The Gastrointestinal System:

Digestive Disorders

“Air-Fluid Levels” seen in small bowel obstructionJ. Carley MSN, MA, RN, CNE

Part I

The G-I System Supplemental

Learning Objects:

Flash Cards (Terminology) See the email I sent you yesterday

G-I System Games Meds for the Gastro Intestinal System

http://www.quia.com/rr/612817.html

G-I System Part Ihttp://www.quia.com/rr/612592.html

GI System Part 2http://www.quia.com/rr/612897.html

G-I System Part 3http://www.quia.com/rr/612899.html

1. Describe the mechanism of action, signs and symptoms, complications, treatments and nursing interventions for gastrointestinal disorders

2. Compare and describe the pathophysiology for Crohn’s Disease and ulcerative colitis

3. Explain pathophysiology, types, risk factors, and treatment for gastritis

LEARNING OUTCOMESAt the conclusion of this learning activity, the nurse will be able to:

4. Explain the use of radiography in diagnosis of GI health problems

5. Discuss the physical assessment findings in a client with digestion, nutrition, and elimination health problems

6. Describe procedures, risk factors, potential complications, nursing monitoring, and interventions for scope procedures

LEARNING OUTCOMESAt the conclusion of this learning activity, the nurse will be able to:

7. Describe preparation, post-op interventions, and teaching needs for a patient with a new colostomy

8. Analyze medications, usage, precautions, side effects, and mechanism of action

9. Apply the nursing process to medication administration and usage

LEARNING OUTCOMESAt the conclusion of this learning activity, the nurse will be able to:

10. Explain causes, sign/ symptoms, nursing interventions, treatments, and complications of a bowel obstruction

11. Explain pathophysiology, risk factors, and medical management of gastrointestinal disorders

12. Explain causes of bowel obstruction

LEARNING OUTCOMESAt the conclusion of this learning activity, the nurse will be able to:

A Rough Outline:For the Left Hemispheric Dominant Learners

Terminology A&P GI Disorders GERD Hiatal Hernias PUD

G-I Pharmacology Antacids Prokinetic Agents H 2 Receptor

Antagonists Proton Pump Inhibitors Mucosal Barriers

G-I Diagnostic Testing

Key Terms & word roots* -algia -dynia volvulus dyspepsia regurgitation hypersalivation pyrosis eructation dysphagia odynophagia -enter/o -col/o -gastr/o -esophag/o

ulceration aspiration ischemia diverticula diverticulitis colostomy illeostomy tenesmus steatorrhea diarrhea fistula defecation --rrhea steato-

Anatomy and Pathophysiology

Length = 27-30 feet(9-10 meters)

GI Tract Functions Secretion Digestion Absorption Motility Elimination

CN X: Vagus Nerve Involves: esophagus, stomach, small

intestines, gallbladder, and large intestines

Parasympathetic: stimulates motor and secretory activity, relaxes sphincters

Oral Cavity Teeth: chewing Mucin and amylase: breaks down

food Tongue Pharynx Esophagus: 2 sphincters

Esophagus

Stomach

Function of Stomach Ingestion of food Food reservoir Digestive process: -movement -gastrin secretion: hydrochloric acid

and pepsin -chyme

GI Disorders

PHARMACOLOGY ASSESSMENT

Physical Assessment Inspection Palpation Percussion AuscultationKEY ASSESSMENTSLab Monitoring

Care PlanningPlan for client adl’s, Monitoring, med admin.,Patient education, more…basedOn Nursing Process: A_D_O_P_I_E***Preparing for Diagnostic Tests

Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary

PathophysiologyUpper GI Lower GI

Inflammatory Inflammatory

Non-Inflammatory

G.E.R.D.Peptic Ulcers Gastric Ulcers Duodenal UlcersGastritis

G.E.R.D.Hiatus Hernias

Acute AppendicitisPeritonitisUlcerative colitisCrohn’s DiseaseDiverticulitis

Non-Inflammatory

Constipation & DiarrheaIrritable Bowel SyndromeDumping SyndromeIntestinal ObstructionHemorrhoids & PolypsMalabsorption

Concept Map: Selected Topics in Gastro-Intestinal Nursing

***Diagnostic Testing

Anti-Acids (Antacids)Prototype: aluminum hydroxide gel (Amphojel)

Prokinetic Agents:Prototype: metoclopramide (Reglan)

Histamine 2 Receptor AgonistsPrototype: ranitidine hydrochloride (Zantac)

Proton Pump Inhibitors)Prototype: omeprazole (Prilosec)

Mucosal BarriersPrototype: sucralfate (Carafate)

Disease Specific Medications:

Nursing Skills: NG Tube Insertion Enteral Feedings

GI DisordersINFLAMMATORY NON-INFLAMMATORY

Upper GI Gastroesphageal Reflux

Disease Ulcers Gastritis

Upper GI Gastroesphageal Reflux

Disease Hiatus Hernia/hernias

GI DisordersINFLAMMATORY NON-INFLAMMATORY

Lower GI Acute Appendicitis Peritonitis Ulcerative colitis Crohn’s Disease Diverticulitis

Lower GI Constipation & Diarrhea Irritable bowel syndrome Dumping syndrome Intestinal Obstruction Hemorrhoids and polyps Malabsorption syndrome

The Inflammatory Process Acute local inflammation: -edema, pain, heat, and redness -exudates may or may not be

present

Acute systemic inflammation: -fever -leukocytosis (increased WBC) -plasma protein synthesis

Inflammatory Process Chronic Inflammation: -increased duration>2 weeks -proceeds after unsuccessful acute inflammatory response -may occur without distinct

inflammation

Overview:Gastroesophageal Reflux

Disease (GERD) GERD : common condition

(affects 14% of Americans) characterized by gastric content and enzyme leakage into the esophagus.

These corrosive fluids irritate the esophageal tissue and limit its ability to clear the esophagus.

Causes are related to the weakness or transient relaxation of the lower esophageal sphincter (LES) at the base of the esophagus, or delayed gastric emptying.

The chief symptom of GERD is frequent and prolonged retrosternal heartburn (dyspepsia) and regurgitation (acid reflux) in relationship to eating or activities.

Other symptoms can include chronic cough, dysphagia, belching (eructation), flatulence (gas), atypical chest pain, and asthma exacerbations.

Gastroesophageal Reflux Disease(GERD)

Backward flow of gastrointestinal contents into esophagus

Cause of GERD Inappropriate relaxation of lower

esophageal sphincter (food, medication, etc)

GERD: Etiology ETIOLOGY: Any factor that relaxes the

LES, such as smoking, caffeine, alcohol, or drugs.

Any factor that increases the abdominal pressure, such as obesity, tight clothing at the waist, ascites, or pregnancy.

Older age and/or a debilitating condition that weakens the LES tone.

CONTIBUTING FACTORS:

Excessive ingestion of foods that relax LES, e.g., fatty / fried foods, chocolate, tomatoes, alcohol

Distended abdomen from overeating or delayed emptying

Increased abdominal pressure resulting from obesity, pregnancy, bending at the waist, ascites or tight clothing at the waist

Drugs that relax the LES, such as theophylline, nitrates, calcium channel blockers, anticholinergics, and diazepam (Valium)

Drugs, such as NSAIDs, or events (stress) that increase gastric acid

Debilitation or age-related conditions resulting in weakened LES tone

Hiatal hernia (LES displacement into the thorax with delayed esophageal clearance)

Lying flat

Signs & Symptoms of GERD

Classic symptoms:

Dyspepsia, especially after eating an offending food / fluid, and regurgitation.

Other symptoms:

Symptoms from throat irritation (chronic cough, laryngitis), hypersalivation, eructation, flatulence, or atypical chest pain from esophageal spasm.

Chronic GERD can lead to dysphagia (difficulty swallowing).

Complications of GERD Irritation to esophagus and mucosal

injury Aspiration Barrett’s esophagus Esophageal erosions, ulcerations, or

tears Chronic bronchitis Asthma (adult onset)

Barrett’s Esophagus

Diagnostic Testing History and Physical Dietary monitoring 24 hour ambulatory pH monitoring Esophageal manometry Endoscopy

Diagnostic Interventions : GERD

Barium Upper GI:

Prepare the client for the procedure.

Post procedure: Assess

for bowel sounds and potential constipation.

Endoscopy :

Conscious sedation to observe for tissue damage

Post procedure: Verify gag response prior to providing oral fluids or food.

Barium Sulfate (Ba SO4)

Medical Management for GERDNon-surgical

Goals: relief of symptoms and prevent complications

Life style changes: -Diet: smaller meals more frequent, limit or

avoid carbonated beverages, coffee, chocolate, fats, mints, spicy or acidic food

Medical Management Continued Life Style Changes: -Elevate HOB, sleep on LEFT side -AVOID smoking and ETOH -Avoid tight or restrictive clothing -Lose weight

Medical Management Antacids, E.g., aluminum hydroxide (Mylanta),

neutralize excess acid. -- should be administered when the acid secretion is highest (1 to 3 hr after eating and at bedtime). --Antacids should be separated from other medications by at least 1 hr.

Histamine 2 (H2) receptor antagonists

E.g., ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid), and cimetidine (Tagamet), reduce the secretion of acid.

The onset is longer than antacids, but the effect has a longer duration.

Proton Pump inhibitors (PPI)

E.g., pantoprazole (Protonix),omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid) reduce gastric acid by inhibiting the cellular pump necessary to secrete it.

Studies show that PPI are more effective than H2 antagonists.

Other Medications E.g., metoclopramide hydrochloride

(Reglan), increase the motility of the esophagus and stomach.

Invasive Interventions for GERD Endosopic therapy: BESS (Bard

EndoCinch Suturing System), Stretta, and Enteryx procedures

Surgery: Laparoscopic Nissen Fundoplication (The”Gold Standard”)

Nursing Interventions Post operative or procedure

management: - Monitor vital signs -Monitor swallow/gag reflex -Assess for abdominal pain -Monitor for bleeding -Assess incision sites -Assess and monitor NG tube

Nursing Diagnosis Altered Nutrition Acute or Chronic pain Risk for aspiration Alteration in sleep patterns Knowledge Deficit Impaired Swallowing Potential for complications

Nursing Interventions EDUCATION: -Medication Compliance -Dietary changes -Lifestyle changes Post operative or procedure management

Normal Esophagus

GERD

Barrett’s Esophagitis

Hiatal Hernia Involve protrusion of the stomach

wall through the esophageal hiatus of the diaphragm

Types of Hiatal Hernias Sliding: (Most Common)

esophagogastric junction and portion of the fundus slide upward through the esophageal hiatas

Rolling: the fundus and portions of the stomach rolls through the esophageal hiatas

Causes of Hernias Muscle weakness Anatomic defects Congenital weakness Prolonged increased abdominal

pressure Surgery Trauma Obesity

Symptoms of HerniasSLIDING ROLLING

Adult onset asthma Symptoms worse

after meals Symptoms worse in

recumbent position

Feeling full after eating

Breathlessness or feeling of not be able to breath

Chest pain like angina feeling of suffocation Symptoms worse in

recumbent position

Diagnostic Testing Barium Swallow Study

Medical Management Diet Medications (GERD) Weight Loss Avoid late night food Avoid straining/vigorous exercise No restrictive or binding clothes Surgical repair: Laparoscopic Nissen

Fundoplication

Nursing Interventions Education: -Medication compliance -Dietary changes and monitoring -Lifestyle changes and monitoring Post-op management Assess coping mechanisms

Peptic Ulcer Disease (PUD) A mucosal lesion of the stomach or

duodenum

PUD Causes Results when gastric mucosal

defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin

Types of PUD Gastric Ulcers: -a break in mucosal barrier, hydrochloric

acid injures epithelium -back diffusion of acid or dysfunction of

the pyloric sphincter -Mucosal Inflammation

Duodenal Ulcers: -increase acid content dumped into

duodenum

Types of PUD “Stress Ulcers:” -Unknown etiology, presence of

increased levels of hydrochloric acid, ischemia, and erosive gastritis seen

-Trauma, head injuries, respiratory failure, shock sepsis

Signs and Symptoms Intermittent sharp, burning, or

gnawing pain Gastric pain occurs to the left and

may be relieved by food A change in appetite with or weight

loss (gastric) Nausea or vomiting Bloody stools

Signs and Symptoms Frequent burping or bloating

Duodenal pain is usually to the right of the epigastruim and pain occurs 90 min-3 hours after eating.

Pain often awakes patient’s up at night

A change in appetite with weight gain (duodenal)

Diagnostic Tests History and Physical (family history) Endoscopy (EGD) Stool for occult blood H-pylori test (carbon ureas breath

test) Gastric secretion studies Biopsy

Medical Management Drug Therapy Diet Therapy Lifestyle Changes Surgical Intervention

Nursing Diagnosis Actual pain Anxiety/Fear Ineffective individual coping Potential fluid volume deficit Knowledge deficit Disturbed sleep pattern Nutrition deficit

Nursing Interventions Assessment of symptoms and family

history Assess for complications Medication and diet education Monitor pain management Monitor nutritional status Encourage smoking and alcohol

cessation

Complications Gastrointestinal bleeding Gastric Perforation Pyloric obstruction

Treatment of Complications

GI bleed Perforation Pyloric obstruction

Surgical Interventions Vagotomy & Pyloroplasty Gastroenterostomy

pyloroplasty

Post Operative Management

Assess patient Assess vital signs Monitor gastric decompression and

output Monitor labs Monitor continued ileus Monitor for gastric delay emptying

and recurrent ulcerations

End of Part IGastrointestinal System

The Appendix follows on this Power Point (Medication Information, etc…)

Pharmacology:

Anti-Acids (Antacids)Prototype: aluminum hydroxide gel ( Amphojel )

Pharmacological Action Neutralize gastric acid and inactivate pepsin.

Mucosal protection may occur by the antacid’s ability to stimulate the production of prostaglandins.

Therapeutic Uses Treat peptic ulcer disease (PUD) by promoting

healing and relieving pain. Symptomatic relief for clients with GERD.

Nursing Interventions and Client Education

Clients taking tablets should be instructed to chew the tablets thoroughly and then drink at least 8 oz of water or milk.

Teach the client to shake liquid formulations to ensure even dispersion of the medication.

Compliance is difficult for clients because of the frequency of administration.

Administered seven times a day: 1 hr before and 3 hr after meals, and again at bedtime.

Teach clients to take all medications at least 1 hr before or after taking an antacid.

Evaluation of Medication Effectiveness

Depending on therapeutic intent, effectiveness may be evidenced by:

Healing of gastric and duodenal ulcers.

Reduced frequency or absence of GERD symptoms.

No signs or symptoms of GI bleeding.

Back to Concept Map

Pharmacology:

Prokinetic AgentsPrototype : metoclopramide ( Reglan )

Pharmacological Action Block dopamine and serotonin receptors

in the chemoreceptor trigger zone (CTZ), and thereby suppress emesis.

Prokinetic agents augment action of acetylcholine which causes an ↑ in upper GI motility.

Therapeutic Uses Control postoperative and chemotherapy-

induced nausea and vomiting. Prokinetic agents are used to treat GERD. Prokinetic agents are used to treat

diabetic gastroparesis.

Side Effects / Adverse Effects Extra Pyramidal Symptoms (EPS) Sedation Diarrhea

Contraindications / Precautions Contraindicated in clients with GI perforation,

GI bleeding, bowel obstruction, and hemorrhage

Contraindicated in clients with a seizure disorder due to ↑ risk of seizures

Use cautiously in children and older adults due to the ↑ risk for EPS.

Nursing Interventions and Client Education

Monitor clients for CNS depression and EPS. Can be given orally or intravenously. If dose is < 10

mg, it may be administered undiluted over 2 min. If the dose is > 10 mg, it should be diluted and infused

over 15 min. Dilute medication in at least 50 mL of D5W or lactated Ringer’s solution.

Evaluation of Medication Effectiveness

Control of nausea and vomiting

Back to Concept Map

Pharmacology:Histamine 2 (H2) Receptor Agonists

Prototype : ranitidine hydrochloride (Zantac) Pharmacological Action Suppress the secretion of gastric acid

by selectively blocking H2 receptors in parietal cells lining the stomach.

Therapeutic Uses Gastric and peptic ulcers,

gastroesophageal reflux disease (GERD), and hypersecretory conditions, such as Zollinger-Ellison syndrome.

Used in conjunction with antibiotics to treat ulcers caused by H. pylori.

Therapeutic Nursing Interventions and Client Education

Encourage client to avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).

Ranitidine can be taken with or without food.

Treatment of peptic ulcer disease is usually started as an oral dose twice a day until he ulcer is healed, followed by a maintenance dose, which is usually taken once a day at bedtime.

Evaluation of Medication Effectiveness

Depending on therapeutic intent, effectiveness may be evidenced by:

Reduced frequency or absence of GERD symptoms (e.g., heartburn, bloating, belching).

No signs or symptoms of GI bleeding.

Healing of gastric and duodenal ulcers.

Back to Concept Map

Pharmacology:

Proton Pump InhibitorsPrototype : omeprazole (Prilosec)

Pharmacological Action Reduce gastric acid secretion by irreversibly

inhibiting the enzyme that produces gastric acid.

Reduce basal and stimulated acid production.

Therapeutic Uses Prescribed for gastric and peptic ulcers, GERD,

and hypersecretory conditions (e.g., Zollinger-Ellison syndrome).

Precaution: Increases the risk for pneumonia. Omeprazole ↓

gastric acid pH, which promotes bacterial colonization of the stomach and the respiratory tract.

Use cautiously in clients at high risk for pneumonia (e.g., clients with COPD).

Nursing Interventions and Client Education

Do not crush, chew, or break sustained-release capsules.

The client may sprinkle the contents of the capsule over food to facilitate swallowing.

The client should take omeprazole once a day prior to eating.

Encourage the client to avoid irritating medications (e.g., ibuprofen and alcohol).

Active ulcers should be treated for 4 to 6 weeks.

Pantoprazole (Protonix) can be administered to the client intravenously.

Monitor the client’s IV site for signs of inflammation (e.g., redness, swelling, local pain) and change the IV site if indicated.

Teach clients to notify the primary care provider for any sign of obvious or occult GI bleeding (e.g., coffee ground emesis).

Evaluation of Medication Effectiveness Depending on therapeutic intent, effectiveness

may be evidenced by:

Healing of gastric and duodenal ulcers. Reduced frequency or absence of GERD

symptoms (e.g., heartburn, sour stomach). No signs or symptoms of GI bleeding.

Back to Concept Map

Pharmacology:

Mucosal BarriersPrototype: sucralfate ( Carafate )

Pharmacological Action

Changes into a viscous substance that adheres to an ulcer; protects ulcer from further injury by acid and pepsin.

Viscous substance adheres to the ulcer for up to 6 hr.

Sucralfate has no systemic effects.

Therapeutic Uses

Acute duodenal ulcers and maintenance therapy.

Investigational use in gastric ulcers and gastroesophageal reflux disease. (GERD)

Nursing Interventions and Client Education

Assist the client with the medication regimen. Instruct the client that the medication should

be taken on an empty stomach. Instruct the client that sucralfate should be

taken four times a day, 1 hr before meals, and again at bedtime.

The client can break or dissolve the medication in water, but should not crush or chew the tablet.

Encourage the client to complete the course of treatment.

Evaluation of Medication Effectiveness

Depending on therapeutic intent, effectiveness may be evidenced by:

Healing of gastric and duodenal ulcers. No signs or symptoms of GI bleeding.

Back to Concept Map

***Diagnostic Tests Blood Tests Complete Blood Count (CBC c

Diff)

Stool Tests: Stool for occult blood; (Guiac) Stool for ova & parasites

(O&P); Stool for Clostridium difficile

(C-Diff) Stool Culture & Sensitivity

(C&S)

Radiology:

Upper GI Series (UGI) Upper GI Series with Small

Bowel Follow-Through (UGI-SBFT)

Barium Enema Endoscopy

Endoscopy:

Return toConcept Map

Clostridium difficile