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Older Adults Pt 2 > 4.1 Care of Upper/Lower GI System > Flashcards

4.1 Care of Upper/Lower GI System Flashcards

1
Q

Abdominal Regions

A

Right Hypochondriac Epigastric Left Hypochondriac
Right Lumbar Umbilical Left Lumbar
Right Iliac Hypogastric Left Iliac

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2
Q

Major Functions of GI Tract

A
  • Digestion
  • Absorption
  • Elimination
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3
Q

Major Enzymes of GI System

A
  • Saliva/Salivary Amylase (Chewing and Swallowing)
  • Hydrochloric Acid, Pepsin, Intrinsic Factor (Gastric Function)
  • Amylase, Trypsin, Bile (Small Intestines)
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4
Q

History of Present Illness

A
  • Abdominal Pain
  • Dyspepsia (indigestion)
  • Flatulence
  • N/V
  • Diarrhea
  • Constipation
  • Fecal Incontinence
  • Jaundice
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5
Q

Pain

A
  • Onset
  • Location
  • Duration
  • Characteristics
  • Aggravating Factors
  • Relieving Factors
  • Time
  • Distribution of referred pain
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6
Q

Abdominal Pain

A
  • May be referred from area of dysfunction to nearby or remote locations
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7
Q

Common Issues

A

Dyspepsia - The most common GI dysfunction
Intestinal Gas - Ask about bloating, distention, flatulence, food intolerances, gallbladder disease
N/V - Vague and uncomfortable

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8
Q

Other Issues

A

Change in bowel habits/stool characteristics
- Can be sign of colonic dysfunction or disease. (Constipation/Diarrhea)

Past health, family, social history
- Oral care, dentist visits, lesions in mouth, discomfort with foods, alcohol/tobacco, dentures.

Assessment of Oral Cavity
- Lips, tongue, gums

Rectal Inspection
- Done as appropriate

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9
Q

GERD (Gastroesophageal Reflux Disease)

A
  • There is no single cause
  • Reflux of hydrochloric acid and pepsin from stomach into lower esophagus causing irritation and inflammation.
  • Intestinal proteolytic enzymes (trypsin) and bile salts add to irritation
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10
Q

GERD Risk Factors

A
  • Obesity due to increased intra-abdominal pressure
  • Hiatal Hernia (stomach bulges into diaphragm)
  • Decreased esophageal clearance
  • Decreased gastric emptying
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11
Q

Primary Factor of GERD

A
  • Results in decreased pressure in distal portion of esophagus
  • Patient must report several episodes of reflux for diagnosis of GERD
  • Gastric contents move from stomach to esophagus
  • Can be due to caffeine, chocolate, anticholinergics
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12
Q

Complications of GERD

A
  • Related to direct local effect of gastric acid on the esophageal mucosa
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13
Q

Barrett’s Esophagus

A
  • Esophageal metaplasia

- Development of pre-cancerous lesions

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14
Q

Esophagitis

A
  • Inflammation of Esophagus

- Repeated exposure results in esophageal stricture (tightening of esophagus) which results in dysphagia

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15
Q

GERD Diagnostic

A
  • Endoscopy
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16
Q

Management of GERD

A
  • Lifestyle modifications
  • Low fat diet
  • Avoidance of caffeine, tobacco, beer, milk, peppermint/spearmint, and carbonated drinks
  • Avoid eating or drinking 2-3 hours before bedtime
  • Elevated head of bed by 30 degrees
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17
Q

Hiatal Hernia/Diaphragmatic Hernia/Esophageal Hernia

A
  • Herniation of esophagogastric junction and lower portion of stomach into the chest through the esophageal hiatus of diaphragm
  • Most common abnormality found on x-ray of UGI tract
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18
Q

Types of Hiatal Hernia’s

A

Sliding - Most common type (slides in and out of your chest)
Rolling (Paraoesophageal) - Medical Emergency (stomach protrudes up through a hole in the diaphragm)

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19
Q

Etiology of Hiatal Hernia

A
  • Weakening of muscles in diaphragm possibly due to aging
  • Increased intraabdominal pressure from obesity
  • Pregnancy
  • Heavy lifting
  • Ascites
  • Tumors
  • Intense physical exertion
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20
Q

Clinical Manifestations of Hiatal Hernia

A
  • May be asymptomatic or with GERD
  • Bending over causes severe burning pain relieved by sitting or standing
  • Heartburn especially after eating or lying supine
  • Dysphagia
  • Feeling full or uncomfortable after eating
  • Associated with large meals, alcohol, and smoking
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21
Q

Diagnostic for Hiatal Hernia

A
  • Esophagram (barium swallowing)

- Gastroscopy

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22
Q

Surgical Therapy for Hiatal Hernia

A
  • Laparoscopically surgeries are most common anti-reflux surgeries (small incisions through abdomen)

Nissen Fundoplication (creation of esophageal sphincter) via the thoracic or abdominal approach is another treatment

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23
Q

Peptic Ulcer Disease (PUD)

A
  • Erosion of GI Mucosa from digestive action of HCl acid and pepsin.
  • Ulceration penetrates the mucosal wall of GI tract
  • Ulcers can develop in lower esophagus, lesser curvature of stomach, duodenum (most common), or margin of gastrojejunal anastomosis after surgical procedures.
  • Ulcers can only develop in places with acid
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24
Q

Heliobacter Pylori Bacterium (H. Pylori)

A
  • Associated with significant amount of gastric ulcers

- Produces enzyme urease which activates immune response, antibody production, and release of inflammatory cytokines.

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25
Q

Aspirin/NSAIDS

A
  • Inhibits prostaglandin synthesis
  • This causes increased gastric acid secretions and reduces integrity of mucosal barrier.
  • Responsible for majority of Non-H. Pylori Peptic Ulcers
  • NSAIDS in the presence of H. Pylori increase risk of PUD
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26
Q

Gastric Ulcer Clinical Manifestations

A
  • Pain high in epigastrium
  • Pain radiates to back
  • Relieved by antacids
  • Occurs 1-2 hours after meals
  • “Burning” or “Gaseous”
  • Food aggravates pain, especially if the ulcer has eroded through the gastric mucosa.
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27
Q

Duodenal Ulcers

A
  • Mid-Epigastric Region beneath xiphoid process
  • Back pain only happens if ulcer is located in the posterior aspect
  • Occurs 2-5 hours after meal
  • “Burning” or “Cramp-like”
  • Tendency to occur, disappear, and occur again
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28
Q

Nursing Diagnosis

A
  • Acute Pain
  • Anxiety
  • Imbalanced Nutrition
  • Deficient Knowledge
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29
Q

Major Goals for Peptic Ulcer Disease

A
  • Relief of pain
  • Reduced anxiety
  • Maintenance of Nutritional Requirements
  • Knowledge about the management and prevention of ulcer recurrence
  • Absence of Complications
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30
Q

Care for patient with Peptic Ulcer

A
  • Abdominal Assessment
  • Assess pain and relief methods
  • Dietary intake and 72 hour diet diary
  • Lifestyle modifications such as cigarettes and alcohol use
  • Medications including antacids, h2 blockers, proton pump inhibitors
  • Educate about signs of anemia or bleeding
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31
Q

Hemorrhage (PUD Complications)

A
  • Assess for bleeding
  • Hematemesis (vomiting blood that may look red or like coffee grounds)
  • Melena (passage of black tarry stools)
  • Symptoms of shock and anemia
    TREATMENT
  • IV Fluids
  • NG Tube
  • Saline or Water Lavage (irrigation of stomach)
  • Oxygen
  • Monitor VS and UO (urinary output)
  • May require endoscopic coagulation or surgical intervention
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32
Q

Perforation or Penetration

A
  • Lethal Complication
  • Severe abdominal pain that may refer to shoulder
  • Vomiting and collapse
  • Tender board like abdomen
  • Symptoms of shock
  • Requires immediate surgery when ulcer is penetrates serosal surface with spillage into peritoneal cavity
  • Large perforations require immediate surgical closure
  • Small perforations may spontaneously seal themselves
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33
Q

Pyloric Obstruction (Gastric Outlet Obstruction)

A
  • N/V
  • Constipation
  • Epigastric fullness
  • Anorexia and weight loss
    TREATMENT
  • Insert NG Tube to decompress stomach
  • Provide IV fluids and electrolytes
  • Balloon dilation or surgery may be required
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34
Q

MEDICATIONS

A
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35
Q

Prokinetic Agents

A
  • Metoclopramide (Reglan)

- Promotes gastric motility, accelerates gastric emptying

36
Q

Antacids/Acid Neutralizing Agents

A
  • Calcium Carbonate (Tums)
  • Aluminum Hydroxide
  • Simethicone (Maalox)
  • Neutralizes gastric acid by producing neutral salts and inactivating pepsin
37
Q

Proton Pump Inhibitors (PPI’s)

A
  • Pantoprazole (Protonix)
  • Omeprazole (Prilosec)
  • Esomeprazole (Nexium)
  • Decreases gastric secretion by slowing H+, K+ ATPase Pump
  • Reduces gastric secretion by irreversibly inhibiting the enzyme that produces gastric acid
38
Q

Surface Agents/Alginate-Based Barriers (Protectants)

A
  • Sucralfate (Carafate)

- Protective barrier that adheres to an ulcer, protecting it from further injury from acid and pepsin

39
Q

Reflux Inhibitors

A
  • Bethanechol Chloride (Urecholine)
  • Used mainly for urinary retention but can occasionally be used for GERD
  • Used to increase muscle tone & increase lower esophageal pressure in treatment of gastric reflux
40
Q

Histamine-2 (H2) Receptor Antagonist

A
  • Famotidine (Pepcid)
  • Ranitidine (Zantac)
  • Cimetidine (Tagamet)
  • Decreases the amount of HCL produced by the stomach by blocking the action of histamine on histamine receptors of parietal cells in the stomach
41
Q

Irritable Bowel Syndrome (IBS)

A
  • Chronic functional disorder
  • Intermittent abdominal pain and stool pattern irregularities
  • No cause known
  • Often report GI infections and food intolerances (food allergy unclear)
  • More frequent in women
  • Longer and stronger contractions of intestines that disrupt movement of food causing diarrhea or constipation
  • They also may have oversensitive nerves of intestinal track
42
Q

IBS Diagnoses

A
  • Based solely on symptoms
  • ROME 4 Criteria - Any combination of motility disturbance, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, altered CNS processing.
43
Q

Changes from ROME 3 to ROME 4

A
  • Pain is still essential but “discomfort” is removed
  • Occurs at least one day a week
  • May or may not experience pain improvement after defecation
  • Change in form/frequency of stool
  • Pain and change in stool frequency don’t always coincide
44
Q

IBS Categories

A
  • IBS with constipation
  • IBS with diarrhea
  • IBS mixed
  • IBS unsubtyped
45
Q

Dietary Considerations for IBS

A
  • No single therapy effective for all patients
  • Gradually increase fiber (>20g/day) and stool bulking agents (gradually to reduce gas)
  • Eliminate gas producing foods (beans, brussel sprouts, cabbage, cauliflower, raw onions, grapes, plums, raisins)
  • Eliminate fructose and sorbitol
  • Yogurt may be better tolerated than milk
  • Probiotics may be used (alterations in bacteria are believed to exacerbate symptoms)
46
Q

FODMAPs

A 
- Carbohydrates (sugar) that contribute to IBS sufferers 
F - Fermentable
O - Oligo-saccharides 
D - Di-saccharides
M - Mono-saccharides
A - And
P - Polyols

These include fructose, lactose, fructans, galactans, and polyols.

  • Review patient food that is high in FODMAP’s and teach to use low FODMAP diet. Follow regime for 6-8 weeks then gradually introduce new foods based on provider direction.
47
Q

Nursing Care of IBS

A
  • Identify relationship between diarrhea and food, activities, or emotional stressors
  • Provide ready access to bathroom or commode
  • Encourage bed rest to reduce peristalsis
  • Administer medication as prescribed
  • Record frequency/consistency/character and amount of stool
48
Q

Patient Education for IBS

A
  • Daily weight
  • Understanding symptoms of dehydration/fluid loss
  • Encourage oral hydration
  • Nutrition/dietary modifications
  • Diversional activities
  • Prevention of fatigue
  • Medications Possible ileostomy care
49
Q

Inflammatory Bowel Disease (IBD)

A
  • Inflammation of GI Tract
  • Ulcerative Colitis vs Crohn’s Disease
  • Cause is unknown but involve genetics and alteration in function of immune system
  • Onset peaks at age 15-25
  • Second peak is in 6th decade
  • No cure
50
Q

IBD

A
  • Autoimmune disease with immune reaction to own intestinal tract
  • Triggers cause an overactive sustained immune response that results in widespread inflammation and tissue destruction
  • Periods of remission and periods of exacerbation
51
Q

Crohn’s Disease (IBD)

A
  • Involves any segment of GI Tract from mouth to anus

- NOD2 bacterial sensor is a gene associated with CD

52
Q

Ulcerative Colitis

A
  • Usually only affects the colon
53
Q

Crohn’s Disease

A
  • Inflammation occurs anywhere in digestive tract
  • Inflammation occurs in patches or “skip lesions”
  • Pain commonly in LOWER RIGHT abdominal quadrant
  • Bleeding from rectum uncommon
  • Colon wall is thick “cobblestone”
54
Q

Ulcerative Colitis

A
  • Large intestines is typically the only affected site
  • Inflammation is continuous throughout affected sites
  • Pain is commonly in LOWER LEFT QUADRANT
  • Bleeding is common from rectum during bowel movements
  • Colon wall is thin and inner lining inflammation
55
Q

Clinical Manifestations of UC

A
  • Primary symptom includes constipation
  • Bloody stools with Tenesmus (feeling of needing to pass stool even if bowels are already empty)
  • Pain in left lower quadrant for moderate to severe cases
  • Nausea and Vomiting not as common as CD
56
Q

Clinical Manifestations of CD

A
  • Common manifestation is abdominal cramping and pain in right lower quadrant
  • Nausea and Vomiting is common
57
Q

Clinical Manifestations of IBD

A
  • Constipation/Diarrhea
  • Abdominal Distention
  • Excessive flatulence
  • Trapped gas
  • Bloating
  • Fecal urgency
  • Sensation of incomplete evacuation
58
Q

Psychological Manifestations of IBD

A
  • Anxiety
  • Panic disorders
  • Depression
  • Post-traumatic stress disorder
59
Q

Diagnostic Tests for IBD

A
  • History/Physical Exam
  • CBC
  • Electrolytes
  • Erythrocyte Sediment Rate (ESR)
  • C-reactive protein (CRP)
  • Stool C/S (culture and sample)
  • Abdominal CT or MRI
  • Colonoscopy
60
Q

Care for IBD

A
  • Balanced Diet (Nutritional Therapy)
  • Drug treatment is to maintain remission
  • Drugs are used to suppress proinflammatory cytokines
  • Antimicrobials, corticosteroids, immunosuppressants, 5-ASA
  • First use less toxic therapies then “step-up”
  • “step-down” target antibodies first
61
Q

Surgery for IBD

A

Ulcerative Colitis - Total proctocolectomy (remove large intestines, rectum, anus) with ileal pouch and anastomosis (connection)

Crohn’s Disease - Resection of diseased segments with re-anastomosis or strictureplasty

62
Q

Post-OP Treatment for IBD

A
  • At risk for Short Bowel Syndrome (SBS)
  • Inadequate surface area to absorb fluids and nutrients
  • Can lead to chronic diarrhea
  • Issues lead to electrolyte imbalances, cardiac dysrhythmias, GI bleeding with fluid loss, and perforation of bowels.
63
Q

Diverticular Disease

A
  • Herniations or saclike outpouchings (haustra) of mucosa through muscle layers.
  • Mostly located in sigmoid colon but can be anywhere from esophagus to anus
64
Q

Diverticulosis

A
  • Asymptomatic disease in presence of diverticula
65
Q

Diverticulitis

A
  • Inflammation in presence of diverticula
66
Q

Diverticular Disease

A
  • Older than age 60 Risk Factor
  • Prevention through proper nutrition and high fiber diet
  • Treatment focuses on dietary modification to prevent infection
67
Q

Clinical Manifestations of Diverticular Disease

A
  • Pain in lower left quadrant
  • Diarrhea/Constipation
  • Distention or Flatulence
  • Exacerbated by eating certain foods, especially hard to digest foods like corn, nuts, seeds and popcorn.
68
Q

Diagnosis of Diverticular Disease

A

Based on

  • CBC (especially WBC count)
  • Urinalysis
  • Guaiac Testing of Stool
  • Abdominal X-ray
  • ABD Ultrasound
  • CT Scan of ABD with contrast (most effective)
69
Q

Management of Diverticular Disease

A
  • High fiber diet
  • Pain medication
  • Antibiotics for diverticulitis (ciprofloxacin, metronidazole, cephalexin, doxycycline)
  • Anticholinergics to relieve muscle spasms and reduce pain
  • Severe episodes need for administering IV Fluids/IV antibiotics
  • May require temporary colostomy
70
Q

Complications of Diverticular Disease

A
  • Perforations
  • Peritonitis
  • Abscess
  • Fistulas
  • Complete intestinal obstruction
  • Severe bleeding
71
Q

Upper GI Bleeding (UGI)

A 
- Stomach and duodenum 
Most common cause
- Peptic Ulcer 
- H. Pylori and chronic infection
- Drug use such as aspirin/NSAIDs
- Esophageal bleeding most likely due to esophagitis (inflammation), Mallory-Weiss tears, or esophageal varices (enlarged veins)
72
Q

Dividing point between Upper and Lower GI Bleed

A
  • Duodenojejunal Junction
73
Q

Lower GI Bleeding (LGI)

A
  • Diverticular Disease
  • IBD
  • Tumors
  • Polyps of colon
  • Hemorrhoids
  • Anal Fissures
74
Q

GI Bleed

A

Occult - Asymptomatic
Frank - Obvious
- Severity depends on if bleeding is venous, capillary, arterial
Arterial - Profuse and bright red (has not come in contact with gastric acid)

75
Q

Hematemesis

A
  • Blood that is bright red and has not come in contact with gastric contents
76
Q

Vomitus

A
  • Blood has been in stomach for some time

- “Coffee Grounds”

77
Q

Melana

A
  • Sticky, Dark Maroon, Black Tarry Stool
78
Q

Hematochezia

A
  • Passage of bright red blood through rectum

- Cause is not easy to determine

79
Q

Massive Upper GI Hemorrhage

A
  • 1500 mL of blood

- 80-85% spontaneously stop bleeding

80
Q

Emergency Assessment and Management of GI Bleed

A
  • Respiratory Status is assessed
  • VS every 15-30 minutes
    s/s of Shock include
  • Tachycardia, weak pulse, hypotension, cool extremities, prolonged capillary refill, apprehension
    ABD Examination
  • Bowel sounds
  • Tense rigid abdomen can mean perforation and peritonitis
81
Q

Fluid Replacement

A
  • IV Fluid Replacement
  • Begin with isotonic crystalloid solution (NS or Lactated Ringer)
    3: 1 rule
  • 3mL of crystalloid for every 1mL of blood loss
82
Q

Blood Replacement

A
  • Used for massive hemorrhage
  • Whole blood, packed RBCs, or fresh frozen plasma
  • Packed RBC’s are the preferred method due to risk of fluid overload or immune reactions
83
Q

Laboratory Studies

A
  • CBC
  • Typing and crossmatching for transfusions
  • Electrolytes
  • Testing vomitus and stools occult blood test
  • BUN during hemorrhage (blood protein is broken down in GI Tract resulting in elevated BUN)
  • Prothrombin/Partial Thromboplastin time
  • Liver Enzyme Measurement
84
Q

NG Tube

A

GI Intubation
- Decompress the stomach, lavage the stomach, compress a bleeding site, aspirate gastric contents for analysis
Types of Tubes
- Lavage tubes - Cleaning stomach through irrigation
- Gastric (Salem) Sump - Double Lumen Gastric Suctioning
- Levin Tube - Used for intestinal decompression
- Blakemore Tube - Stop bleeding in stomach or esophagus

85
Q

Lavage Tube

A
  • 50-100 mL of fluid at a time
  • Fluid can be aspirated or drained by gravity
  • Keep HOB elevated and observe for aspirate of blood
86
Q

Hemorrhage from Chronic Alcohol Abuse

A
  • Monitor delirium tremens, agitation, uncontrolled shaking, sweating, vivid hallucinations
87
Q

NG Tube Verification

A
  • DO NOT AUSCULTATE OR ASPIRATE TO VERIFY PLACEMENT

- Use Radiography or pH measurement

Older Adults Pt 2 (17 decks)

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