Magasjúkdómar - Deniz Flashcards
Upper GI system - The upper gastrointestinal tract consists of;
- mouth
- pharynx
- esophagus
- stomach
- duodenum
Gastroesophageal Reflux Disease
(GERD)
- It is chronic symptom of mucosal damage
- Caused by reflux of stomach acid into the lower esophagus
- HCL acid and pepsin cause esophageal irritation and inflammation (esophagitis)
Gastroesophageal Reflux Disease
(GERD) - Etiology (orsök)
- Incompetent Lower Esophageal Sphincter (LES)
- Normally, LES is antireflux barrier
- Incompetent LES lets gastric contents move from stomach to the esophagus
when patient is supine or has an increase intraabdominal pressure - Factor effecting LES pressure
- Alcohol
- Chocolate
- Drugs
- Fatty foods
- Nicotine
- Peppermint
- Tea, coffee
Gastroesophageal Reflux Disease
(GERD) - Symptoms (einkenni)
- Heartburn (pyrosis)—lower sternum—spreads upward to the throat or jaw,
burning sensation - Relieve with antacids
- Dyspepsia and regurgitation
- Dyspepsia (is another word for indigestion); feelings of stomach pain, over-
fullness and bloating during and after eating - Regurgitation; hot, bitter, or sour liquid coming into the throat or mouth
- Respiratory symptoms; wheezing, coughing, and dyspnea
- Disturbed sleep patterns
- Hoarseness, sore throat, hypersalivation, choking
GERD: Nursing Management
1- Lifestyle Modifications
2- Drug therapy
3- Nutritional Therapy
4- Surgical Therapy
5- Endoscopic therapy
1- Lifestyle Modifications
- The head of bed is elevated 30 degrees (with pillow or blocks)
- Pt should not be supine for 2 to 3 hours after a meal
- Encourage patients who smoke to stop
- Stress management– if stress cause symptoms
- Nutritional advices
2- Drug Therapy - the focus of the drug therapy
- Decreasing the volume and acidity of reflux
- Improving LES function
- Increasing esophageal clearance
- Protecting the esophageal mucosa
2 - Drug Therapy - The most common and effective treatments
- Proton pump inhibitors (PPIs)
- Histamine (H2) receptor blockers
3-Nutritional Therapy
- No specific diet is used to treat GERD
- Avoiding some food; chocolate, peppermint, fatty foods, coffee, and tea
- Tomato-based products, orange juice, cola, red wine may irritate the esophagus
- Avoid late dinner, nighttime snacking and milk
- Small, frequent meals and drinking fluids between meals, helpful
- Weight reduction if the pt is overweight
4- Surgical Therapy
- Nissen and Toupet fundoplication—most
common antireflux surgeries - After surgery reflux symptoms should
decrease - Recurrence is possible
- If the pt has mild dysphagia, pt should
report it - LINX Reflux Management System
- LINX system can cause difficulty
swallowing, nausea, and pain when
swallowing food. - Pt Education: should not have MRI—can
cause serious harm
Peptic Ulcer Disease (PUD)
- PUD is characterized by discontinuation in the inner
lining of the gastrointestinal (GI) tract because of
gastric acid secretion (HCL) or pepsin - It extends into the muscular layer of the gastric
epithelium. - It usually occurs in the stomach and proximal
duodenum - It may involve the lower esophagus, distal
duodenum, or jejunum.
Peptic Ulcer Disease
(PUD)
Etiology ( orsök )
1- Helicobacter Pylori
-H. pylorus is a gram-negative bacillus
-Found within the gastric epithelial cells
-This bacterium is responsible for 90% of
duodenal ulcers
and 70% to 90% of gastric ulcers.
-H. pylori infection is commonly acquired during
childhood
2-Medication-Induced Injury
- Nonsteroidal anti-inflammatory drugs (NSAID) use is the second most common cause of
PUD after H. pylori infection.
- non-steroidal anti-inflammatory agents, such as ibuprofen, aspirin, naproxen
- NSAIDs increase gastric acid secretion
- Reduce the integrity of mucosal barrier
3- Lifestyle Factors
High alcohol intake
Smoking
Coffee
Psychologic distress (stress and depression..)
Peptic Ulcer Disease (PUD)
Gastric Ulcers:
- more prevalent: Women and over 50 years of age
- can occur in any part of the stomach
- Less common
- H.pylori, NSAIDs, bile reflux are the main risk factors
Peptic Ulcer Disease (PUD)
Duodenal ulcers:
Duodenal ulcers
* 80% of all the peptic ulcers
* Incidence is high: 35-45 years of age
* H.pylori is most common risk factor
Peptic Ulcer Disease (PUD)
Clinical manifestations - Gastric Ulcer
- Discomfort—after 1-2 hours after meals– epigastrium
- Pain is like—burning, gaseous
- Perforation symptoms
Peptic Ulcer Disease (PUD)
Clinical manifestations -Duodenal Ulcer
- Symptoms occur 2-5 hours after meal—midepigastric region
- Pain is like—burning, cramplike
- Can also cause back pain
Peptic Ulcer Disease (PUD)
Diagnose (greining)
- Endoscopy
- Biopsy– tissue specimens for H.pylori
- Serology, stool and breath test—H.pylori
- Barium contrast study
- Lab. Tests; CBC—shows anemia, liver enzyme – detect liver problems (in terms of
ulcer threatment), stool test—blood
Peptic Ulcer Disease (PUD)
Management - Conservative Care:
Adequate rest, drug therapy, smoking cessation, dietary
modifications, and long-term follow-up
* Drug Therapy: antibiotic therapy, proton pump inhibitors, cytoprotective drug therapy
(sucralfate), adjunct drugs (H2 receptor blockers and antacids)
* Nutritional Therapy:
Peptic Ulcer Disease (PUD)
Management - Surgical therapy:
If the conservative care is not effective or there is complication
Peptic Ulcer Disease (PUD)
Nursing Management - Planning
- Adhere to the prescribed therapeutic regimen
- Reduction or absence of discomfort
- Have no signal of GI complications
- Have complete healing of the peptic ulcer
- Make appropriate lifestyle changes to prevent recurrence
Peptic Ulcer Disease (PUD)
Nursing Management - Nursing Diagnosis:
(example) Acute pain, lack of knowledge, nausea
Peptic Ulcer Disease (PUD)
Nursing Management - Nursing Assessment:
data obtained from pt
Peptic Ulcer Disease (PUD) - Nursing Management - Nursing Implementation:
- Health Promotion: Early diagnose
- Acute Care:
- If NPO-explain importance
- Mouth care is important
- Check analyze results
- Record input and output
- Vitals
- Rest, pain killer (needed)
- Follow complication signs: hemorrhage, perforation, gastric outlet obstruction
(such as; increased nausea or vomiting, increased epigastric pain, bloody emesis or
tarry stool)
Stomach (Gastric) Cancer -
Etiology (orsök)
- Begins with a nonspecific mucosal injury because of infection (H.pylori),
autoimmune-related inflammation, repeated exposure to irritants such as bile or
NSAIDs, and tobacco use. - Diet: smoked foods, salted fish and meat
- H.pylori—early age
- Atrophic gastritis
- Pernicious anemia
- Adenomatous polyps
- Smoking and obesity
- Heredity
Stomach (Gastric) Cancer - Clinical Manifestation
- Unexplained weight loss
- Abdominal discomfort and pain
- Signs and symptoms of anemia
Stomach (Gastric) Cancer - Diagnose
- Upper GI endoscopy
- Biopsy
- USG, CT, MRI, PET scanning
- Blood and stool tests
Stomach (Gastric) Cancer - Management
- Surgical therapy: aim is to remove tumor
- Lesion is antrum or pyloric region: Billroth I
or II procedure (subtotal gastrectomy) - Lesion is in in the fundus: total gastrectomy
with esophagojejunostomy is done - CT and RT
- Targeted Therapy
Stomach (Gastric) Cancer - Nursing Management - Nursing assessment:
Nursing assessment: nutritional assessment, psychosocial history, physical
examination..
Stomach (Gastric) Cancer - Nursing Management - Nursing diagnoses:
impaired nutritional intake, impaired nutritional status, acute
pain, anxiety
Stomach (Gastric) Cancer - Nursing Management - Planning - overall goals:
- Have minimal discomfort
- Achieve optimal nutritional status
- Maintain spiritual psychologic well-being
Stomach (Gastric) Cancer - Nursing Management - Nursing implementation
- Health promotion: early detection
- Acute Care:
- Emotional and physical support
- Pt can be malnourished
- The pt can better tolerate several small meals
- Pre-op teaching and post-op care
- CT and RT instructions
Gastric Surgery
Gastric surgeries perform
to treat
- Stomach cancer
- Polyps
- Perforation
- Chronic gastritis
- PUD
Gastric Surgery
Surgeries include
- Partial gastrectomy-gastroduodenostomy,
gastrojejunostomy - Gastrectomy-anastomos: esophagus and
jejunum - Vagotomy: decrease gastric acid secretion
- Pyloroplasty-surgical enlargement of
pyloric sphincter
Post Operative Complications
- Acute: bleeding
- Long term;
1-Dumping syndrome
2-Postprandial hypoglycemia
3-Bile reflux gastritis
Post Operative Complications
Dumping Syndrome
- Direct result of surgical removal of a large part of
stomach and pyloric sphincter - Normally gastric chyme enters the
small intestine in small amount - After operation, stomach cannot control it and large amount of gastric chyme
enter to small intestine - Symptoms starts 15-30 minutes after eating
- Patients have general weakness, sweating, palpitation, dizziness
- Pt may have abdominal cramps, audible abdominal sounds, urge to defecate
- Short rest period after each meal reduce the chance of dumping syndrome
Post Operative Complications
Postprandial Hypoglycemia
- A variant of dumping syndrome
- Result of uncontrolled gastric emptying of a bolus of fluid high in carbohydrate
into the small intestine - Concentrated carbohydrate —–hyperglycemia—-release excess amount of
insulin into circulation—hypoglycemia - Symptoms are similar to hypoglycemic reaction
- Sweating, weakness, mental confusion, palpitation, tachycardia, anxiety
- 2 hours of eating—symptoms occur
Post Operative Complications
Bile Reflux Gastritis
- Prolonged contact with bile causes damage to the gastric mucosa , chronic
gastritis, PUD - Continuous epigastric distress—increase after meal
Gastric Surgery - Nursing Management - Preoperative Care
- Teaching patient about surgery
- Include:
1. pain relief
2. Coughing and breathing exercises
3. NG tube
4. IV fluids
Gastric Surgery - Nursing Management - Postoperative Care
- Fluid-electrolyte balance
- Preventing respiratory complications
- Preventing infection
- NG tube—decompression—observe: color, amount, odor
- NG tube needs to work—if there is no drainage—blood cloth
- Before NG tube removes, pt starts clear liquid—toleration
- Anastomotic leak—tachycardia, dyspnea, fever, abdominal pain, anxiety,
restlessness
Gastric Surgery - Nursing Management - Postoperative Care—Nutritional Therapy
- Long term comp: malnutrition, metabolic bone disease, anemia, weight loss
- Wound healing may impair
- Pernicious anemia– lack of cobalamin results pernicious anemia and neurologic
complications - Meal size needs to reduce (6 small feeding)—not to drink with meals
- First weeks after surgery; soft bland foods with low fiber and high carb and
protein - Teach the pt to AVOID: simple sugar, lactose, fried foods, extreme temperature
in food
Gastritis
An inflammation of the gastric mucosa
Gastritis - Etiology:
- Result of breakdown in normal gastric mucosal barrier
- Mucosal barrier protects stomach tissue from the corrosive action of HCI and
pepsin - When the barrier broken, HCI and pepsin can diffuse back into the mucosa
- Result in; tissue edema, disruption of capillary wall, hemorrhage
Gastritis - Risk Factors
- Drug-related gastritis: especially NSAID and corticosteroids
- Diet: alcohol, spicy irritating foods
- Helicobacter pylori
- Other risk factors: infections, reflux of bile salts from duodenum to stomach,
prolonged vomiting, intense emotional response
Gastritis - Clinical Manifestation - Chronic gastritis;
- Like acute gastritis, sometimes
asymptomatic, lack of cobalamin and
pernicious anemia
Gastritis - Clinical Manifestation - Acute gastritis;
- Anorexia, Nausea, Vomiting,
epigastric tenderness, feeling of
fullness
Gastritis - Diagnostic studies
- Acute gastritis: diagnosed based on
pt’s symptoms - Occasionally, endoscopic examination
with biopsy is required
Upper Gastrointestinal Bleeding - types of upper GI bleeding - Hemetemesis
Bloody vomitus, appearing as fresh, bright red blood or
“coffee grounds” appearance (dark, grainy digested blood)
Upper Gastrointestinal Bleeding - types of upper GI bleeding - Melena
Black, tarry stools (often foul smelling) caused by digestion on blood in the GI tract.
Upper Gastrointestinal Bleeding - types of upper GI bleeding - Occult bleeding
Small amounts of blood in gastric secretions, vomitus, or stools not apparent by apperence
Upper Gastrointestinal Bleeding - Causes - Stomach and duodenum
- Drug-induced
- Erosive gastritis
- Polyps
- PUD
- Stress-related mucosal disease
- Stomach cancer
Upper Gastrointestinal Bleeding - Causes - Esophagus
- Esophageal varices
- Esophagitis
Upper Gastrointestinal Bleeding - Causes - Systemic diseases
- Blood dyscrasias (leukemia, aplastic
anemia..) - Renal failure
Upper Gastrointestinal Bleeding - Nursing Management - Abdominal and GI Findings
- Abdominal pain
- Abdominal rigidity
- Hematemesis
- Melena
- Nausea
Upper Gastrointestinal Bleeding - Nursing Management - Hypovolemic shock
- BP (fellur)
- Pulse pressure (fellur)
- Level of consciousness (fellur)
- Urine output
- Tachycardia
- Cool, clammy skin
- Slow capillary refill
Emergency Management: Assessment Findings
Upper Gastrointestinal Bleeding - Nursing Management - Emergency Management: Assessment Interventions
- If unresponsive—assess circulation,
airway and breathing - If responsive– monitor airway,
breathing and circulation - Establish IV access with large catheter
and start IV fluid replacement, insert
second large catheter if shock present - Give Oxygen via nasal canula
- Initiate ECG monitoring
- Obtain blood
- Insert NG tube as needed
- Insert indwelling urinary catheter
- Give IV PPI therapy
- Ongoing monitoring
- Monitor vital signs, level of
consciousness, bowel sounds,
intake/output - Assess amount and character of
emesis - Keep patient NPO
Emergency Management: Assessment Interventions
Disorders of the Liver
- Hepatitis
- Cirrhosis
- Acute Liver Failure
Hepatitis
- Hepatitis is inflammation of the liver
- Most common cause is viruses
- It can be caused by substances (alcohol, medications, chemicals), autoimmune
diseases, and metabolic problems
Viral Hepatitis
- There are 5 main hepatitis viruses, types A, B, C, D and E.
- These 5 types are of greatest concern because of the burden of illness and death
they cause and the potential for outbreaks and epidemic spread. - Types B and C lead to chronic disease in hundreds of millions of people and,
together, are the most common cause of liver cirrhosis and cancer
Hepatitis A virus (HAV)
is present in the feces of infected persons and is most
often transmitted through consumption of contaminated water or food
* Fecal-oral contamination
* Certain sex practices can also spread HAV
* Infections are in many cases mild, with most people making a full recovery and
remaining immune from further HAV infections
* However, HAV infections can also be severe and life threatening
* Most people in areas of the world with poor sanitation have been infected with
this virus. Safe and effective vaccines are available to prevent HAV.
Hepatitis B virus (HBV)
is transmitted through exposure to infective blood,
semen, and other body fluids
* HBV can be transmitted from infected mothers to infants at the time of birth or
from family member to infant in early childhood
* Transmission may also occur through transfusions of HBV-contaminated blood
and blood products, contaminated injections during medical procedures, and
through injection drug use
* HBV also poses a risk to healthcare workers who sustain accidental needle stick
injuries while caring for infected-HBV patients
* Safe and effective vaccines are available to prevent HBV.
Hepatitis C virus (HCV)
is mostly transmitted through exposure to infective blood
* This may happen through transfusions of HCV-contaminated blood and blood
products, contaminated injections during medical procedures, and through
injection drug use
* Sexual transmission is also possible but is much less common
* There is no vaccine for HCV
Hepatitis D virus (HDV) (also called delta)
infections occur only in those who are
infected with HBV
* The dual infection of HDV and HBV can result in a more serious disease and
worse outcome
* HDV is transmitted like HBV
* Hepatitis B vaccines provide protection from HDV infection
Hepatitis E virus (HEV)
is mostly transmitted through consumption of
contaminated water or food
* Fecal-oral route
* HEV is a common cause of hepatitis outbreaks in developing parts of the world
and is increasingly recognized as an important cause of disease in developed
countries
* Safe and effective vaccines to prevent HEV infection have been developed but
are not widely available
Clinical Manifestations of Hepatitis - Acute Hepatitis
- Anorexia
- Clay-colored stool
- Dark urine
- Decreased sense of taste and smell
- Diarrhea or constipation
- Fatigue, lethargy, malaise
- Flu-like symptoms
- Hepatomegaly
- Low-grade fever
- Lymphadenopathy
- Nausea, vomiting
- Pruritus (itching-intense, systemic)
- Right upper quadrant tenderness
- Splenomegaly
- Weight loss
- Jaundice (icteric)
Clinical Manifestations of Hepatitis - Chronic Hepatitis
- ALT, AST elevation
- Ascites and lower extremity edema
- Asterixis (“liver flap”)
- Bleeding abnormalities (thrombocytopenia,
easy bruising, prolonged clotting time) - Fatigue
- Hepatic encephalopathy
- Hepatomegaly
- Increased bilirubin
- Palmar erythema
- Spider angiomas
- Jaundice (icteric)
Viral Hepatitis - Management - Diagnostic Assessment
- History and physical examination
- Liver function test
- PT time and INR
- Hepatitis testing
- FibroScan (like usg, to measure
damage) - FibroSure (Fibro test)
Viral Hepatitis - Management/ Chronic HBV an HCV
Management
Acute and Chronic
* Well-balanced diet
* Vitamin supplements
* Rest
* Avoiding alcohol and drugs
Chronic HBV an HCV
* Drug therapy
Viral Hepatitis - Nursing Management - Nursing Diagnoses;
- Impaired nutritional intake
- Activity intolerance
- Risk for bleeding
Viral Hepatitis - Nursing Management - planning;
- Have relief of discomfort
- Be able to resume normal activities
- Return to normal liver function without complications
Viral Hepatitis - Nursing Implementation-Preventive measures for Hepatitis A - General Measures:
- Hand washing
- Proper personal hygiene
- Environmental sanitation
- Control and screening of food
handlers - Serologic screening
- Active immunization: HAV vaccine
Viral Hepatitis - Nursing Implementation-Preventive measures for Hepatitis A - Use of Immune Globulin:
- Early administration (1-2 week after
exposure) - Prophylaxis for travelers
Viral Hepatitis - Nursing Implementation-Preventive measures for Hepatitis A - Special considerations for health care personnel:
- Wash hands
- Use infection control precautions
Viral Hepatitis - Nursing Implementation-Preventive measures for Hepatitis B and C - Percutaneous Transmission:
- Screening of donated blood
- Use of disposable needles and
syringes - Sexual Transmission
- Acute exposure: HBIG administration
to sexual partner (HBsAG+ person) - HBV vaccine series (uninfected sexual
partner) - Condom use
Viral Hepatitis - Nursing Implementation-Preventive measures for Hepatitis B and C - General measure:
- Hand washing
- Avoid sharing toothbrushes and
razors - HBIG administration for one time
exposure - Active immunization: HBV vaccine
Viral Hepatitis - Nursing Implementation-Preventive measures for Hepatitis B and C - Special Consideration For Health Care
Personnel:
- Use infection control precautions
- Reduce contact with blood and
secetions - Dispose of needles properly
Viral Hepatitis - Nursing Implementation- Acute Care
- Assess the presence and degree of jaundice (sclera of eyes and skin)
- Adequate nutrition
- Mouth care, antiemetics
- Adequate fluid intake
- Rest
- Comfort measures to relieve itching, headache
Cirrhosis
- Cirrhosis is the end stage of liver disease
- It is characterized by extensive degeneration and destruction of the liver cells
- This results in the replacement of liver tissue by fibrosis (scar tissue)and
regenerative nodules
Cirrhosis - Etiology
- Excess alcohol use
- Non-alcoholic fatty liver disease (NAFLD)
- Hepatitis B and C
Cirrhosis - Clinical Manifestation - Early
fatigue, enlarged liver, diagnose is made
later
Cirrhosis - Clinical Manifestation - Late
- jaundice,
- peripheral edema,
- ascites,
- skin lesions: spider angiomas, palmar
erythema - hematologic problems,
- endocrine problems,
- peripheral neuropathies
Cirrhosis - Complications
- Portal hypertension: increased pressure within the liver’s
circulatory system– splenomegaly, large collateral veins,
ascites, varices - Esophageal and gastric varices: enlarged veins—can bleed
easily - Peripheral edema
- Abdominal ascites: serous fluid in peritoneal or abdominal
cavity - Hepatic encephalopathy: neuropsychiatric manifestation-
impaired consciousness, inappropriate behavior - Hepatorenal syndrome: type of renal failure
Cirrhosis - Management - Conservative therapy:
- Rest
- B-complex vitamins
- Avoiding alcohol
- Minimizing or avoiding aspirin, NSAID
Cirrhosis - Management - Ascites
- Low-sodium diet
- Diuretics
- Paracentesis
Cirrhosis - Management - Esophageal and gastric varices:
- Endoscopic band ligation or sclerotherapy
- Balloon tamponade
- Transjugular intrahepatic portosystemic
shunt (TIPS)
Cirrhosis - Management - Hepatic Encephalopathy:
- Drug therapy—antibiotics
Cirrhosis - Nursing Management
- Nursing Diagnoses:
- Impaired nutritional status
- Ineffective tissue perfusion
- Activity intolerance
- Fluid imbalance
Cirrhosis - Nursing Management
- Planning:
- Relief of discomfort
- Ave minimal to no complication
- Return to normal lifestyle
Cirrhosis - Nursing Management- Implementation - Health Promotion;
- Reducing risk factors: alcohol use, malnutrition, viral hepatitis, obesity etc
Cirrhosis - Nursing Management- Implementation - Acute care:
- Bed rest: take precautions to protect pt form side effects of complete bed rest
- Nutritional support: oral hygiene and modifications on meals
- Itching—relieve
- Follow: urine and stool
- Assessment edema and ascites, recording intake-output, daily weight
- Semi-fowler’s position—dyspnea
- Skin care
- ROM exercises
- Elevation of lower extremity—if scrotal edema is present, support is necessary
Cirrhosis - Nursing Management- Implementation - Bleeding Varices
- Observe hematemesis and melena
- If hematemesis occurs, call the MD—usually ICU necessary
- Maintain pt’s airway
- Keep monitoring pt
Cirrhosis - Nursing Management- Implementation - Hepatic Encephalopathy:
- Maintain safe environment
- Pt confused, risk for fall and other injuries
- Assess pt: level of responsiveness, sensory and motor abnormalities, fluid and
electrolyte imbalance - Assess neurologic status– every 2 hours
- Have emergency equipment ready
- Measures to minimize constipation is important (reduce ammonia production)
Patient and caregiver education
Disorders of Pancreas - Acute Pancreatitis
- Acute inflammation of the pancreas
- the degree of inflammation varies
Acute Pancreatitis - Etiology
- Gallbladder diseases
- Chronic alcohol use
- Drug reactions
- Pancreatic cancer
- Hypertriglyceridemia
- Auto digestion of panaceas
Acute Pancreatitis - Clinical Manifestations
- Abdominal pain—left upper quadrant –or mid-epigastric
- Severe, deep, piercing, and continuous or steady
- Nausea and vomiting
- Low grade fewer
- Leukocytosis
- Hypotension
- Tachycardia
- Abdominal tenderness
Acute Pancreatitis - Management - Diagnoses
- History and physical examination
- Serum amylase and lipase
- Blood glucose
- Serum calcium
- Serum triglycerides
- Abdominal USG
- Endoscopic USG
- ERCP
- CT
Acute Pancreatitis - Managemen
- NPO with NG
- Albumin
- IV calcium gluconate
- Lactated Ringer’s solution
Acute Pancreatitis - Management - Drug therapy
Drug Therapy
* Pain medication
* PPI (eg omeprazole)
* Antibiotics
Acute Pancreatitis - Nursing Management - Nursing Diagnoses:
- Acute pain
- Fluid imbalance
- Electrolyte imbalance
- Impaired nutritional intake
Acute Pancreatitis - Nursing Management - Planning:
- Relief pain
- Normal fluid and electrolyte balance
- Minimal to no complications
- No recurrent attacks
Acute Pancreatitis - Nursing Management- Implementation
- During the acute phase—monitor vital signs
- Monitor response to IV fluid
- Monitor fluid-electrolyte balance
- Assess respiratory function
- Monitor hypocalcemia symptoms: Chvostek’s or Trousseau sign
- Pain relieve
- NPO- NG tube—oral and nasal care
- Blood glucose level
- Surgery can be necessary for some cases
Disorders of Biliary Tract - Cholelithiasis and Cholecystitis
- Cholelithiasis—stone in gallbladder
- Cholecystitis-inflammation of gallbladder wall
Cholelithiasis and Cholecystitis - Clinical Manifestation
- Pain
- Tenderness in the right upper quadrant
- Pain attacks often occurs 3-6 hours after a high fat meal or patient lies down
- Total obstruction—clay colored stool, bleeding tendency, dark, amber color urine, fewer and chills, intolerance for fatty foods, pruritus
Cholelithiasis and Cholecystitis - Management - Diagnoses
- History and physical examination
- USG
- ERCP
- Liver function test
- White blood cell count
- Serum bilirubin
Cholelithiasis and Cholecystitis - Management - Surgical therapy
- LAP cholecystectomy
- Open cholecystectomy
Cholelithiasis and Cholecystitis - Management - Conservative therapy
- IV fluid
- NPO with NG tube
- Antiemetics
- Analgesics
- Fat soluble vitamins (A,D,E,K)
- Antispasmodics
- Antibiotics
- ERCP
Cholelithiasis and Cholecystitis - Nursing Management - Nursing Diagnoses
- Acute pain
- Lack of knowledge
Cholelithiasis and Cholecystitis - Nursing Management - Planning
- Relief of pain and discomfort
- No complications postoperatively
- No recurrent attacks
Cholelithiasis and Cholecystitis - Nursing Management-Implementation - Acute Care:
- Pain medication—as ordered
- Nausea and vomiting—NG necessary
- Oral care, input-output
- Observation of blockage signs
- Monitoring vital signs
Cholelithiasis and Cholecystitis - Nursing Management-Implementation - Postoperative Care
- Monitoring complications: bleeding
- Pain to the shoulder—normal because of LAP surgery—CO2
- Clear liquids
- Walking
- Pain medication
- Open surgery—respiratory complications
Constipation
- Constipation is characterized by difficult or infrequent bowel movements
- Constipation is a symptom not a disease
- It can be acute, usually lasting less than 1 week, or chronic, lasting over 3 months
Constipation - Etiology
- Improper diet
- Reduced fluid intake
- Lack of exercises
- Certain medications
Can cause constipation
Constipation - Clinical Manifestation
- Varies from mild to severe
- Stools are absent or hard, dry and sifficult pass
- Abdominal distention, increased flatulence and increase rectal pressure
Constipation - Management
- Increase dietary fiber (fruit, vegetable, grains)
- Adequate water intake
- Exercise
- Laxatives and enemas
- Management target pt needs: needs further examination
Constipation
Nursing management
- Assessment: usual bowel habit, stool characteristics, diet, straining etc.
- Interventions:
Teach patients: - Diet, adequate fluid, regular exercise,
- High fiber diet
- Regular time to defecate
- Discourage the use of laxatives and enemas
- Privacy, elevation bed –bedpan use
Irritable Bowel Syndrome (IBS)
- IBS is a disorder characterized by chronic abdominal pain or discomfort and
alteration of bowel patterns - Patients may have diarrhea or constipation, alternating periods of both
Irritable Bowel Syndrome (IBS) - Etiology:
- Has no known organic cause
- Psychologic stressors
- Pt mostly have GI infection disorders and adverse reaction to food
Irritable Bowel Syndrome (IBS) - Diagnose:
- Solely on symptoms
- Presence of abdominal pain or discomfort, change in stool frequency, change in
stool form - Other symptoms: Abdominal distention, nausea, flatulence, bloating, urgency,
mucus in stool, sensation of incomplete evacuation - Non GI symptoms: fatigue, headache, sleep problems
Irritable Bowel Syndrome - Treatment
- No single therapy
- Dealing with psychologic factors,
- dietary changes
- drugs regulate stool output and reduce discomfort
Appendicitis
- Inflammation of the appendix
- Appendicitis is the most common
reason for emergency abdominal
surgery
Appendicitis - Etiology
- Most common in those 10-30 years of age
- Most common cause is obstruction of the lumen by fecalith (accumulated feces)
- Obstruction results in distention, venous engorgement, accumulation of mucus
and bacteria—lead to gangrene, perforation and peritonitis
Appendicitis - Clinical Manifestations
- Typically begins with dull periumbilical pain, anorexia, nausea, vomiting
- Pain is persistent and continuous (localized; halfway between the umbilicus and
right iliac crest) - Low-grade fever
- Localized tenderness, rigidity, rebound tenderness
- Coughing, sneezing and deep inhalation worsen pain
Appendicitis - Diagnose and treatment
- Examination: complete history, physical examination, differential WBC count
- Most pt have high WBC count
- Urinalysis
- CT scan, USG, MRI
- If there is a delay in diagnostic and treatment, the appendix can rupture and
resulting peritonitis can be fatal - Standard treatment is an immediate appendectomy (surgical removal of
appendix) - Antibiotics and fluid resuscitation are started before surgery
Appendicitis - Nursing Management
- Managing focus on: preventing fluid volume deficit, relieving pain, and
preventing complications - Ensure that stomach is empty
- Keep pt NPO
- Monitor vital signs
- Give IV fluids, analgesics, antiemetics as ordered
- Post operative care
- Most patients resume normal activities 2-3 weeks after surgery
Inflammatory Bowel Disease (IBD)
- IBD is a chronic inflammation of the GI track
- Crohn’s Disease
- Ulcerative Colitis (UC)
Inflammatory Bowel Disease (IBD) - Etiology
- Do not know exact cause
- Autoimmune disease, immune reaction to a person’s own intestinal tract
- Environmental factors (diet, smoking, stress) increase susceptibility
- Thought: dietary factors of industrialized countries: high intake of refined sugar,
total fats —eating fewer raw fruits and vegetables, omega 3-rich foods, NSAIDs,
antibiotics, oral contraceptives—- increase risk
Inflammatory Bowel Disease (IBD) - Diagnose
- History and physical examination
- Erythrocyte sedimentation rate
- Serum chemistries (diarrhea, vomiting)
- Testing of stool for occult blood and infection
- Capsule endoscopy
- Radiologic studies with barium contrast
- Sigmoidoscopy and/or colonoscopy with biopsy
Inflammatory Bowel Disease (IBD) - Management
- High calorie, high-vitamin, high-protein diet
- Drug therapy
- Aminosalicylates– (decrease inflammation)
- Antimicrobials – (prevent or treat secondary infection)
- Biologic therapies—(inhibits cytokine tumor necrosis factor)
- Corticosteroids– (decrease inflammation)
- Immunosuppressants – (suppress immune response)
- Physical and emotional rest
- Referral for counseling or support group
- Surgical therapy
Inflammatory Bowel Disease (IBD) - Management - Surgical therapy
- Drainage of abdominal abscess
- Failure to respond to conservative therapy
- Fistulas
- Intestinal obstruction
- Massive hemorrhage
- Perforation
- Severe anorectal disease
- Suspicion of cancer
Inflammatory Bowel Disease (IBD) - Nursing Management Assessment - Nursing Diagnoses
- Diarrhea
- Impaired nutritional status
- Difficulty coping
- Chronic pain
Inflammatory Bowel Disease (IBD) - Nursing Management Assessment - Planning
- Maintain normal fluid and electrolyte balance
- Be free from pain or discomfort
- Adhere to medical regiments
- Maintain nutritional balance
- Improve quality of life
Inflammatory Bowel Disease (IBD) - Nursing Implementation - Acute Care
- Hemodynamic stability
- Pain control
- Fluid-electrolyte balance
- Nutritional support
- Intake-output record
- Monitor stool—blood
- Orthostatic hypotension—education
- Perineal skin care—because of diarrhea
Inflammatory Bowel Disease (IBD).- Nursing Implementation - Ambulatory care
- Teaching pt:
- Importance of rest and diet management
- Perianal care
- Drug action and side effects
- Symptoms of recurrence of disease
- When to seek medical care
- Ways to reduce stress
Diverticulosis and Diverticulitis
- Diverticula are dilations or
outpouching of mucosa—develop in
colon - Diverticulosis is the presence of
multiple noninflamed diverticula - Diverticulitis is inflammation of 1 or
more diverticula, resulting in
perforation into peritoneum
Diverticulosis and Diverticulitis - Etiology
- Mostly occurs in left colon
- Genetic and environmental factors are effective
- Main cause constipation and lack of dietary fiber
- Uncommon in vegetarians
- Obesity, inactivity, smoking, excess alcohol use, NSAID use—risk factors
Diverticulosis and Diverticulitis - Clinical Manifestation
- Most pt has no symptom
- Abdominal pain, bloating, flatulence, and changes in bowel habits
- The most common signs of diverticulitis are acute pain in the left lower quadrant,
distention, decreased bowel sound, nausea, vomiting and systemic signs of infection
Diverticulosis and Diverticulitis - Diagnose
- Typically found during routine sigmoidoscopy and colonoscopy
- History and physical examination
- CT scan with oral contrast
Diverticulosis and Diverticulitis - Management and Nursing Care - Prevention:
- High-fiber diet, mainly from fruits and vegetables with decreased intake of fat
and red meat - Physical activity
Diverticulosis and Diverticulitis - Management and Nursing Care - Treatment:
- Goal: let the colon rest and inflammation subside—clear diet can help
- Hospitalized pt: NPO, bed rest, IV fluids and antibiotics, input-output record, NG
tube ca be necessary - If there is abscess or obstruction—surgery may be necessary—resection of
involved colon and anastomosis. Maybe colostomy (temporary) - Pt education: condition and adhere to precautions
Hemorrhoids
- Dilated hemorrhoidal veins
- Can be internal or external
Hemorrhoids - Etiology
- Cause– increased anal pressure, weakening of the connective tissue
Risk factors: - pregnancy,
- constipation,
- straining to defecate,
- diarrhea,
- heavy lifting,
- prolonged standing and sitting,
- obesity
Hemorrhoids - Clinical Manifestation
- Bleeding with defecation
- Internal hemorrhoids: painless, bright red bleeding with stool, on the toilet
paper, or dripping into toilet water. - External hemorrhoids are reddish blue and seldom bleed. Itching, burning and
edema
Hemorrhoids - Diagnose:
- Visual inspection and digital examination-external hemorrhoids
- Digital examination, sigmoidoscopy, anoscopy—internal hemorrhoids
Hemorrhoids - Management
- Dietary advices– if the cause is constipation
- Ointments can relieve discomfort
- Stool softeners, sitz bath (for pain relieve)
- Internal hemorrhoid—nonsurgical: rubber band ligation, laser treatment etc.
- Hemorrhoidectomy
Hemorrhoids - Nursing Care - Teaching;
- Prevent constipation and avoid prolonged sitting and standing
- Severe symptoms (pain, bleeding..)
- Sitz bath (15-20 minutes, 2 or 3 times each day) reduce discomfort.
Starts 1-2 days after surgery (1-2 week)—warm sitz bath provide comfort and keep
clean anal area - Nursing care after hemorrhoidectomy: pain management, wound healing
- Pt resists defecation—before pain medication, stool softener can help
Anorectal Problems
- Anal fissure: is a skin ulcer or a crack in the lining of the anal wall
- Anal Fistula: is an abnormal tunnel leading from the anus or rectum. It may
extend to the outside of the skin, vagina, buttocks - Pilonidal Sinus: is a small tract under the skin between the buttocks in the
sacrococcygeal area.
Colorectal Cancer
- Colorectal cancer arise from a polyp.
- This process begins with an aberrant crypt, evolving into a neoplastic precursor lesion (a polyp), and eventual progressing to colorectal cancer over an estimated 10–15 year period.
Colorectal Cancer- Risk Factors - Hereditary factors
- Hereditary colorectal cancer syndromes
- Positive family history
Colorectal Cancer- Risk Factors - Modifiable risk factors (high risk)
- Smoking
- Processed meat
- alcohol intake
- red meat
- low intake of vegetables and fruits
- body fat and obesity
Colorectal Cancer- Risk Factors - Modifiable risk factors (low risk)
- Physical activity
- Whole grains
- Dietary fibre
- Dairy products
- Fish intake
- Tree nuts
- vitamins (D, D, and others)
- Calcium supplements
Colorectal Cancer- Risk Factors - Other factors
- Aspirin or NSAID use
- Menopausal hormone therapy
- Statin use
- ethnicity
- Male gender
- Type 2 diabetes
- Inflammatory bowel disease
Colorectal Cancer- Symptoms
Patients can present with a wide range of signs and symptoms such as;
* Occult or overt rectal bleeding
* Change in bowel habits
* Anemia, or abdominal pain
* Colorectal cancer is largely an asymptomatic disease until it reaches an advanced
stage.
Colorectal Cancer- Diagnosis
- Colonoscopy
- Imaging: CT-Scan, MRI, PET-CT
- Laboratory: complete blood count,
carcinoembryonic antigen concentrations - Pathology
Colorectal Cancer- Management
- Endoscopic treatment- Early stage
- Surgical treatment
- Radiotherapy- Preoperative, rectal cancer
- Chemotherapy- post operative
Colorectal Cancer - Nursing management - Primary Prevention
- Smoking cessation,
- Healthy diet,
- Regular exercise can prevent the development of colorectal cancer
- Physical activity of at least 30 min,
- Consumption whole grains, fresh fruits, tree nuts, and vegetables
- Intake of calcium and fiber
Colorectal Cancer - Nursing Management - Secondary prevention
- Consider starting screening at age 45
- Those with close relatives with colorectal cancer should start screening earlier
- Colonoscopy
- Testing the stool for blood (hemoccult), fecal DNA
- Flexible sigmoidoscopy (shorter scope)
Colorectal Cancer
Nursing Management
Acute Care
- Routine postoperative care
- Post-op care includes: sterile dressing change, care of drains, patient and
relatives teaching on ostomy,
Colorectal Cancer - Nursing Management - Ambulatory Care
- Psychologic support
- Ostomy rehabilitation—referral WOCN
Bowel Resections and Ostomy Surgery - Surgical resection of the bowel may be done;
1- remove cancer
2- repair perforation, fistula, or traumatic injury
3- relieve an obstruction or stricture
4- treat an abscess, inflammatory disease, or hemorrhage
Bowel Resections and Ostomy Surgery
- Depending on the problem being treated, these procedures may be done;
-Total proctocolectomy with IPAA: removes the entire colon and rectum while
preserving the anal sphincter, ileal pouch construction and temporary ileostomy
- Proctocolectomy with a permanent ileostomy: removal of colon, rectum and
anus with closure of the anal opening - Right hemicolectomy: removal of ascending colon
- Left hemicolectomy: removal of descending colon and sigmoid colon
- Abdominal-perineal resection (APR): removal of rectum and creation of
permanent colostomy - Low anterior resection (LAR): removal of rectum and with anastomosis of the
colon to the anal canal (maybe temporary stoma)
Bowel Diversions-Ostomy
- Temporary or permanent opening (stoma) is
created surgically by bringing part of the intestine
out through the abdominal wall - Surgical openings are called an ileostomy or
colostomy depend on which part of intestinal tract
is used to create the stoma
Ostomy Types
- End Stoma: an end stoma is made by dividing the bowel and bringing out the
proximal end as a single stoma - Loop stoma: a loop stoma is made by bringing a loop of bowel to the abdominal
surface and then opening the anterior wall of the bowel to provide fecal
diversion - Double-Barreled Stoma: to create stoma, surgeon divides the bowel, and both
the proximal and distal ends are brought through the abdominal wall as 2
separate stomas
Bowel Resections and Ostomy Surgery - Nursing Management - Preoperative Care:
- Psychologic preparation for the ostomy
- Educational preparation
- Selecting the best site for the stoma— WOCN visit
Bowel Resections and Ostomy Surgery - Nursing Management - Post operative Care
- Assess the incision: sign of infection? Suture integrity?
- Assess the wound regularly and record bleeding, excess drainage and unusual
odor - Monitor for edema, erythema, and drainage around suture line, high fever, WBC
count - Wound care—dressing change, observing drainage
- If stoma present, assess the stoma and place a clear pouching system
Post operative Care-Ostomy
- Patient Education
- Stoma Assessment
- Stoma care
WOCN
Stoma Assessment
- Surgery performed
- Stoma type, duration of the stoma
- Stoma site
- Color, moisture—color every 4 hours
- Stoma height and shape
- Peristomal skin
- Diameter of the stoma, Rod
- Complications
Stoma care
- First, the adapter is separated from the skin from top to bottom
- The area around the stoma is wiped with gauze moistened with tap water and dried.
- The diameter of the stoma is measured
with the help of a stoma ruler. - The appropriate size is a 2mm gap
between the edge of the bag and the
stoma. - The adapter is cut with the help of
scissors according to the diameter of
the stoma measured. - The paper on the sticky part of the cut adapter
is removed and a toothpaste-like “paste” is
applied to the inside. - The paste is a barrier between the stoma and the bag, preventing leakage. The role of the paste is to protect the skin around the stoma from feces.
Paste prevents feces from contaminating the skin. - By removing the adhesive papers on
the edges, the adapter is fully adhered
to the skin. - The stoma bag suitable for the adapter is
placed on the adapter in a circular motion
starting from a point. - After placing the bag, the clamp of the bag is closed.
- Check if the bag is firmly seated in the adapter
by pulling it lightly on ourselves. After placing the bag, the clamp of the bag is closed.
Patient Education
- Stoma equipment
- Assessment of stoma
- Emptying the bag
- changing the bag
- changing the wafer
- paste application
- Skin care/cleaning
- Complication managenment
- drug use
- Emergency situations
- Daily life activities (bathing, dressing, travel, worship, sexuality, nutrition)
