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Gastrointestinal Med Surg 1 (Day 1)

Terms in this set (55)

Barium uses
-Id tumors, inflammation, or obstruction of jejunum or ileum
-Id polyps, tumors, strictures of rectum, sigmoid colon, descending colon
-xray done with barium in and after barium expelled
-laxatives
Barium side effect
Constipation
enteroclysis
small bowel enema
Nursing considerations before Barium Exams
- Npo except h2o & meds before, clear liquids or low residue diet for several days before
- Laxative (go-lytley) prep night before
- Enemas x3 or till clear
Nursing considerations after barium exams
-push po fluids, monitor for bowel obstruction & tell pt stool will be white
-pt may need laxative to help excrete barium
Oral Cholecystogram (gallbladder series)
-rarely done-replaced by ultrasound
-assess for iodine allergy
-schedule before barium exams
-npo after iodine tablets
-may give fatty meal after done then take more xrays
cholangiogram
- Used to visualize biliary system ducts when ultrasound & oral test inconclusive or not possible, or in pt. Who has biliary s/s after cholecystectomy
-contrast given iv, via t tube
Cholangiogram nursing considerations
- Obtain informed consent
- Assess for iodine allergy
- Complete bowel prep if ordered
- Npo
- Tell pt. That dye injection cause a warm, funny feeling & nausea
- Push po fluids after to excrete dye
Radionuclide scans
-technetium ion orally or iv
-organ scanned -tells size, defects, & lesions, gi bleeding & emptying
-good for liver, pancreas, gi tract
Nursing consideration for Radionuclide scans
- Assess for allergy to radioactive nuclides
- Weigh pt. (dose wt. Based)
- Ask female pt. If any possibility of p.g.
- Teach breast feeding pt. To pump & discard breast milk
- Wear gloves & wash hands after handling urine & feces
Mri & ct
Used to id structural abnormalities, metastasis
• Ct may use oral or iv contrast
MRI Nursing consideration
-usually pt, teaching & facility checklist
CT Nursing considerations
- Bowel prep, give oral contrast & meds to alter gi motility if ordered
- Npo
Ultrasound
-used for liver, pancreas, & biliary tract
-Shows size & location, outline of structures & lesions, cholecystitis, cholelithiasis, pyloric stenosis
Liver biopsy
- Obtains sample of liver cells to examine for infection, cancer, structural changes ie cirrhosis
- Done in pt. Room or in x-ray
(May be guided by mri or ct)
Liver biopsy nursing
-obtain (biopsy tray & informed consent, baseline vital signs, most recent labs esp. pt/inr, ptt, hct)
• Put pt. Supine with rolled towel beneath right lower ribs & r. Hand behind head
• Give sedation if ordered & monitor pt.
• Instruct pt. To take deep breath & hold it when needle inserted
• Post bx. Apply pressure drsg to site & turn pt. Onto r. Side
• Monitor vs, breath sounds, abd. & bleeding per policy - report changes to md
• Label &take specimen to lab stat
EGD (esophagogastroduodenoscopy)
- most common done at bedside
- Used to visually inspect the gi mucosa & lesions, obtain biopsies & samples, inject dyes, treat
certain lesions & conditions
Nursing considerations before endoscopy
• Npo
• Bowel prep for colonoscopy
• Obtain informed consent
• Obtain baseline vital signs
• Give sedation as ordered
Nursing considerations after endoscopy
- Conscious sedation monitoring
- Monitor for complications
- Fever, chest pain (ruptured esophagus), gi distress, bleeding, shock r/t organ damage
- Npo & sidelying position until gag reflex returns
- When able to take po start with chips & sips (ice chips & h2o) in small amounts ( 30cc/h)
Endoscopic retrograde cholangiopancreatography (ercp)
- Insert endoscope orally into common bile, hepatic, & pancreatic ducts
- Dye injected & x-rays taken
- Shows location of obstructions
- Stones may be able to be removed
- Nursing same as egd
Endoscopic ultrasound (eus)
- Used for tumors of pancreas, stomach & rectum
- Ultrasound is done through the endoscope
Py test
- Used to detect helicobacter pylori reactivation in pt. Who can't tolerate egd
• Pt. Swallows c-urea capsule & waits 10 min.
• Pt. Blows up a balloon
• Balloon air is analyzed for gastric urase (given off by h pylori)
Nursing considerations before py test
- No antibiotics & bismuth (pepto bisthmol) x 1 month
- No proton pump inhibitors or sucralafate x 2 weeks
- Npo x 6 hrs.
- Tell pt. Not to handle or chew c-urea capsule
Stool analysis
- H. Pylori antigen (new)
- C&s
- Ova & parasites
- Fat
- Guiac
- No red meat or food containing peroxidase x 3 days before (see box in text book)
Blood tests for GI
- Hepatic enzymes
- Ast (aspartate aminotransferase)
- Alt (alanine aminotransferase)
- Ldh (lactate dehydrogenase)
- Alkaline phosphatase
- Bilirubin -- liver
- Total, direct, indirect
- Albumin -- nutrition & liver
- Amylase & lipase -- pancreas
- Ammonia -- liver
- Antigens & titers - liver
- Antigen - h-pylori - will not detect reactivation
- Cbc
- Chemistries
- Clotting factors -- liver
- Tumor markers (cea)
Urine tests for GI
- Amylase - pancreatitis
- Urobilinogen - liver
- Bilirubin -- liver
Peptic Ulcer Disease
erosion of tissue in an area of the gi tract which is in contact with hcl & pepsin
Complications of PUD
- Hemorrhage (gi bleed)
- Perforation -> peritonitis, death
- Erosion through & into adjacent organ (esp. Pancreas) -> organ damage & dysfunction
Patho of Esophagus PUD
- R/t gerd because esophagus doesn't have protective mucosal layer to protect from acids
Patho of Gastric, pyloric, dudoenal PUD
R/t imbalance between mucosal protective (prostaglandin e) & mucosal destructive factors ->
mucosal layer disrupted -> gastric acids (hcl & pepsin) penetrate mucosal layer -> digest the wall
-> histamine released ->hcl & pepsin -> inflammation ->capillary permeability -> mucosal
edema -> easy bleeding
Risk Factors of PUD
- H. Pylori infection (80-90%) **
• Secretes enzyme that depletes mucosal protection
- Family hx.
- Male gender (pre-menopause)
- Age 40-60 y/o
- Smoking
- Etoh
- Asa/nsaid use (inhibit prostaglandins)
- Type o blood
- Copd/crf
-Stress ulcers (shock, anxiety, trauma, epi secretion)
Clinical manifestations
-pain (dull, gnawing, burning abd. or back,
-r epigastric tenderness, heart burn.
diagnostic tests in PUD
- Egd preferred so biopsy can be done to check for abnormal cells & c&s for h. Pylori, may be able to
correct problem if bleeding
- Upper gi series
- Cbc (low rbc, hct, hgb r/t chronic blood loss)
- Electrolytes r/t vomiting
- Py breath test - can tell if current infection & is noninvasive
- Blood test for antibody to h. Pylori (can't tell whether current or past eradicated infection)
- New test - stool antigen -- monitors presence & rx. Of h. Pylori
Management of PUD Goal
eradicate h. pylori & manage acid secretion
management of PUD dietary
-avoid etoh, caffeine, irritating foods (foods that increase acid: milk & milk products, coffee & decaf), very hot or very cold, meat extracts.
Management of PUD meds:
- Antibx for h. Pylori (amoxicillin, flagyl, biaxin, tetracycline)
- Bismuth to suppress h. Pylori (pepto-bismol)
- Proton pump inhibitors & h2 blockers to block acid secretion
- Antacids to buffer acids
- Anticholinergics (probanthine) to block acetylcholine from vagus nerve (stimulates
acid)
- Carafate to coat & protect ulcer from acid (give on empty stomach & 2 hr. After other
meds or they won't absorb)
- Cytotec - prostaglandin e analog -- acid secretion & quality of mucosa (often
used with nsaids to protect stomach)
- New meds - prevpac & helidac = antibx+ either acid reducer or protector
management of PUD (other)
- Ng tube (possibly)
- Tissue edema may cause obstruction distention & vomiting
- Allows emptying of blood from stomach & ns lavage if hemorrhage
- Iv fluids to restore & maintain f&e balance
- Transfusion
GI bleeds from pud treatement
- Inject epi into ulcer -> vasoconstriction & sclerosis of vessels
- Laser sclerosis of bleeding vessels
- Cauterize
- Most gi bleeds fixed this way these days
- Usu. Don't re-bleed
• Surgery for persistent or if re-bleed criteria met
PUD-types of surgery
- Vagotomy acid production
- Pyloroplasty - done with vagotomy & if scarring causes gastric emptying
- Antrectomy - remove antrum & pylorus
- Partial gastrectomy
- Bilroth i - vagotomy, partial gastrectomy, pylorus, part of duodenum - remaining stomach anastomosed to
remaining duodenum
- Bilroth ii - same as bilroth i but all duodenum removed or closed off & remaining stomach anastomosed to
jejunum
- Total gastrectomy
- Usu. Remove stomach & duodenum & anastomose esophagus to jejunum (may use thoracic approach)
Nursing considerations for surgery treatments of pud
- Pt. Hx.
- Pain
- Monitor i&o, f&e balance, iv's, transfusions, ng tube
- Maintain npo status as ordered
- Egd pre (npo) & post care (conscious sedation)
pt teaching for pud management
- Dietary modification
- Avoid etoh, caffeine, irritating foods (foods that acid: milk & milk products, coffee & decaf),
very hot or very cold, meat extracts

- Meds - caution not to stop meds when feels better in about 1 week or problem will return
- Stress reduction
- Help id cause, refer for biofeedback, behavior mod
- Regular meal times
- Smoking cessation
- Close f/u x at least 1 yr
NG tube care for post gastric surgery
- Ng tube care
- Expect small amounts dark old bloody drainage x 8 -12 hrs. Then yellow-green
- A lot of blood, esp. Bright red, must be reported to md stat
- Closely monitor for occlusion - accumulation of drainage can strain suture line
- Do not move, reposition or irrigate without md order r/t can perforate suture line
- If order to irrigate ng use only 20cc ns & be very gentle
- Monitor for bowel sounds & passing flatus (usu. Within 48 hrs.) To know when to expect md
order to d/c ng & start po
complications of gastric surgery
- May need vitamin b12 injections for life depending on what portion of stomach removed - die in 5 yrs. Without it
-Dumping syndrome
dumping syndrome patho
- Chyme is hypertonic & enters jejunum rapidly causing:
• Distention
• Draws fluid to itself from vascular space -> hypovolemia & more bowel distention -> low bp &
diarrhea
• Carbohydrates in hypertonic chyme absorbed rapidly -> sharp rise in blood glucose -> pancreas secretes
->insulin -> blood glucose drops sharply -> hypoglycemia
Clinical manifestations of dumping syndrome
- Sensation of fullness, weakness, faintness, dizziness, syncope, palpitations, diaphoresis, abd cramping, diarrhea, pallor, headache, feelings of warmth, drowsiness
Management and teaching of dumping syndrome
Teach pt.
- Lie down 20-30 min. After eating to delay gastric emptying
- No fluids with meals (can have 1 hr. Before & 1 hr. After)
- Low cho (esp. Simple cho) meals to decrease tonicity of chyme
- Small freq. Meals, eat slowly
- Antispasmodics to delay gastric emptying
- Safety r/t falling while dizzy
Diverticulosis
Herniations of the bowel mucosa through weakened areas in the muscular layer of the bowel wall causing outpouchings; weakness may be associated with aging
- Asymptomatic condition = diverticulosis
- Symptoms r/t inflammation = diverticulitis
clinical manifestations of diverticulosis
- Constipation alternating with diarrhea
- Flatulence
- Llq pain, tenderness, & ? Palpable mass
- Fever
- Currant jelly stools r/t bleeding of diverticulae
diagnostic tests of diverticulosis
- Ct shows diverticulae
- Barium enema shows irregular mucosal wall
- May use h20 soluble contrast if possible perforation
- Colonoscopy shows inflamed areas
- Cbc = increased wbc
- Stool guiac positive
Management of Diverticulosis (asymptomatic)
-asymptomatic=no rx.
-prevention diet
-no seeds- get stuck in outpouchings increases inflammation
-increase fiber, bran ,metamucil to decrease constipation
-avoid constipation r/t increased pressure in bowel, increased divertiuclae & inflammation
management of symptomatic diverticulitis
- residue diet
- May need npo & iv
- Analgesics
- Antibx for infected diverticulae
- May need surgery if perforates or causes obstruction
• Colostomy -- temporary or permanent - allows healing
- Usu. Take down 6 weeks
teach pt. diverticulitis
Teach pt.
- Diet, fluids, avoid constipation
- Pain control - analgesics, antidiarrheals
- Self management techniques
- Seek help for severe pain or blood in stool - may mean perforation
Abdominal inspection things to look for and pt position
supine
-flat, round, concave (scaphoid), distended
-dyspnea ? r/t distended abd. crowding chest
Auscultation of abdomen
-auscultate each quadrant
-note pitch, freq. location, quality (Tinkle vs gurgle)
-normal bowel sounds=q5-30 sec.
-listen x 5 min. Each quad. to confirm absence
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