NURSING CARE OF PATIENT WITH DISTURBANCES IN METABOLISM MAJOR FUNCTIONS OF THE GI SYSTEM Secretion Digestion Motility Absorption Elimination

ation ASSESSMENT NUTRITIONAL PROBLEMS ASSESS CHARACTERISTICS Typical 24-hour diet recall Usual weight Weight loss or gain Appetite ASSESS ASSOCIATED FACTORS Food preferences Family or individual routines associated with eating Cultural and religious values Psychological factors Physical factors Access/transportation to grocery stores Eating habits, self-imposed dietary restrictions Body image Nutritional knowledge Finances ASSESS ASSOCIATED FACTORS Other symptoms: fever, nausea, vomiting, diarrhea, constipation, anorexia, weight loss, dyspepsia ASSESS HISTORY Family history of GI cancer, ulcer disease, inflammatory bowel diseases Previous history of tumors, malignancy, or ulcers INDIGESTION (DYSPEPSIA) ASSESS CHARACTERISTICS Associated Symptoms: feeling of fullness, heartburn, excessive belching, flatus, nausea, bad taste, mild or severe pain

 Appetite Pain or tenderness and location Pain radiation Precipitating factors of pain Alleviating or aggravating factors Symptoms association with food intake If associated with food, describe the amount and type of food ASSESS ASSOCIATED FACTORS Presence of nausea, vomiting, blood in bowel movements or diarrhea History of alcohol, non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin use ASSESS HISTORY Cancer, inflammatory bowel disease Bowel obstruction Previous abdominal surgeries NAUSEA AND VOMITING ASSESS CHARACTERISTICS Stimuli such as specific foods, odors, activity or a certain time of the day Occurence: before or after food intake How many times per day? Specific foods/fluids tolerated when vomiting occurs Amount, color and consistency of vomitus ASSESS ASSOCIATED FACTORS Fever, headache, dizziness, weakness or diarrhea Missed menstrual period Weight loss ASSESS HISTORY Gallbladder disease Ulcer disease GI cancer Unprotected intercourse

NATURE OF VOMITUS CHARACTER Yellowish or Greenish Bright red (arterial) Dark red (venous) Coffee grounds Undigested food Bitter Taste Sour or Acid Fecal components POSSIBLE SOURCE May contain bile Medication e.g. Senna Hemorrhage or peptic ulcer Hemorrhage Esophageal or gastric varices Digested blood from slowly bleeding gastric or duodenal ulcer Gastric tumour Ulcer, obstruction Bile Gastric contents Intestinal obstruction

DIARRHEA ASSESS CHARACTERISTICS Duration Frequency, consistency, color, quantity, and odor of stools Presence of blood, mucus, food particles in the stools Change in bowel habits Nocturnal diarrhea Aggravating or alleviating factors Weight loss ASSESS ASSOCIATED FACTORS Fever, nausea, vomiting, abdominal pain, abdominal distention, flatus, cramping, urgency with straining Use of antibiotics Recent travel to foreign countries with highest risk of travelers diarrhea (Mexico, South America, Africa, and Asia) Emotional stress or anxiety ASSESS HISTORY Colon cancer, ulcerative colitis, Crohns disease or malabasorption syndrome

Use of ginger as antiemetic (known to cause heartburn) Use of licorice root for upset stomach and ulcers (known to cause sodium and water retention and loss of potassium) POSSIBLE CAUSES OF DIARRHEA Infectious agents Food poisoning Medications Fecal impaction Bowel diseases Malabsorption syndromes Short bowel syndrome Malignant syndromes e.g. Zollinger-Ellison syndrome CONSTIPATION ASSESS CHARACTERISTICS Frequency, consistency, color of the stools Change in bowel habits Gradual or sudden Size of the stools Dietary changes Presence of blood or mucus Use of laxatives ASSESS ASSOCIATED FACTORS Periods of diarrhea Abdominal pain or distention Stress Changes in activity level Regular time for defecation Use of antacids containing calcium or anticholinergics ASSESS HISTORY Family history of colorectal cancer Depression or metabolic disorders such as hypothyroidism or hypercalcemia POSSIBLE CAUSES OF CONSTIPATION Inadequate fluid intake Psychological factors Electrolyte imbalances Hormonal abnormalities Mechanical bowel obstruction

Medications Loss of innervation e.g. Hirschprungs disease Neurological disorders Anorectal disorders DYSPHAGIA ASSESS CHARACTERISTICS Onset: acute or gradual Problem with swallowing: intermittent or continuous Association with solid foods, liquids or both ASSESS ASSOCIATED FACTORS Presence of regurgitation, heartburn, chest or back pain, weight loss Any hoarseness, voice change, or sore throat ASSESS HISTORY Family history of esophageal cancer Stroke, palsy or any other neurologic conditions Alcohol or tobacco intake Physical Examination ASSESSMENT TECHNIQUES FOR PHYSICAL ASSESSMENT I Inspection A Auscultation P Percussion P Palpation SIGNIFICANT FINDINGS FINDINGS Tenting of the skin Abnormal body weight Palpable mass Rebound tenderness, guarding Protuberant or bulging abdomen Distention and absence of bowel sounds

SIGNIFICANCE/IMPLICATION Dehydration Obesity, anorexia nervosa or malignancy Enlarged organ, inflammation, malignancy or hernia Appendicitis, cholecystitis, peritonitis, pancreatitis, duodenal ulcer Ascites (may be confirmed by test for SHIFTING DULLNESS and FLUID WAVE) Intestinal obstruction

Shifting Dullness Test 1. The patient is examined in the supine position.

2. Direct percussion is done over the abdomen, from the umbilicus to the flanks. 3. The location of the transition from tympany to dullness is noted. 4. Positive test: Percussion note is tympanitic over the umbilicus and dull over the lateral abdomen and flank areas. Fluid Wave Test

Small, dry, rocky-hard Currant jelly Ribbon-like Marble-sized stool pellets

Constipation, obstruction Intussusception Hirschprungs disease Spastic colon syndrome

STOOL CHARACTERISTICS AND IMPLICATIONS CHARACTERISTIC IMPLICATION/SIGNIFICANCE Tarry black (MELENA) Bright red Blood streaked fatty, bulky, foamy, grayish stool (STEATORRHEA) Clay-colored (NO BILE) With mucus or pus Upper GI bleeding Lower GI bleeding Lower rectal or anal bleeding

Laboratory Tests: HEMOCCULT OR GUAIAC TEST (FECAL OCCULT BLOOD) test to CHECK PRESENCE OF BLOOD in stool INDICATION detects presence of GASTROINTESTINAL BLEEDING and COLORECTAL CANCER PATIENT INSTRUCTIONS BEFORE THE PROCEDURE (should be observed by the patient 3 DAYS BEFORE THE TEST) Consume a HIGH-FIBER diet Avoid RED MEAT in the diet Avoid foods with HIGH PEROXIDASE content such as TURNIPS, CAULIFLOWER, BROCCOLI, HORSERADISH AND MELON Avoid IRON PREPARATIONS, IODIDES, BROMIDES, ASPIRIN, NSAIDS, VITAMIN C supplements greater than 250 mg/day Avoid ENEMA OR LAXATIVE before stool collection INSTRUCTIONS ON COLLECTION OF SPECIMEN Stool must not be contaminated with TOILET PAPER OR TISSUE Specimen should be submitted for laboratory exam WITHIN 6 DAYS FECALYSIS examination of stool AMOUNT, CONSISTENCY AND COLOUR INDICATION detects presence of PARASITES, PUS, BLOOD CELLS and other abnormal findings suggestive of pathology PATIENT INSTRUCTIONS avoid drugs such as CASTOR OIL AND LAXATIVES avoid drugs that interfere with results such as MINERAL OIL, NEOMYCIN AND POTASSIUM CHLORIDE

Liver problem or hepatitis

Biliary obstruction Ulcerative colitis or shigellosis

Eat HIGH-FAT DIET and refrain from ALCOHOL FOR 3 DAYS before the test and during the collection (if the patient is for STOOL EXAM FOR LIPIDS) Submit stool within 30 MINUTES TO 1 HOUR after collection

NPO for 6 hours before the test Advice client to swallow the capsule intact

HYDROGEN BREATH TEST Test used to EVALUATE CARBOHYDRATE ABSORPTION A radioactive substance is ingested, and, after a certain period of time, exhaled gases are measured INDICATION Detects presence SHORT BOWEL SYNDROME LACTOSE INTOLERANCE Bacterial overgrowth of the intestine like in CROHNS DISEASE NURSING AND PATIENT CARE CONSIDERATIONS NPO 12 HOURS before the procedure AVOID SMOKING after midnight before the test AVOID ANTIBIOTICS AND LAXATIVES OR ENEMAS 1 WEEK before the test HELICOBACTER PYLORI TESTING 1. SERUM IMMUNOGLOBULIN G ANTIBODY TEST POSITIVE ANTIBODY TEST may not differentiate between active and inactive disease A NEGATIVE TEST mean no antibodies or antibodies are present INDICATION Detects GASTRITIS and PEPTIC ULCER DISEASE caused by helicobacter pylori NURSING AND PATIENT CARE CONSIDERATIONS Stop treatment 2 weeks before the test to prevent false-negative test Negative tests may require second test for confirmation 2. PY test H. PYLORI BREATH TEST Client take a 14C urea capsules Waits approximately 10 minutes & blows up a balloon. Air balloon is the transferred to a special vial for analysis Presence of gastric urease - the client most likely has H.pylori infection 90% accurate Nursing considerations Avoid antibiotic or bismuth for 1 month Avoid proton pump inhibitors for 2 weeks

GASTRIC ANALYSIS Analysis of gastric fluids Assists in determining problems with secretory activity of the gastric mucosa NURSING AND PATIENT CARE CONSIDERATIONS NPO for 8-12 hours before the test Content are aspirated every 15 minutes for at least 1 hour Analyze for Acidity ( pH ),volume and cytology Radiology And Imaging Studies BARIUM SWALLOW (UPPER GI SERIES) Fluoroscopic X-ray examinations of the ESOPHAGUS, STOMACH AND SMALL INTESTINE after ingestion of BARIUM SULFATE INDICATION detects presence of strictures, ulcers, tumors, polyps, hiatal hernias and motility problems PATIENT PREPARATION BEFORE THE TEST Maintain on LOW-RESIDUE DIET for 2-3 days No smoking, chewing gum, and mints Place on NPO after midnight before the test Instruct to avoid SMOKING Withhold OPIOIDS and ANTICHOLINERGICS 24 hours before the test CARE OF THE PATIENT AFTER THE PROCEDURE Administer LAXATIVE to help expel the barium and prevent fecal impaction Assess abdomen for distention and bowel sounds Observe stool for presence of barium Check the color of stool (initially whitish but should be brown within 72 hours) Check for barium impaction (manifested by constipation with distended abdomen)

BARIUM ENEMA (LOWER GI SERIES)

Flouroscopic X-ray examination of the large intestine after enema with barium sulfate Air may be introduced after barium to provide a double contrast study Procedure usually takes about 15 to 30 minutes INDICATION Detects structural changes such as tumors, polyps, diverticula, fistula, obstructions, and ulcerative colitis CLIENT PREPARATION maintain on low-residue, low-fat or clear liquid diet for 2 days prior to the test Administer laxative a day before the test Place on NPO after midnight Perform enema on the morning before the examination Instruct client that barium sulfate will be given per rectum PATIENT CARE AFTER THE PROCEDURE Administer laxative or perform enema after the test to prevent barium impaction Instruct client to increase fluid intake to prevent fecal impaction Check color of stool (stools are white for 24-72 hours after the test) Instruct the client to report pain, bloating, absence of stool, or bleeding (may indicate BARIUM IMPACTION) ULTRASONOGRAPHY (ULTRASOUND) Non-invasive test using high-frequency sound waves to obtain image of the abdominal organs INDICATION Detects small abdominal masses, fluid-filled cysts, gallstones, dilated bile ducts, ascites and vascular abnormalities CLIENT PREPARATION Maintain patient on a special diet, laxative, or other medication to cleanse the bowel and decrease gas Place patient on NPO 8-12 hours before the test COMPUTED TOMOGRAPHY SCAN (CT SCAN) An X-ray technique that provides excellent anatomic definition May be used with ultrasound to perform guided needle aspiration of fluid or cells from lesions anywhere in the abdomen INDICATION Detects tumors, cysts and abscesses

Detects dilated bile ducts, pancreatic inflammation, gallstones Detects changes in intestinal wall thickness CLIENT PREPARATION Place patient on NPO after midnight ENEMA or administer LAXATIVES to cleanse the bowel Check for allergy to IODINE and SEAFOODS if a contrast will be used Inform the client that the procedure is PAINLESS Instruct the client to REMAIN STILL during the procedure Withhold the procedure if patient is PREGNANT REPORT ITCHING OR SHORTNESS OF BREATH after administration of contrast medium (may INDICATE ALLERGIC REACTION)

PARACENTESIS Procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes ENDOSCOPIC PROCEDURES ENDOSCOPY Use of flexible (fiberoptic endoscope) tube to visualize the GI tract and perform certain diagnostic and therapeutic procedures Images are produces through a video screen or telescopic eyepiece It may be inserted through the rectum or mouth TYPES 1) Capsule endoscopy 2) Esophagogastroduodenoscopy 3) Proctosigmoidoscopy and Colonoscopy CAPSULE ENDOSCOPY Involves swallowing a capsule (camera device) which passes through the GI tract After 8 hours, the capsule is excreted and connected to computer to the download the images INDICATION Detects abnormalities of the small bowel such as ACTIVE BLEEDING, POLYPS, ULCERATIONS, TUMORS, CAUSES OF DIARRHEA and NUTRITIONAL MALABSORPTION CONTRAINDICATIONS

 Small bowel obstruction Dysphagia Fistula Severe delayed gastric emptying Gastrectomy with gastrojejunostomy GI stricture Pacemakers or implanted defibrillators CLIENT PREPARATION Discontinue IRON PREPARATIONS AND CARAFATE 5 days before to prevent mucosal staining Discontinue ANTISPASMODICS, PEPTO-BISMOL AND ANTIDIARRHEALS 24 HOURS before procedure Instruct to STOP SMOKING 24 HOURS before the test to prevent mucosal staining Maintain on CLEAR LIQUID DIET A DAY BEFORE the procedure NPO AFTER MIDNIGHT or 10 hours before SHAVE AREA ABOVE AND BELOW UMBILICUS before attaching sensor array leads Instruct patient to AVOID STRENUOUS ACTIVITY, HEAVY LIFTING, BENDING OR STOOPING, OR IMMERSION IN WATER while wearing leads and recorder After ingesting the capsule, instruct the patient NOT TO EAT OR DRINK FOR AT LEAST 2 HOURS, then can advance to CLEAR LIQUID DIET Instruct patient to avoid RADIO EQUIPMENT which may interfere with capsules signal Tell patient that capsule is excreted after1-3 DAYS Watch out for signs of CAPSULE OBSTRUCTION such as ABDOMINAL PAIN, CHEST PAIN, NAUSEA AND VOMITING, STRIKING SENSATION OR FEVER ESOPHAGOGASTRODUODENOSCOPY (UPPER GI ENDOSCOPY) Visualization of the ESOPHAGUS, STOMACH AND DUODENUM May also be used to perform biopsy, remove polyps, foreign bodies, control bleeding, or open strictures INDICATION Detects acute or chronic upper GI bleeding, esophageal or gastric varices, polyps, malignancy, ulcers, gastritis, esophagitis, gastroesophageal reflux

CLIENT PREPARATION NPO 8 HOURS before the test Remove DENTURES and BRIDGES to prevent airway obstruction Administer medications as prescribed ANTICHOLINERGICS (ATROPINE SULFATE) SEDATIVES, NARCOTICS OR TRANQUILIZERS (DIAZEPAM, MEPERIDINE HCL) * LOCAL SPRAY ANESTHETIC to the posterior pharynx.

PATIENT CARE AFTER THE PROCEDURE Maintain patient in LATERAL POSITION to prevent aspiration Maintain NPO until gag reflex returns (2-4 hours) Offer LOZENGES or NORMAL SALINE GARGLES for throat irritation or hoarseness Assess for SIGNS OF PERFORATION (abdominal or chest pain, dyspnea, tachycardia, lightheadedness, distended abdomen, bleeding, fever, and dysphagia) Instruct to AVOID DRIVING FOR 12 HOURS if sedative was used PROCTOSIGMOIDOSCOPY AND COLONOSCOPY (LOWER GI ENDOSCOPY) PROCTOSIGMOIDOSCOPY visualization of the ANAL CANAL, RECTUM, AND SIGMOID COLON through a fiber optic sigmoidoscope COLONOSCOPY visualization of the ENTIRE LARGE INTESTINE, SIGMOID COLON, RECTUM AND ANAL CANAL INDICATION detects malignancy, polyps, inflammation, or strictures COLONOSCOPY is used for surveillance in patients with history of chronic ulcerative colitis, previous colon cancer or colon polyps CLIENT PREPARATION Withhold ASPIRIN or ASPIRIN-CONTAINING products or IRON SUPPLEMENTS 7 days before the test Maintain on CLEAR LIQUID DIET 24 HOURS before the test Administer CASTOR OIL or LAXATIVE to clear bowel Perform CLEANSING ENEMA Place patient in KNEE-CHEST, LATERAL OR SIMS POSITION

CLEAR LIQUID DIET FOOD GROUP Fruit juices Soup Desserts Beverages FOODS INCLUDED All clear or strained fruit juices Clear broth Clear flavored gelatin, ice pops, fruit-flavored ices, hard candy Coffee, tea, carbonated beverages, beverages, such as Kool-aid, Gatorade

Allergy to coffee, potatoes, cheese, nuts, citrus fruits, and gluten Vitamin deficiency Systemic disease Irritants Chemotherapy Radiation

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY Visualization of the common bile duct, the pancreatic , hepatic ducts through the ampula of vater in the duodenum Uses the endoscope in combination with xray techniques. Uses contrast material (dye) CLIENT PREPARATION Place on NPO 8 HOURS before the test Remove DENTURES and BRIDGES to prevent airway obstruction Administer medications as prescribed ANTICHOLINERGICS (ATROPINE SULFATE) SEDATIVES, NARCOTICS OR TRANQUILIZERS (DIAZEPAM, MEPERIDINE HCL) * LOCAL SPRAY ANESTHETIC to the posterior pharynx Assess for allergy to dye Disorders of the Mouth STOMATITIS Inflammation of the oral cavity TYPES OF STOMATITIS 1) Primary APHTHOUS STOMATITIS or canker sores MOST COMMON TYPE herpes simplex virus I and II 2) Secondary candidiasis or oral thrush may be due to overgrowth of normal flora ETIOLOGY Infection

Clinical Manifestations CANKER SORES whitish gray center and erythematous ring Whitish plaque-like lesion, appears red and sore when wiped away COMMON IF WITH CANDIDIASIS Dysphagia Dry or hot sensation on area of lesions Elevation of temperature RARE Nursing diagnosis

Pain r/t inflammation of oral mucous membrane. Imbalanced nutrition, less than body requirements r/t difficulty swallowing LABORATORY ASSESSMENT COMPLETE BLOOD COUNT may reveal INFECTION CYTOLOGIC CULTURE and GRAM STAIN TESTING to identify the CAUSATIVE MICROORGANISM NURSING CARE Provide ORAL CARE EVERY 2 HOURS and twice at night Use SOFT-BRISTLED TOOTHBRUSH OR FOAM SWABS Use SODIUM BICARBONATE solution (baking soda), WARM SALINE or HYDROGEN PEROXIDE in rinsing the mouth Avoid COMMERCIAL MOUTHWASHES Provide SOFT, BLAND and NONACIDIC foods Apply TOPICAL ANALGESICS or ANESTHETICS as prescribed DRUG THERAPY TYPE OF STOMATITIS

(Mycostatin)

ANTI-INFLAMMATORY AGENTS AND IMMUNE MODULATORS Triamcinolone in Benzocaine Dexamethasone Levamisole Amlexanox Thalidomide SYMPTOMATIC TOPICAL AGENTS FOR PAIN Benzocaine Camphor phenol 15 ml 2% viscous Lidocaine gargle of mouthwash every 3 hours (maximum of 8 doses per day) Disorders of the Esophagus GASTROESOPHAGEAL REFLUX DISEASE (GERD) BACKWARD FLOW (reflux) of gastrointestinal contents into the esophagus MOST COMMON upper GI disorder Common in PEOPLE OVER AGE 45 CAUSE Inappropriate relaxation of lower esophageal sphincter PREDISPOSING FACTORS Ingestion of LARGE MEALS Conditions associated with DECREASED GASTRIC EMPTYING Recumbent or SUPINE positioning Insertion of nasogastric tube (NGT) INCREASED INTRAABDOMINAL and INTRAGASTRIC PRESSURE FACTORS THAT RELAX LOWER ESOPHAGEAL SPHINCTER TONE Fatty foods Caffeinated beverages Chocolate Citrus fruits, tomatoes and tomato products Nicotine in cigarette smoke Medications e.g. calcium channel blockers, anticholinergic drugs Peppermint, spearmint Alcohol High levels of estrogen and progesterone

DRUG

CONSIDERATIONS

USUAL DOSE: General Tetracycline Syrup 250 mg/10 ml for 10 days INSTRUCTION: rinse for 2 minutes then swallow USUAL DOSE: Herpes Simplex Acyclovir (Zovirax) 5 mg/kg for 1 hour IV INSTRUCTION: make sure client has no renal problem USUAL DOSE: 600,000 units QID oral suspension

Fungal

Nystatin

ASSESSMENT HEARTBURN or PYROSIS suggests reflux DYSPHAGIA suggests narrowing of lumen Dyspepsia MOST COMMON SYMPTOM; occurs 30-60 minutes after meals and with reclining position Regurgitation with sour or bitter taste Hypersalivation (water brash) Odynophagia Chronic cough Eructation (belching) DIAGNOSTIC TESTS

24-hour ambulatory pH monitoring most accurate method Endoscopy Esophageal manometry Nursing diagnosis Imbalanced nutrition less than body requirements, r/t difficulty swallowing Risk for for aspiration r/t difficulty swallowing Acute pain r/t difficulty swallowing Deficient knowledge MANAGEMENT DIET THERAPY Avoid CAFFEINATED AND CARBONATED foods Avoid SPICY and ACIDIC FOODS SMALL FREQUENT FEEDINGS (4-6 small meals) Avoid foods 3 hours before going to bed LIFESTYLE CHANGES ELEVATE HEAD OF THE BED 6-8 inches for sleep DO NOT LIE DOWN 3-4 hours after eating Avoid NICOTINE and ALCOHOL LOSE WEIGHT if the patient is obese Avoid CONSTRICTIVE CLOTHING, STRAINING or BENDING OVER DRUG THERAPY ANTACIDS Aluminum or Magnesium Hydroxide Maalox, Mylanta INDICATION: management of heartburn ACTION: elevates gastric pH and deactivates pepsin SIDE EFFECTS: constipation and diarrhea CLIENT INSTRUCTIONS: take the antacid 1 hour before and 2-3 hours after meals HISTAMINE RECEPTOR ANTAGONISTS famotidine (Pepcid) ranitidine (Zantac) cimetidine (Tagamet) nizatidine (Axid) INDICATION: management of heartburn ACTION: lowers the acidity of the gastric mucosa DRUG INTERACTION: CIMETIDINE may have significant interactions with WARFARIN, THEOPHYLLINE, PHENYTOIN, NIFEDIPINE and PROPANOLOL

PROTON PUMP INHIBITORS Omeprazole (Priolosec) Lansoprazole (Prevacid) Rabeprazole (Aciphex) Pantoprazole (Protonix) Esomeprazole (Nexium) INDICATION: management of heartburn ACTION: inhibits production of gastric acid secretion CLIENT INSTRUCTIONS: should be taken 30-60 minutes before meals OTHER DRUGS ANTI-EMETIC Metoclopramide (Plasil) ACTION increase rate of gastric emptying ADVERSE EFFECTS fatigue, anxiety, ataxia and hallucinations SURGICAL MANAGEMENT LAPAROSCOPIC NISSEN FUNDOPLICATION (LNF) GOLD STANDARD for surgical management of GERD WRAPPING and ANCHORING a portion of the stomach fundus around the lower esophageal sphincter NURSING CARE AFTER SURGERY Elevate head of the bed at least 30 degrees to lower the diaphragm and facilitate lung expansion Facilitate insertion of NGT to prevent excessive tightening of the fundoplication Monitor drainage of NGT (should be normal yellowish green after within first 8 hours after surgery) Check placement every 4-8 hours Avoid alcohol, caffeinated and carbonated foods Monitor for dysphagia (sign that fundoplication is too tight) Monitor for gas bloat syndrome Administer Simethicone 80 mg QID for excessive gas ENDOSCOPIC THERAPIES STRETTA PROCEDURE to INHIBIT THE ACTIVITY of the vagus nerve use of radiofrequency energy through needles to induce THERMAL BURN in the gastroesophageal junction ENTERYX PROCEDURE to TIGHTEN the lower esophageal sphincter

INJECTION OF SOFT, SPONGY PERMANENT IMPLANT made of liquid polymeric material into the LES muscle PATIENT CARE AFTER ENDOSCOPIC THERAPIES Maintain on CLEAR LIQUIDS for 24 hours After the DAY 1 shift to SOFT DIET such as custard, pureed vegetables, mashed potatoes Avoid NSAIDs and ASPIRIN for 10 days Give LIQUID MEDICATIONS as much as possible Avoid NGT INSERTION for at least 1 month Watch out for CHEST or ABDOMINAL PAIN, BLEEDING, DYPHAGIA, SHORTNESS OF BREATH, NAUSEA or VOMITING HIATAL HERNIA The opening of the diaphragm through which the esophagus passes becomes enlarged. Part of the stomach tends to move into the lower portion of the thorax TYPES Sliding Hiatal Hernia Upper stomach and the gastroesophageal junction are displaced upward and slide in and out of the thorax Paraesophageal Hiatal Hernia All part of the stomach pushes through the diaphragm beside the esophagus Clinical Manifestation Heartburn Regurgitation Dysphagia Sense of fulness after eating or chest pain Diagnostic Procedure Xray Barium swallow Fluoroscopy Management Same pharmacological management w/ GERD Small frequent feeding Advised not to recline 1 hour after eating Elevate HOB Surgery is indicated in about 15% of patients Surgical Management

Nissen Fundoplication

PATHOPHYSIOLOGY

NISSEN FUNDOPLICATION (to treat GERD and hiatal hernia) Disorders of the Stomach and Small Intestine GASTRITIS Inflammation of the stomach mucosa CLASSIFICATION A. Acute Gastritis includes erosive gastritis and stress ulcers B. Chronic Gastritis includes non-erosive gastritis TYPES OF CHRONIC GASTRITIS 1. Type A inflammation of the glands in the fundus and body 2. Type B inflammation of the glands from fundus to antrum 3. Atrophic diffuse inflammation and destruction of deeply located glands ETIOLOGY Acute Gastritis Local irritants (drug, alcohol, corrosive subs.) Bacterial invasion by salmonella, E. Coli and H. Pylori) Chronic Gastritis Atrophy of the gastric glands and achlorydria May occur due to bile acid reflux (complication of gastrojejunal surgery or peptic ulcer disease) Chronic use of irritants

CLINICAL MANIFESTATION ACUTE GASTRITIS rapid onset of epigastric pain Pain not relieved by food Dyspepsia hematemesis gastric haemorrhage CHRONIC GASTRITIS vague epigastric pain pain relieved by food

 intolerance of fatty or spicy foods pernicious anemia SIMILARITIES ANOREXIA Nausea and Vomiting DIAGNOSTIC TEST Esophagogastroduodenoscopy with biopsy DRUG THERAPY H2 Receptor Antagonists Antacids Proton Pump Inhibitors Vitamin B12 (if there is pernicious anemia) Triple Therapy (if there is H. Pylori in biopsy) 1) 1 Bismuth subsalicylates or proton pump inhibitor (omeprazole) 2) 1 Antibiotic (metronidazole) 3) 1 Antibiotic (tetracycline, clarithromycin, amoxicillin) DRUGS TO AVOID aspirin, ibuprofen

1. Gastric Ulcers 2. Duodenal Ulcers 3. Stress Ulcers (Curling Ulcer) Parameter Age Gender Blood group General Nourishment Stomach acid production Occurrence Clinical course Gastric Ulcer Usually 50 years or older Male:Female 1:1 No differentiation May be malnourished Normal secretion or hyposecretion Mucosa exposed to acidpepsin secretion Healing and recurrence Occurs 30-60 minutes after meal; at night rarely Accentuated by ingestion of food Healing with appropriate therapy Hematemesis more common than melena Perhaps in less than 10% Tends to heal and recurs often in the same location Atrophic gastritis Duodenal Ulcer Usually 50 years or older Male: Female 1:1 Most often type O Usually well nourished Hypersecretion Mucosa exposed to acid-pepsin secretion Healing and recurrence Occurs 1-3 hours after a meal; at night 1-2 am Relieved by ingestion of food Healing with appropriate therapy Melena more common that hematemesis Rare 60% recurrence in the same year No gastritis

DIET THERAPY Instruct client to limit intake of foods and spices that cause distress Instruct client to avoid alcohol and tobacco Give soft, bland diet and smaller, more frequent meals STRESS REDUCTION Progressive muscle relaxation Cutaneous stimulation Guided imagery Distraction SURGICAL MANAGEMENT Partial gastrectomy Pyloroplasty Vagotomy Total gastrectomy PEPTIC ULCER DISEASE ulceration of the gastric mucosa, duodenum and rarely the lower esophagus and jejunum TYPES

Pain Pain Quality Response to treatment Hemorrhage Malignant change Recurrence Surrounding mucosa

PREDISPOSING FACTORS Stress Irregular hurried meals Smoking and alcoholism Caffeinated, fatty, spicy, acidic foods Ulcerogenic medications Aspirin, NSAIDs, Steroids GI disorders Gastritis, Zolliger-Ellison Syndrome Type A personality Type O blood

COMPLICATIONS Hemorrhage Perforation

Pyloric Obstruction Intractable Disease ASSESSMENT HISTORY Alcohol and tobacco use Use of corticosteroids, aspirin and NSAIDs CLINICAL MANIFESTATIONS Epigastric tenderness Rigid, boardlike abdomen with rebound tenderness Diminishing hyperactive bowel sounds Dyspepsia Vomiting DIAGNOSTIC TESTS Low hemoglobin and hematocrit Positive fecal occult blood test Barium examination Esophagogastroduodenoscopy (most accurate) Elevated Immunoglobulin G antibodies (suggest H. Pylori infection) Fecalysis DRUG THERAPY TRIPLE THERAPY (most successful regimen) 1. Bismuth compound or proton-pump inhibitor (omeprazole) 2. Metronidazole 3. Tetracyline or Clarithromycin and Amoxicillin HYPOSECRETORY DRUGS 1) Histamine Receptor Antagonists 2) Proton Pump Inhibitors 3) Prostaglandin Analogues MISOPROSTOL (CYTOTEC) gastric secretion and resistance of mucosa to injury CONTRAINDICATION: pregnancy MUCOSAL BARRIER FORTIFIERS SUCRALFATE (CARAFATE) ACTION: binds bile and pepsin to reduce mucosal injury INSTRUCTION: take 1 hour before meals and at bedtime SIDE EFFECT: constipation DIET THERAPY Bland diet Small frequent feedings (6 small meals/day) Avoid caffeine-containing foods

Avoid tobacco and alcohol

Gastrojejunostomy (Billroth II) Partial Gastrectomy Pyloroplasty

MANAGEMENT FOR HYPOVOLEMIA Monitor VS, I/O Monitor serum electrolytes to determine need for replacement Administer ISOTONIC SOLUTIONS (NSS or lactated Ringers) Perform BLOOD TRANSFUSION as prescribed to expand blood volume If there is active bleeding, administer FRESH FROZEN PLASMA MANAGEMENT FOR BLEEDING Monitor for the following: signs of SHOCK (hypotension, chills, palpitations, diaphoresis, weak thready pulse) Occult blood hematocrit, hemoglobin and coagulation studies Perform GASTRIC DECOMPRESSION OR LAVAGE AVOID NSAIDS to minimize GI bleeding ENDOSCOPIC THERAPY GOAL: promote blood clot formation METHODS OF ENDOSCOPIC THERAPY (1) THERMAL CONTACT heater probe or multi electrocoagulation (2) Inject bleeding site with diluted EPINEPHRINE (3) Laser therapy (4) Mechanical clip CLIENT PREPARATION Administer SEDATIVES e.g. midazolam and meperidine Place on NPO 6 hours prior the procedure CARE AFTER THE PROCEDURE Resume diet once gag reflex is present MANAGEMENT FOR PERFORATION Replace lost fluids, blood and electrolytes* Administer of antibiotics Place on NPO Gastric lavage or decompression Monitor for signs of septic shock (fever, pain, tachycardia, lethargy or anxiety SURGICAL MANAGEMENT FOR OBSTRUCTION Gastroduodenostomy (Billroth I)

CLIENT PREPARATION Insert NGT connected to suction to remove secretions and empty the stomach POST-OPERATIVE CARE Monitor placement, patency and drainage of NGT Monitor for DUMPING SYNDROME Gastric Dumping Syndrome Rapid gastric emptying is a condition where ingested foods bypass the stomach too rapidly and enter the small intestine largely undigested. EARLY SIGNS OF DUMPING SYNDROME (within 30 minutes after feeding) Vertigo Tachycardia Syncope Sweating Pallor Desire to lie down LATE SIGNS OF DUMPING SYNDROME (90 minutes-3 hours after feeding) Dizziness Light-headedness Palpitations Diaphoresis Confusion MANAGEMENT FOR DUMPING SYNDROME Small frequent feeding Do not take fluids with meals Advise high-protein, high-fat, low-to-moderate carbohydrate diet Administer pectin to prevent the syndrome GASTROENTERITIS

 Inflammation of the mucous membranes of the stomach and the intestinal tract CLASSIC MANIFESTATION increase in the frequency and water content of the stools or vomiting TYPES o VIRAL caused by norwalk virus or rotavirus o BACTERIAL caused by E. Coli, campylobacter enteritis or shigellosis PATHOPHYSIOLOGY

Myalgia Headache Malaise Abdominal tenderness SIGNS OF DEHYDRATION Poor skin turgor Dry mucous membranes Hypotension Oliguria Viral Duration of Diarrhea Stool WBCs RBCs 24-48 hours Campylo bacter 20-30 defecation for 7 days Watery Foul-smelling Some blood None Yes E. Coli 10 days Watery Some blood Some mucus None None Shigella 5 days Watery Some blood Some mucus Yes None

Watery None None

ASSESSMENT Nausea and vomiting (first 2 days of illness) Diarrhea

MANAGEMENT FLUID REPLACEMENT Monitor vital signs, I and O and weight (1 kg weight loss is equivalent to 1 L loss) Administer HYPOTONIC IV FLUIDS (0.45% NaCl) Oral Rehydration Salts (Oresol) If with HYPOKALEMIA Incorporate potassium supplements Observe standard precautions DIET THERAPY IF NOT ACTIVELY VOMITING clear liquids with electrolytes IF VOMITING NPO IF TREATED saltine crackers, toast and jelly IF IMPROVING bland diet AVOID caffeine DRUG THERAPY LOPERAMIDE (IMODIUM) to inhibit peristalsis

 SKIN CARE

BISMUTH SUBSALICYLATES (PEPTO-BISMUL) to reduce watery volume of stool ANTIBIOTICS NORFLOXACIN OR CIPROFLOXACIN If caused by bacteria TRIMETHOPRIM OR SULFAMETHOXAZOLE (BACTRIM) if caused by If shigellosis is the cause. Avoid toilet paper and harsh soap Use warm water and absorbent cotton Apply cream, oil or gel to excoriated skin Provide witch hazel compress and sitz bath

Abdominal pain Weight loss

Intervention

Yes Yes TPN Steroids Azulfidine Ileostomy or Proctosigmoidoscopy

yes Yes TPN Azulfidine Ileostomy or Colectomy

Disorders of the Lower GI Tract INFLAMMATORY BOWEL DISEASES ULCERATIVE COLITIS chronic inflammatory process affecting the mucosa and submucosa of the COLON and RECTUM CROHNS DISEASE (REGIONAL ENTERITIS) chronic inflammatory bowel disease affecting segmental areas along the ENTIRE WALL OF THE GI TRACT; most commonly noted at within the TERMINAL ILEUM

PARAMETER Other Name Location

ULCERATIVE COLITIS None Rectum/lower colon Unknown Familial Jewish Emotional stress 15-40 y.o Severe Stool with pus, mucus and blood Mild 100% 20-30 watery stool/day

CROHNS DISEASE Regional Enteritis Ileum/ascending colon Unknown Jewish race Environmental 20-30 y.o 40-60 y.o moderate Stool with pus and mucus Severe 20% 5-6 soft stool/day

Cause

Age Bleeding Perianal Involvement Rectal Involvement Diarrhea

PATHOPHYSIOLOGY OF ULCERATIVE COLITIS AND CROHNS DISEASE CLINICAL MANIFESTATIONS PARAMETER ULCERATIVE CROHNS

FEVER FOOD INTOLERANCE WEIGHT LOSS FREQUENCY OF BM STOOL ABDOMINAL PAIN OTHER SIGNS

COLITIS Low-grade Intolerance to dairy, spicy and greasy foods Yes 10-20/day Bloody Cramping Tenesmus Anorexia Fatigue

DISEASE Low-grade none Yes 5-6/day Loose Periumbilical Perianal ulceration

Tenesmus - the feeling of constantly needing to pass stools, even though bowels are already empty. DIAGNOSTIC ASSESSMENT PARAMETER ULCERATIVE COLITIS CROHNS DISEASE HEMOGLOBIN Low Low HEMATOCRIT Low Low WBC High Normal ALBUMIN Low Low ESR High High SODIUM Low Normal POTASSIUM Low Low CHLORIDE Low Normal MAGNESIUM Normal Low FOLIC ACID Normal Low COBALAMIN Normal Low PYURIA None Yes OCCULT BLOOD Yes None OTHER TESTS Barium Enema Proctosigmoidoscopy DRUG THERAPY SALICYLATE COMPOUNDS Sulfasalazine (Azulfidine) Indication Management of ulcerative colitis Action inhibit prostaglandin synthesis to reduce inflammation Adverse effects leukopenia and anemia

take the drug with a full glass of water take the drug after meal to prevent GI discomfort ORAL OR INTRAVENOUS CORTICOSTEROIDS Prednisone Indication to reduce inflammation Adverse Effects hyperglycemia, osteoporosis, peptic ulcer disease, increased risk for infection IMMUNOSUPPRESIVE DRUGS Should be given in combination with steroids to be effective Drug Name cyclosporine, mercaptopurine Indication to reduce inflammation Adverse Effects thrombocytopenia, leukopenia, anemia, renal failure, infection, headache, stomatitis, hepatotoxicity ANTI-DIARRHEAL DRUGS diphenoxylate HCl, atropine sulfate (lomotil), loperamide (imodium) INFLIXIMAB (REMICADE) for refractory disease or for toxic megacolon an immunoglobulin G that neutralizes activity of tumour necrosis factor DIET THERAPY If client has severe symptoms: NPO Total Parenteral Nutrition (TPN) If client has slightly less severe symptoms: Elemental formula e.g. Vivonex If client has less severe symptoms: Low-fiber (low-residue) diet Foods to avoid: Whole-wheat grains Nuts fresh fruits and vegetables lactose containing foods caffeinated beverages Pepper Alcohol Smoking COMPLEMENTARY AND ALTERNATIVE THERAPIES Vitamin C Biofeedback

Hypnosis Yoga Acupuncture o

Use skin sealants and ostomy skin creams Monitor skin for irritation

SURGICAL MANAGEMENT INDICATIONS FOR SURGERY Bowel perforation Toxic megacolon Hemorrhage Colon cancer Failure of conventional treatment TOTAL PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY Terminal ileum is pulled through the abdominal wall and forms a stoma or ostomy PRE-OPERATIVE CARE Administer oral or parenteral antibiotic such as neomycin sulfate (Mycifradin) as a bowel antiseptic Administer laxative or enema POST-OPERATIVE CARE Monitor color, odor, consistency of ileostomy output (effluent) Instruct client to report any foul or unpleasant odor (it may indicate intestinal blockage or infection) Instruct the client to wear pouch system at all times Apply skin barrier (gelatin, pectin) to prevent irritation and injury to the skin TOTAL COLECTOMY WITH CONTINENT ILEOSTOMY Alternative to traditional ileostomy with external pouch Creation of an internal reservoir called a Kocks ileostomy or ileal reservoir to be drained periodically Post-Operative Care Monitor character and quality of effluent Teach the client to drain stoma when sensation of fullness is felt Apply a small dressing to keep stoma moist TOTAL COLECTOMY WITH ILEOANAL ANASTOMOSIS Removal of the colon and rectum with anastomosis of the ileum and the anal canal DISCHARGE INSTRUCTIONS FOR CLIENTS WITH ILEOSTOM o SKIN CARE Use pectin-based skin barrier to protect skin from irritation

POUCH CARE Empty pouch when it is 1/3 full Change pouch at intervals such as before meals, before bedtime, before walking at morning, 2-4 hours after meals Change pouch system every 3-7 days

DIET Chew food thoroughly Be cautious in taking high-fiber and high-cellulose foods such as popcorn, peanuts, coconut, string beans, shrimp and lobster, rice, skinned vegetables (tomatoes, corn and peas) MEDICATIONS Avoid taking enteric-coated and capsule medications Do not take laxative or enema Contact physician if no stool has passed in 6-12 hours DANGER SIGNS Drastic increase or decrease in effluent Stomal swelling, abdominal cramping, distention, and absence of drainage INTERVENTIONS FOR DANGER SIGNS Remove pouch Lie down and assume knee-chest position Begin abdominal massage Apply moist towels to the abdomen Drink hot tea Contact health care provider IRRITABLE BOWEL SYNDROME Also known as SPASTIC BOWEL OR MUCUS COLITIS Different from ulcerative colitis because there is no inflammation or ulceration present RISK FACTORS Emotional stress or anxiety Diverticulitis Intolerance to gastric stimulants such as caffeine or spicy foods or lactose INCIDENCE

Common among women, Caucasians and Jewish population

Instruct on lifestyle changes (regular exercise, adequate rest periods, stress management)

PATHOPHYSIOLOGY AND CLINICAL MANIFESTATIONS

TWO FORMS OF DIVERTICULAR DISEASE 1. DIVERTICULOSIS asymptomatic multiple out-pouching of the intestinal mucosa WITHOUT INFLAMMATION 2. DIVERTICULITIS symptomatic multiple out-pouching of the intestinal mucosa WITH INFLAMMATION; causes retention of hardened stool

NURSING INTERVENTIONS Administer antidiarreals, antispasmodics, bulk-forming laxatives as ordered Encourage high-fiber diet and avoid fatty and gas forming foods (carbonated beverages, cauliflower or beans) Instruct client to avoid alcohol and tobacco Encourage to increase oral fluids intake

INCIDENCE More common in older adults More prevalent in men PREDISPOSING FACTORS

 Diet low in fiber Diet high in refined carbohydrates COMPLICATIONS Bowel perforation and peritonitis Bowel obstruction Hemorrhage ASSESSMENT Crampy abdominal pain in the left lower quadrant Abdominal distention Low-grade fever Chronic constipation Occult bleeding Nausea and vomiting Leucocytosis DIAGNOSTIC TESTS Barium enema and colonoscopy (contraindicated if there is diverticulitis) Complete blood count Urinalysis NURSING INTERVENTIONS Instruct client to eat high-fiber foods Encourage to increase fluids Administer bulk laxatives and anticholinergics as prescribed Encourage client to lose weight and avoid activities that increase intra-abdominal pressure SURGICAL MANAGEMENT Colon resection with temporary colostomy APPENDICITIS Inflammation of the vermiform appendix More common in males 10-30 years of age ETIOLOGY Obstruction by fecal impaction, kinking of the appendix, parasites or infections Low fiber diet High intake of refined carbohydrates

PATHOPHYSIOLOGY

ASSESSMENT Acute abdominal pain at RLQ or McBurneys point (halfway between the umbilicus and the anterior iliac crest) Anorexia, nausea and vomiting Rigid and guarded abdomen

 Blumberg sign (rebound tenderness) Fever (temperature of 38-38.5 C) Psoas Sign (lateral position with right hip flexion) Decreased or absent bowel sounds DIAGNOSTIC TESTS WBC Count Leukocytosis: WBC above10,000/mm3 Perforation: suggested if WBC is above 20,000/mm3 Ultrasound may reveal enlarged appendix Barium Enema or CT Scan Ordered if symptoms are recurrent or prolonged May reveal presence of fecalith MANAGEMENT Maintain patient on NPO for possible admission Administer IV fluids as prescribed to prevent fluids and electrolyets imbalance Maintain patient in semi-Fowlers position to prevent upward spread of infection DO NOT GIVE LAXATIVE NOR ENEMA to prevent perforation of the appendix DO NOT APPLY LOCAL HEAT to prevent inflammation and perforation; instead apply COLD HEAT SURGICAL MANAGEMENT LAPAROSCOPY A small incision in the umbilicus is made and a small endoscope is used to visualize the appendix If diagnosis is not definitive LAPAROTOMY An open approach in which large abdominal incision is made APPENDECTOMY Removal of the inflamed appendix Guided with laparoscopy Done with spinal anesthesia NURSING CARE AFTER APPENDECTOMY Maintain client flat on bed for 6-8 hours Monitor for return of sensation in the lower extremities Maintain on NPO until peristalsis returns Instruct client to ambulate after 24 hours Tell the client that he can resume normal activities within 2-4 week

PERITONITIS Inflammation of the peritoneum TYPES OF PERITONITIS 1. PRIMARY PERITONITIS acute bacterial infection resulting from contamination of the peritoneum through the vascular system May occur from tuberculosis, cirrhosis and ascites 2. SECONDARY PERITONITIS bacterial invasion resulting from acute bacterial abdominal disorder May occur from gangrenous bowel, visceral perforation, bile leakage, blunt or penetrating trauma

PATHOPHYSIOLOGY

CLINICAL MANIFESTATIONS RIGID, BOARDLIKE ABDOMEN (CLASSIC SIGN) Abdominal pain (localized, may refer to shoulder or thorax) Distended abdomen Nausea, anorexia and vomiting Diminishing bowel sounds Inability to pass flatus or feces Rebound tenderness in the abdomen

High fever Dehydration Oliguria Hiccups DIAGNOSTIC ASSESSMENT ELEVATED WBC: 20,000/MM3 Abdominal x-ray may show dilation, edema, inflammation of the small and large intestine Peritoneal Lavage may reveal the following WBC: 500/ml RBC: 50,000/ml Gram stain: (+) bacteria MANAGEMENT Administration of the following as prescribed IV fluids to replace lost fluids Broad spectrum antibiotics Oxygen if there is dyspnea due to ascites Monitor daily weight, I/O to monitor fluid status NGT insertion to decompress the stomach and intestine Maintain client on NPO SURGICAL MANAGEMENT 1. Abdominal surgery guided by exploratory laparotomy 2. Appendectomy if there is appendicitis 3. Colon resection with or without colostomy if there is bowel perforation NURSING CARE AFTER SURGERY Maintain patient in SEMI-FOWLERS POSITION to promote drainage of peritoneal contents and allow adequate lung expansion Perform PERITONEAL IRRIGATION as prescribed Check for presence of abdominal distention or pain (suggetive of irrigant retention) Instruct client to AVOID LIFTING for at least 6 weeks HEMORRHOIDS dilated and painful veins in the rectum CLASSIFICATIONS Internal hemorrhoids ABOVE the anal sphincter External hemorrhoids BELOW the anal sphincter RISK FACTORS Familial tendency

 Straining at stool Prolonged sitting or standing Pregnancy Obesity Portal hypertension Anal intercourse Colon malignancy ASSESSMENT Bleeding with defecation and pain (suggestive of internal hemorrhage) DIAGNOSTIC TESTS Digital rectal examination Sigmoidoscopy NURSING INTERVENTIONS Instruct client on the importance of HIGH-FIBER DIET and INCREASED FLUID INTAKE Instruct client to take STOOL SOFTENERS and use ointments such as dibucaine, anti-inflammatories, or astringents Apply ICE PACKS for several hours followed by warm packs SURGICAL MANAGEMENT HEMMORHOIDECTOMY Laser surgery Atomising Cryosurgery Sclerotherapy (5% phenol in oil) Rubber band ligation PREOPERATIVE CARE Advise low residue diet Administer stool softeners NURSING CARE AFTER HEMORRHOIDECTOMY Watch out for bleeding Place the client in PRONE OR SIDE-LYING POSITION Administer analgesics as prescribed Administer stool softeners Offer warm Sitz baths 3-4 times a day Disorders Involving the Accessory Organs CHOLELITHIASIS STONE FORMATION in the in the gallbladder and accessory ducts

CHOLECYSTITIS INFLAMMATION of the gallbladder RISK FACTORS: 5Fs 1. Female gender 2. Fat (Obesity) 3. Fair (Caucasian) 4. Forty (age) 5. Fertile (multigravida; use of contraceptive pills) PATHOPHYSIOLOGY

CAUSE

EFFECTS/MANIFESTATIONS

 fat emulsification

Inflammation bile flow to colon serum bilirubin

Fat intolerance Anorexia Nausea and vomiting Weight loss Gaseous eructation Flatulence Steatorrhea Pain (Right Upper Quadrant) Fever Leukocytosis Acholic stool vitamin K absorption Jaundice Pruritus Tea-colored urine

DIAGNOSTIC TESTS Ultrasonography Oral cholecystogram IV cholangiogram Liver function tests Complete blood count ORAL CHOLECYSTOGRAPHY radiographic examination of the gallbladder PURPOSES OF ORAL CHOLECYSTOGRAPHY To detect gallstones Assess the ability of the gallbladder to fill, concentrate its contents, contract and empty NURSING CONSIDERATIONS ASSESS FOR ALLERGIES to iodine, seafood, or contrast media Administer contrast medium 10-12 hours before x-ray study Instruct patient to remain NPO AFTER TAKING THE CONTRAST medium to prevent contraction and emptying of the gallbladder DEFER THE PROCEDURE IF PATIENT IS JAUNDICED!!! TYPES OF CHOLECYSTOGRAPHY 1) ORAL done 10 HOURS after administration of contrast medium 2) INTRAVENOUS done 10 MINUTES after administration of contrast medium PREPARING A PATIENT FOR CHOLECYSTOGRAPHY Instruct to have FAT FREE DINNER Place patient on NPO 2 HOURS BEFORE the test

PREPARING A PATIENT FOR CHOLANGIOGRAPHY ASSESS FOR ALLERGY TO IODINE!!! Instruct to drink ample amount of fluids after administration of dye NURSING CARE AFTER CHOLANGIOGRAPHY Check for HYPERSENSITIVITY REACTION Instruct client that excretion of dye would cause BURNING SENSATION during urination NURSING INTERVENTIONS Administer MEPERIDINE HCL (drug of choice) as prescribed for pain relief AVOID ADMINISTERING MORPHINE!!! it may cause spasm of the sphincter of Oddi Use BAKING SODA or CALAMINE-CONTAINING LOTIONS for pruritus Encourage LOW-FAT DIET Administer BILE SALTS such as Chenodeoxycholic acid or Ursodioxycholic acid (UDCA) SURGICAL MANAGEMENT Cholecystectomy PREOPERATIVE NURSING CARE Administer IV fluids to replace electrolytes Administer vitamin K injection, especially if prothrombin time is prolonged POSTOPERATIVE NURSING CARE Place patient in SEMI-FOWLERS POSITION to promote lung expansion NGT DECOMPRESSION to prevent gastric distention LOW-FAT DIET for 2-3 months Encourage ambulation after 24 hours Encourage to resume normal activities within 2-3 days Monitor T-Tube if common bile duct exploration was done T-TUBE INSERTION to DRAIN BILE Drainage Characteristics It should be BROWNISH RED for the first 24 hours It should be 300-500 ML for the first 24 hours Nursing Responsibilities Place drainage bottle AT THE LEVEL OF THE INCISION

PANCREATITIS Inflammation of the pancreas TYPES 1. Acute Pancreatitis 2. Chronic Pancreatitis RISK FACTORS Alcohol abuse MEDICATIONS: Antihypertensives, diuretics, antimicrobials, immunosuppresives, oral contraceptives GI DISORDERS: Biliary obstruction and intestinal diseases PATHOPHYSIOLOGY

Flexion of the spine Low-grade fever and leukocytosis CHRONIC PANCREATITIS HEAVY, GNAWING, OCCASIONAL BURNING OR CRAMPY L.U.Q abdominal pain malabsorption and weight loss mild jaundice with dark urine and steatorrhea diabetes mellitus DIAGNOSTIC TESTS Elevated serum and urinary amylase serum lipase serum bilirubin alkaline phosphatase sedimentation rate White blood cell count Fecal fat determinations Blood and urine glucose NURSING INTERVENTIONS Administer MEPERIDINE HCL (DEMEROL) as ordered MORPHINE SULFATE PAIN MEDICATION OF CHOICE Place client on NPO DURING ACUTE PHASE bland, LOW-FAT DIET; avoid alcohol NGT DECOMPRESSION insertion to remove gastrin and prevent further stimulation of the pancreas Administer CALCIUM SUPPLEMENTS (WITH VITAMIN D) if there is hypocalcemia Administer INSULIN as ordered if there is hyperglycemia LIVER CIRRHOSIS Irreversible chronic inflammatory disease characterized by massive degeneration and destruction of hepatocytes resulting in a disorganized lobular pattern of regeneration TYPES/CAUSES 1. LAENNECS - caused by ALCOHOLISM or hepatotoxic drugs 2. POST-NECROTIC- caused by viral HEPATITIS or industrial hepatotoxins 3. BILIARY - caused by BILIARY PROBLEMS 4. CARDIAC - caused by CHF

ASSESSMENT ACUTE PANCREATITIS SEVERE, CONTINUOUS left upper quadrant pain radiating to the back Pain aggravated by eating Pain not relieved by vomiting

the portal vein causes large veins (varices) to develop across the esophagus and stomach to bypass the blockage. The varices become fragile and can bleed easily. PATHOPHYSIOLOGY DIAGNOSTIC TESTS LIVER BIOPSY (definitive test) Abdominal x-ray Ct scan Endoscopy Elevated Aspartate Aminotrasferase (AST), Alanine Aminotrasferase (ALT), bilirubin Prolonged prothrombin time (PT) Decreased serum albumin CBC reveals anemia PREPARING A PATIENT FOR ULTRASOUND OF THE LIVER NPO 8-12 hours before the procedure Administer laxative a night before the test Maintain adequate hydration PREPARING A PATIENT FOR LIVER BIOPSY Place patient on NPO 2-4 hours prior ADMINISTER VITAMIN K Monitor prothrombin time Position patient in LEFT LATERAL POSITION with pillow under right shoulder Instruct to HOLD BREATH 5-10 seconds during needle insertion NURSING CARE AFTER LIVER BIOPSY Turn the patient to sides q4 hours Place on bed rest for 24 hours Monitor for signs of bleeding NURSING INTERVENTIONS Place client on BED REST with bathroom privileges Offer LOW-PROTEIN, HIGH CARBOHYDRATES and vitamins (ADEK, B-complex), LOW SODIUM RESTRICT AMOUNT OF ORAL FLUIDS and eliminate alcohol intake Provide meticulous skin care Monitor weight, I/O and ABDOMINAL GIRTH Assist in paracentesis if necessary Monitor for bleeding of esophageal varices Perform tap water or NSS enema

ASSESSMENT vitamin K absorption bleeding tendencies glycogen stores hypoglycemia serum albumin hydrostatic pressure edema and ascites bilirubin metabolism hyperbilirubinemia jaundice Portal hypertension esophageal varices, hepatomegaly ADH hyponatremia serum ammonia hepatic encephalopathy Portal hypertension - an increase in the pressure within the portal vein (the vein that carries blood from the digestive organs to the liver). The increase in pressure is caused by a blockage in the blood flow through the liver. Increased pressure in

 Avoid giving aspirin (causes bleeding) and sedatives (hepatotoxic) MEDICATIONS FOR A PATIENT WITH CIRRHOSIS ANTACID to prevent GI bleeding SPIRONOLACTONE (Potassium-sparing diuretic) diuretic of choice to manage ascites; does not cause hypokalemia FUROSEMIDE diuretic given if patient has hyperkalemia after prolonged use of spironolactone VITAMIN K prevents bleeding tendencies INTRAVENOUS ALBUMIN to manage ascites and edema DUPHALAC (Lactulose) reduces levels of ammonia NEOMYCIN SULFATE reduce colonic bacteria responsible for ammonia formation PREVENTION OF BLEEDING OF ESOPHAGEAL VARICES Avoid Valsalva maneuver Avoid bending or stooping Avoid hot spicy foods Avoid lifting heavy objects INTERVENTIONS FOR BLEEDING ESOPHAGEAL VARICES Place patient in SEMI-FOWLERS POSITION to prevent aspiration Suction the mouth Perform gastric lavage with tap water Insert SENGSTAKEN-BLAKEMORE TUBE Administer IV fluids, blood transfusion as ordered Administer VASOPRESSIN to constrict splanchnic arteries PREPARING A PATIENT FOR PARACENTESIS Ask to empty bladder to prevent puncture Check serum protein studies Place patient in sitting or upright position NURSING CARE AFTER PARACENTESIS Check urine output Watch out for board-like abdomen (sign of PERITONITIS) Monitor for signs of hypovolemic shock