Gastrointestinal Nursing

Ulcerative Colitis and Crohn's Disease

Ulcerative Colitis

  • Ulcerative inflammatory bowel disease, affecting the large intestine.

Crohn's Disease (Regional Enteritis)

  • Inflammation and erosion primarily of the ileum (small intestine) but can occur anywhere in the GI tract.

Signs and Symptoms (Common to Both)

  • Diarrhea
  • Rectal bleeding
  • Weight loss
  • Vomiting
  • Cramping
  • Dehydration
  • Blood in stools
  • Anemia
  • Rebound tenderness
  • Fever

Rebound Tenderness

  • Indicates peritoneal inflammation.
  • Elicited by pressing on the abdomen and quickly releasing, causing pain.

Treatment (Similar for Both Diseases)

  • Diet:
    • Low-fiber diet to limit motility and conserve fluids.
    • Avoid cold or very hot foods and smoking, as they increase motility.
  • Medications:
    • Anti-diarrheal medications: Given only for mildly symptomatic ulcerative colitis.
    • Antibiotics: Such as Gantrasin (a sulfonamide), for GI tract infections.
    • Steroids: To decrease inflammation; long-term use can cause other problems.

Psychological Factors

  • GI tract can be sensitive to emotions (e.g., test anxiety).
  • Anxiety can manifest as diarrhea.
  • During NCLEX, students can request to use the restroom even if it is not break time, particularly if they are experiencing explosive diarrhea.

Surgery for Ulcerative Colitis

  • Total colectomy: Removal of the entire colon, resulting in an ileostomy.
  • Kock pouch (J-pouch): A continent ileostomy, no external bag needed, with a valve to open and close to empty intestines.
  • Removal of colon and rectum: Reconnecting the remaining GI tract; may involve a temporary colostomy.
  • Temporary colostomy is a basic nursing concept post GI surgery: Allows intestines to rest and heal.

Surgery for Crohn's Disease

  • Surgery is avoided if possible; if necessary, only the affected area is removed.
  • If all small intestine is removed, a colostomy results.

Ileostomy Care

  • Drains liquid continuously, leading to dehydration.
  • Never gets clogged, so irrigation is not needed.
  • Emphasis on fluid and electrolyte replacement.
  • Avoid foods hard to digest and rough foods that increase motility.
  • Patients need Gatorade because they are always a little dehydrated and it assists with replacing electrolytes
  • Risk for kidney stones due to dehydration.

Colostomy Care

  • Regulation through bowel training and irrigation.
  • Irrigation is not needed for all colostomies; depends on the location of the stoma.
  • Purpose of irrigation: To empty the intestines, similar to an enema.
  • Stoma location affects stool consistency: the further down the colon, the more formed the stool.
  • Ascending colostomy: Liquid stool, no irrigation needed.
  • Transverse colostomy: May require irrigation due to potential for clogging.
  • Descending colostomy: Stoma close to the rectal area may result in near-normal bowel movements.
  • Irrigation Schedule
    • Best time to irrigate: same time every day to establish routine; after a meal due to increased peristalsis.
      Irrigation Technique
  • If inexperienced, ask the patient for guidance. Be respectful of the patient’s stoma.
  • Use same principles as administering an enema but avoid positioning the patient on their left side (applicable only if a rectum is present).
  • If cramping occurs during irrigation, lower the bag or stop the procedure; irrigation is frequently self-administered.
  • Patients with stomas close to the rectum may have near normal bowel movements.

Appendicitis

  • Often related to low-fiber diet.
  • Inflammation of the appendix due to bowel contents.
  • Risk of rupture leading to leakage of bowel contents into the abdomen.
  • Positioning a patient with a ruptured appendix: Sit them up to contain the bowel contents in one area.
  • Positioning is vital in nursing and may not always be ordered, requiring nurses to make informed decisions.
  • Patients returning from the bronch lab should have their head elevated and turned to the side to avoid aspiration.
  • Every time you give an intermittent tube feeding, turn the patient to their right side and elevate their head.
  • Stop tube feeding before turning or repositioning a patient and check placement before restarting.

Appendicitis Signs and Symptoms

  • Generalized abdominal pain initially, localizing to the right lower quadrant (McBurney's point) as it worsens.
  • Elevated white blood cell count.
  • Nausea and vomiting.
  • Rebound tenderness.
  • Pre-Op Nursing Considerations
    • Surgeon may order a cleansing enema (dangerous with appendicitis due to the risk of rupture particularly by a new nurse).
      *Elevate the head a little bit post-operatively to decrease pressure on the abdomen and suture line

Peptic Ulcers

  • Common cause of GI bleeding, occurring in the esophagus, stomach, or duodenum.
  • More common in males, but increasing in females.
  • Erosion leads to burning pain, usually in the mid-epigastric area, sometimes radiating to the back.
  • May manifest as hunger or gnawing sensation even after eating.
  • Treatment:
    • Antacids: Liquid preferred to coat the stomach, taken when the stomach is empty and at bedtime to protect ulcer from acid.
      *H2 antagonists, PPIs, and GI cocktails in the ER
    • Antibiotics: For H. pylori infection (e.g., Biaxin, Amoxil, Tetracycline, Flagyl).
    • Carafate: Forms a barrier over the ulcer to protect it from acid; can be given as a pill or slurry.
    • Lifestyle changes: Decrease stress, stop smoking, eat tolerable foods.
    • Avoid temperature extremes in foods, spicy foods, and caffeine.
      *Treatment followed for a year to ensure full recovery.

Gastric vs. Duodenal Ulcers

  • Gastric Ulcers:
    • Laboring people, malnourished.
    • Pain 1/2 to 1 hour after meals.
    • Food doesn't help, vomiting does, so vomit blood.
  • Duodenal Ulcers:
    • Executive type, well-nourished.
    • Nighttime pain and 2 to 3 hours after meals.
    • Food helps, blood in stools.

Dumping Syndrome

  • Stomach empties too quickly, causing fullness, weakness, palpitations, cramping, faintness, and diarrhea.
  • Occurs after gastric bypass, gastrectomy, or with gallbladder troubles. *Treatment
    • Semi-recumbent position with meals.
    • Lie down afterward on their left side to keep food in the stomach.
    • No fluids with meals (drink between meals).
    • Low carbs

Hiatal Hernia

  • Stomach moves up into the thoracic cavity due to a large opening in the diaphragm.
  • Causes: Large abdomen (increased pressure), congenital abnormality, trauma, or surgery.
  • Signs and Symptoms:
    • Heartburn.
    • Fullness after eating.
    • Regurgitation.
    • Dysphagia.
    • Reflux.
      *Treatment includes weight loss.
    • Small meals, sitting up after eating.
      *Elevate the head of the bed to keep the stomach down and prevent symptoms, especially at night. Surgery can be performed, but recurrence is possible with persistent abdominal pressure.

Hyperalimentation (TPN, Total Parenteral Nutrition)

  • May also see PPN (Peripheral Parenteral Nutrition).
  • Keep refrigerated, warm for administration.
  • Central line required due to high particle content.
  • Use a filter and a dedicated line; do not mix with anything else.
  • Discontinue gradually to avoid hypoglycemia.
  • Monitor:
    • Daily weights (should not lose weight).
    • Urine for glucose and ketones (not protein).
      • If there is glucose in the urine, it may be necessary to start the patient on Insulin. The presents of ketones in the urine indicates that the patient is braking down body fat, so the administration of Lipids or fat emulsions
    • Accuchecks every six hours to monitor blood sugar.
  • Prepared by pharmacy, not mixed ahead of time, as mixture changes daily based on electrolytes.
  • TPN can only hang for 24 hours, tubing changed with each new bag, and bag may be covered to prevent chemical breakdown.
  • Administered via a pump.
  • emphasize hand washing to prevent infection.

Central Line Insertion

  • Have Saline ready for the line and syringes for each port
  • Fluids not started until placement is confirmed by chest x-ray.
  • Patient Position: Trendelenburg (to distend veins) is the most common position.
    *Someone holds the the patient's head to prevent movement
    *Talk to the patient ans reassure them

Air Embolism

*Turn the patient to the left side. Another option would be to turn the patient to the left side and Trendelenburg

Changing tubing and preventing air from entering

*Tell the patient to take a deep breath and hold it as you change the lines or preform the Valsalva maneuver.

Post insertion

Perform an X-Ray. The two reasond for this are to check for placement and ensure the doctor did not cause a pneumothorax.

  • When you are using the bed, make sure you spend practice with it so it turns out right.

Flushing Central Line:

  • Flush central line using push pause method.
    *Use a 10 milliliter syringe as syringes that are smaller may impart too much pressure.