MS2 - GI - Concepts Flashcards
Patient position for tube feedings
- Elevate the head of bed to minimum of 30 degrees, preferably 45 degrees, to prevent aspiration
- Intermittent feedings: head should remain elevated for 30-60 minutes after feeding
For patients with enteral feedings:
Check gastric residual volumes every ___ hours during the first ____ hours.
After enteral feeding goal rate is achieved, gastric residual monitoring may be decreased to every ___ to ___ hours in non-critically ill patients or continued every ___ hours in critically ill patients.
Check gastric residual volumes every 4 hours during the first 48 hours.
After enteral feeding goal rate is achieved, gastric residual monitoring may be decreased to every 6 to 8 hours in non-critically ill patients or continued every 4 hours in critically ill patients.
If gastric residual volume is >___ mL, hold enteral nutrition and reassess patient tolerance.
500 mL
Etiological factors and risks associated with GERD
Primary etiologic factor - incompetent LES (decreased LES pressure)
Things that decrease LES pressure:
Certain foods (caffeine, chocolate, peppermint/spearmint, fatty)
Drugs (anticholinergics, calcium channel blockers, diazepam, morphine, B-Adrenergic blockers, Nitrates, progesterone, theophylline)
Cigarette/cigar smoking
Other risks:
Obesity (due to increased intraabdominal pressure)
Common cause - hiatal hernia
Patient teaching for GERD
- Avoid factors that trigger symptoms (particular attention to diet and drugs that affect LES, acid secretion, or gastric emptying)
- Small, frequent meals to prevent gastric distention
- Advise not to lie down 2-3 hours after eating, don’t wear tight closing around waist, and don’t bend over (especially after eating)
- Avoid eating within 3 hours of bedtime
- Recommend sleeping with HOB elevated on 4-6” blocks (approx 30 degrees)
- Info on any drugs the patient will receive
- Recommend weight reduction if overweight
- Encourage to cease smoking if applicable
- Stress coping techniques if applicable
Two classifications of hiatal hernias
Sliding:
Junction of stomach and esophagus is above diaphragm - part of stomach slides through hiatal opening. Occurs when patient is supine, hernia usually goes back into abdominal cavity when upright. (Most common type).
Paraesophageal (rolling):
Esophagogastric junction remains in normal position, but fundus and curvature of the stomach roll up through the diaphragm - forms pocket alongside the esophagus. Acute paraesophageal hernia is a medical emergency.
Human Digestive System Order
Mouth Pharynx Esophagus Lower Esophageal Sphincter Stomach Pyloric Sphincter Duodenum Jejunum Ileum Cecum Ascending colon Transverse colon Descending colon Sigmoid colon Rectum Anus
Upper GI barium swallow
- Upper GI series - X-ray study with fluoroscopy (barium swallowed then x-ray)
- Examines organs of upper part of digestive system (esophagus, stomach, duodenum)
- Identifies disorders such as esophageal strictures, polyps, tumors, hiatal hernias, foreign bodies, peptic ulcers
Mgmt:
NPO/no smoking 8-12 hours
Pt will need to assume various positions on x-ray table
Need fluids and laxatives afterwards to prevent contrast medium impaction
Stool may be white for up to 72 hours
Small Bowel Series
- Contrast medium (not barium) taken - clear w/motility accelerant
- Films/fluoroscopy taken every 20 min til contrast reaches terminal ileum
Mgmt:
- Same as Upper GI
- Paddle w/ball pressed against abdomen while patient in various positions
- May have diarrhea afterward
Lower GI barium enema
- Examines rectum, large intestine, and lower part of small intestine
- Given in rectum as enema
- X-ray of abdomen shows strictures (narrowed areas), obstructions (blockages), other problems
- Air-contract or double-contrast has air infused after barium enema given
Mgmt:
- Colon must be clean - enemas, laxatives, drink gallon of electrolyte solution or combination
- Clear liquids 1-3 days in advance
- NPO after midnight
- Teach about barium enema, balloon inflation in rectum to retain barium and air, position changes, cramping, and need to defecate
- Fluids, laxatives, and/or suppositories to expel barium
Ultrasound
- Used to view internal organs as they function, and to assess blood flows through various vessels
- Gel applied to area being studied and transducer placed on skin - sends sound waves into body that bounce off organs and return to machine to produce image
Mgmt:
- NPO 8-12 hours before
Contraindications for Valsalva maneuver
- Head injury
- Eye surgery
- Cardiac problems
- Hemorrhoids
- Abdominal surgery
- Liver cirrhosis with portal hypertension
Computed Tomography Scan (CT Scan)
- Noninvasive; combination of xrays and computer technology
- Produces cross-sectional images (slices), both horizontal and vertical
- Detailed images of any part of the body (including bones, fat, organs, muscles)
- More detailed than general xrays
- Contrast may be injected
Mgmt:
- Contrast: check for iodine allergies, forewarn if injected in lower pelvis feels very warm like urinating on self
Magnetic Resonance Imaging (MRI)
- Combination of magnets, radiofrequencies, computer
- Detailed images of organs and structures within body
- Painless, noninvasive, no radiation exposure
Mgmt:
- Metal objects cannot be in MRI room - not for pts with pacemakers, metal clips/rods inside body. Remove jewelry
- NPO 6-8 hours preprocedure
- Pt may need sedative if issues with confined spaces or unable to hold still during test
Esophageal manometry
- Helps determine strength of muscles in esophagus
- Helpful evaluating gastroesophageal reflux and swallowing abnormalities
- Small tube through nostril, into throat, then esophagus - measures pressure esophageal muscles produce at rest
Esophagogastroduodenoscopy (EGD)
Upper GI endoscopy
- Thin, flexible lighted tube to see inside esophagus, stomach, duodenum
- Can insert instruments through scope for sample for biopsy if needed
Mgmt:
- NPO for 8 hours
- Need sign consent
- Throat will be sprayed with topical anesthetic or pt will gargle w/topical anesthetic
- Pt will have light sedation - may cause amnesia for 1-2 hrs
- Pt will be positioned on left side, keep chin tucked toward chest, and breathe through mouth
- Takes 5-10 min plus recovery time
- Keep NPO til gag reflex returns
- Notify HCP w/temp >101F, sharp severe chest ab pain, vomiting blood, black tarry stools
Colonoscopy
- View entire length of large intestine, help id abnormal growths, inflamed tissue, ulcers, bleeding
- Long flexible lighted tube, to view, biopsy if needed, treat some problems found (polypectomy, cauterize bleeding)
Mgmt:
- Keep pt on clear liquids 1-3 days before procedure, no red liquids/jello
- Colon must be clean - enemas, laxatives, electrolytes until clear
- Light sedation at beginning, more later if needed - may cause amnesia for 1-2 hrs
- Positioned on left side, may feel cramping during procedure (biopsies will have no pain)
- 10-30 min + recovery time
- Gas, ab cramping, distention may occur afterward
- Contact HCP if >2 Tbsp rectal bleeding, persistent ab distention, severe ab or chest pain, temp >101F, tachycardia, diaphoresis
- Unless otherwise indicated, may eat as soon as sedation wears off
Clinical manifestations of irritable bowel syndrome
Abdominal pain
Diarrhea and/or constipation
History of GI infection and food intolerances
Excessive flatulence, bloating, urgency, sensation of incomplete evacuation, fatigue and sleep disturbances
Diet recommendations for IBS
Fiber Water (very important) Elimination of certain foods - only necessary for some pts (milk/lactose/fructose/gas-forming foods) Caffeinated beverages Alcohol
Diagnostic studies for IBS
- History and physical examination
- Use of diagnostic tests to rule out other disorders
Medications for IBS
Loperamide - synthetic opioid that slows intestinal transit - used to treat diarrhea
Alosetron - serotonergic antagonist used for iBS clients with severe symptoms of pain and diarrhea. Used only for women who have not responded to other treatments (can have serious side effects)
Lubiprostone - used for constipation in women
Linaclotide - IBS with constipation in men and women
Differences between Crohn’s and ulcerative colitis
- High fiber and fruit intake decreases risk in CD; veg intake decreases risk in UC
- Skipped areas of lesions with CD (segments of healthy bowel between); continuous lesions with UC
- Weight loss more common with CD; bloody stools with UC
- All layers of bowel for CD (can lead to fistulas); mucosa and submucosa for UC (no fistulas)
- CD can be anywhere from mouth to anus (terminal ileum most common); UC is rectum to colon
- CD drug treatment (but surgery can be indicated later); UC colectomy
- CD cramp/pain in RLQ; UC LLQ
Symptoms for IBD
- Diarrhea, bloody stools, weight loss, abdominal pain, fever, fatigue
- Mild to severe exacerbations occur at unpredictable intervals over many years
- With CD, weight loss (due to malabsorption), diarrhea, crampy pain more common
- UC: bloody stools more common
Differences for complications between CD and UC
- Crohns: Fistulas, strictures, anal absess, perforation, nutritional problems, increased risk for small intestinal cancer
- Ulcerative colitis: Toxic megacolon, colorectal cancer
Diet modifications for IBD
Crohns: High calorie, high protein
UC: Low residue diet, low fat, high protein, no dairy (severe cases: NPO to rest bowel, TPN), avoid foods that exacerbate symptom
Toxic megacolon
- Complication of ulcerative colitis
- Usually involves transverse colon; dilates and lacks peristalsis
S/S:
- Fever
- Tachycardia
- Hypotension
- Dehydration
- Changes in stools
- Abdominal cramping
