Transcript Nursing of Adult Patients with Medical & Surgical Conditions

Nursing of Adult Patients
with
Medical & Surgical Conditions
Gastrointestinal
Disorders
Part I
Laboratory & Diagnostic
Examinations
• Upper GI Series
– Rationale
• Series of radiographs of the lower esophagus,
stomach, and duodenum using barium sulfate as the
medium contrast
– Nursing Interventions
• NPO after midnight
• Ensure pt. Expels barium
– increase fluid intake
– Milk of Magnesia
• Gastric Analysis
– Rationale
• Aspiration of stomach contents to determine the amount of
acid produced gy the parietal cells in the stomach, estimate
acid secretory capacity for intrinsic factor
– Nursing Interventions
• No anticholinergic medications for 24 hours before the test
• NPO after midnight
• No smoking
• Esophagogastroduodenoscopy
(EGD)
– Rationale
• Direct visualization of the upper GI
tract by means of a long, fiberoptic,
flexible scope
• Assess for disease, remove
abnormalities, dilate strictures
– Nursing Interventions
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NPO after midnight
Informed consent
IV sedative as ordered
Do not allow pt. to eat or drink until
gag reflex returns (2-4 hrs)
• Assess for s/s of perforation (pain,
bleeding)
• Barium Swallow
– Rationale
• Through study of the esophagus using barium contrast
• Assess for anatomical abnormalities
• Use Gastrografin if perforation is suspected
– water soluble and easily absorbed
– Nursing Interventions
• NPO after midnight
• Ensure pt. expels barium
– increase fluids
– Milk of Magnesia
• Bernstein Test
– Rationale
• Reproduces the symptoms of gastroesophageal reflux
• Differentiates esophageal pain from angina
• Tube is inserted to the lower esophagus and hydrochloric acid
is inserted
– Nursing Interventions
• NPO for 8 hours prior to test
• Hold any antacids and analgesics
• No sedation (pt must describe the pain)
• Stool for Occult Blood
– Rationale
• Detect hidden blood in the stool
• May be caused from tumors, ulcerations, and
inflammation
– Nursing Interventions
• Stool should be free of urine, toilet paper, etc.
• Sigmoidoscopy
– Rationale
• Visualization of the anus,
rectum, and sigmoid colon
• May obtain biopsies, remove
polyps, or specimens of
ulcerations
– Nursing Interventions
• Informed consent
• Enemas the evening before
and/or the morning of the exam
• Observe for s/s of perforation
(pain, bleeding)
• Barium Enema
– Rationale
• Series of radiographs of the colon using barium contrast
• Assess for presence of polyps, tumors, and diverticula
– Nursing Interventions
• Administer cathartics
– Magnesium citrate
• Cleansing enema the evening before and/or the morning of the
exam
• Ensure pt. expels barium
– Increase fluids
– Milk of Magnesia
• Colonoscopy
– Rationale
• Visualization of the colon from anus to cecum
• Detection of neoplasms, inflammations, ulcerations,
and bleeding
• Biopsies can be obtained and small tumors removed
– Nursing Interventions
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Informed consent
Clear liquid diet 1-3 days prior to exam
NPO 8 hours before exam
Administer cathartic
– GoLYTELY
• Enemas as ordered
• IV sedative as ordered
• Stool Culture and Sensitivity; Stool for Ova
and Parasites
– Rationale
• Stool examined for bacteria, ova, and parasites
– Nursing Interventions
• Use only normal saline enemas if required to obtain
specimen
• Take to lab within 30 minutes
• Flat Plate of the Abdomen
– Rationale
• Group of radiographic studies on the abdomen of
pts. suspected of bowel obstruction, paralytic ileus,
perforation, or abcess
– Nursing Interventions
• Schedule before any barium studies
Dental Plaque and Caries
• Etiology/Pathophysiology
– Erosive process that results from the action of
bacteria on carbohydrates in the mouth, which
produces acids that dissolve tooth enamel
Dental Plaque and Caries
• Cause
– Presence of plaque
– Strength of acids and ability of saliva to
neutralize them
– Length of time acids are in contact with the
teeth
– Susceptibility of tooth to decay
Dental Plaque and Caries
• Treatment
– Removal of affected area and replace with
dental material
Candidiasis
• Etiology/Pathophysiology
– Infection caused by a species of Candida,
usually Candida albicans
– Fungus normally present in the mouth,
intestine, vagina, and on the skin
– Also refered to as thrush and moniliasis
Candidiasis
• Signs and Symptoms
– Small white patches on the mucous membrane
of the mouth
– Thick white discharge from the vagina
Candidiasis
• Treatment
– Nystatin
• oral suspension
• vaginal tablets
– Half strength hydrogen peroxide/saline mouth
wash
– Ketoconazole oral tablets
– Meticulous handwashing
Carcinoma of the Oral Cavity
• Etiology/Pathophysiology
– Malignant lesions on the lips, oral cavity, tongue, or
the pharynx
– Usually squamous cell epitheliomas
• grow rapidly and metastasize quickly
Carcinoma of the Oral Cavity
• Signs and Symptoms
– Leukoplakia
• white, firmly attached patch
on the mouth or tongue
mucosa
– Roughened area on the tongue
– Difficulty chewing, swallowing, or speaking
– Edema, numbness, or loss of feeling in the
mouth
– Earache, faceache, and toothache become
constant
Carcinoma of the Oral Cavity
• Treatment
– Stage I
• Surgery or radiaiton
– Stage II & III
• Both surgery and radiation
– Stage IV
• palative
Carcinoma of the Esophagus
• Etiology/pathophysiology
– Malignant epithelial neoplasm that has invaded
the esophagus
• 90% are squamous cell carcinoma associated with
alcohol intake and tobacco use
• 6% are adenocarcinomas associated with reflux
esophagitis
• Other causes are environmental carcinogens,
nutritional deficiencies, chronic irritation, and
mucosal damage
Carcinoma of the Esophagus
• Signs & Symptoms
– Progressive dysphagia over a six month period
– Sensation of food sticking in throat
Carcinoma of the Esophagus
• Treatment
– Radiation
• May be curative or pallative
• Complication
– Fistula formation may cause aspiration
– Surgery
• may be palliative, increase longevity, or curative
• Types of Surgical Procedures
– Esophagogastrectomy: remove a portion of the esophagus and
stomach
– Esophagogastrostomy: remove a portion of the esophagus with
anastomosis to the stomach
– Esophagoenterostomy: remove the esophagus with anastomosis
to the colon
– Gastrostomy: insertion of a feeding tube into the stomach
through the abdominal wall
Esophagoenterostomy
Esophagogastrostomy
Achalasia
• Etiology/Pathophysiology
– Inability of the cardiac sphincter of the stomach to relax
– Also called cardiospasm
– Possible causes: nerve degeneration, esophageal dilation,
and hypertrophy
Achalasia
• Signs and Symptoms
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Dysphagia
Regurgitaion of food
Substernal chest pain
Loss of weight
Poor skin turgor
Weakness
Achalasia
• Treatment
– Medications
• Anticholinergics, nitrates, and calcium channel blockers
– Dilation of cardiac sphincter
• Balloon is inflated and remains in place for 1 minute; 1-2 times
– Surgery
• Cardiomyectomy
– Incision of the muscular layer
Acute Gastritis
• Etiology/Pathophysiology
– Inflammation of the lining of the stomach
– May be associated to alcoholism, smoking, and
stressful physical problems
– Usually a single occurance, resolving when
offending agent is removed
Acute Gastritis
• Signs and Symptoms
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Fever
Epigastric pain
Nausea
Vomiting
Headache
Coating of the tongue
Loss of appetite
Acute Gastritis
• Treatment
– Antiemetics
• Compazine
• Tigan
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Antacids & Tagamet or Zantac
Antibiotics
IV fluids
NG tube and administration of blood, if bleeding
NPO until s/s subside
Peptic Ulcers
• Gastric Ulcers & Duodenal Ulcers
– Ulcerations of the mucous membrane or
deeperstructures of the GI tract
– Most commonly occur in the stomach and
duodenum
– Result of acid and pepsin imbalances
• Excess of gastric acid or
• Decrease in protection from acid and pepsin
– H.pylori
• Bacterium found in 70% of pts. with gastric ulcers
and 95% of pts. with duodenal ulcers
Peptic Ulcers (Gastric)
• Etiology/Pathophysiology
– Most common site is the distal half of the
stomach
– Risk factors:
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Irregular diet
Genetic predisposition
Excessive use of salicylates
Use of tobacco
H.pylori
– Gastric mucosa is damaged, acid is secreted,
mucosa errosion occurs, and an ulcer develops
Peptic Ulcers (Duodenal)
• Etiology/Pathophysiolosy
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Excessive production or release of gastrin
Increased sensitivity to gastrin
Decreased ability to buffer the acid secretions
Risk factors:
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H.pylori
NSAID’s
Smoking
Coffee
Peptic Ulcers
(Gastric & Duodenal)
• Signs & Symptoms
– Pain
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Dull, burning, boring, or gnawing
Epigastric
Occurs between meals with gastric ulcers
Duodenal ulcer pain may awaken pt. at night
– Dyspepsia
• Nausea, eructation, and distention
– Hematemesis
– Melena
Peptic Ulcers
(Gastric & Duodenal)
• Treatment
– Antacids
• Neutralize or reduce the acidity of the stomach
– Maalox, Gaviscon, Rolaids, Tums, Mylanta, Riopan
– Histamine H2 Receptor Blockers
• Decrease acid secretion by blocking the histamine H2 receptors
– Tagamet, Zantac, Pepcid, and Axid
– Proton Pump Inhibitor
• Antisecretory agent ot inhibit secrtion of gastrin by the parietal
cells of the stomach
– Prilosec, Losec, and Prevacid
Peptic Ulcers
(Gastric & Duodenal)
– Mucosal Healing Agents
• Heal ulcers without antisecretory properties
• Adhere to the proteins in the ulcer base
– Carafate and Cytotec
– Antibiotics
• Eradicates H.Pylori
– Flagyl, tetracycline, amoxicillin, and Biaxin
– Usually combined with some of the other medications
Peptic Ulcers
(Gastric & Duodenal)
• Diet
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High in fat and carbohydrates
Low in protein and milk products
Small frequent meals
Limit coffee, tobacco, alcohol, and aspirin use
Peptic Ulcers
(Gastric & Duodenal)
• Surgery
– Antrectomy
• Removal of entire antrum(gastric producing portion of the
lower stomach)
– Gastrodudodenostomy (Billroth I)
• Fundus of the stomach is directly anastomosed to the
duodenum
– Gastrojejunostomy (Billroth II)
• Duodenum is closed, and the fundus of the stomach is
anastomosed into the jejunum
Billroth Procedures
Peptic Ulcers
(Gastric & Duodenal)
– Total Gastrectomy
• Removal of the entire stomach
– Vagotomy
• Removal of the vagal
innervation to the fundus
• Decreases acid production
– Pyloroplasty
• Surgical enlargement of the
pylorus to provide drainage of
the gastric contents
Peptic Ulcers
(Gastric & Duodenal)
• Complications
– Dumping Syndrome
• Rapid gastric emptying causing distention of the
duodenum or jejunum produced by a bolus of
hypertonic food
• Increased intestinal motility and peristalsis and
changes in blood glucose levels
• Diaphoresis, nausea, vomiting, epigastric pain,
explosive diarrhea, borborygmi (noises from gas),
and dyspepsia
Peptic Ulcers
(Gastric & Duodenal)
– Dumping Syndrome
• Treatment
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Six small meals a day
Diet high in protein and fat, low in carbohydrates
No fluids during meals
Anticholenergics
Lying down for approximately 1 hour after meals
Peptic Ulcers
(Gastric & Duodenal)
– Pernicious Anemia
• Caused by a deficiency of the intrinisic factor
– Aids in absorption of Vitamin B12
• Treatment
• Vitamin B12 Injections
– Iron Deficiency Anemia
• Caused by impaired absorption in the duodenum and jejunum
as a result of rapid gastric emptying
• Treatment
– Oral iron replacement
» Ferrous sulfate
Cancer of the Stomach
• Etiology/Pathophysiology
– Most commonly adenocarcinoma
– Primary location is the pyloric area
– Risk Factors:
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History of polyps
Pernicious anemia
Hypochlorhydria
Gastrectomy
Chronic gastritis
Gastric ulcer
Diet high in salt, perservatives, and carbohydrates
Diet low in fresh fruits and vegetables
Cancer of the Stomach
• Signs & Symptoms
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Early stages may be asymptomatic
Vague epigastric discomfort or indigestion
Postparandial fullness
Ulcer-like pain that does not respond to therapy
Anorexia
Weakness
Weight loss
Blood in stools
Hematemesis
Vomiting after fluids and meals
Cancer of the Stomach
• Treatment
– Surgery
• Partial or total gastric resection
• Post-Op Complications
– Dehiscence
» Separation of wound edges
– Evisceration
» Viscera protrudes through the wound
» Caused by coughing, straining, malnutrition, obesity,
and infection
» Nursing Interventions: Pt. should remain quite and
calm, position with knees bent and semi-fowlers
postion, cover eviseration with a warm sterile saline
soaked dressing
– Chemotherapy
– Chemotherapy and radiation
Infection of the Intestines
• Etiology/Pathophysiology
– Invasion of the alimentary canal by pathogenic
microorganisms
– Most commonly enters through the mouth on
food or water
– Person to person contact
– Fecal-Oral transmission
• due to poor handwashing
– Long-term antibiotic therapy can cause an
overgrowth of the normal intestinal flora
(c.difficile)
Infection of the Intestines
• Signs & Symptoms
– Diarrhea
• May contain blood and mucus
– Rectal urgency
– Tenesmus
• Ineffective and painful straining with defecation
– Nausea & vomiting
– Abdominal cramping
– Fever
Infection of the Intestines
• Treatment
– Antibiotics
• Stool postive for leukocytes
– Fluid and electrolyte replacement
• Oral or IV
– Kaopectate
• Increase stool consistency
– Pepto-Bismol
• Decrease intestinal secretions and decrease diarrhea
Irritable Bowel Syndrome
• Etiology/Pathophysiology
– Episodes of alteration in bowel function
– Low pain threshold to intestinal distention
caused by abnormal intestinal sensory neural
circuitry
– May be associated with psychological problems
– Spastic and uncoordinated muscle contractions
of the colon, usually due to excessively course
or highly seasoned foods
Irritable Bowel Syndrome
• Signs & Symptoms
– Abdominal pain
• Relieved after bowel movement
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Frequent bowel movements
Sense of incomplete evacuation
Flatulance
Constipation and/or diarrhea
Irritable Bowel Syndrome
• Treatment
– Diet and Bulking Agents
• Increase dietary fiber
• Administer fiber agents
• Avoid food which cause exacerbation
– Medications
• Anticholinergics
– Relieve abdominal cramps
• Milk of Magnesia, fiber, or mineral oil for constipation
• Opioids for diarrhea
• Antianxiety drugs for panic attacks