GI exam #2 Flashcards
Intestinal obstruction
- impairment of forward flow of intestinal contents
- caused by complete or partial blockage
Intestinal obstruction most often occurs in….
the small bowel
–the narrowest part. (ileum)
Mechanical obstruction
Congenital
- stenosis
- aganglionic
- megacolon
Acquired obstruction
ADHESIONS - scar tissue which inhibits bowel function and increases pressure bc the bowel is not working right. (most common cause)
Hernias
intestinal loop protrudes thru weak segment of abdominal wall
Intussusception
- unknown cause
- -slipping of one part of the intestine into another part just below it.
- -becomes ensheathed
Volvulus
- unknown cause
- -twisting of bowel on itself
- twisted loop may become strangulated
- most common at ileocecal junction
Other obstructions…
tumors, foreign objects, fecal impaction, masses outside intestines, Bezoar
Trico-bezoar/fido bezoar
hair ball and undigested veggie fiber
Neurogenic Obstruction
- neurologic impairment of the bowel
- -**paralytic or adynamic ileus (most common)
- -** resolves spontaneously after 2-3 days of result of surgery
- can occur after surgery, may be related to bowel manipulation, abd trauma, electrolyte imbalance
Vascular obstruction
- occurs when blood supply to bowel is disrupted
- -atherosclerosis, emboli, rare irreversible situation
- emergency- peristalsis stops and ischemia occurs quickly
Signs and symptoms of an intestinal obstruction
- depends on location of obstruction
- abdominal distention is common
- abdominal pain
- N/V
- bowel sounds usually increase proximal to obstruction, borborygmi
- within a few hours, bowel becomes flaccid and bowel sounds cease
Obstruction and stool appearance
- partial obstruction = liquid stool
- complete obstruction = no stools
Diagnosis of bowel obstruction
- flat plate of abdomen
- abdominal survey
- blood tests (high H&H, BUN, WBC, and low electrolytes
Treatment for bowel obstruction
- high mortality rate if not treated in 24 hrs
- surgical emergency
- NG tube to relieve abdominal distention
- NPO
- fluid and electrolyte replacement
- **pain control, IV antibiotics, surgery (bowel resection)
Nursing care for bowel obstruction
- monitor NG tube (suction, color, amount)
- monitor I&O
- pain management
- good mouth care
- OOB/ambulation
- dressings and drains
- deep breathing, splinting, coughing, IS
Indications for enteral feeding
- physiologic: inability to swallow
- psychologic: mental disorders that prevent intake of nutrition
- pathophysiologic: diseases that affect nutrition
Who can not have enteral feedings?
GI tract not functioning or on bowel rest
Placement of a enteral tube
- check placement before each feeding or every 8 hours with continuous feeding
- -aspirate contents
- -pH meter or paper
- **x-ray
- check residual volumes= increased risk for aspiration with increased residual volume (don’t overfill the stomach and aspirate)
incomplete, balanced complete, and optimental formulas
- incomplete: do not provide all nutritional needs
- balanced complete: contains intact proteins
- optimental: hydrolyzed proteins or chemically pure amino acids, for patients unable to digest food and/or absorb nutrients
Continuous drip
- continuous feeding 16-24 hours/day
- best if delivered via pump for constant flow
- less regurgitation, complications
- increased absorption, utilization of nutrients
- follow nutritionist/physician orders on how to start (strength, mls per hr)
Intermittent drip
- 250-400 ml formula over 20-40 minutes five to eight times a day
- gravity or pump
- allows freedom between feedings
- tolerance may be a problem
- initiate feedings gradually
Bolus feeding
- rapid administration of formula
- similar to 2-3 meals a day
- 250-400 ml formula given over a few minutes
- usually pour in tube via barrel or syringe
- poorly tolerated
- result in nausea, diarrhea, aspiration, abdominal distention, cramps
Administration sets (for enteral feedings)
- for gravity or pump use
- ready-to-hang set good for 48 hours
- top-fill set good for 24 hours
- label with date and time when hang
- rinse container before hanging more formula
- clean well! may get bacteria in sets
Documenting enteral feeding
- type and rate of feeding
- volume of formula and water given
- daily weights
- I&O
- frequent oral hygiene
Nursing care for enteral feedings
- HOB 30 degrees
- care of nares (no pet. jelly, water soluble only)
- tape tube correctly
- frequent oral care
- dressing change
- skin care
- comfort measures
GI intubation
- insertion of short or long flexible silicone or plastic tube
- -into stomach, intestine
- -by way of nose or mouth, connected to suction
Uses for GI intubation
- decompresses stomach or small intestines by removing gas and fluids
- administer medications/feedings
- treat an obstruction or bleeding site
- obtain gastric contents sampling for analysis
- diagnose GI motility or disease processes
NG tubes
- short tubes inserted into stomach
- 2 main types:
- -single lumen: levine
- -double lumen: salem
Levine
-single lumen
-16-18 FR is most common size
-stomach depression
-instillations
-short term feedings
-***use intermittent suction ONLY with levine tube.
tube will collapse if constant suc.
-80-120 mm/Hg to prevent gastric mucosa damage
-check patency by aspiration or irrigation with saline
Salem Sump
- double lumen
- blue sump port or “pigtail”
- -air vent, allows flow of atmospheric air into stomach as contents are suctioned out, prevents damage to gastric mucosa*
- may use continuous low suction
- soft hissing sound continuously
- patency: check suction lumen by aspiration or irrigation with normal saline, check vent lumen by irrigating with saline or air
Insertion of NG tubes
- START with patient teaching
- high fowlers position
- lubricate end of tube with water soluble gel to minimize injury to nasal passage
- tell pt to hold head straight and upright
- insert tube into nostril aiming tube downward and toward ear closer to nostril
- advance slowly, when tube reaches nasopharynx, tell pt to lower head slightly to close trachea and open esophagus
- tell pt to swallow (watch for signs for resp distress)
- stop advancing when reach marked length
Best way to confirm placement of NG tube
X-RAY
-injecting air, aspirate gastric contents and test ph
Removing and NG tube
- explain procedure
- assess bowel sounds
- patient in semi-fowlers
- drape towel across chest, loosen tape from nose
- ask pt to hold breath to close epiglottis
- withdraw tube
- provide tissue and mouth care
Intestinal or nasoenteric tubes
- decompression in bowel obstruction
- cantor tube: single lumen, miller abbott: double lumen, tungsten: weighted
Insertion of intestinal tubes
- done by physicians
- inserted same as gastric tube
- tube carried to intestines by peristalsis
- may take carried to intestines by peristalsis
- may take several hours to reach ileum
- monitored daily by x-ray for placement
- DO NOT secure until desired point in intestines is reached
Once intestinal tube placed…
-**once tube is in stomach, patient lies on right side for 2 hours, supine with head elevated for 2 hours, left side for two hours
Removal of intestinal tubes
- remove slowly to prevent damage
- remove 1-2 inches at a time
- if tube has passed through the ilececal valve, cut at the nose and remove by peristalsis via the rectum
Nursing care for intestinal tubes
- ensure patency
- correct suction
- accurate I&O
- ***amount irrigated should be aspirated or included in intake
- irrigate with normal saline
- with gastric surgery, never irrigate or manipulate the tube without physician order
Preventing oral inflammations
- frequent mouth care
- ice chips
- toothettes
- chapstick
- never use lemon & glycerine swabs
- suck on hard candy if not contraindicated
Monitor for complications with intestinal tubes
- *fluid and electrolyte losses (dehydration, hyponatremia/kalemia
- *aspiration pneumonia (chk breath sounds and placement)
- *gastric ulceration
- laryngeal edema and obstruction
- emotional support
Diarrhea
passage of frequent, loose, unformed stool
2 types of diarrhea
- large volume (excess fecal water)
- small volume (without excess fecal water)
Acute Diarrhea
usually from infection, self-limiting
Chronic diarrhea
at least 4 weeks.
Can be life threatening from dehydration/electrolyte imbalance
Assessment for diarrhea
- Subjective: patient describes change in bowel pattern
- Objective: timing, stool appearance, foods eaten, medications, stress, weight loss, laxative abuse
- Assess fluid and electrolyte status: diarrhea can rapidly lead to dehydration, shock, and acid-base imbalance
Treatment for diarrhea
- based on cause
- replacement fluids and electrolytes
- medications to decrease motility and relieve diarrhea
Tenesmus
painful spasm with bowel movement
Nursing interventions for diarrhea
- bowel rest - NPO
- IV fluids and electrolyte replacements
- strict I&O
- stool characteristics
- monitor for weakness, dehydration, cardiac arrhythmias (K+)
- administer medications as ordered (immodium)
- perineal skin care
Antibiotic related diarrhea
- destroys the bowel’s normal flora
- permits overgrowth of C-diff
- pseudomembranous colitis–>whitish membrane forms over damaged areas
Pseudomembranous colitis
whitish membrane forms over damaged areas
Signs and symptoms of Antibiotic related diarrhea
- severe diarrhea
- fever/chills
- abdominal distention
- crampy pain
- anorexia
Diagnosis of Antibiotic related diarrhea
- stool culture
- endoscopy
Treatment for Antibiotic related diarrhea
- discontinue implicated antibiotics
- correct fluid & electrolyte imbalances
- administer intestinal flora modifiers
- drug therapy- vancomycin, flagyl
Fecal incontinence
relaxation of external sphincter resulting in involuntary passage of stools
Causes of fecal incontinence
- CNS or spinal cord injury
- damage or weakness of sphincter
- fecal impaction
- —high fiber and fluid diet, bowel training, perineal exercises, skin protection and odor control.
How often should a pt have a bowel movement in the hospital
at least every 3 days
Constipation
retention or delay of fecal material in colon results in dry, hard stools
Causes of constipation
- inadequate dietary fiber and/or fluid intake
- ignoring urge to go
- bowel obstruction
- inability to increase intra-abd pressure (COPD)/ lack of exercise
- side effects of meds (narcotics, diuretics, aluminum, antacids)
Signs and symptoms of constipation
- abdominal distention, crampy pain
- increased rectal pressure or flatulence
- anorexia, nausea, headache, malaise
- fecal impaction
- obstipation- so constipated it causes an obstruction
Treatment for constipation
- **high fiber diet and increase fluids
- establish regular bowel pattern
- increase activity
- correct body position when defecating
Bulk forming agents (laxative)
absorbs water, stimulates peristalsis
ex) metamucil, benefiber
Stimulants (laxative)
irritates colon wall to increase peristalsis
ex) ex-lax, correctol (not on fecal impaction)
Stool softeners (laxative)
lubricates intestinal tract & softens stool
ex) colace, mineral oil
Saline and electrolytes
causes retention of fluid in intestinal lumen
ex) Golytely (quick acting)
Acute abdomen
complex of signs and symptoms suggest emergency surgery
- abcess or rupture in abdomen
- bowel obstruction
- peritonitis
- ruptured ovarian cyst
Signs and symptoms of acute abdomen
varied, non-specific
—pain, N/V, bleeding, distention
Treatment for acute abdomen
goal of treatment is to identify and treat the cause
Nursing care for acute abdomen
- prepare for surgery quickly
- post-op- same as for any abdominal surgery
Appendicitis
acute inflammation of vermiform appendix of cecum
Causes of Appendicitis
fecalith, tumors, foreign bodies, worms
Signs and symptoms of appendicitis
- vague or severe abdominal pain/ pain increases/ localizes to RLQ
- N/V
- low grade fever/ increase WBCs
- rebound tenderness (pain with release of palpate
- McBurney’s point- tenderness btwn umbil and right anteriosuperior spine
- like to lay with knees bent
Nursing care pre-op (appendicitis)
-no laxatives, no heat to abdomen, pain management, prepare for surgery, keep NPO
Treatment for appendicitis
Surgery
—if appendix ruptures, peritonitis results
Post-op care for appendectomy
simple: rapid recovery, usually done outpatient through SDS - go home same day
Ruptured appendix: IV antibiotics, NG, NPO for 24-48 hrs, wound drains, observe for S/S peritonitis and abscess formation
Peritonitis
inflammation of all or part of parietal and visceral surfaces of abdominal cavity
Patho of peritonitis
- drainage from perforated or infected area leaks into abdominal cavity = peritoneum becomes inflamed
- peritoneum attempts to localize infection
- if contamination persists, peritoneum ability to combat infection is surpassed, peritonitis worsens
Systemic effects of peritonitis
- infectious process causes increase blood to area to combat bacteria
- shallow, rapid respirations due to increase oxygen requirements when patient is unable to adequate ventilate
- decrease peristalsis causes retention of fluid and air in bowel lumen
- leads to further decreases circulating blood volume
- results in hypovolemic shock
- death
Signs ad symptoms of peritonitis
- PAIN is the most consistent symptom
- tenderness/rebound tenderness/muscle rigidity/abdominal distention
- N/V, absent bowel sounds
- fever/WBCs up bc of infection
- rapid, shallow respirations
- hiccups rt irritated diaphragm
Treatment for peritonitis
-* identify and eliminate the cause
-surgery
-IV fluids/antibiotics
-NPO/NG
-oxygen
-analgesics
(infection pulls 6-8L into abd.)
Nursing care for peritonitis
- **NPO, I&O, IV antibiotics/NG
- semi-fowlers, pain management, drg &drains resp status
Gastroenteritis
inflammation of stomach and intestinal tract, primarily stomach/ small bowel
Causes of gastroenteritis
bacterial, virus, parasite, food poisoning
- NSAIDs, ASA, steroids
- transmitted by fecal oral route
S/S of gastroenteritis
- N/V / cramping / diarrhea
- dehydration/hypotension
- fever/elevated WBCs
Treatment for gastroenteritis
- determine cause (stool sample)
- correct dehydration & electrolytes
- NPO until vomiting stops then clear liquid diet
- antibiotics (if bacterial)
Dysentery
gastroenteritis of large bowel
Irritable bowel syndrome
chronic, non-infectious irritation caused by spasms of colon (disorder of the bowel)
NO PATHOPHYSIOLOGIC CHANGES TO THE BOWEL
-females bwtn 20-40
-caused by stress and anxiety
-intermittent pain and altered bowel motility
-most common bowel disorder seen clinically
IBS: Rome criteria
symptom based criteria
- abd discomfort or pain for at least 3 months
- relieved with defecation
- onset associated with changes in stool pattern freq, or appearance
IBS signs and symptoms
- intermittent crampy abdominal pain (LQ)
- diarrhea alternating with constipation
- pain with defecation
- bloating/belching/abdominal distention
- non-specific symptoms
Nursing care for IBS
- psychological an dietary
- stress management
- individualized balanced diet
- steroids
- mild relaxants
- anticholinergics (bentyl) (slows emptying)
3 side effects anticholinergics can cause
-dry mouth, urinary retention, visual changes
Polyps
projection of mucosal surface of the bowel lumen. Benign or malignant
pedunculated polyp
attaches to intestinal wall by stalk or stem
Sessile polyp
attaches directly to wall. flat, broad based
familial polyposis
genetic (thousands of polyps in the intestine so whole bowel is removed and perm colostomy
Hyperplastic polyps
non-neoplastic growths/never cause clinical symptoms
-rarely bigger than 5 mm in size
Adenomatous polyps
neoplastic polyps - closely linked to colorectal cancer
Cancer of Colon and rectum risk factors
- age, family history, diet, polyps, other colon pathology
- usually asymptomatic so diagnosed late with metastasis (usually to liver first)
Left sided tumors
- tumor obstructs flow of solid stool
- thin stool, constipation, rectal bleeding, diarrhea with alternating constipation
Right sided tumors
- less change in bowel habits
- tumor bleeds easily (melena, anemia), dull abd pain, anorexia, wt loss, malaise, pain late sign
carcinoembryonic antigen (CEA)
-protein secreted by tumor cells measured in blood
Treatment for Cancer of colon and rectum
surgery is primary treatment (depending on location and extent of disease)
- ***bowel prep necessary prior to surgery to decrease amount of bacteria in bowel to decrease risk of infection (high dose antibiotics)
- NPO until bowel sound return or pass gas
- radiation to shrink tumor, chemo
diverticulum
pouchlike protrusions of intestinal mucosa
diverticulosis
multiple diverticula exist
diverticulitis
inflammation of diverticulum
Pathology of diverticulitis
- diverticulitis result from obstruction of diverticula by fecalith.
- causes edema, inflammation = leads to decrease blood supply= increase swelling=abscess, perforation, peritonitis
Signs and symptoms of diverticulitis
(may be asymptomatic)
- intermittent LLQ pain/ cramping/ constipation/ diarrhea
- N/V
- fever/WBCs up
- constipation or diarrhea
- occult bleeding
Treatment for diverticulitis
- combination drug and nutrition therapy
- control acute pain, NPO, IV fluids and antibiotics
Nursing care for diverticulitis
teaching to increase compliance and prevent repeat attacks
- diet high fiber/high fluid
- bulk forming laxatives
Hernias
abnormal protrusion of an organ, tissue, or part of organ through structure that normally contains it.
- -reducible: can be put back
- -irreducible: can’t be put back
Inguinal hernia
weakness in abdominal wall in inguinal canal - where spermatic cord (men) or round ligament (women) emerge. protrusion follows through canal
Femoral hernia
protrusion thru femoral ring into femoral canal
- females
- strangulates easily
Umbilical hernia
occurs due to weakness of rectus muscle or failure of umbilical opening to close
incisional or ventral hernia
occurs due to weakness in abdominal wall at site of previous surgeries
Assessment for hernias
ask patient to raise shoulders and head while in supine position
-contraction of abdominal muscle reveal weakened area
Signs and symptoms of hernia
- protrusion of viscera - lump or bulge
- mild to moderate discomfort
- severe pain with strangulation
- change in bowel
- N/V
Main thing with post-op care hernia repair
NO COUGHING. splint incision
