyperactive bowel sounds), urge to defecate/diarrhea; lasts about 1 hour; easily dehydrated. Reduce with small, frequent meals and rest after eating

(T/F) Dumping syndrome only occurs after surgery for peptic ulcers

False; can occur after any gastric surgery, e.g. bariatric (weight loss) surgery

Why are patients after gastric surgery at risk for pernicious anemia?

Parietal cells in the stomach secrete intrinsic factor, needed to absorb vitamin B12; removing part of the stomach decreases intrinsic factor. After total gastrectomy, patients need B12 supplements for life

Who is most at risk for upper GI bleeding and why?

Older adults, especially women, due to increased NSAID use (e.g. ibuprofen for arthritis). GERD and PUD are the most common causes

What are the types of upper GI bleeding?

-Hematemesis: bloody vomitus, bright red (active) or coffee-ground (digested blood in contact with HCl) -Melena: black, tarry stools from an upper GI source (blood loses its red color moving through the GI tract) -Occult: hidden blood detected by guaiac test; used to help diagnose colorectal cancer

Which statement about checking for bloody stools is correct?

"Stools that are black and tarry occur with slow bleeding from the stomach."

What is considered a massive GI bleed?

Blood loss greater than 1500 mL or 25% of intravascular blood volume; 80-85% stop spontaneously but still need treatment

What are signs of shock to assess for in a GI bleed?

Tachycardia, weak pulse, hypotension, cool extremities, prolonged capillary refill, apprehension

What is one of the best measures of how severe a GI bleed is?

Hourly urine output; a drop in urine output means decreased cardiac output and vital organ perfusion

What is the emergency management of an upper GI bleed?

-Fluid resuscitation (most important): isotonic IV fluids, generally start with LR -Blood/blood product transfusions (replace blood with blood when possible) -Endoscopy to stop the bleeding; surgery if needed -PPIs to decrease acid; oxygen -VS every 5-15 min, hemodynamic monitoring, skin color, cap refill, LOC -Assess for perforation/peritonitis: tense, rigid abdomen, guarding, bowel sounds

What are clinical problems and goals for a patient with upper GI bleeding?

-Problems: fluid imbalance, inadequate tissue perfusion, impaired GI function -Goals: no further bleeding, cause identified and treated, return to normal hemodynamic state

What are key facts about colorectal cancer (CRC)?

-Second leading cause of cancer deaths in men and women combined -Most common type: adenocarcinoma -Higher in men; increases with age; 85% detected over 50; incidence increasing in ages 20-49

What increases and decreases the risk of colorectal cancer?

-Increases: diet high in red meat and processed foods, high fat, low fiber, smoking, family history, IBD -Decreases: exercise; diet high in fruits, vegetables and grains; long-term NSAID use (anti-inflammatory)

What are manifestations of colorectal cancer?

Insidious onset; symptoms often don't appear until advanced, so screening matters -Early: nonspecific fatigue (anemia from slow occult bleeding), loss of appetite, weight loss, or none -Progression: abdominal pain and tenderness, distention, rectal pain, change in bowel habits, palpable mass, hepatomegaly, ascites

What are the classic signs of colorectal cancer?

-Rectal bleeding (most common sign) -Change in bowel habits, especially alternating constipation and diarrhea -Pencil stool: narrow stool from a tumor compressing the intestinal wall

What are differences between right-sided and left-sided colorectal cancer?

-Right-sided: bleeding more common, unrecognized and an early sign of anemia; diarrhea -Left-sided: hematochezia (fresh blood in stool); bowel obstruction

What are complications of colorectal cancer?

Obstruction, bleeding, perforation, peritonitis, fistula formation

When should average-risk adults be screened for colorectal cancer?

Age 45 to 75 (lowered from 50); not needed after 75. Colonoscopy is the gold standard

How often is colonoscopy repeated?

If normal: every 10 years (some guidelines say 5) If a precancerous polyp is removed: repeat in 3 years

What teaching and risks go with a colonoscopy?

-Teaching: bowel prep to clean out the colon (unpleasant solution causing diarrhea) and limited diet about 24 hours before; patient needs encouragement -Risks: invasive -> perforation; sedation/anesthesia

What are alternatives to colonoscopy for average-risk patients?

-Cologuard: at-home stool test for occult blood and cancer DNA markers; no procedure risks but not 100% accurate -Capsule endoscopy: swallowed camera records the GI tract; can miss findings

How is screening different for high-risk patients (strong family history, IBD)?

Screening starts earlier and is done more frequently

How is colorectal cancer staged?

TNM system (tumor, node, metastasis). Surgery decision considers staging, location, and ability to restore bowel function and continence

What is the treatment for stage I and II colorectal cancer?

Removal of the tumor plus at least 5 cm of surrounding intestine and nearby lymph nodes; cancer-free ends are anastomosed; may be done laparoscopically. Caught early, surgery alone can be curative. Some patients need a temporary or permanent ostomy

What is the treatment for stage III and high-risk stage II colorectal cancer?

-High-risk stage II: surgery plus chemotherapy -Stage III: surgery and chemotherapy; may have chemo and radiation before surgery to shrink the tumor

What is the treatment for non-resectable or metastatic colorectal cancer?

Palliative surgery to control hemorrhage or relieve obstruction; chemotherapy and radiation to control spread and relieve pain. Cure is still possible with limited lung or liver metastases after resection and chemo

What is irritable bowel syndrome (IBS)?

A functional GI disorder with chronic abdominal pain/discomfort and altered bowel patterns (diarrhea, constipation, or both). No known cause; linked to psychologic stressors, family history, GI infections, and food intolerances (especially lactose)

How is IBS diagnosed?

Based solely on symptoms using the Rome IV criteria: abdominal pain/discomfort at least 1 day/week for 3 months, associated with two or more defecation changes (change in stool frequency, change in stool form)

What are the categories of IBS?

Categorized by stool pattern: IBS with constipation (IBS-C), IBS with diarrhea (IBS-D), IBS mixed, IBS unsubtyped

What are manifestations of IBS?

-GI: abdominal pain, diarrhea and/or constipation, distention, bloating, flatulence, nausea, mucus in stool, urgency, sensation of incomplete evacuation (feels like not everything came out) -Non-GI: fatigue, headache, sleep problems -Symptoms are intermittent and may last for years or life

What is the treatment for IBS?

No single effective therapy: -Psychologic support: cognitive behavioral therapy, stress management -Dietary changes: low FODMAP diet (fermentable oligo-, di-, monosaccharides and polyols), avoid gluten, eliminate trigger foods -Drugs: antispasmodics, antidiarrheals, pain relievers, antidepressants

What are nursing interventions for IBS?

Teach about medications and diet; encourage a food diary to identify trigger foods; provide support since it's a lifelong quality-of-life issue (patients may avoid leaving home for fear of diarrhea)

What is inflammatory bowel disease (IBD)?

Chronic inflammation of the GI tract with periods of remission and exacerbation; lifelong quality-of-life disease. Begins in teens/early adulthood with a second peak in the 60s -Ulcerative colitis: colon only -Crohn's disease: anywhere, mouth to anus

What are possible causes of IBD?

Unknown; family history, environmental factors, drugs (NSAIDs, antibiotics, oral contraceptives), genetics (200+ genes), possibly autoimmune

What are characteristics of Crohn's disease?

-Mouth to anus; distal ileum and proximal colon most common -Skip lesions: normal tissue between areas of inflammation -Affects all layers of the bowel wall -Cobblestone appearance from deep ulcerations -Strictures -> bowel obstruction -Leaks -> abscesses in the peritoneal cavity -Fistulas (abnormal connections between body parts) common

What are manifestations of Crohn's disease?

Diarrhea, cramping abdominal pain, weight loss from malabsorption, fever, fatigue, some rectal bleeding

What are characteristics of ulcerative colitis?

-Involves the colon; starts in the rectum and spreads to the cecum -Affects only the innermost mucosal layer -Diarrhea and electrolyte loss (can't absorb through inflamed tissue) -Protein loss in stool -Pseudopolyps: tongue-like projections into the bowel

What is the defining manifestation that distinguishes ulcerative colitis from Crohn's?

Bloody diarrhea (think 'ulcer' -> bleeding), along with abdominal pain

What are the severity levels of ulcerative colitis?

-Mild: fewer than 4 semi-formed stools/day, little blood -Moderate: up to 10 stools/day, increased bleeding; fever, malaise, anemia, anorexia -Severe: 10-20 stools/day, bloody diarrhea with mucus; fever, rapid weight loss, anemia, tachycardia, dehydration

What are local (GI tract) complications of IBD?

Hemorrhage, strictures, perforation (with possible peritonitis), abscesses, fistulas, C. diff infection (CDI), colonic dilation (toxic megacolon)

What are systemic complications of IBD?

-High risk for colorectal cancer (regular screening) -Multiple sclerosis, ankylosing spondylitis (autoimmune link) -Malabsorption, liver disease, osteoporosis -> routine liver function tests and bone density scan at baseline and every 2 years

What are the goals of treatment for IBD?

Rest the bowel (may use a temporary ostomy for a few months), control inflammation, combat infection, correct malnutrition, relieve symptoms, improve quality of life

What is the drug therapy for IBD?

Depends on severity and location of inflammation: -UC initial: corticosteroid for symptom relief; aminosalicylate or biologic therapy depending on severity -Crohn's initial: biologic therapy, corticosteroid -Also immunosuppressants, antimicrobials; can be used alone or in combination

Is there a surgical cure for ulcerative colitis or Crohn's disease?

-UC: yes; removing the entire colon cures it, but causes malabsorption and water absorption problems -Crohn's: no; it can affect the whole GI tract. Patients may still need surgery (often multiple times) for fistulas or strictures

What is the nutrition management for IBD?

Replace fluids and electrolytes, monitor for hypovolemia and anemia, prevent weight loss, choose a diet that doesn't worsen symptoms, involve a nutritionist

Which menu shows IBD diet teaching was effective?

Baked cod, baked sweet potato, and canned pears (bland, low residue)

Which ileostomy statement shows the patient needs more teaching?

"I should change the appliance daily to prevent odors." (it should not be changed daily)

What is hepatitis and what causes it?

Inflammation of the liver; causes include viruses (most common), alcohol, medications, chemicals, autoimmune diseases, metabolic problems

What type of virus is hepatitis B (HBV) and how is it transmitted?

Blood-borne DNA virus; transmitted perinatally, percutaneously, and through small cuts on mucosal surfaces with exposure to infectious blood, blood products, or other body fluids

Which body fluids contain hepatitis B?

Almost every body fluid (blood, semen, vaginal secretions, saliva); semen and saliva have lower concentrations than blood. NOT found in urine, feces, tears, or sweat

Who is most at risk for hepatitis B?

Men who have sex with men (especially unprotected anal intercourse) is the most common; also people living with someone with chronic HBV, hemodialysis patients, public safety workers