GI System Review
GI Assessment Procedures
Focus on procedures.
Tubes and Drains (GI System)
NG Tube:
Used for decompression of the stomach.
Used for feeding a patient.
Decompression is needed when the abdomen is distended due to a bowel obstruction, causing a buildup of fluids and toxins.
Leaving the obstruction untreated can lead to patient discomfort as the contents need to go somewhere. The NG tube is used with suction to remove these contents.
NG tube use is temporary (days to a couple of weeks).
G Tube:
More permanent solution compared to NG tube.
Ileostomy vs. Colostomy:
Ileostomy: Located in the ileum.
Stool is more liquid.
Colostomy: Located in the colon.
GERD (Gastroesophageal Reflux Disease)
Commonly known as heartburn or acid reflux.
Involves inflammation of the esophagus due to stomach acid.
Chronic condition where the lower esophageal sphincter is weakened, allowing stomach contents to reflux into the esophagus.
Risk Factors:
Foods high in caffeine, spicy foods, acidic foods, gravies, tomato products, and citrus fruits.
Smoking weakens the lower esophageal sphincter.
Medications like nitrates, calcium channel blockers, estrogen, and progesterone.
Alcohol and obesity.
NG tube.
Signs and Symptoms:
Painful swallowing and regurgitation.
Aspiration myocarditis.
Complications:
Overuse of antacids (Tums) can neutralize hydrochloric acid which is needed to kill bacteria and break down food in the stomach.
Histamine blockers decrease stomach acid production, which can lead to metabolic alkalosis in the long run.
Proton pump inhibitors (PPIs) also reduce stomach acid production.
Lifestyle changes are crucial to manage GERD.
Hiatal Hernia:
Part of the stomach protrudes above the diaphragm.
Sliding Hiatal Hernia:
Part of stomach slides up and down.
Symptoms occur when the stomach is up and subside when it slides back down.
Rolling Hiatal Hernia (Type II):
Also called Paraesophageal hernia
Part of the stomach remains above the diaphragm.
Patient essentially has two stomachs (one small, one normal).
Only fixable through surgery.
Assessments:
Heartburn, regurgitation, chest pain, dysphagia, burning sensation, belching.
Shortness of breath due to the full stomach pressing on the diaphragm.
Treatment includes dietary changes, positioning, antacids, PPIs, and surgery for type II.
Small, frequent meals are recommended.
Avoid triggers (alcohol) , eat meals 2-3 hours before bedtime.
Elevate the head of the bed.
Laparoscopic Nissen fundoplication (LNF) is a surgical procedure to fix the rolling hiatal hernia.
Post-op care focuses on preparing the patient for surgery and managing their condition post-surgery.
Gastric and Duodenal Ulcers (Peptic Ulcers)
Peptic ulcer: Loss of protection of the epithelium from the stomach acid.
Loss of protection of the epithelium from stomach acid, leading to damage.
Main Cause:
H. pylori bacteria.
Can be ingested through contaminated food or water.
NSAIDs, corticosteroids, severe stress, hypersensitivity, excessive alcohol, tobacco, and caffeine.
Normal alcohol consumption is one drink for women and two for men.
Screening:
Patients with gastritis or ulcer symptoms should be screened for H. pylori.
Gastric Ulcers:
Patients tend to be malnourished because eating causes pain, leading them to avoid food.
Duodenal Ulcers:
More common in blood type O individuals.
Patients are typically well-nourished because eating relieves pain for about three hours.
Pathophysiology:
Barrier is damaged, leading to injury of the mucous membranes.
Hydrochloric acid damages blood vessels, causing inflammation, infection, bleeding, and edema.
Acute Gastritis:
Sudden onset and short duration, potentially leading to gastric bleeding.
Chronic Gastritis:
Slow development but can damage parietal cells, leading to pernicious anemia (requiring vitamin supplements or injections).
Gastric Ulcers Result In:
Delayed stomach emptying, increasing gastric acid diffusion back into the stomach.
Duodenal Ulcers Result In:
Increased gastric acid secretion and occult blood in stool.
Key Differences Between Gastric and Duodenal Ulcers:
Pain is similar but location differs.
Gastric: Pain in the abdomen is worsened by eating and relieved by food.
Duodenal: Pain is relieved by eating but returns 1-3 hours later; patients may wake up at night with pain.
Priorities:
Bleeding is the main priority.
Address aspiration risk.
Diagnosis:
Urea breath test for H. pylori.
Barium examination.
Hemoglobin and hematocrit levels.
Stool sample for occult blood.
Goals:
Pain relief, infection elimination, and healing of damage.
Treatment:
Keep patients NPO temporarily to rest the gut, then slowly advance the diet.
Triple drug therapy (PPI and two antibiotics).
PPI, two antibiotics, and bismuth subsalicylate.
PPIs reduce acid production.
Antibiotics treat the infection.
Complications:
Perforation or hemorrhage.
Vomiting bright red blood or coffee ground emesis.
Peptic ulcer perforation is a surgical emergency.
IV PPIs (e.g., protonix drip).
Prioritize ABCs focus on circulation address bleeding.
Two large bore IVs.
Provide blood if needed.
Electrolyte repletion and antibiotics, keep the patient NPO.
Pernicious anemia requires lifelong vitamin injections.
Dumping Syndrome:
Food moves too quickly into the small intestine.
Medication: Octreotide.
Lying down after meals to slow digestion.
Anemia and potential complications.
Peritonitis.
Gastric vs. Duodenal Ulcers Revisited:
Sharp and burning pain with both types.
Gastric ulcer pain: Left upper quadrant.
Duodenal ulcer pain: Right upper quadrant/epigastric.
Duodenal ulcer pain is relieved by food; may wake up at night due to pain.
Melena is more common with duodenal ulcers.
IBS (Irritable Bowel Syndrome)
Chronic functional gastrointestinal disorder with no known cure or etiology.
Theories involve GI motility issues, hypersensitivity, and intestinal inflammation.
Three Types:
Constipation-predominant.
Diarrhea-predominant.
Mixed.
Not an inflammatory bowel disease.
Treatment and Management:
Peppermint, herbal teas, and ginger to relax intestinal muscles and control nausea and diarrhea.
Malnourishment:
Patients may be malnourished due to frequent diarrhea.
May have mucus in stools.
Assessment:
Hyperactive bowel sounds (in diarrhea-predominant IBS).
Check for blood in stool; labs are typically normal but check CBC and albumin.
Monitor ESR.
Medical Management:
Laxatives or anti-diarrheal medications as needed.
Amitriptyline.
Patient Teaching and Interventions:
Encourage 30-40 grams of fiber daily to promote regular bowel movements.
Peritonitis
Non-chemical contamination due to bile or pancreatic enzyme leakage.
Treatment:
Keep patient NPO.
Administer oxygen.
Classic Sign:
Rigid abdomen.
Shallow breathing due to pain; administer oxygen.
Surgical intervention:
Removal of abscesses and toxins.\n* Signs of Infection:
Foul smelling drainage, swelling, redness, warmth.
Hypovolemic shock due to blood supply directed to vital organs (heart, brain, lungs) at the expense of kidneys (leading to acute kidney failure and elevated BUN).
Appendicitis
Appendix gets blocked by feces or food, leading to inflammation and infection.
Major complication: Rupture of the appendix, causing peritonitis.
Right lower quadrant pain (McBurney's point).
Emergency surgery is needed to prevent peritonitis and sepsis.
Manifestations:
Periumbilical abdominal pain at McBurney's point.
Anorexia, tenderness, muscle guarding.
Low-grade fever, elevated white blood cell count.
Enlarged appendix on ultrasound.
Management:
Emergency surgery.
IV normal saline or lactated ringers (LR).
Antibiotics and pain medication.
No heating pads on the abdomen.
Side-lying or semi-Fowler's position.
Post-op:
Monitor for a distended abdomen with absent bowel sounds.
Gastroenteritis
Infection of the gastrointestinal tract caused by viruses, bacteria, or parasites.
Causes watery diarrhea.
Pathogens release toxins within the intestine.
Complications:
Hypotension and dysrhythmias due to loss of potassium.
Assessments:
Intake and output, electrolyte levels (CMP).
Cardiac monitoring.
Diet Modifications:
Avoid caffeine, alcohol, nicotine, and high-fatty foods.
Nursing Interventions:
Fluid administration and hand washing.
Inflammatory Bowel Disease (IBD)
Crohn's Disease:
Characterized by patchy inflammation throughout the intestine.
Ulcerative Colitis:
Inflammation is localized to the colon, sigmoid colon, and rectum.
Both have unknown etiologies.
Diet Recommendations:
High-calorie, high-vitamin, high-protein, and low-residue diet.
Avoid high-fiber foods due to diarrhea.
Ulcerative Colitis in Detail
Intestine appearance: inflamed with pus and mucus.
Remission and exacerbation periods.
Stool contains blood and mucus.
Risk of fluid and electrolyte imbalance, dehydration, and hypokalemia.
Intestine is hyperemic (increased blood flow), edematous, and red.
Ulcers can lead to abscesses and necrosis, potentially causing a narrowed colon and partial bowel obstruction.
Pain is in the left lower quadrant.
Comparison:
Ulcerative colitis patients: 15-20 liquid stools per day with mucus and blood.
Crohn's patients: 5 stools with mucus and pus, but no blood.
Ulcerative colitis: Blood transfusions may be needed.
Rectal Bleeding in Ulcerative colitis.
Medications:
Sulfasalazine and prednisone.
Anti-diarrheal medications (loperamide and atropine sulfate).
Patient Teaching:
No live vaccinations.
Monitor for perforation.
Surgical intervention:
For Ulcerative Colitis Colon resection, and Double-barrel colectomy.
Pre/post-operative care involves antibiotics, IV fluids, NG tube.
Monitor stoma output, more liquid stool occurs with ileostomy.
Monitor CBC and CMP. Watch for any dehydration signs.
Diet should be baked not fried. And may require vitamin supplements.
Diverticulitis
Antibiotics, pain medication, antispasmodic medications, clear liquid diet.
Avoid: Nuts, popcorn, seeds.
No enemas.
Collaboratively all three diseases, diverticulitis, Crohn's, and ulcerative colitis can cause C. diff infection, and C. Diff. is often related to Membranous Colitis, so be ready to head Up.
Diverticulosis
Herniation of the mucosa through the bowel wall, creating pouches where undigested food gets trapped.
Reduced blood supply leads to bacterial growth and inflammation.
B12 injections may be needed.
Malabsorption, malnutrition. B12 injections, bleeding, infection.
Manifestations:
Pain, constipation or diarrhea.
Give medication such as pain medication, hydration, low fiber, clear liquid diet before healing.
Monitor for blood lose, follow follow appointments. Notify the PCP.
Ileostomy Care
Skin protection.
Gas production can stick.
Avoid enteric-coated medications.
So ulcerative colitis, exacerbation sweet diarrhea, What else? And then increased BUN because of dehydration, Hypokalemia, No fiber.