Caring for Individuals Caring for Individuals Experiencing Experiencing

Gastrointestinal/Digestive Gastrointestinal/Digestive ChallengesChallengesNURS 2016NURS 2016

NauseaNausea

A subjective experience, wavelike A subjective experience, wavelike sensation in the back of the throat, sensation in the back of the throat, epigastrium, or abdomen that may lead to epigastrium, or abdomen that may lead to the urge or need to vomitthe urge or need to vomit Increased salivationIncreased salivation Aversion toward foodAversion toward food GaggingGagging Sour tasteSour taste Increased swallowing Increased swallowing

Nursing Management of Nursing Management of NauseaNausea

Identify causeIdentify cause Eliminate or minimize noxious Eliminate or minimize noxious

substance or irritantssubstance or irritants NPO, clear fluids or bland dietNPO, clear fluids or bland diet

Antiemetics – dimenhydrinate Antiemetics – dimenhydrinate (caution if cause is not known)(caution if cause is not known)

VomitingVomiting

Forceful projection of contents from Forceful projection of contents from the stomachthe stomach

Symptom of numerous diseases and Symptom of numerous diseases and treatmentstreatments

Nursing Management of Nursing Management of VomitingVomiting

Identify cause and eliminate or minimizeIdentify cause and eliminate or minimize NPO NPO Monitor emesisMonitor emesis

Amount, consistency, colourAmount, consistency, colour Triggers and timingTriggers and timing

Monitor fluid balance: non-enteral fluid Monitor fluid balance: non-enteral fluid replacementreplacement

Monitor electrolyte balance: non-enteral Monitor electrolyte balance: non-enteral electrolyte replacement (Na+ and K+)electrolyte replacement (Na+ and K+)

GastritisGastritis

Inflammation of gastric mucosaInflammation of gastric mucosa

Acute: short infrequent episodes, often Acute: short infrequent episodes, often related to food or drinkrelated to food or drink

Chronic: longer duration – ulcerChronic: longer duration – ulcer– – may be related to bacterial invasion may be related to bacterial invasion (helicobacter pylori)(helicobacter pylori)

Peptic UlcersPeptic Ulcers

DoudenalDoudenal Mid adulthoodMid adulthood Males more oftenMales more often Lots of HCL stomach Lots of HCL stomach

acidacid Wt gain (feed it)Wt gain (feed it) Pain 2-3 hours pcPain 2-3 hours pc Bleed rare (melena)Bleed rare (melena) Higher perforation rateHigher perforation rate H.pylori, alcohol, H.pylori, alcohol,

smoking, cirrhosis, smoking, cirrhosis, stressstress

GastricGastric Older adultsOlder adults Even sex ratioEven sex ratio Low or normal HCLLow or normal HCL ½ to 1 hour pc½ to 1 hour pc Vomiting commonVomiting common Bleed common Bleed common

(hematemesis)(hematemesis) H.pylori, alcohol, H.pylori, alcohol,

smoking, NSAIDs, streesmoking, NSAIDs, stree

Nursing Care of UlcersNursing Care of Ulcers

Relieving painRelieving pain Reducing anxietyReducing anxiety Maintaining nutritional statusMaintaining nutritional status Monitoring/managing complicationsMonitoring/managing complications

HemorrhageHemorrhage PerforationPerforation Pyloric obstructionPyloric obstruction

ManagementManagementManaging Complications Cont’d:Managing Complications Cont’d: Perforated diverticulumPerforated diverticulum PeritonitisPeritonitis

DietDiet

PharmacologicalPharmacological

SurgicalSurgical

Irritable Bowel SyndromeIrritable Bowel Syndrome 8-15% of population8-15% of population Peristaltic waves affected at specific Peristaltic waves affected at specific

segments of bowelsegments of bowel Bloating, constipation or diarrhea, Bloating, constipation or diarrhea,

cramping, gascramping, gas

Quality of LifeQuality of Life

Nursing Care of IBSNursing Care of IBS Primarily an educational Primarily an educational

role regarding monitoring role regarding monitoring diet and reducing stressdiet and reducing stress

Hydrophilic colloids Hydrophilic colloids (psyllium)(psyllium)

Avoid excess intake of Avoid excess intake of fluids with foodfluids with food

Give anti-diarrhea agents Give anti-diarrhea agents (loperamide)(loperamide)

Anti- depressantsAnti- depressants Anticholinergics &Ca Anticholinergics &Ca

Channel BlockersChannel Blockers

Study findingsStudy findings Nurses believed Nurses believed

pts were pts were demanding and demanding and difficultdifficult

Low pain Low pain tolerance and tolerance and crave attentioncrave attention

Nurse had Nurse had insufficient insufficient knowledge and knowledge and not interested in not interested in moremore

Diverticular DiseaseDiverticular Disease

DiverticulumDiverticulum DiverticulosusDiverticulosus DiverticulitisDiverticulitis

ComplicationsComplications PeritonitisPeritonitis Abscess formationAbscess formation BleedingBleeding

Nursing Care - DiverticulitisNursing Care - DiverticulitisGoalsGoals Aimed primarily at comfort and restAimed primarily at comfort and rest Monitoring development of complicationsMonitoring development of complications Working with client to identify ‘triggers’Working with client to identify ‘triggers’

InterventionsInterventions Assess: bowel patterns, dietary habits, tenesmus, Assess: bowel patterns, dietary habits, tenesmus, Palpate - LLQ for fecal mass Palpate - LLQ for fecal mass Inspect /Lab test – for fecal content for pus, blood and mucusInspect /Lab test – for fecal content for pus, blood and mucus Monitor I & O, bowel patternsMonitor I & O, bowel patterns Ensure fluid intake - 2L/day + fiber to add bulk in stool & peristalsisEnsure fluid intake - 2L/day + fiber to add bulk in stool & peristalsis Stool softener/enemasStool softener/enemas Analgesic (Meperidine) + Anti- spasmodic Analgesic (Meperidine) + Anti- spasmodic

Bowel ObstructionBowel Obstruction Partial or complete Partial or complete

impairment of forward impairment of forward flow of intestinal flow of intestinal contentscontents

May be small or larg May be small or larg bowel (most often bowel (most often small bowel, ileum).small bowel, ileum).

Complete obstruction – Complete obstruction – surgical emergency – surgical emergency – high mortality if not high mortality if not releasedreleased

Figure 38-6 Three causes of intestinal obstruction. (A) Intussusception invagination or shortening of thecolon caused by the movement of one segment of bowel into another. (B) Volvulus of the sigmoid colon;the twist is counterclockwise in most cases. Note the edematous bowel. (C) Hernia (inguinal). The sac ofthe hernia is a continuation of the peritoneum of the abdomen. The hernial contents are intestine,omentum, or other abdominal contents that pass through the hernial opening into the hernial sac.

Bowel Obstruction: Clinical Bowel Obstruction: Clinical manifestationsmanifestations

Small bowelSmall bowel Crampy, wave, Crampy, wave,

colickycolicky No fecal or flatusNo fecal or flatus Peristalsis may Peristalsis may

reverse --vomitingreverse --vomiting

Large bowelLarge bowel Slower progressionSlower progression Crampy lower abd Crampy lower abd

painpain Abd Abd

distention:loops of distention:loops of bowel visiblebowel visible

Fecal emesisFecal emesis

Treatment of ObstructionTreatment of Obstruction

Gastric intubation (sump)Gastric intubation (sump) Surgical interventionSurgical intervention NPONPO Parenteral HydrationParenteral Hydration Temporary or permanent ostomyTemporary or permanent ostomy

Inflammatory Bowel DiseaseInflammatory Bowel Disease

Crohn’sCrohn’s

Ulcerative ColitisUlcerative Colitis

Study table on page 1041Study table on page 1041

UnderstandUnderstand Therapeutic managementTherapeutic management Systemic complicationsSystemic complications

Inflammatory Bowel DiseaseInflammatory Bowel Disease

Nutritional therapyNutritional therapy Low residue, high protein, high calorieLow residue, high protein, high calorie

Pharmacological therapyPharmacological therapy Anti-inflammatory: ASA, corticosteriodsAnti-inflammatory: ASA, corticosteriods ImmunmodulatorsImmunmodulators

Surgical managementSurgical management

Inflammatory Bowel DiseaseInflammatory Bowel Disease

Focus on assisting client to deal with Focus on assisting client to deal with symptoms and treatment modalitiessymptoms and treatment modalities

Nsg DxNsg Dx Altered nutrition (less than body Altered nutrition (less than body

requirements) related to restrictive requirements) related to restrictive diet, nausea, and malabsorptiondiet, nausea, and malabsorption

Nursing Role Common to GI Nursing Role Common to GI ChallengesChallenges

Assessment, planning, intervening and Assessment, planning, intervening and evaluation related toevaluation related to

Pain controlPain control HydrationHydration Nutritional StatusNutritional Status Knowledge and understanding of Knowledge and understanding of

medication and treatment regimemedication and treatment regime

Nutritional RoutesNutritional Routes

Enteral: all or most of Enteral: all or most of the GI tract is usedthe GI tract is used

TraditionalTraditional

ModifiedModified

Parenteral: GI tract is Parenteral: GI tract is not utilized as a not utilized as a nutritional routenutritional route

Enteral TherapyEnteral Therapy

Nasogastric, gastric intubationNasogastric, gastric intubation Gastrointestinal tract integrity Gastrointestinal tract integrity

preserved.preserved. Normal sequence of intestinal Normal sequence of intestinal

hepatic metabolism preserved.hepatic metabolism preserved.

Goal: Maintaining nutritional balanceGoal: Maintaining nutritional balance

Feeding SolutionsFeeding Solutions

OsmolalityOsmolality Lactose-freeLactose-free 1cal/ml1cal/ml IntermittentIntermittent ContinuousContinuous

Nursing ConsiderationsNursing Considerations

Temperature, volume, flow rate Temperature, volume, flow rate Total fluid intakeTotal fluid intake Residual gastric contentResidual gastric content Medication administrationMedication administration

TPNTPN

Increase nutritional statusIncrease nutritional status Establish +ve Nitrogen balanceEstablish +ve Nitrogen balance Maintain muscle massMaintain muscle mass Promote weight gainPromote weight gain Enhance healing processEnhance healing process

TPN AdministrationTPN Administration

5-6x the solute [ ] of blood5-6x the solute [ ] of blood Administer in high flow vessel Administer in high flow vessel

(subclavian)(subclavian) Large bore central lineLarge bore central line

PICCPICC HICKMAMHICKMAM PORT-A-CATHPORT-A-CATH

Complications of TPNComplications of TPN

PneumothoraxPneumothorax Air embolismAir embolism Clotted catheter lineClotted catheter line Catheter displacementCatheter displacement SepsisSepsis Hyperglycemia or rebound Hyperglycemia or rebound

hypoglycemiahypoglycemia Fluid overloadFluid overload

A glimpse at LaxativesA glimpse at Laxatives

Bulk formingBulk forming

Saline agentSaline agent