Gastrointestinal System4

Ma. Victoria J. Recinto, BSN, RN, Ma. Victoria J. Recinto, BSN, RN, USRNUSRN

Philippine General Hospital Philippine General Hospital University of the Philippines-ManilaUniversity of the Philippines-Manila

OverviewOverview

Functions:Functions: digestion digestion absorption absorption eliminationelimination

OverviewOverviewAccessory organsAccessory organsI. I. Salivary GlandsSalivary Glands - for mechanical - for mechanical digestion (amylase: digestion (amylase: ptyalin)ptyalin)

Parotid (below & in front of Parotid (below & in front of ears)ears)oSaliva produced- 1,200-1,500 Saliva produced- 1,200-1,500 ml/dayml/day

SublingualSublingualSubmaxillarySubmaxillary

Salivary GlandsSalivary Glands

MUMPSMUMPSCausative agent: Causative agent: ParamyxovirusParamyxovirus

Signs & SymptomsSigns & Symptoms

swollen parotid glandswollen parotid gland

dysphagiadysphagia

feverfever

chills chills

anorexiaanorexia

MUMPSMUMPS

MUMPSMUMPS

Signs & SymptomsSigns & Symptoms

nausea & vomiting nausea & vomiting

general body general body malaisemalaise

weight lossweight loss

MUMPSMUMPS

Prevent ComplicationsPrevent Complications Male Male

orchitis (puberty stage orchitis (puberty stage sterility)sterility)

virus attacks the sperms virus attacks the sperms produced by Leydig cells produced by Leydig cells at seminiferous tubulesat seminiferous tubules

OrchitisOrchitis

MUMPSMUMPS

FemaleFemalevaginitis vaginitis

cervicitis cervicitis

oophoritisoophoritis

MUMPSMUMPS

Nursing ManagementNursing Management Strict respiratory isolationStrict respiratory isolation

Administer meds as Administer meds as orderedordered

AntipyreticAntipyretic

AnalgesicAnalgesic

AntibioticsAntibiotics

MUMPSMUMPS

Nursing Nursing ManagementManagement

Cool packCool pack

General liquid to soft General liquid to soft dietdiet

APPENDICITISAPPENDICITISInflammation of Vermiform Inflammation of Vermiform

AppendixAppendixsmall structure extending small structure extending from the cecum at the R from the cecum at the R iliac/inguinal regioniliac/inguinal region

produces WBC during fetal produces WBC during fetal life, ceases to function once life, ceases to function once baby is bornbaby is born

APPENDICITISAPPENDICITIS


Predisposing Predisposing FactorsFactors Microbial agentsMicrobial agents Fecalith (undigested Fecalith (undigested food particles)food particles)

Intestinal obstructionIntestinal obstruction

APPENDICITISAPPENDICITISSigns & SymptomsSigns & Symptoms (+) rebound (+) rebound

tenderness & tenderness & abdominal abdominal rigidity rigidity

Pain at the Pain at the RR iliac regioniliac region

Position of Position of comfort: side-comfort: side-lying with lying with abdominal abdominal guarding & legs guarding & legs flexedflexed

APPENDICITISAPPENDICITISSigns & Signs & SymptomsSymptoms Low grade Low grade feverfever

Anorexia, Anorexia, N/V, N/V, diarrhea, diarrhea, constipationconstipation

Late SignLate Sign - - tachycardiatachycardia


(+) (+) rebound rebound tendernetenderness at ss at McBurneMcBurney’s pointy’s point


Diagnostic ProcedureDiagnostic Procedure CBC- mild leukocytosisCBC- mild leukocytosis U/A- U/A- acetone acetone

SurgerySurgery Appendectomy within Appendectomy within 24-48 hrs24-48 hrs

Pre-op Nursing Pre-op Nursing Interventions: Interventions:

APPENDECTOMYAPPENDECTOMYInformed consentInformed consentNPO, IVF, skin prep, NO NPO, IVF, skin prep, NO ENEMA/LAXATIVES! NO ENEMA/LAXATIVES! NO RECTAL TEMP! NO HEAT RECTAL TEMP! NO HEAT APPLICATION!APPLICATION!Position of comfort: R side-Position of comfort: R side-lying or semi-Fowler’slying or semi-Fowler’sIce packs for 20-30 mins qhIce packs for 20-30 mins qhAntipyretics & antibiotics as Antipyretics & antibiotics as orderedordered

Pre-op Nursing Pre-op Nursing Interventions: Interventions:

APPENDECTOMYAPPENDECTOMYMonitor Monitor

VS, I/O, pain level,bowel sounds VS, I/O, pain level,bowel sounds

N: 5-30X/min or q 5-15 sec, N: 5-30X/min or q 5-15 sec, Listen to each quadrants for 5 Listen to each quadrants for 5 mins mins

Borborygmi- > 60 sounds/min- Borborygmi- > 60 sounds/min- hyperactive bowel hyperactive bowel

WOF ruptured appendix & WOF ruptured appendix & peritonitisperitonitis

PERITONITISPERITONITISPeritoneumPeritoneum

Lines the abdominal cavityLines the abdominal cavityForms the mesentery that supports Forms the mesentery that supports

the intestines & blood supplythe intestines & blood supplySigns & Symptoms of PeritonitisSigns & Symptoms of Peritonitis

HR, HR, RR, RR, T & chillsT & chillsPallor, restlessnessPallor, restlessnessProgressive abdominal distention Progressive abdominal distention

& pain& painR guarding of the abdomenR guarding of the abdomen

PERITONITISPERITONITIS

Post-op Nursing Post-op Nursing Interventions: Interventions:

APPENDECTOMYAPPENDECTOMYNPO until bowel function NPO until bowel function returnedreturnedIf appendix has If appendix has ruptured, expect: ruptured, expect:

Penrose drain (with Penrose drain (with profuse output for the profuse output for the 11stst 12 hrs) 12 hrs) Or opened incision to Or opened incision to heal from the inside outheal from the inside out

Post-op Nursing Post-op Nursing Interventions: Interventions:

APPENDECTOMYAPPENDECTOMYPosition: R side-lying or low Position: R side-lying or low Semi-Fowler’s with legs Semi-Fowler’s with legs flexed (to facilitate drainage)flexed (to facilitate drainage)Wound irrigation & dressingWound irrigation & dressingAntipyretics & antibiotics as Antipyretics & antibiotics as orderedorderedMonitor T, incision site for Monitor T, incision site for infection, Penrose drain infection, Penrose drain outputoutput

LIVERLIVER

LIVERLIVER

Largest gland, occupies Largest gland, occupies most of the most of the RR hypochondriac regionhypochondriac region

Weighs 3-4 lb (adult)Weighs 3-4 lb (adult)Covered by fibrous capsule Covered by fibrous capsule (capsule of (capsule of GlissonGlisson)- )- makes the liver scarlet makes the liver scarlet brown, transparent in brown, transparent in naturebnatureb

LIVERLIVERWith R & L lobesWith R & L lobes

Functional unit:Functional unit: liver lobules liver lobulesWith canaliculi (receptacles of With canaliculi (receptacles of bile) produced by the bile) produced by the hepatocyteshepatocytes

Composed of sinusoids Composed of sinusoids (“Processing Plant”)(“Processing Plant”)Lined with Mononuclear Lined with Mononuclear Phagocyte Sytem (Kuppfer Phagocyte Sytem (Kuppfer Cells) which remove pathogens Cells) which remove pathogens in the portal venous bloodin the portal venous blood

LIVERLIVERBlood Supply Blood Supply

Even if the liver Even if the liver receives 30% of receives 30% of CO/min., the portal CO/min., the portal system remains low-system remains low-pressuredpressured

LIVERLIVERBlood Supply Blood Supply

From Hepatic artery & From Hepatic artery & Portal veinPortal vein Sinusoids Sinusoids (capillaries of the liver, (capillaries of the liver, carries admixture of venous carries admixture of venous & arterial blood & arterial blood Provide both O2 & nutrients Provide both O2 & nutrients Drains to Hepatic vein Drains to Hepatic vein IVC IVC

LIVERLIVER

Blood Blood Supply Supply

LIVERLIVER FunctionsFunctions Produce BILE- to Produce BILE- to emulsify fats; gives emulsify fats; gives color to urine color to urine (urobilinogen) & stool (urobilinogen) & stool (stercobilinogen to (stercobilinogen to stercobilin)stercobilin)

LIVERLIVERBILEBILE

Liver secretes 500- 1,000 Liver secretes 500- 1,000 ml of bile/dayml of bile/day

Composed of bilirubin, Composed of bilirubin, plasma electrolytes, plasma electrolytes, water, bile salts, water, bile salts, bicarbonate, cholesterol, bicarbonate, cholesterol, FA & lecithinFA & lecithin

FATE OF HEMOGLOBINFATE OF HEMOGLOBINHemoglobinHemoglobin

HemeHeme GlobinGlobin

UnconjugatedUnconjugated Iron (Ferritin)Iron (Ferritin)Amino acidAmino acid

Indirect BilirubinIndirect Bilirubin (stored in liver)(stored in liver) poolpool

(Fat-soluble)(Fat-soluble)

FATE OF HEMOGLOBINFATE OF HEMOGLOBINUnconjugated/Indirect Bilirubin (Fat-Unconjugated/Indirect Bilirubin (Fat-

soluble)soluble)

Attached to albuminAttached to albuminLiver (with enzyme glucoronyl Liver (with enzyme glucoronyl

transferase)transferase)

Conjugated/Direct Bilirubin (Water-Conjugated/Direct Bilirubin (Water-soluble)soluble)

Excreted in BileExcreted in Bile

Small Intestine Small Intestine KidneysKidneysstercobilinogen to stercobilinstercobilinogen to stercobilin

urobilinogenurobilinogen

LIVERLIVERHepatic DuctsHepatic DuctsDeliver bile to the gall Deliver bile to the gall bladder via cystic ductbladder via cystic duct

Deliver bile to the duodenum Deliver bile to the duodenum via common bile ductvia common bile duct

Common bile duct: with Common bile duct: with pancreatic duct at the pancreatic duct at the ampulla of Vaterampulla of Vater

Sphincter prevents reflux of Sphincter prevents reflux of intestinal contents into the intestinal contents into the common bile duct & common bile duct & pancreatic ductpancreatic duct

LIVERLIVER

FunctionsFunctionsVitamin ADEK synthesisVitamin ADEK synthesisStores & filters blood Stores & filters blood (200-400 ml)(200-400 ml)

Stores Vitamins A, D, B & Stores Vitamins A, D, B & iron iron

Detoxifies drugsDetoxifies drugsDestroys excess estrogenDestroys excess estrogen

LIVERLIVER

FunctionsFunctionsMetabolize Metabolize macronutrients:macronutrients: CHOCHO

glycogenesis glycogenesis glycogenolysis glycogenolysis gluconeogenesisgluconeogenesis

LIVERLIVER

FunctionsFunctions CHON CHON

synthesis of albumin & synthesis of albumin & globulinglobulin

Synthesis of Synthesis of prothrombin & prothrombin & fibrinogenfibrinogen

Conversion of NH4 to Conversion of NH4 to ureaurea

LIVERLIVER

FunctionsFunctionsFATSFATS

synthesis of synthesis of cholesterol to cholesterol to neutral fats or neutral fats or triglyceridestriglycerides

LIVER DISORDER: LIVER DISORDER: CIRRHOSISCIRRHOSIS

Chronic, progressive disease characterized by diffuse damage to cells with fibrosis & nodular regenerationRepeated destruction of hepatic cells causes formation of scar tissue

Types of CirrhosisTypes of Cirrhosis

Postnecrotic CirrhosisPostnecrotic CirrhosisAfter massive liver necrosisAfter massive liver necrosisCx of acute viral hepatitis or Cx of acute viral hepatitis or exposure to hepatotoxinsexposure to hepatotoxins

Scar tissue destroys liver Scar tissue destroys liver lobules & entire lobeslobules & entire lobes


Biliary CirrhosisBiliary CirrhosisFrom chronic biliary From chronic biliary obstruction, bile stasis, obstruction, bile stasis, inflammation resulting inflammation resulting in severe obstructive in severe obstructive jaundicejaundice


Cardiac CirrhosisCardiac CirrhosisAssociated with severe Associated with severe RSHF, resulting RSHF, resulting enlarged, edematous enlarged, edematous congested livercongested liver

Anoxic liverAnoxic liver cell cell necrosis & fibrosisnecrosis & fibrosis


Laennec’s CirrhosisLaennec’s CirrhosisAlcohol-induced, Alcohol-induced, nutritional, portalnutritional, portal

Cellular necrosisCellular necrosis scar scar tissue with fibrotic tissue with fibrotic infiltrationinfiltration

LAENEC’S CIRRHOSISLAENEC’S CIRRHOSIS

LIVER DISORDERSLIVER DISORDERS

Predisposing FactorsPredisposing Factors Chronic alcoholismChronic alcoholism Malnutrition- Malnutrition- primary reason for primary reason for Laennec’s cirrhosisLaennec’s cirrhosis VirusesViruses


Predisposing FactorsPredisposing Factors Toxicity- CCl4Toxicity- CCl4 Hepatotoxic agents Hepatotoxic agents (Acetaminophen, (Acetaminophen, Chlorpromazine, Chlorpromazine, INH, Halothane)INH, Halothane)

LIVER DISORDERSLIVER DISORDERSEarly Signs & SymptomsEarly Signs & Symptoms

Weakness & fatigueWeakness & fatigueAnorexia, early am N/V, Anorexia, early am N/V, hematemesis, wt. losshematemesis, wt. loss

Indigestion, Flatulence, Indigestion, Flatulence, SteatorrheaSteatorrhea

Abdominal pain/tendernessAbdominal pain/tendernessJaundice/Icteric scleraeJaundice/Icteric sclerae

LIVER DISORDERSLIVER DISORDERSEarly Signs & SymptomsEarly Signs & Symptoms

PruritusPruritusPalmar erythemaPalmar erythemaHepatomegalyHepatomegaly bowel soundsbowel soundsLoss of axillary & pubic Loss of axillary & pubic hairhair

LIVER DISORDERSLIVER DISORDERSLate Signs & SymptomsLate Signs & Symptoms

Hema changesHema changesPancytopenia, petechiae, Pancytopenia, petechiae, ecchymosisecchymosis

Spider Spider angiomas/telangiectasiangiomas/telangiectasi

Caput medussae (abdomen)Caput medussae (abdomen)Endocrine changesEndocrine changes

GynecomastiaGynecomastia

Spider angioma & Caput Spider angioma & Caput medussaemedussae

LIVER DISORDERSLIVER DISORDERSLate Signs & Late Signs & SymptomsSymptomsGIT changesGIT changes

Ascites, peripheral Ascites, peripheral edemaedema

Bleeding esophageal Bleeding esophageal varicesvarices


Late Signs Late Signs & & SymptomsSymptoms

CNS CNS changes: changes: AsterixisAsterixis

LIVER DISORDERSLIVER DISORDERSLate Signs & SymptomsLate Signs & Symptoms

Hepatic encephalopathyHepatic encephalopathy

Asterixis (liver flap)-coarse, Asterixis (liver flap)-coarse, flapping hand tremorsflapping hand tremors

LOCLOC

headache, confusion, headache, confusion, deliriumdelirium

Fetor hepaticus (fruity, Fetor hepaticus (fruity, musty breath odor of musty breath odor of chronic liver disease)chronic liver disease)


Diagnostic ProcedureDiagnostic ProcedureLiver EnzymesLiver Enzymes

SGPT/ALT(specific SGPT/ALT(specific for liver disease) & for liver disease) & SGOT (AST)SGOT (AST)

Serum indirect Serum indirect bilirubinbilirubin


Diagnostic ProcedureDiagnostic Procedure Serum cholesterol & Serum cholesterol & NH4NH4

CBC- pancytopeniaCBC- pancytopenia Prolonged PTProlonged PT Hepatic UTZ- fat Hepatic UTZ- fat necrosis of liver lobulesnecrosis of liver lobules

LIVER DISORDERSLIVER DISORDERS Nursing ManagementNursing Management CBR, High Fowler’s CBR, High Fowler’s positionposition

Enteral feeding or TPN as Enteral feeding or TPN as orderedordered

Diet: Diet: Ca+2, Vit (B complex, Ca+2, Vit (B complex, A, C, K, folic acid & A, C, K, folic acid & thiamine) & min, thiamine) & min, to to moderate CHON & fatsmoderate CHON & fats

Meticulous skin careMeticulous skin care


Nursing Nursing ManagementManagement Monitor neuroVS, I/O, Monitor neuroVS, I/O, e+ balancee+ balance

Weight & abdominal Weight & abdominal girth ODgirth OD

Reverse isolationReverse isolation Restrict fluids & NaRestrict fluids & Na

LIVER DISORDERSLIVER DISORDERSNursing ManagementNursing ManagementPrevent ComplicationsPrevent Complications

ASCITES- fluid in peritoneal ASCITES- fluid in peritoneal cavitycavityAdminister meds as Administer meds as orderedorderedLoop DiureticLoop DiureticK+ supplementsK+ supplements


Nursing ManagementNursing ManagementPrevent ComplicationsPrevent Complications

ASCITESASCITES Na+ dietNa+ dietAssist in abdominal Assist in abdominal paracentesisparacentesis

LIVER DISORDERSLIVER DISORDERSParacentesis: transabdominal Paracentesis: transabdominal removal of fluid from the removal of fluid from the peritoneal cavity for analysisperitoneal cavity for analysisPre-opPre-op

Informed consentInformed consentEmpty the bladder (to prevent Empty the bladder (to prevent puncture)puncture)Baseline wt, abdominal girth, VSBaseline wt, abdominal girth, VSPosition: Upright (High Fowler’s) Position: Upright (High Fowler’s) on the edge of the bed with back on the edge of the bed with back support & feet resting on a stoolsupport & feet resting on a stool

LIVER DISORDERSLIVER DISORDERSParacentesisParacentesisPost opPost op

Dry, sterile pressure dressing at Dry, sterile pressure dressing at insertion site, WOF bleedinginsertion site, WOF bleedingMeasure fluid collected, describe Measure fluid collected, describe & record, label & send to lab for & record, label & send to lab for analysisanalysisMonitor VS, abdominal girth & wtMonitor VS, abdominal girth & wtWOF hypovolemia, e+ loss, WOF hypovolemia, e+ loss, encephalopathy, hematuria encephalopathy, hematuria (bladder trauma)(bladder trauma)

LIVER DISORDERSLIVER DISORDERSNursing ManagementNursing Management

Prevent ComplicationsPrevent ComplicationsBleeding esophageal varicesBleeding esophageal varices

Administer meds as orderedAdminister meds as orderedVitamin KVitamin KVasopressin (Pitressin)Vasopressin (Pitressin)BTBT


Bleeding esophageal Bleeding esophageal varicesvaricesNGT decompression NGT decompression via gastric lavagevia gastric lavageMonitor for NGT Monitor for NGT outputoutput


Bleeding esophageal varicesBleeding esophageal varicesAssist in mechanical Assist in mechanical decompression (gastric decompression (gastric intubation)intubation)Sengstaken Blakemore tube Sengstaken Blakemore tube (Esphagogastric balloon (Esphagogastric balloon tamponade)tamponade)

WOF hemorrhageWOF hemorrhagePrepared at bedside: scissorsPrepared at bedside: scissors

Sengstaken Blakemore tubeSengstaken Blakemore tube


Prevent ComplicationsPrevent ComplicationsHepatic Encephalopathy: end-Hepatic Encephalopathy: end-stage hepatic failure stage hepatic failure characterized with altered characterized with altered LOC, neuro Sxs & LOC, neuro Sxs & neuromuscular disturbancesneuromuscular disturbancesAssist in mechanical Assist in mechanical ventilationventilation

Monitor VS, neuro VSMonitor VS, neuro VS


Hepatic EncephalopathyHepatic EncephalopathySide rails upSide rails upAdminister meds as orderedAdminister meds as ordered

Neomycin (Mycifradin): Neomycin (Mycifradin): NH4 NH4 production by N bacterial flora production by N bacterial flora of the bowelof the bowel

Lactulose (Chronulac): Lactulose (Chronulac): promotes excretion of NH4promotes excretion of NH4

No sedatives, narcotics, No sedatives, narcotics, barbiturates & hepatotoxic barbiturates & hepatotoxic meds/substancesmeds/substances


Prevent ComplicationsPrevent ComplicationsHepatorenal syndrome: Hepatorenal syndrome: progressive renal failure progressive renal failure associated with hepatic associated with hepatic failurefailure

Sudden Sudden in U.O., in U.O., serum serum BUN & Crea, BUN & Crea, urine Na urine Na excretion, excretion, urine osmolality urine osmolality

PANCREASPANCREAS Located behind stomachLocated behind stomachAs exocrine gland (80%)As exocrine gland (80%)

Secretes NaHCO3: neutralizes Secretes NaHCO3: neutralizes stomach’s contents entering stomach’s contents entering the duodenumthe duodenum

Secretes pancreatic juices: Secretes pancreatic juices: with enzymes for digesting with enzymes for digesting macronutrientsmacronutrients

PANCREASPANCREASAs endocrine gland (20%)As endocrine gland (20%)

Islets of Langerhans- Islets of Langerhans- secretes insulin (hypogly) secretes insulin (hypogly) & glucagon (hypergly)& glucagon (hypergly)

Secretes Somatostatin: Secretes Somatostatin: with hypogly effectwith hypogly effect

PANCREASPANCREAS

PANCREATITISPANCREATITISAcute or Chronic Acute or Chronic inflammation of pancreas inflammation of pancreas leading to pancreatic edema, leading to pancreatic edema, suppuration, necrosis & suppuration, necrosis & hemorrhage due to hemorrhage due to autodigestion autodigestion

Cause: activation of Cause: activation of proteolytic pancreatic proteolytic pancreatic enzymes (Trypsin, Elastase, enzymes (Trypsin, Elastase, Lipases)Lipases)

PANCREATITISPANCREATITIS

PANCREATITISPANCREATITIS Predisposing FactorsPredisposing Factors

AlcoholismAlcoholismHepatobiliary disorder Hepatobiliary disorder (Cholelithiasis)(Cholelithiasis)

Drugs toxic to pancreas: Drugs toxic to pancreas: steroids, OCP, thiazide steroids, OCP, thiazide diuretics, Rentam (for diuretics, Rentam (for AIDS), ASAAIDS), ASA

Peptic ulcer diseasePeptic ulcer disease

PANCREATITISPANCREATITIS Predisposing FactorsPredisposing Factors

Metabolic disordersMetabolic disorders hyperparathyroidism hyperparathyroidism (hyperCa)(hyperCa)

hyperlipidemia hyperlipidemia (obesity)(obesity)

Ischemic vascular Ischemic vascular diseasedisease

PANCREATITISPANCREATITIS Predisposing Predisposing FactorsFactors Na+ intakeNa+ intakeTraumaTraumaSurgerySurgeryPancreatic TumorPancreatic TumorViral/Bacterial Viral/Bacterial InfectionInfection

ACUTE PANCREATITISACUTE PANCREATITIS Signs & SymptomsSigns & Symptoms

Pain at midepigastric or Pain at midepigastric or LUQ radiating to the back, LUQ radiating to the back, flank & substernal area flank & substernal area with DOB, aggravated by with DOB, aggravated by eating a large fatty meal or eating a large fatty meal or an episode of heavy an episode of heavy alcohol intake or lying in alcohol intake or lying in recumbent positionrecumbent positionLasts for hours & daysLasts for hours & days


HR & T, HR & T, BP to BP to ShockShock

Shallow respirationShallow respiration Anorexia, N/V, wt. lossAnorexia, N/V, wt. loss bowel sounds bowel sounds (paralytic ileus)(paralytic ileus)

Indigestion/dyspepsiaIndigestion/dyspepsia


(+) Cullen’s sign- (+) Cullen’s sign- ecchymosis at umbilicusecchymosis at umbilicus

(+) Grey Turner’s sign- (+) Grey Turner’s sign- ecchymosis at flank ecchymosis at flank areaarea

hypocalcemia (due to hypocalcemia (due to extensive lipolysis)extensive lipolysis)

Cullen’s Sign & Grey Turner’s Cullen’s Sign & Grey Turner’s Sign Sign

ACUTE PANCREATITISACUTE PANCREATITIS

Diagnostic ProcedureDiagnostic Procedure WBC, WBC, Hct, Hct, bilirubin, bilirubin,

alkaline phosphatase, alkaline phosphatase, urinary amylase, urinary amylase, CBG CBG

serum Ca+2, Mg+2serum Ca+2, Mg+2Abdominal UTZ & CT scan- Abdominal UTZ & CT scan-

enlarged pancreasenlarged pancreasChest X-ray- pleural effusionChest X-ray- pleural effusion


Diagnostic Diagnostic ProcedureProcedure serum amylase (serum amylase ( 200 Somogyi units) & 200 Somogyi units) & lipase (lipase ( 1.5 U/ml) 1.5 U/ml)


Nursing ManagementNursing ManagementNPO, NGT to suction, NPO, NGT to suction, TPN (with vit. & min.) TPN (with vit. & min.) as orderedas ordered Cx: hyperglycemia, Cx: hyperglycemia, air embolism, infectionair embolism, infection

If can eat: diet- If can eat: diet- CHO, CHO, CHON, CHON, fats fats

ACUTE PANCREATITISACUTE PANCREATITISNursing ManagementNursing Management

Administer meds as orderedAdminister meds as orderedNarcotic analgesic- Demerol Narcotic analgesic- Demerol (no Morphine & Codeine SO4- (no Morphine & Codeine SO4- causes spasms of sphincter of causes spasms of sphincter of Oddi aggravating pain)Oddi aggravating pain)

Antacids, H2 blockers: Antacids, H2 blockers: Ranitidine (to Ranitidine (to HCL HCL production & prevent production & prevent activation of pancreatic activation of pancreatic enzymes)enzymes)

ACUTE PANCREATITISACUTE PANCREATITISNursing ManagementNursing Management

Administer meds as orderedAdminister meds as orderedAnticholinergics (to Anticholinergics (to vagal vagal stimulation, stimulation, GI motility, GI motility, inhibit pancreatic enzyme inhibit pancreatic enzyme secretion)secretion)

Smooth muscle relaxantSmooth muscle relaxantVasodilators- NTGVasodilators- NTGCalcium gluconateCalcium gluconate

ACUTE PANCREATITISACUTE PANCREATITIS Nursing ManagementNursing Management

Assume comfortable positionAssume comfortable positionKnee-chest, fetal-likeKnee-chest, fetal-likeStress Management Technique: Stress Management Technique: DBE, yogaDBE, yoga

Prevent Complications: Prevent Complications: chronic hemorrhage, chronic hemorrhage, septicemia septicemia

CHRONIC PANCREATITISCHRONIC PANCREATITIS Signs & SymptomsSigns & Symptoms

Abdominal pain & Abdominal pain & tendernesstenderness

LUQ massLUQ massSteatorrhea Steatorrhea Wt lossWt lossMuscle wastingMuscle wastingJaundiceJaundiceS/Sx of DMS/Sx of DM

CHRONIC PANCREATITISCHRONIC PANCREATITISNursing InterventionsNursing Interventions

Diet: limited fat & CHON, Diet: limited fat & CHON, vit. & min. supplements, no vit. & min. supplements, no heavy meals, no alcoholheavy meals, no alcohol

Administer meds as Administer meds as orderedorderedPancreatic enzymes with Pancreatic enzymes with mealsmeals

Insulin & OHA to control DMInsulin & OHA to control DM

PANCREATITISPANCREATITIS

Health TeachingsHealth TeachingsImportance of avoiding Importance of avoiding

alcoholalcoholImportance of follow-up Importance of follow-up

care/visit with the MDcare/visit with the MDNotify MD if acute abdominal Notify MD if acute abdominal

pain, jaundice, clay-colored pain, jaundice, clay-colored stools, steatorrhea or dark stools, steatorrhea or dark urine developsurine develops

GALL BLADDERGALL BLADDERReceives bile from the liver Receives bile from the liver Stores, concentrates & releases Stores, concentrates & releases

bile to the common bile duct to bile to the common bile duct to the duodenum upon the duodenum upon stimulation (presence of fatty stimulation (presence of fatty foods)foods) gall bladder contracts gall bladder contracts & sphincter of Oddi relaxes& sphincter of Oddi relaxes

Common bile duct: joined Common bile duct: joined cystic & hepatic ductscystic & hepatic ducts

Sphincter of Oddi: guards the Sphincter of Oddi: guards the entrance into the duodenumentrance into the duodenum

GALL BLADDERGALL BLADDERCholecystitis- gall bladder Cholecystitis- gall bladder

inflammationinflammationAcute: caused by gallstonesAcute: caused by gallstonesChronic: r/t inefficient bile emptying Chronic: r/t inefficient bile emptying

& gall bladder muscle disease& gall bladder muscle disease fibrotic & contracted gall bladderfibrotic & contracted gall bladder

Acalculus: (-) gallstones, r/t Acalculus: (-) gallstones, r/t bacterial invasion via the lymphatic bacterial invasion via the lymphatic or vascular systemsor vascular systems

Cholelithiasis- gallstonesCholelithiasis- gallstones

GALL BLADDERGALL BLADDER Predisposing FactorsPredisposing Factors

High riskHigh risk Female, 40 years Female, 40 years old, menopausal, old, menopausal, obeseobese

CholelithiasisCholelithiasis

GALL BLADDERGALL BLADDERSigns & SymptomsSigns & Symptoms

Localized pain at RUQ, (+) Localized pain at RUQ, (+) mass mass

Epigastric pain radiating to Epigastric pain radiating to scapula 2-4 hrs after taking scapula 2-4 hrs after taking heavy meal/fatty foods, heavy meal/fatty foods, persisting for 4-6 hrs, usually at persisting for 4-6 hrs, usually at nightnight

Fatty intolerance, N/V, Fatty intolerance, N/V, indigestion, belching, flatulenceindigestion, belching, flatulence

GALL BLADDERGALL BLADDER

Signs & SymptomsSigns & SymptomsGuarding, rigidity & rebound Guarding, rigidity & rebound tendernesstenderness

Murphy’s sign: can’t take a Murphy’s sign: can’t take a deep breath when examiner’s deep breath when examiner’s finger’s are passed below the finger’s are passed below the hepatic marginhepatic margin

HR, HR, T, S/Sx of dehydrationT, S/Sx of dehydration


Signs & Symptoms (Biliary Signs & Symptoms (Biliary Obstruction) Obstruction) JaundiceJaundiceDark orange & foamy urineDark orange & foamy urineSteatorrhea & clay-colored Steatorrhea & clay-colored stoolsstools

PruritusPruritusEasy bruisingEasy bruising

GALL BLADDERGALL BLADDER Diagnostic ProceduresDiagnostic ProceduresCholecystography: to detect gall Cholecystography: to detect gall

stones; to assess the ability of the gall stones; to assess the ability of the gall bladder to fill, concentrate its contents, bladder to fill, concentrate its contents, contract & emptycontract & empty

Pre-opPre-opAsk for hx of allergies to iodine, Ask for hx of allergies to iodine,

seafood or dyeseafood or dyeContrast dye may be given 10-12 hrs Contrast dye may be given 10-12 hrs

prior to test (evening before)prior to test (evening before)NPO after giving of dyeNPO after giving of dyeWOF anaphylactic reaction to dyeWOF anaphylactic reaction to dye

GALL BLADDERGALL BLADDER Diagnostic Procedures: Diagnostic Procedures: CholecystographyCholecystographyPost-opPost-opDysuria is common because Dysuria is common because the dye is excreted in the the dye is excreted in the urineurine

N diet is resumed: fatty N diet is resumed: fatty meal enhances excretion of meal enhances excretion of dyedye

GALL BLADDERGALL BLADDER Diagnostic ProceduresDiagnostic ProceduresEndoscopic retrograde Endoscopic retrograde cholangiopancreatography cholangiopancreatography (ERCP): exam of the (ERCP): exam of the hepatobiliary system via hepatobiliary system via endoscope inserted into the endoscope inserted into the esophagus to the duodenum; esophagus to the duodenum; multiple positions are required multiple positions are required during the procedure to pass during the procedure to pass the endoscopethe endoscope

GALL BLADDERGALL BLADDER Diagnostic Procedure: ERCPDiagnostic Procedure: ERCPPre-opPre-opNPO X several hrs NPO X several hrs Sedation as orderedSedation as orderedPost-opPost-opMonitor VS, return of gag Monitor VS, return of gag reflexreflex

WOF perforation or infectionWOF perforation or infection


Diagnostic ProceduresDiagnostic Procedures Oral cholecystogram Oral cholecystogram Gall Bladder Series)- Gall Bladder Series)- (+) gall stones(+) gall stones

Serum alkaline Serum alkaline phosphatasephosphatase

GALL BLADDERGALL BLADDER Nursing ManagementNursing Management Administer meds as orderedAdminister meds as ordered

Narcotic analgesic- Narcotic analgesic- Demerol (no Morphine & Demerol (no Morphine & Codeine SO4)Codeine SO4)

Anticholinergics/ Anticholinergics/ Antispasmodics to relax Antispasmodics to relax smooth musclessmooth muscles Pro-BanthinePro-Banthine AtSO4AtSO4

Anti-emeticsAnti-emetics


Nursing ManagementNursing Management Monitor V/S, bowel Monitor V/S, bowel soundssounds

Small, frequent mealsSmall, frequent meals Diet: Diet: CHO, CHO, CHON, CHON, fats, no gas-forming fats, no gas-forming foodsfoods

Meticulous skin careMeticulous skin care

GALL BLADDERGALL BLADDERNon-Surgical InterventionsNon-Surgical InterventionsDissolution therapy (of Dissolution therapy (of cholesterol stones)cholesterol stones)

Meds: Chenodeoxycholic acid Meds: Chenodeoxycholic acid (Chenodiol) or Ursodiol (Chenodiol) or Ursodiol (Actigall) po(Actigall) po

Direct contact with repeated Direct contact with repeated injections & aspirations of a injections & aspirations of a dissolution agent via dissolution agent via percutaneous cathpercutaneous cath

GALL BLADDERGALL BLADDERSurgical Interventions Surgical Interventions

under Exploration under Exploration Laparoscopy/Peritoneoscopy: Laparoscopy/Peritoneoscopy: direct visualization of organs & direct visualization of organs & structures within the abdomen structures within the abdomen using fiberscope; bx can be using fiberscope; bx can be obtainedobtained

Cholecystectomy: gall bladder Cholecystectomy: gall bladder removalremoval

Choledochotomy: common bile Choledochotomy: common bile duct incision to remove stoneduct incision to remove stone

GALL BLADDERGALL BLADDERNursing Interventions: s/p Gall Nursing Interventions: s/p Gall Bladder SurgeryBladder SurgeryCoughing (splint the abdomen) Coughing (splint the abdomen) & DBE, early ambulation& DBE, early ambulation

NPO & NGT to suction, then NPO & NGT to suction, then progressive diet as orderedprogressive diet as ordered

Administer meds as orderedAdminister meds as orderedAntiemeticsAntiemeticsAntipyreticsAntipyreticsAntibiotics Antibiotics

GALL BLADDERGALL BLADDERNursing Interventions: s/p Nursing Interventions: s/p Gall Bladder SurgeryGall Bladder SurgeryMonitor drainage from the Monitor drainage from the T-tubeT-tube

Purpose: preserves the Purpose: preserves the patency of the common bile patency of the common bile duct & ensures bile duct & ensures bile drainage until edema drainage until edema resolves & bile is effectively resolves & bile is effectively draining into the duodenumdraining into the duodenum

GALL BLADDERGALL BLADDERNursing Interventions: Nursing Interventions: s/p Gall Bladder Surgerys/p Gall Bladder SurgerySemi-Fowler’s position, Semi-Fowler’s position, drain system by gravitydrain system by gravity

Avoid irrigation, Avoid irrigation, aspiration or clamping aspiration or clamping the T-tube without the T-tube without MD’s ordersMD’s orders

GALL BLADDERGALL BLADDERNursing Interventions: s/p Gall Nursing Interventions: s/p Gall Bladder SurgeryBladder SurgeryAs ordered, clamp the T-tube As ordered, clamp the T-tube before meals, WOF abdominal before meals, WOF abdominal pain/distention, N/V, pain/distention, N/V, T (if T (if noted, unclamp the T-tube & noted, unclamp the T-tube & notify MD)notify MD)

Monitor amount, color, Monitor amount, color, consistency & odor of drainageconsistency & odor of drainage

Refer sudden Refer sudden in bile output in bile outputPrevent skin irritationPrevent skin irritation

ESOPHAGUSESOPHAGUSCollapsible Collapsible muscular tube about muscular tube about 10 inches long10 inches long

Carries food from Carries food from pharynx to the pharynx to the stomachstomach

Gastroesophageal Reflux Gastroesophageal Reflux Disease (GERD)Disease (GERD)

or Chalasia or Chalasia Backflow of Backflow of gastric & gastric & duodenal contents duodenal contents into the into the esophagusesophagus

GERDGERD

GERDGERDCausesCauses

Incompetent lower Incompetent lower esophageal sphincter (LES)esophageal sphincter (LES)

Pyloric stenosisPyloric stenosisMotility disorderMotility disorderProlonged gastric Prolonged gastric intubationintubation

Ingestion of corrosive Ingestion of corrosive chemicalschemicals

GERDGERDCausesCauses

UremiaUremiaInfectionsInfectionsMucosal alterationsMucosal alterationsSystemic disease Systemic disease (SLE)(SLE)

GERDGERDSigns & Symptoms (mimic Signs & Symptoms (mimic

those of MI)those of MI)Substernal pain (due to Substernal pain (due to frequent regurgitation frequent regurgitation through gastroesophageal through gastroesophageal junction), aggravated by junction), aggravated by postural changes especially postural changes especially when in supinewhen in supine

DyspepsiaDyspepsiaDysphagiaDysphagiaHypersalivation Hypersalivation

GERDGERDComplicationsComplications

Pulmonary Pulmonary aspirationaspiration

EsophagitisEsophagitisEsophageal CAEsophageal CA

ESOPHAGITISESOPHAGITISInflammation of Inflammation of esophageal mucosa, esophageal mucosa, most often results most often results from GERD due to from GERD due to prolonged vomiting prolonged vomiting or an incompetent or an incompetent LESLES

ESOPHAGITISESOPHAGITIS Signs & SymptomsSigns & Symptoms

precipitated by ingestion precipitated by ingestion of fatty foods & alcoholof fatty foods & alcoholHeart burnHeart burnRetrosternal discomfortRetrosternal discomfortRegurgitation of sour, Regurgitation of sour, bitter materialbitter material

ESOPHAGITISESOPHAGITIS Signs & SymptomsSigns & Symptoms

Dysphagia for both Dysphagia for both solids & liquids (r/t solids & liquids (r/t permanent strictures)permanent strictures)

BleedingBleeding IDA IDANocturnal reflux (in Nocturnal reflux (in upright or supine upright or supine position or both)position or both)

GERD & ESOPHAGITISGERD & ESOPHAGITIS Diagnostic ProceduresDiagnostic Procedures

pH in esophagus- 0.8- pH in esophagus- 0.8- 22

Esophageal biopsy- Esophageal biopsy- (+) inflammatory (+) inflammatory changeschanges

GERD & ESOPHAGITISGERD & ESOPHAGITISDiagnostic Procedure: GASTRIC Diagnostic Procedure: GASTRIC

ANALYSISANALYSISEsophageal reflux of gastric Esophageal reflux of gastric

acid may be done by acid may be done by ambulatory pH monitoring; a ambulatory pH monitoring; a probe is placed just above the probe is placed just above the LES & connected to an external LES & connected to an external recording device; provides a recording device; provides a computer analysis & graphic computer analysis & graphic display of resultsdisplay of results

GERD & ESOPHAGITISGERD & ESOPHAGITISDiagnostic Procedure: GASTRIC Diagnostic Procedure: GASTRIC

ANALYSISANALYSISPre-op: NPO X 8-12 hrs, no Pre-op: NPO X 8-12 hrs, no

tobacco & chewing gum X 6 tobacco & chewing gum X 6 hrs, hold meds that can hrs, hold meds that can stimulate gastric secretions X stimulate gastric secretions X 1-2 days1-2 days

Post-op: Resume N activities, Post-op: Resume N activities, place gastric samples in ref if place gastric samples in ref if not tested within 4 hrsnot tested within 4 hrs


Upper GI study/series Upper GI study/series (Barium swallow): done (Barium swallow): done under fluoroscopy after the under fluoroscopy after the pt drinks Barium SO4pt drinks Barium SO4

Pre-op: NPO after 12 MNPre-op: NPO after 12 MNPost-op: Laxative as ordered, Post-op: Laxative as ordered, Force fluids, WOF passage of Force fluids, WOF passage of chalk-white stools (Barium chalk-white stools (Barium can cause GI obstruction)can cause GI obstruction)


Barium swallow- poorly Barium swallow- poorly distensible, shortened, distensible, shortened, stricture & or ulcerated stricture & or ulcerated esophagusesophagus

Gastroesophageal Gastroesophageal scintiscan (X-ray to scintiscan (X-ray to document amount of document amount of reflux)reflux)

GERD & ESOPHAGITISGERD & ESOPHAGITISNursing InterventionsNursing Interventions

Position: Position: head of bed head of bed on 6 to 8-inch blockson 6 to 8-inch blocks

Diet: Diet: fat, fat, fiber fiber Avoid caffeine, tobacco, Avoid caffeine, tobacco, carbonated drinks, eating carbonated drinks, eating & drinking 2hrs before & drinking 2hrs before HSHS

No tight clothesNo tight clothes

GERD & ESOPHAGITISGERD & ESOPHAGITISNursing InterventionsNursing Interventions

Administer as orderedAdminister as orderedAntacids, H2 blockers, Antacids, H2 blockers, proton-pump inhibitorsproton-pump inhibitors

Prokinetic meds (to Prokinetic meds (to gastric emptying)gastric emptying)

No anticholinergic No anticholinergic meds! (meds! ( gastric gastric emptying)emptying)

MEDICAL MANAGEMENT Cholinergic Meds

Bethanecol – to esophageal tone & peristaltic activity

Metochlopramide (Reglan/Plasil)- to esophageal pressure by relaxing pyloric & duodenal segments, peristalsis without stimulating secretions

MEDICAL MANAGEMENT Cholinergic Meds

H2 blockers- to gastric acidity & pepsin secretion

Proton-pump inhibitors- gastric acidity

Antacids (Maalox)- to neutralize gastric acid between feedings

SURGICAL MANAGEMENT Nissen Fundoplication Nissen Fundoplication

(under EL)(under EL) Creation of valve Creation of valve

mechanism by mechanism by wrapping the greater wrapping the greater curvature of stomach curvature of stomach (gastric fundus) around (gastric fundus) around the LESthe LES

To create pressure & To create pressure & prevent backflow to prevent backflow to esophagusesophagus

NISSEN FUNDOPLICATION

HIATAL HERNIA or Esophageal or or Esophageal or

Diaphragmatic HerniaDiaphragmatic Hernia A portion of the A portion of the

stomach herniates stomach herniates through the weak through the weak muscles of the muscles of the diaphragm & into the diaphragm & into the thoraxthorax

HIATAL HERNIAHIATAL HERNIA

HIATAL HERNIA Aggravated by factors Aggravated by factors

intraabdominal pressure: intraabdominal pressure: pregnancy, ascites, pregnancy, ascites, obesity, tumors, heavy obesity, tumors, heavy liftinglifting

Cx: ulceration, Cx: ulceration, hemorrhage, hemorrhage, regurgitation, aspiration, regurgitation, aspiration, strangulation, strangulation, incarceration of the incarceration of the stomach in the chest with stomach in the chest with necrosis, peritonitis & necrosis, peritonitis & mediastinitismediastinitis

HIATAL HERNIA Signs & SymptomsSigns & Symptoms

HeartburnHeartburn Regurgitation or Regurgitation or

vomitingvomiting DysphagiaDysphagia Feeling of fullness Feeling of fullness

HIATAL HERNIA Nursing, Medical & Nursing, Medical &

Surgical InterventionsSurgical InterventionsSame as in GERDSame as in GERDSmall frequent Small frequent

meals, minimal meals, minimal amount of fluidsamount of fluids

Avoid reclining for 1 Avoid reclining for 1 hr after eatinghr after eating

STOMACHSTOMACH J - shape J - shape Widest section of alimentary Widest section of alimentary canalcanal

With valvesWith valves Cardiac sphincter - between Cardiac sphincter - between esophagus & stomachesophagus & stomach

Pyloric sphincter- between Pyloric sphincter- between stomach & duodenum, olive-stomach & duodenum, olive-shapeshape

STOMACHSTOMACH

PartsParts CardiaCardia FundusFundus BodyBody Antrum Antrum PylorusPylorus

STOMACHSTOMACH

STOMACHSTOMACHMucous GlandsMucous Glands

Prevent Prevent autodigestion by autodigestion by providing alkaline providing alkaline protective coveringprotective covering

STOMACHSTOMACH CellsCells

Chief/zymogenic cellsChief/zymogenic cells Gastric amylase -Gastric amylase - digests CHOdigests CHO

Gastric lipaseGastric lipase - digests - digests fatsfats

PepsinPepsin - digests CHON - digests CHON RenninRennin - digests milk - digests milk productsproducts

STOMACHSTOMACH

Parietal/Oxyntic cellsParietal/Oxyntic cells Produces Intrinsic Produces Intrinsic Factor (glycoprotein) Factor (glycoprotein) for reabsorption of for reabsorption of Vit B12 for RBC Vit B12 for RBC maturationmaturation

Secretes HCl- aids Secretes HCl- aids in digestionin digestion

STOMACHSTOMACH

Endocrine cells (G-Endocrine cells (G-cells)cells) Stimulates Stimulates gastrin (controls gastrin (controls gastric acidity)gastric acidity)

STOMACHSTOMACH

FunctionsFunctions Mechanical & Mechanical & chemical digestionchemical digestion

Storage of foodStorage of foodCHO & CHON: 2-3 CHO & CHON: 2-3 hrshrs

Fats: 3-4 hrsFats: 3-4 hrs

GASTRITISGASTRITISInflammation of the the stomach Inflammation of the the stomach

or gastric mucosaor gastric mucosaCauses of Acute GastritisCauses of Acute Gastritis

Ingestion of food with bacteria, Ingestion of food with bacteria, fungi, virusfungi, virus

Highly-seasoned/irritating foodHighly-seasoned/irritating foodOveruse of NSAIDsOveruse of NSAIDsAlcoholismAlcoholismBile refluxBile refluxRadiation therapyRadiation therapy

GASTRITISGASTRITISSigns & Symptoms: Acute Signs & Symptoms: Acute GastritisGastritisA/N/VA/N/VAbdominal discomfortAbdominal discomfortHeadacheHeadacheHiccuping Hiccuping

GASTRITISGASTRITISCauses of Chronic GastritisCauses of Chronic Gastritis

Benign or malignant Benign or malignant ulcersulcers

H. pylori H. pylori bacteriabacteriaAutoimmune diseasesAutoimmune diseasesDiet, MedsDiet, MedsSmoking & alcoholismSmoking & alcoholismReflux Reflux

GASTRITISGASTRITISSigns & Symptoms: Signs & Symptoms: Chronic GastritisChronic GastritisA/N/VA/N/VBelchingBelchingHeartburn after eatingHeartburn after eatingSour taste in the mouthSour taste in the mouthVit. B12 deficiencyVit. B12 deficiency

GASTRITISGASTRITISNursing InterventionsNursing Interventions

NPO until Sx subside, then NPO until Sx subside, then progressive dietprogressive diet

WOF hemorrhagic gastritis & notify WOF hemorrhagic gastritis & notify MD: hematemesis, MD: hematemesis, HR, HR, BPBP

Avoid irritating/spicy/highly seasoned Avoid irritating/spicy/highly seasoned foods, caffeine, alcohol & nicotinefoods, caffeine, alcohol & nicotine

Administer as orderedAdminister as orderedAntibioticsAntibioticsBismuth salts (Pepto-Bismol)Bismuth salts (Pepto-Bismol)Vit B12 injections Vit B12 injections

PEPTIC ULCERPEPTIC ULCER Erosion/excoriation of Erosion/excoriation of mucosal & submucosal mucosal & submucosal lining (extending to lining (extending to muscle) due tomuscle) due to Hypersecretion of acid Hypersecretion of acid pepsinpepsin

resistance of mucosal resistance of mucosal barrier to hyperaciditybarrier to hyperacidity

PEPTIC ULCERPEPTIC ULCER

PEPTIC ULCERPEPTIC ULCER Incidence RateIncidence Rate

M- 2-3 X higher riskM- 2-3 X higher risk Low income, laborerLow income, laborer

Predisposing FactorsPredisposing Factors HereditaryHereditary Hx of gastritisHx of gastritis Emotional stressEmotional stress

PEPTIC ULCERPEPTIC ULCER Predisposing FactorsPredisposing Factors

SmokingSmoking AlcoholismAlcoholism CaffeineCaffeine Irregular DietIrregular Diet Rapid EatingRapid Eating

PEPTIC ULCERPEPTIC ULCER Predisposing FactorsPredisposing Factors

Ulcerogenic drugsUlcerogenic drugs ASA ASA Ibuprofen Ibuprofen IndomethacinIndomethacin PhenylbutazonesPhenylbutazones SteroidsSteroids

PEPTIC ULCERPEPTIC ULCER Predisposing Predisposing

FactorsFactors Gastrin-producing Gastrin-producing

tumorstumorsZollinger-Ellison Zollinger-Ellison syndromesyndrome

Microbial invasionMicrobial invasion Helicobacter Helicobacter pyloripylori

PEPTIC ULCERPEPTIC ULCERTypes depending on:Types depending on:SeveritySeverity

Acute- affects Acute- affects submucosal & mucosal submucosal & mucosal liningslinings

Chronic- affects deeper Chronic- affects deeper tissues tissues heals heals scars scars

PEPTIC ULCERPEPTIC ULCERTypes depending on:Types depending on:LocationLocation

Stress ulcerStress ulcerEsophagealEsophagealGastric ulcerGastric ulcerDuodenal ulcer- 90-95% Duodenal ulcer- 90-95% less Bicarbonateless Bicarbonate


Stress UlcerStress Ulcercommon among common among critically-ill ptcritically-ill pt

PEPTIC ULCERPEPTIC ULCERStress UlcerStress Ulcer

Curling’s Ulcer- due to Curling’s Ulcer- due to trauma & major burns trauma & major burns hypovolemia hypovolemia GIT GIT ischemia ischemia resistance of resistance of mucosal barrier to HCl mucosal barrier to HCl acid secretion acid secretion ulceration ulceration

PEPTIC ULCERPEPTIC ULCERStress UlcerStress Ulcer

Cushing’s Ulcer- due to Cushing’s Ulcer- due to head trauma/injury (e.g. head trauma/injury (e.g. CVA) CVA) Vagal stimulation Vagal stimulation hyperacidity hyperacidity ulcerationulceration


GASTRIC GASTRIC VS.VS.

ULCERULCER

AntrumAntrum

30 mins- 1 or 2 hrs 30 mins- 1 or 2 hrs p.c.p.c.

Epigastric painEpigastric pain

(L midepigastric (L midepigastric pain)pain)

DUODENAL ULCERDUODENAL ULCER

Duodenal bulbDuodenal bulb

2-3 or 4 hrs p.c.2-3 or 4 hrs p.c.

Mid-epigastric Mid-epigastric painpain

PEPTIC ULCERPEPTIC ULCERGASTRIC GASTRIC VS.VS.

ULCERULCER

Gaseous pain & Gaseous pain & burningburning

Not relieved by Not relieved by food/antacidfood/antacid

N gastric acid N gastric acid secretionsecretion

DUODENAL DUODENAL ULCERULCER

Cramping & Cramping & burningburning

Relieved by Relieved by food/antacidfood/antacid

Gastric acid Gastric acid secretionsecretion

PEPTIC ULCERPEPTIC ULCERGASTRIC GASTRIC VS.VS.

ULCERULCER

HematemesisHematemesis

Weight lossWeight loss

Stomach CA, Stomach CA,

pyloric obstruction, pyloric obstruction,

hemorrhage, hemorrhage, perforationperforation

60 y/o & 60 y/o &

DUODENAL ULCERDUODENAL ULCER

MelenaMelena

Weight gainWeight gain

Perforation, gastric Perforation, gastric outlet obstruction, outlet obstruction, intractable diseaseintractable disease

20 y/o & 20 y/o &

PEPTIC ULCERPEPTIC ULCERDiagnostic ProceduresDiagnostic Procedures

Upper GI Fiberoscopy Upper GI Fiberoscopy (Esophagogastroduodenoscop(Esophagogastroduodenoscopy)y)

After sedation, an endoscope After sedation, an endoscope is passed down the is passed down the esophagus to view the gastric esophagus to view the gastric wall, sphincters & duodenum; wall, sphincters & duodenum; tissue specimens can be tissue specimens can be obtainedobtained

Upper GI FiberoscopyUpper GI Fiberoscopy

PEPTIC ULCERPEPTIC ULCER Diagnostic Procedures: Diagnostic Procedures:

EsophagogastroduodenoscopyEsophagogastroduodenoscopyPre-opPre-opNPO X 6-12 hrsNPO X 6-12 hrsLocal anesthetic (spray or gargle) along Local anesthetic (spray or gargle) along

with Midazolam IV (conscious sedation)with Midazolam IV (conscious sedation)AtSO4 IV (AtSO4 IV ( secretions), Glucagon (to secretions), Glucagon (to

relax smooth muscles)relax smooth muscles)Position: L-side lying (to drain Position: L-side lying (to drain

secretions & easy access of endoscope)secretions & easy access of endoscope)Prepare emergency equipment at Prepare emergency equipment at

bedsidebedside

PEPTIC ULCERPEPTIC ULCERDiagnostic Procedures: Diagnostic Procedures:

EsophagogastroduodenoscopyEsophagogastroduodenoscopyPost-opPost-opCBR until pt is alertCBR until pt is alertNPO X 1-2 hrs (until gag reflex NPO X 1-2 hrs (until gag reflex

returns)returns)Lozenges, saline gargles or oral Lozenges, saline gargles or oral

analgesics can relive minor sore analgesics can relive minor sore throatthroat

WOF perforation (pain, bleeding, WOF perforation (pain, bleeding, dysphagia, dysphagia, T)T)

PEPTIC ULCERPEPTIC ULCERDiagnostic ProceduresDiagnostic Procedures

Endoscopic exam- extent Endoscopic exam- extent & depth of ulceration& depth of ulceration

Stool- (+) occult bloodStool- (+) occult bloodUpper GI series (Barium Upper GI series (Barium swallow)- (+) ulcerationswallow)- (+) ulceration

PEPTIC ULCERPEPTIC ULCERDiagnostic Procedure: GASTRIC Diagnostic Procedure: GASTRIC

ANALYSISANALYSIS(pH, apperance, vol.): after NGT (pH, apperance, vol.): after NGT

insertion, the entire gastric insertion, the entire gastric contents are aspirated, contents are aspirated, specimens are collected q 15 specimens are collected q 15 mins X 1hrmins X 1hr

Histamine or Pentagastrin SQ Histamine or Pentagastrin SQ (to stimulate gastric secretions, (to stimulate gastric secretions, may produce a flushed feelingmay produce a flushed feeling

Pre & Post-op Care: See GERDPre & Post-op Care: See GERD

PEPTIC ULCERPEPTIC ULCERNursing ManagementNursing Management

Avoid smoking, NSAIDsAvoid smoking, NSAIDsDiet: bland, no caffeine Diet: bland, no caffeine & chocolate, no milk & & chocolate, no milk & its products, give its products, give crackerscrackers

Adequate rest, reduce Adequate rest, reduce stressstress

PEPTIC ULCERPEPTIC ULCERAdminister meds as orderedAdminister meds as ordered

AntacidsAntacidsMaalox- combined with Maalox- combined with S/E than 2 antacids S/E than 2 antacids separatelyseparatelyMAD- Mg containing MAD- Mg containing antacid, S/E- diarrheaantacid, S/E- diarrhea

AAC- Al containing AAC- Al containing antacid, S/E- constipationantacid, S/E- constipation


Nursing ManagementNursing ManagementAdminister meds as Administer meds as orderedordered

H2 blockersH2 blockersRanitidine (Zantac)Ranitidine (Zantac)Cimetidine (Tagamet)Cimetidine (Tagamet)Famotidine (Pepsin)Famotidine (Pepsin)


Administer meds as orderedAdminister meds as orderedMucosal barrier Mucosal barrier protectants: creates a protectants: creates a paste-like substance that paste-like substance that coats the gastric mucosacoats the gastric mucosa

Taken 1 hr a.c.Taken 1 hr a.c.SucralfateSucralfateCytotecCytotec


Administer meds as orderedAdminister meds as orderedAnticholinergics,Anticholinergics,

AntispasmodicsAntispasmodicsAtSO4, BuscopanAtSO4, Buscopan

Sedatives/Tranquilizer Sedatives/Tranquilizer (Valium)(Valium)


Assist in surgical proceduresAssist in surgical proceduresVagotomy- prior to gastric Vagotomy- prior to gastric surgery to surgery to hemorrhage hemorrhage

Pyloroplasty: to Pyloroplasty: to obstruction, to obstruction, to gastric gastric emptyingemptying


SUBTOTAL GASTRECTOMYSUBTOTAL GASTRECTOMYBilroth I Bilroth I (Gastroduodenostomy)(Gastroduodenostomy)Removal of 1/3 to ½ Removal of 1/3 to ½ uppermost stomach & uppermost stomach & anastomosis of the gastric anastomosis of the gastric stump to the duodenumstump to the duodenum


SUBTOTAL GASTRECTOMYSUBTOTAL GASTRECTOMYBilroth II (Gastrojejunostomy)Bilroth II (Gastrojejunostomy)

Removal of 2/3 of stomach Removal of 2/3 of stomach duodenal walls & duodenal walls & anastomosis of the gastric anastomosis of the gastric stump to the jejunumstump to the jejunum

SUBTOTAL GASTRECTOMYSUBTOTAL GASTRECTOMY


GASTRIC RESECTION or GASTRIC RESECTION or Antrectomy: removal of lower Antrectomy: removal of lower half of stomachhalf of stomach

TOTAL GASTRECTOMYTOTAL GASTRECTOMYRemoval of the stomach & Removal of the stomach & attachment of esophagus to attachment of esophagus to the jejunum or duodenum the jejunum or duodenum (Esophagojejunostomy)(Esophagojejunostomy)

PEPTIC ULCERPEPTIC ULCERNursing Management Nursing Management Post-opPost-opMonitor VS, I/O, bowel soundMonitor VS, I/O, bowel soundFowler’s positionFowler’s positionNPO for 1-3 days, NGT to NPO for 1-3 days, NGT to suction (don’t suction (don’t irrigate/remove NGT)irrigate/remove NGT)

PEPTIC ULCERPEPTIC ULCERNursing Management Post-opNursing Management Post-op

Monitor NGT outputMonitor NGT outputImmediately post-op- bright redImmediately post-op- bright red12-16 hrs post-op- greenish12-16 hrs post-op- greenish> 24 hrs- tea-colored, dark red> 24 hrs- tea-colored, dark red

Progressive diet to 6 small, bland Progressive diet to 6 small, bland meals/daymeals/day

PEPTIC ULCERPEPTIC ULCERNursing Nursing Management Post-opManagement Post-opAdminister as orderedAdminister as ordered

IVF & e+IVF & e+AntibioticsAntibioticsAnalgesicsAnalgesicsAnti-emeticsAnti-emetics

PEPTIC ULCERPEPTIC ULCERNursing Management Nursing Management Post-opPost-opPrevent ComplicationsPrevent Complications

Bleeding Bleeding Hemorrhage Hemorrhage Shock Shock

Paralytic ileusParalytic ileusPeritonitisPeritonitis

PEPTIC ULCERPEPTIC ULCERNursing Management Nursing Management Post-opPost-opPrevent ComplicationsPrevent Complications

Pernicious anemiaPernicious anemiaThrombophlebitisThrombophlebitisHypoK, HypoglyHypoK, HypoglyDumping SyndomeDumping Syndome

DUMPING SYNDROMEDUMPING SYNDROME

Rapid Rapid emptying of emptying of hypertrophic hypertrophic food solution food solution (chyme) (chyme) from from stomach to stomach to jejunum jejunum hypovolemiahypovolemia

DUMPING SYNDROMEDUMPING SYNDROME

Signs & Symptoms (occur Signs & Symptoms (occur 30 mins p.c.)30 mins p.c.)N/VN/VAbdominal fullness, crampingAbdominal fullness, crampingDiaphoresisDiaphoresisPalpitation, Palpitation, HR HRWeakness, dizzinessWeakness, dizzinessDiarrheaDiarrheaBorborygmiBorborygmi

DUMPING SYNDROMEDUMPING SYNDROMENursing ManagementNursing Management

Diet: Diet: CHO, CHO, fat, fat, CHON CHONSmall, frequent meals (divided Small, frequent meals (divided into 6 equal parts/day), no into 6 equal parts/day), no fluids with mealsfluids with meals

Avoid sugar, salt, chilled Avoid sugar, salt, chilled solutionsolution

Pt lie flat for 30 mins p.c.Pt lie flat for 30 mins p.c.Antispasmodics as ordered to Antispasmodics as ordered to gastric emptying gastric emptying

SMALL INTESTINESMALL INTESTINE

SMALL INTESTINESMALL INTESTINEDivided into: Divided into:

Duodenum (with openings of the Duodenum (with openings of the bile & pancreatic ducts)bile & pancreatic ducts)

Jejunum (8 ft long)Jejunum (8 ft long)Ileum (12 ft long)Ileum (12 ft long)

Terminates into the cecumTerminates into the cecumFunctions: digestion & absorption Functions: digestion & absorption

of ingested nutrients & waterof ingested nutrients & waterAlterations:Alterations:

MalabsorptionMalabsorptionMaldigestionMaldigestion

SMALL INTESTINESMALL INTESTINEPancreatic intestinal juice enzymesPancreatic intestinal juice enzymes

Amylase: starch Amylase: starch maltose maltoseMaltase: maltose Maltase: maltose glucose glucoseLactase: lactose Lactase: lactose galactose galactose glucoseglucose

Sucrase: sucrose Sucrase: sucrose fructose fructose glucoseglucose

Nucleoses: nucleic acids Nucleoses: nucleic acids nucleotidesnucleotides

Enterokinase: activates trypsinogen Enterokinase: activates trypsinogen trypsin trypsin

SMALL INTESTINESMALL INTESTINEDisordersDisorders

Vomiting, diarrheaVomiting, diarrheaGastroenteritisGastroenteritisMalabsorption syndromeMalabsorption syndrome

Cystic Fibrosis (CF)Cystic Fibrosis (CF)Celiac Disease (Non-tropical Celiac Disease (Non-tropical sprue/Gluten Enteropathy)sprue/Gluten Enteropathy)

Tropical sprueTropical sprueRegional enteritis (Chron’s Regional enteritis (Chron’s Disease)Disease)

CYSTIC FIBROSIS (CF)CYSTIC FIBROSIS (CF) Or Mucoviscidosis or Or Mucoviscidosis or

Fibrocystic disease of the Fibrocystic disease of the PancreasPancreas

Multisystem disorderMultisystem disorder Incidence: most fatal Incidence: most fatal

genetic disease in genetic disease in Caucasians & EuropeansCaucasians & Europeans

CYSTIC FIBROSIS (CF)CYSTIC FIBROSIS (CF) Genetic characteristicsGenetic characteristics

Transmitted by autosomal Transmitted by autosomal recessive inheritancerecessive inheritance

Mutation on gene on Mutation on gene on Chromosome 7q31Chromosome 7q31

Deletion of an AA resulting CF Deletion of an AA resulting CF transmembrane conductance transmembrane conductance regulator (CFTR)regulator (CFTR)

CYSTIC FIBROSIS (CF)CYSTIC FIBROSIS (CF)

CYSTIC FIBROSIS (CF)CYSTIC FIBROSIS (CF) PathophysiologyPathophysiology

CFTR: N located on cells of exocrine CFTR: N located on cells of exocrine gl&s (lungs, liver, pancreas, gl&s (lungs, liver, pancreas, intestines, sweat gl&s, RT) intestines, sweat gl&s, RT) regulating electrolytes & water regulating electrolytes & water channelschannels

In CF: inadequate sythesis of In CF: inadequate sythesis of CFTRCFTR pores are lacking for pores are lacking for release of electrolytes at cell release of electrolytes at cell surfacessurfaces affects Cl- transport ( affects Cl- transport ( NaCl in sweat)NaCl in sweat)

CYSTIC FIBROSIS (CF)CYSTIC FIBROSIS (CF) PathophysiologyPathophysiology

On stimulation: exocrine On stimulation: exocrine ducts release thick, ducts release thick, viscous secreations viscous secreations causing plug causing plug anatomical anatomical & physiologic changes& physiologic changes

CYSTIC FIBROSIS (CF)CYSTIC FIBROSIS (CF) CharacteristicsCharacteristics

Pancreatic enzyme Pancreatic enzyme deficiencydeficiency fat & Vit fat & Vit ADEK malabsorptionADEK malabsorption

CYSTIC FIBROSIS (CF)CYSTIC FIBROSIS (CF) CharacteristicsCharacteristics

Large volume of thick, Large volume of thick, viscous bronchial viscous bronchial secretions secretions chronic chronic pulmonary diseasepulmonary disease

NaCl in sweatNaCl in sweat

CYSTIC FIBROSIS (CF)CYSTIC FIBROSIS (CF) Signs & SymptomsSigns & Symptoms

dry, repetitive cough dry, repetitive cough followed by vomiting; followed by vomiting; thick, sticky sputumthick, sticky sputum

CYSTIC FIBROSIS (CF)CYSTIC FIBROSIS (CF) Diagnostic TestsDiagnostic Tests

Pilocarpine iontophoresis Pilocarpine iontophoresis sweat test: simplest, most sweat test: simplest, most reliable method reliable method

N: <60mEq/L sweat Cl-N: <60mEq/L sweat Cl- CXR: CXR: diameter of upper diameter of upper

chest, overaerated lungs, chest, overaerated lungs, fibrotic changesfibrotic changes

CYSTIC FIBROSIS (CF)CYSTIC FIBROSIS (CF) Diagnostic TestsDiagnostic Tests

Pancreatic deficiency: (-) Pancreatic deficiency: (-) trypsintrypsin

Fecal fat test: steatorrhea Fecal fat test: steatorrhea (+) 15-30 g fat/day(+) 15-30 g fat/dayN: 4 g fat/dayN: 4 g fat/day

CYSTIC FIBROSIS (CF)CYSTIC FIBROSIS (CF) ManagementManagement Gene therapyGene therapy Respiratory: Respiratory:

Tobramycin IV & aerosol: Tobramycin IV & aerosol: prevent P. aeruginosaprevent P. aeruginosa

Coenzyme Q10,N-Coenzyme Q10,N-Acetylcystein: Acetylcystein: mucus mucus viscosityviscosity

CYSTIC FIBROSIS (CF)CYSTIC FIBROSIS (CF) Management: GIManagement: GI

Vit ADEK supplementVit ADEK supplement Ursodeoxycholic acid Ursodeoxycholic acid

(UDCA): (UDCA): bile viscositybile viscosity Correct steatorrheaCorrect steatorrhea

Pancreatic enzyme Pancreatic enzyme replacement therapyreplacement therapy

Lecithin, Taurine, MCTLecithin, Taurine, MCT

CHRON’S DISEASECHRON’S DISEASEOr Regional Enteritis Or Regional Enteritis Idiopathic, chronic, Idiopathic, chronic, relapsing granulomatous relapsing granulomatous inflammatory disease of inflammatory disease of the intestinal tract, the intestinal tract, affecting the terminal ileum affecting the terminal ileum or colonor colon

With periods of remissions With periods of remissions & exacerbations& exacerbations

CHRON’S DISEASECHRON’S DISEASE

Predisposing Predisposing FactorsFactors M=F, depressed & M=F, depressed & dependentdependent

higher in members higher in members of Jewish raceof Jewish race

familial familial predispositionpredisposition

CHRON’S DISEASECHRON’S DISEASE

Predisposing Predisposing FactorsFactorsonset- 15-20 y/o; onset- 15-20 y/o; peak- 55 & 60 y/opeak- 55 & 60 y/o

common in US, common in US, Britain, ScandinaviaBritain, Scandinavia

CHRON’S DISEASECHRON’S DISEASECausesCauses

Infectious (viruses, Infectious (viruses, Pseudomonas spp., Pseudomonas spp., atypical atypical mycobacteria)mycobacteria)

ImmunologicImmunologic

CHRON’S DISEASECHRON’S DISEASECausesCauses

PsychosomaticPsychosomaticDietaryDietaryHormonal Hormonal Unknown Unknown

CHRON’S DISEASECHRON’S DISEASEPathogenesisPathogenesis

Lesions in lymph nodes next to SI Lesions in lymph nodes next to SI Obstruction of lymphatic drainageObstruction of lymphatic drainageLymphoid tissue hyperplasia & Lymphoid tissue hyperplasia & lymphedemalymphedema

Bowel thickeningBowel thickeningBowel lumen narrowingBowel lumen narrowingInflamed & Inflamed & ulcerated mucosa ulcerated mucosa with with grayish- white grayish- white abscesses abscesses fistulafistula formationformation

CHRON’S DISEASECHRON’S DISEASEComplicationsComplications

intestinal intestinal stenosis/stricture due stenosis/stricture due to abscesses to abscesses obstructionobstruction

Fistula developmentFistula development rupture rupture peritonitis peritonitis

CHRON’S DISEASECHRON’S DISEASESigns & SymptomsSigns & Symptoms

Cramplike & Colicky pain Cramplike & Colicky pain in RLQ p.c.in RLQ p.c.

Mild, intermittent diarrhea Mild, intermittent diarrhea with mucus & pus (2-5 with mucus & pus (2-5 stools/day)- dominant stools/day)- dominant featurefeature

SteatorrheaSteatorrhea(+) occult blood in stool(+) occult blood in stool

CHRON’S DISEASECHRON’S DISEASESigns & SymptomsSigns & Symptoms

A/N/V, wt. loss, fever, A/N/V, wt. loss, fever, anemia, malaiseanemia, malaise

Dehydration & e+ Dehydration & e+ imbalance, imbalance, MalnutritionMalnutrition

CHRON’S DISEASECHRON’S DISEASE Diagnostic ProceduresDiagnostic Procedures

CBC- CBC- RBC, RBC, WBC WBC Deranged Serum electrolytesDeranged Serum electrolytesileum biopsy- (+) ileum biopsy- (+) inflammatory changesinflammatory changes

Barium swallow- (+) String Barium swallow- (+) String SignSign

Endoscopic exam- (+) skip Endoscopic exam- (+) skip lesionslesions

CHRON’S DISEASECHRON’S DISEASENursing, Medical Nursing, Medical InterventionsInterventionsSame as in ulcerative Same as in ulcerative colitiscolitis

Surgery is avoided as much Surgery is avoided as much as possible because as possible because recurrence of the disease recurrence of the disease process in the same region process in the same region is likely to occuris likely to occur

LARGE INTESTINELARGE INTESTINEAbout 5 ft long About 5 ft long Absorbs water (1,800 to Absorbs water (1,800 to 3,000 ml) with few 3,000 ml) with few electrolytes, provides for electrolytes, provides for the final water balance in the final water balance in the GISthe GIS

Eliminates wastesEliminates wastesBacterial flora synthesize Bacterial flora synthesize some B Vitamins & Vit. Ksome B Vitamins & Vit. K

LARGE INTESTINELARGE INTESTINEFrom cecum, colon From cecum, colon (subdivided into ascending, (subdivided into ascending, transverse & descending), transverse & descending), sigmoid, rectum & anussigmoid, rectum & anus

Ileoceccal valve: prevents Ileoceccal valve: prevents backflow of LI contents to backflow of LI contents to the ileumthe ileum

Anal sphincters: guard the Anal sphincters: guard the anal canalanal canal

ULCERATIVE COLITISULCERATIVE COLITISChronic inflammatory disease of Chronic inflammatory disease of

the mucous membranes of the the mucous membranes of the coloncolon

Commonly begins in the rectum & Commonly begins in the rectum & spreads upward toward the cecumspreads upward toward the cecum

Bowel fills with bloody, mucoid Bowel fills with bloody, mucoid secretion that produces a secretion that produces a characteristic cramping pain, characteristic cramping pain, rectal urgency & diarrhearectal urgency & diarrhea

With periods of remissions & With periods of remissions & exacerbationsexacerbations

ULCERATIVE COLITISULCERATIVE COLITIS

ULCERATIVE COLITISULCERATIVE COLITISPredisposing FactorsPredisposing Factors

Unknown causeUnknown causeGenetic basis suggestedGenetic basis suggestedAssociated with viruses other Associated with viruses other microorganisms & autoimmunitymicroorganisms & autoimmunity

Peak occurrence: 15-35 y/oPeak occurrence: 15-35 y/oCommon among Whites than in Common among Whites than in other racesother races

ULCERATIVE COLITISULCERATIVE COLITISPathogenesisPathogenesis

ACUTE PHASE ACUTE PHASE edematous colon develop edematous colon develop bleeding lesions & ulcersbleeding lesions & ulcers perforationperforation

CHRONIC PHASECHRONIC PHASEulcerations become scarsulcerations become scars elasticityelasticity malabsorption, bowel malabsorption, bowel thickening, shortening & thickening, shortening & narrowingnarrowing

ULCERATIVE COLITISULCERATIVE COLITISSigns & SymptomsSigns & Symptoms

Abdominal tenderness & Abdominal tenderness & cramping cramping

Severe bloody diarrhea with Severe bloody diarrhea with mucusmucus

Vit. K deficiencyVit. K deficiencyA/, wt. loss, fever, anemia, A/, wt. loss, fever, anemia, malaisemalaise

Dehydration & e+ imbalance, Dehydration & e+ imbalance, malnutritionmalnutrition

ULCERATIVE COLITISULCERATIVE COLITISDiagnostic Procedures Diagnostic Procedures

CBC- CBC- RBC, RBC, WBC WBC Serum albuminSerum albumin Deranged serum Deranged serum electrolyteselectrolytes

serum alkaline serum alkaline phosphatasephosphatase

ULCERATIVE COLITISULCERATIVE COLITISDiagnostic Procedures Diagnostic Procedures

Lower GI study/series (Barium Lower GI study/series (Barium enema)- fluoroscopic & radiographic enema)- fluoroscopic & radiographic exam of LI after rectal instillation of exam of LI after rectal instillation of Barium SO4, may be done with or Barium SO4, may be done with or without airwithout air

Pre-op: Pre-op: fiber diet X 1-2days, CL diet fiber diet X 1-2days, CL diet or laxative at pm, NPO after 12MN, or laxative at pm, NPO after 12MN, cleansing enemas in amcleansing enemas in am

Post-op: Laxative as ordered, Force Post-op: Laxative as ordered, Force fluids, WOF passage of chalk-white fluids, WOF passage of chalk-white stools (Barium can cause GI stools (Barium can cause GI obstruction), Notify MD if no bowel obstruction), Notify MD if no bowel mov’t within 2 daysmov’t within 2 days


Diagnostic Diagnostic Procedures Procedures Barium enema- Barium enema- sigmoidoscopic appearance sigmoidoscopic appearance of the mucosaof the mucosa

Colon Biopsy & culture to Colon Biopsy & culture to r/o carcinoma & bacterial r/o carcinoma & bacterial diarrheadiarrhea


ComplicationsComplicationsIntestinal obstructionIntestinal obstructionDehydrationDehydrationFluid & electrolyte Fluid & electrolyte imbalancesimbalances

MalabsorptionMalabsorptionChronic IDAChronic IDA

ULCERATIVE COLITISULCERATIVE COLITISNursing InterventionsNursing Interventions

CBRCBRNPO, IVF or TPN as ordered NPO, IVF or TPN as ordered to progressive diet (CL to to progressive diet (CL to fiber, fiber, CHON, vit. & min.)CHON, vit. & min.)

Avoid gas-forming foods, Avoid gas-forming foods, milk products, wheat grains, milk products, wheat grains, nuts, raw fruits, vegetable, nuts, raw fruits, vegetable, pepper, alcohol & caffeinepepper, alcohol & caffeine

ULCERATIVE COLITISULCERATIVE COLITISNursing InterventionsNursing Interventions

Avoid smokingAvoid smokingMonitor stool color, Monitor stool color, consistency, presence of consistency, presence of bloodblood

WOF perforation, WOF perforation, peritonitis & hemorrhageperitonitis & hemorrhage


Nursing Nursing InterventionsInterventionsAdminister as orderedAdminister as ordered

Bulk-forming agents: bran, Bulk-forming agents: bran, psyllium, methylcellulosepsyllium, methylcellulose

AntibioticsAntibioticsCorticosteroidsCorticosteroidsImmunosuppressants Immunosuppressants

ULCERATIVE COLITISULCERATIVE COLITISSurgical InterventionsSurgical Interventions

Total proctocolectomy with Total proctocolectomy with permanent ileostomypermanent ileostomyCurative, removal of entire Curative, removal of entire colon, rectum & anus with anal colon, rectum & anus with anal closureclosure

Terminal ileum at RLQ: with Terminal ileum at RLQ: with stomastoma


Kock (continent) ileostomyKock (continent) ileostomyIntraabdominal pouch that stores Intraabdominal pouch that stores feces constructed from the terminal feces constructed from the terminal ileumileum

The pouch is connected to the The pouch is connected to the stoma with nipplelike valve; the stoma with nipplelike valve; the stoma is flush with the skinstoma is flush with the skin

Cath. is used to empty the pouch, & Cath. is used to empty the pouch, & a small dressing or adhesive a small dressing or adhesive bandage is worn over the stoma bandage is worn over the stoma between emptyingsbetween emptyings

KOCK’S ILEOSTOMYKOCK’S ILEOSTOMY


Ileoanal reservoirIleoanal reservoirA 2-stage procedureA 2-stage procedureInvolves excision of rectal Involves excision of rectal mucosa, an abdominal mucosa, an abdominal colectomy, construction of a colectomy, construction of a reservoir to the anal canal & reservoir to the anal canal & temporary loop ileostomytemporary loop ileostomy

The ileostomy is closed in 3-4 The ileostomy is closed in 3-4 mos. after the capacity of the mos. after the capacity of the reservoir is increasedreservoir is increased

ILEOANAL RESERVOIRILEOANAL RESERVOIR


Ileoanal anastomosis Ileoanal anastomosis (Ileorectostomy)(Ileorectostomy)Does not require ileostomyDoes not require ileostomyRequires a large, compliant Requires a large, compliant rectumrectum

A 12- to 15-cm rectal stump is A 12- to 15-cm rectal stump is left after the colon is removed, left after the colon is removed, the SI is inserted into this rectal the SI is inserted into this rectal sleeve & anastomosedsleeve & anastomosed

COLO/ILEOSTOMY PRE-OP CARECOLO/ILEOSTOMY PRE-OP CARE

Consult with enterostomal therapist Consult with enterostomal therapist to identify optimal placement of to identify optimal placement of ostomyostomy

Low-residue diet for 1-2 days pre-opLow-residue diet for 1-2 days pre-opGive intestinal antiseptics & Give intestinal antiseptics &

antibiotics, laxatives & enemas as antibiotics, laxatives & enemas as orderedordered

ILEOSTOMY POST-OP CAREILEOSTOMY POST-OP CARE

Post-op drainage: dark green to Post-op drainage: dark green to yellow (as the pt begins to eat)yellow (as the pt begins to eat)

Expect liquid stoolExpect liquid stoolWOF dehydration & e+ imbalanceWOF dehydration & e+ imbalanceAvoid suppositories through Avoid suppositories through

ileostomyileostomy

COLOSTOMY POST-OP CARECOLOSTOMY POST-OP CAREApply petroleum jelly over the stoma to keep Apply petroleum jelly over the stoma to keep

it moist followed by dry sterile gauze if pouch it moist followed by dry sterile gauze if pouch system is not yet in placesystem is not yet in place

Monitor the stoma for size, unusual bleeding Monitor the stoma for size, unusual bleeding or necrotic tissueor necrotic tissue

Monitor the stoma for color Monitor the stoma for color N: pink or red indicating N: pink or red indicating vascularityvascularityPale: anemia, Violet/Blue/Black: Pale: anemia, Violet/Blue/Black:

compromised circulationcompromised circulation

COLOSTOMY POST-OP CARECOLOSTOMY POST-OP CARECheck pouch system for proper fit & leakageCheck pouch system for proper fit & leakageAscending colon colostomy: expect liquid stoolAscending colon colostomy: expect liquid stoolTransverse colon colostomy: expect loose to Transverse colon colostomy: expect loose to

semiformed stoolsemiformed stoolDescending colon: expect close to N stoolDescending colon: expect close to N stoolEmpty pouch when 1/3 full, remove feces from Empty pouch when 1/3 full, remove feces from

the skinthe skinAvoid gas/odor-forming foodsAvoid gas/odor-forming foods

COLOSTOMY POST-OP CARECOLOSTOMY POST-OP CARE

WOF perineal wound WOF perineal wound infection (if present)infection (if present)

Administer as orderedAdminister as orderedAnalgesics & antibioticsAnalgesics & antibioticsStoma irrigationStoma irrigation

COLOSTOMYCOLOSTOMY

COLOSTOMY APPLIANCECOLOSTOMY APPLIANCE

COLOSTOMY IRRIGATIONCOLOSTOMY IRRIGATIONEnema given through the stoma Enema given through the stoma

to stimulate bowel emptyingto stimulate bowel emptyingDone at the same time each day, Done at the same time each day,

1 hr p.c. by instilling 500-1000ml 1 hr p.c. by instilling 500-1000ml of lukewarm tap water through of lukewarm tap water through the stoma, allowing the water & the stoma, allowing the water & stool to drain into a collection bagstool to drain into a collection bag

COLOSTOMY IRRIGATIONCOLOSTOMY IRRIGATIONIf ambulatory: allow the pt sit on a toiletIf ambulatory: allow the pt sit on a toiletIf bedridden: pt on side-lying positionIf bedridden: pt on side-lying positionHang the irrigation bag with its bottom at the Hang the irrigation bag with its bottom at the

level of the pt’s shoulder or higherlevel of the pt’s shoulder or higherInsert irrigation tube carefullyInsert irrigation tube carefullyBegin the flow of irrigationBegin the flow of irrigationIf cramping occurs, clamp the tubing; release it If cramping occurs, clamp the tubing; release it

as cramping subsidesas cramping subsidesAvoid frequent irrigations with waterAvoid frequent irrigations with water fluid & fluid &

e+ imbalancee+ imbalance

COLOSTOMY IRRIGATIONCOLOSTOMY IRRIGATION

COLOSTOMY IRRIGATIONCOLOSTOMY IRRIGATION

DIVERTICULOSIS & DIVERTICULOSIS & DIVERTICULITISDIVERTICULITIS

DIVERTICULOSIS: DIVERTICULOSIS: outpouching of herniation of outpouching of herniation of the intestinal mucosa, can the intestinal mucosa, can occur in any part of the occur in any part of the intestine (most common in the intestine (most common in the sigmoid colon)sigmoid colon)

DIVERTICULITIS- DIVERTICULITIS- inflammation of one of the inflammation of one of the diverticula when these diverticula when these perforatesperforates peritonitis peritonitis

DIVERTICULOSIS/DIVERTICULITISDIVERTICULOSIS/DIVERTICULITIS


Signs & SymptomsSigns & SymptomsLLQ pain esp. when LLQ pain esp. when coughing, straining or coughing, straining or liftinglifting

N/V, flatulence, N/V, flatulence, TTAbdominal distention, Abdominal distention, cramps & tendernesscramps & tenderness

Palpable, tender rectal Palpable, tender rectal massmass

Blood in stoolsBlood in stools


Nursing InterventionsNursing InterventionsCBRCBRNPO then progressive diet NPO then progressive diet as orderedas ordered

Diet: If inflammation Diet: If inflammation resolves- Soft, resolves- Soft, fiber foods fiber foods (whole grains), Force fluids(whole grains), Force fluids

If with inflammation: If with inflammation: Avoid Avoid fiber foods (can fiber foods (can irritate the mucosa furtherirritate the mucosa further


Nursing InterventionsNursing InterventionsAvoid gas forming-foods, Avoid gas forming-foods, indigestible roughage, seeds indigestible roughage, seeds or nuts (can be trapped in the or nuts (can be trapped in the diverticula & cause diverticula & cause inflammation)inflammation)

Avoid any form of Valsalva Avoid any form of Valsalva maneuvermaneuver

WOF perforation, WOF perforation, hemorrhage, fistulas & hemorrhage, fistulas & abscessesabscesses


Nursing InterventionsNursing InterventionsAdminister as orderedAdminister as ordered

AntibioticsAntibioticsAnalgesicsAnalgesicsAnticholinergicsAnticholinergicsSmall amount of bran Small amount of bran ODOD

Bulk-forming laxativesBulk-forming laxatives


Surgical InterventionsSurgical InterventionsColon resection with Colon resection with primary anastomosisprimary anastomosis

Temporary or Temporary or permanent colostomy permanent colostomy (for (for bowel bowel inflammation)inflammation)

HEMORRHOIDSHEMORRHOIDSDilated varicose veins of the Dilated varicose veins of the anal canal, caused by portal anal canal, caused by portal HTN, straining, irritation, HTN, straining, irritation, venous or venous or abdominal pressureabdominal pressure

Internal: above the anal Internal: above the anal sphincter (can’t be seen on sphincter (can’t be seen on inspection of the perianal area)inspection of the perianal area)

External: below the anal External: below the anal sphinctersphincter

Prolapsed: can become Prolapsed: can become thrombosed or inflammedthrombosed or inflammed

HEMORRHOIDSHEMORRHOIDSSigns & SymptomsSigns & Symptoms

Bright red bleeding Bright red bleeding with defecationwith defecation

Rectal pain & itchingRectal pain & itching

HEMORRHOIDSHEMORRHOIDSNursing InterventionsNursing Interventions

Cold packs followed by Cold packs followed by Sitz bath as orderedSitz bath as ordered

Apply witch hazel soaks & Apply witch hazel soaks & topical anesthetics as topical anesthetics as orderedordered

Stool softeners as orderedStool softeners as orderedfiber-diet, force fluidsfiber-diet, force fluids

HEMORRHOIDSHEMORRHOIDSEndoscopic proceduresEndoscopic procedures

SclerotherapySclerotherapyEndoscopic ligationEndoscopic ligation

Surgical interventionsSurgical interventionsCryosurgeryCryosurgeryHemorrhoidectomyHemorrhoidectomy

HEMORRHOIDSHEMORRHOIDSPost-op Nursing Interventions Post-op Nursing Interventions

Position: prone or side-lyingPosition: prone or side-lyingIce packs over dressing as Ice packs over dressing as orderedordered

fiber-diet, force fluidsfiber-diet, force fluidsStool softeners as orderedStool softeners as orderedLimit sitting to short Limit sitting to short periods of timeperiods of time

Sitz bath 3-4X/day as Sitz bath 3-4X/day as orderedordered

WOF urinary retentionWOF urinary retention

CGFNS/NCLEX QuestionCGFNS/NCLEX QuestionWhen assessing a pt When assessing a pt who underwent who underwent colostomy several colostomy several months ago, a nurse months ago, a nurse would expect the would expect the stoma to appearstoma to appear

CGFNS/NCLEX QuestionCGFNS/NCLEX Question

A. dryA. dry

B. redB. red

C. edematousC. edematous

D. retractedD. retracted


Which of the following Which of the following statements would a statements would a nurse include in the pre-nurse include in the pre-operative instructions operative instructions for a pt who is scheduled for a pt who is scheduled for an ileostomy?for an ileostomy?


A. “Your urine will be collected in A. “Your urine will be collected in a pouch subsequent to surgery.”a pouch subsequent to surgery.”

B. “Your bowel will be visualized B. “Your bowel will be visualized with a laparoscope during with a laparoscope during surgery.”surgery.”

C. “You will have a NGT in your C. “You will have a NGT in your nose after surgery.”nose after surgery.”

D. “You can drink liquids within 24 D. “You can drink liquids within 24 hours following surgery.”hours following surgery.”


Which of the following Which of the following assessment techniques assessment techniques should a nurse use to should a nurse use to determine the determine the appropriate placement appropriate placement of NGT? of NGT?

CGFNS/NCLEX QuestionCGFNS/NCLEX QuestionA. Aspirating drainage A. Aspirating drainage through the NGTthrough the NGT

B. Auscultating for bowel B. Auscultating for bowel soundssounds

C. Palpating over the C. Palpating over the epigastric regionepigastric region

D. Inserting the open end of D. Inserting the open end of the NGT into waterthe NGT into water


A RN would instruct a A RN would instruct a pt who had an pt who had an ileostomy to avoid ileostomy to avoid which of the following which of the following food?food?


A. potatoesA. potatoes

B. beefB. beef

C. popcornC. popcorn

D. yogurtD. yogurt


Which of the following Which of the following serum lab results serum lab results would a nurse expect would a nurse expect to identify in a pt who to identify in a pt who has pancreatitis?has pancreatitis?


A. A. cholesterol cholesterol

B. B. glucose glucose

C. C. amylase amylase

D. D. creatinine creatinine

CGFNS/NCLEX QuestionCGFNS/NCLEX QuestionWhich of the following Which of the following questions would be most questions would be most important for a nurse to ask important for a nurse to ask when gathering data from a when gathering data from a pt who is suspected of pt who is suspected of having acute pancreatitis?having acute pancreatitis?

CGFNS/NCLEX QuestionCGFNS/NCLEX QuestionA. “Have you had a recent blood A. “Have you had a recent blood work-up?”work-up?”

B. “Do you have a hx of diabetes?”B. “Do you have a hx of diabetes?”

C. “When was your last bowel C. “When was your last bowel movement.”movement.”

D. “How much alcohol do you drink D. “How much alcohol do you drink in a week?”in a week?”

CGFNS/NCLEX QuestionCGFNS/NCLEX QuestionThe nurse is caring for a pt The nurse is caring for a pt with a dx of pancreatitis. with a dx of pancreatitis. All of the following meds All of the following meds are ordered for the pt. are ordered for the pt. Which one should the Which one should the nurse question?nurse question?


A. Meperidine HCl (Demerol)A. Meperidine HCl (Demerol)

B. Morphine SO4B. Morphine SO4

C. Propantheline Br C. Propantheline Br

(Pro-Banthine)(Pro-Banthine)

D. Cimetidine (Tagamet)D. Cimetidine (Tagamet)


The nurse should The nurse should teach a pt who has teach a pt who has acute pancreatitis to acute pancreatitis to avoid which of the avoid which of the following foods?following foods?


A. Pasta & tomato juiceA. Pasta & tomato juice

B. Rice & green beansB. Rice & green beans

C. Steak & baked potatoC. Steak & baked potato

D. Bread & baked appleD. Bread & baked apple

CGFNS/NCLEX QuestionCGFNS/NCLEX QuestionWhich of the following Which of the following factors, if noted in a pt’s factors, if noted in a pt’s hx, would indicate a hx, would indicate a predisposition for predisposition for developing cholecystitis?developing cholecystitis?


A. obesityA. obesity

B. hypertensionB. hypertension

C. depressionC. depression

D. childlessnessD. childlessness

CGFNS/NCLEX QuestionCGFNS/NCLEX QuestionA 10-y/o boy is admitted A 10-y/o boy is admitted to the hospital with a hx to the hospital with a hx of fever & RLQ of fever & RLQ abdominal pain. Which abdominal pain. Which of the following comfort of the following comfort measures would be measures would be taken until a dx is made?taken until a dx is made?

CGFNS/NCLEX QuestionCGFNS/NCLEX QuestionA. maintain the child in A. maintain the child in recumbent positionrecumbent position

B. apply warm compress to the B. apply warm compress to the affected areaaffected area

C. obtain an order for an age C. obtain an order for an age appropriate analgesicappropriate analgesic

D. distract the child with an age D. distract the child with an age appropriate videoappropriate video


When a 12-year old child When a 12-year old child has a dx of appendicitis, has a dx of appendicitis, which of the following which of the following manifestations would be manifestations would be most important for the most important for the RN to follow-up?RN to follow-up?


A. tympanic temp of 101.2 F A. tympanic temp of 101.2 F (38.4 C)(38.4 C)

B. absence of stool for 24 hrsB. absence of stool for 24 hrs

C. nausea when exposed to C. nausea when exposed to food odorsfood odors

D. cessation of abdominal D. cessation of abdominal painpain


Which of the following Which of the following statements, if made by a pt statements, if made by a pt who has gastroesophageal who has gastroesophageal reflux disease (GERD), reflux disease (GERD), would support a nursing dx would support a nursing dx of Knowledge Deficit?of Knowledge Deficit?


A. “I will lie down for 30 minutes A. “I will lie down for 30 minutes after meals.”after meals.”

B. “I will restrict spicy foods in my B. “I will restrict spicy foods in my diet.”diet.”

C. “I should sleep with the head of C. “I should sleep with the head of the bed elevated.”the bed elevated.”

D. “I should decrease my intake of D. “I should decrease my intake of caffeine.”caffeine.”


Which of the following Which of the following findings in a pt who has findings in a pt who has Chron’s disease would Chron’s disease would indicate that indicate that corticosteroid therapy corticosteroid therapy has been effective?has been effective?

CGFNS/NCLEX QuestionCGFNS/NCLEX QuestionA. expansion of muscle massA. expansion of muscle mass

B. increase in the bulk of B. increase in the bulk of stoolstool

C. moon-like appearance of C. moon-like appearance of the facethe face

D. decreased complaints of D. decreased complaints of abdominal painabdominal pain


Which of the following Which of the following explanations should a explanations should a nurse give to a pt nurse give to a pt regarding the primary regarding the primary cause of peptic ulcer cause of peptic ulcer disease?disease?


A. “A spicy diet contributes to ulcer A. “A spicy diet contributes to ulcer development.”development.”

B. “Seasonal changes are B. “Seasonal changes are associated with ulcer disease.”associated with ulcer disease.”

C. “Executive job positions C. “Executive job positions predispose people to ulcer predispose people to ulcer formation.”formation.”

D. “Infection with Helicobacter D. “Infection with Helicobacter pylori causes ulcers.”pylori causes ulcers.”


The nurse should The nurse should monitor a pt who is monitor a pt who is receiving lactulose receiving lactulose (Cephulac) for which of (Cephulac) for which of the following adverse the following adverse side effects?side effects?


A. DiarrheaA. Diarrhea

B. PetechiaeB. Petechiae

C. PolyuriaC. Polyuria

D. FlushingD. Flushing


A nurse should expect a A nurse should expect a Sengstaken Blakemore Sengstaken Blakemore tube to be ordered for a tube to be ordered for a pt who has bleeding pt who has bleeding esophageal varices in esophageal varices in order toorder to


A. cause vasoconstriction to A. cause vasoconstriction to the splenic arterythe splenic artery

B. ensure airway patencyB. ensure airway patency

C. provide for enteral C. provide for enteral nutritionnutrition

D. apply direct pressure to D. apply direct pressure to the areathe area


Which of the following Which of the following nursing measures would nursing measures would be most appropriate for be most appropriate for a pt who has ascites?a pt who has ascites?


A. withholding fluidsA. withholding fluids

B. measuring abdominal B. measuring abdominal girthgirth

C. encouraging ambulationC. encouraging ambulation

D. monitoring for pedal D. monitoring for pedal edemaedema

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Gastrointestinal System4