GI system Study Guide - GI REVIEW PDF

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GI System Study Guide Need of Client on a Special Diet Nasogastric – tube inserted through the nose into the stomach Orogastric Tube – tube inserted through the mouth into the stomach Before insertion of the NG tube you must measure from tip of nose to pts ear then down to the xiphoid process.  Short Term (4-6 weeks) Linda (tutor says 2-4 weeks NG tube) o Single Lumen (Levin) for intermittent suction o Double Lumen (Salem Sump) for decompression (removal of gastric contents and gas allowing stomach to heal after surgery or pancreatitis). 1 lumen for decompression and 1 lumen to prevent tube from adhering to gastric walls (prevents trauma)  Long Term (more than 6 weeks) o Enterostomal tube – is a tube inserted in to the pts stomach or jejunum (PEG tube) Nursing Considerations for Feeding Tube o Safety o Tubes get kinked, and dislodged (by vomiting, sneezing, coughing laughing, etc movement) o Insertion issues (lungs, brain and intestines). Three ways to ensure placement 1. Placement can be confirmed by XRAY (best method and always 1st check) 2. auscultation (30 mls of air/swooshing sound heard underneath the left ribcage) 3. removal of gastric contents - If removal of content is more than 500 mls, hold off on feeding and contact

the physician. Also check color of contents - gastric contents should be greenish brownish. If greater than 250 mls keep HOB up  Check skin integrity  Always feed at room temp – take out of fridge for it wo warm up. o Complications  Dumping syndrome – when food or fluid (high carbs) moves from your stomach to your intestines very quickly. The patient may feel fullness, cramping, nausea, dizziness, diaphoresis and osmotic diarrhea. This can lead to dehydration, hypotension and tachycardia. This can be avoided or diminished by:  Feeding 30ml/hr  Solution @ room temp  Semi-fowlers position for @ least 1 hour after feeding  Avoid extra PO fluids  Know signs and symptoms of hypo & hyperglycemia  Hyperglycemia/Hypoglycemia  Liquid diet causes stomach to release peptin which increases the release of glucose, as glucose rises insulin is released. In response to the release of glucose patient goes into hyperglycemia when glucose depletes our bodies respond and stop insulin, this causes a rebound effect of hypoglycemia.  Monitor client for pulmonary complications  Coughing and clearing of pharynx are impaired with NG or ORO tubes. Aspirations can occur from

regurgitated stomach contents and improperly positioned tube  Assess placement, ck gastric content, position HOB 30-40 degrees, check lung sounds (right upper lobe especially), check motility, check for tube obstruction.  Pts at risk: over 70 years of age, altered mental status, unable to protect airways, on mechanical vents, and supine position.  Patients can experience abnormal Bowel Elimination Patterns – diarrhea or constipation (Make sure pt is getting enough water to avoid constipation )– administer prescribed meds  Skin breakdown – assess skin (nose, oral mucosa, periabdominal area for signs of skin breakdown and INFECTION o Provide comfort measures - assess coping abilities – the psychological goal is to support and encourage patient to physical changes relating to treatment. Encourage self-care w/I pts parameters of activity level, and reinforce optimistic indicators of progress. Before any feeding  Check placement of tube (swooshing w/ 30 ml of air and listen

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under the left ribcage for sound or the removal of gastric content. If removal of content is more than 500 mls, hold off on feeding and contact the physician.) HOB at 30 degrees or higher Check lung sounds Antiemetics (anti vomiting meds: ondansetron, metoclopramide, prochlorperazine and promethazine) Check motility (bowel sounds

*** TO PREVENT TUB OBSTRUCTIONS CHECK FOR PATENCY AND FLUSH TUBE WITH 10 – 15 MLS OF WATER BEFORE AND AFTER EACH MEDICATION *** Closed/Open Systems  Closed System (feeding is already in the bag – disposable bag) tubing must be changed every 24 hours  Open System (feeding is put into a bag; EX: Ensure, Glucerna) tubing must be changed every 4 hours Peripheral Parenteral Nutrition – administered through peripheral IV site, provides some vitamins and electrolytes, less hypertonic than fullcalories parenteral nutrition (not nutritionally complete due low dextrose content) Central Method – Central Parenteral Nutrition (CPN) has 5 to 6 times the solute concentration of blood and are given into the vascular system through a catheter inserted into a high flow large blood vessel (ex: ideally through subclavian into the vena cava/right atriocaval junction). o Physician inserts w/use of a guided wire (nurse supports pt and maintains sterile field during procedure). o Increased risk for infection o Sterile dressing technique required o Placement checked w/X-ray, once confirmed nutrition can be started o Usually triple lumen (1. Meds 2. Parenteral nutrition 3. Fluids) o Types: (mentioning these because we talked about them in LAB)  Percutaneous Nontunneled Central Catheter - short-term (less than 6 weeks),

 PICC Line – used for intermediate use (several days to months)  Surgically Placed Tunneled Central Catheter long-term use (may remain in for years)  Implanted Vascular Access Ports - long term IV therapy (ex: chemotherapy) o Puncture into thoracic cavity can occur, if this happens chest tube for blood draining will be necessary o Glucose and phosphates must be checked o Assess for behavioral changes ******DO NOT STOP PARENTERAL FEEDING ABRUPTY, CLIENT COULD EXPERIENCE REBOUND HYPOGLYCEMIA. DISCONTINUATION MUST BE GRADUAL; (signs of hypoglycemia include weakness, shakiness, cold, confusion, increased HR)******************************** Complications of Parenteral Nutrition (TABLE 44-5 pg 1260)  Insertion problems –  Pneumothorax can occur from improper placement and inadvertent puncture of pleura.  Air embolism can occur from disconnected tubing, cap missing from port and blocked segment of vascular system.  Infection - sterile technique required to change dressing which must be changed every 7 days unless bloody, loose or soiled. During dressing change nurse and client must wear mask to reduce possibility of airborne contamination.  Clotted catheter can happen from inadequate flushing.  Catheter displacement and contamination can happen with excessive movement and separation of tubing

 Sepsis can happen from separation of dressing, contaminated solution, and infection @ site  Metabolic alterations, F&E and acid-base imbalances  Hyperglycemia – happens from glucose intolerance  Fluid overload - happens when fluid is infused too rapidly;  Rebound hypoglycemia – happens feeding is stopped too abruptly  Refeeding Syndrome – metabolic disturbances when nutrition is reinstituted in a person who is malnourished/starving. (can happen in someone who has been starved, is critically ill and could not eat or even someone recovering from surgery)  S & S – serum electrolytes fall including Phosphorus and magnesium, dysrhythmias, increase glucose, and confusion.  Shift of fluid because of highly concentrated solutions  Check hydration status  Check urinary output Normal Function of GI System Gastric function – most made up of HCl which breaks down food so that it is more easily absorb and aids in the destruction of bacteria that is ingested.  Stores food  Pass contents into small intestines  Absorbs small amounts of water, minerals and meds  Mix food w/secretions: HCl, cyanocobalamin (chemical form of B12) combines with intrinsic factor so vit B12 can be absorb in small intestines; people who have had a gastrectomy have to have

life-long injections of B12 cyanocobalamin), Pepsin (aids in digestion of proteins).  Small intestines absorb most of the nutrients unless the food passes to quickly. Bowel Function –  motility, absorption (amount of absorption depends on speed of food moving), defecation caused by reflex.  Feces produced in large intestines and peristalsis moves feces to rectum for defecation. If a person does not defecate when the need to, water can be reabsorbed into large intestines and stool becomes hard.  Normal bowel function - characteristics of normal feces are o 75% water o 25% solid (fat, fiber, protein) o Brown color (bilirubin, enzymes - bile) o Odor from solids – chemicals formed due to presence of bacteria o Normal bowel function varies (everyone has their own normal baseline and frequency) ****perceived constipation is changes in bowel habits as we age due to slow motility. Then a person takes laxatives which increase osmotic pressure putting more water into bowels and decreases muscle tone. Pain - not an early sign of GI problems – might be localized, might be referred. As far as GI pain is usually associated with eating.

Assessment - common symptoms are abdominal pain, dyspepsia (upper abdominal discomfort associated with eating - indigestion), gas, N/V, diarrhea, constipation, fecal incontinence

Physical assessment – inspection, auscultate, percussion, palpation  Inspection – (look for masses and symmetry) Begin with oral cavity checking, lips, gums, tongue. Check color, presence of blood, breath odor. While inspecting abdomen client lies supine with knees flexed slightly and divide abdomen into 4 quads or nine regions. This allows for consistent results every time.  Auscultate – 5-30 secs (hear snap, crackle, pop) Normal sounds are heard every 5-20 sec, hyperactive sounds are heard 5-6 sounds every 30 secs, and hypoactive sounds are 1-2 sounds every two mins, absent sounds no sounds 3-5 min  Percussion – (hear tympani sounds – air in stomach or small intestines, dullness – heard over organs and solid masses) used to assess size and density of abdominal organs and used to detect presence of air-filled, fluid-filled or solid masses. Can be used independently or with palpation.  Palpation – light palpation to identify areas of tenderness, and muscular resistance.  Abdominal – o measurement of abdominal girth (essential for monitoring ascites). o Perirectal examination - inspect for fistulas, cysts excoriation (reddening of skin from diarrhea)  Hemoccult Test (GUIAC) – looks for hidden blood in stool. Positive test shows blue color and indicates hidden blood in stool. Should not be performed if there is hemorrhoidal bleeding.  Stool culture- looking for atypical (bacteria that isn’t normal flora c-dif, salmonella) microbes. Scoop it and send it to lab warm. Interpretation of feces color o White – barium

o Gray, tan – lack of bile, obstruction o Red – lower GI bleed o Black – rapid peristalsis o Black and tarry – upper GI bleed o Black and dry – rapid peristalsis o Green and diarrhea – infection ****remember stool turns black from iron******* Labs – LFT’s (liver function Test), bilirubin, gastric analysis (detects absence of HCL – you swallow resin and if HCl is absent urine will turn blue), HGB, HCT, BUN, amylase (enzyme) Diagnostic Test o Radiological (indirect visualization) – looking at a negative of upper GI series and involves barium swallow/barium enema. Not used as much, usually see ENDOs o Endoscopic exams (direct visualization)  Esophagogastroduodenoscopy – examine the lining of the esophagus, stomach and first part of small intestines. Also used to evaluate motility of the upper GI. The gastroenterologists views through a lens and is able to take pictures. Biopsy forceps or cytology brushes can be passed through scope and obtained for study. Patient under topical anesthesia and moderate sedation. Patient can experience gagging, nausea, or choking. Very important to monitor and maintain airway. NI – pt should be NPO for 8 hr prior to exam; pt positioned in left lateral position; informed consent obtained; after procedure assess LOC, vital signs, O2 sat, pain level and monitor for bleeding (signs decrease BP, increase HR). After gag reflex returns pt may be given fluids. Until fully

alert pt remains in bed; pt must be transported home by family member.  Colonoscopy/sigmoidoscopy – same capabilities as EGD but larger and longer. Direct visual inspection of anus, rectum, sigmoid, transcending and ascending colon. Most frequently used to detect cancer or surveillance of cancer pt in remission. Tissue biopsies can be obtained polyps removed and evaluated. Patient lying on left side with legs drawn toward chest. Complications are cardiac dysrhythmias and respiratory depression for medications administered. Procedure typically takes 1 hour. NI – Patient may be given a combination of laxatives, saline enemas, and PEG electrolyte lavage solutions the day before procedure. Patient starts clear-liquid diet at noon day before then ingest the lavage solutions every 3-4 hours. S/E’s of preparation include nausea, bloating, cramping, F&E imbalance, fullness. *****S/E are problematic in older adult because their physiological ability to compensate for fluid loss is diminished***** Advise diabetes pts to consult w/primary doctor about meds to avoid hypo/hyperglycemia. Informed consent is obtained. Opioid analgesic or sedative is given for moderate sedation and anxiety relief. During procedure monitor for cardiac and respiratory changes. Pt remains in bed until fully alert; pt may experience abdominal cramping. Monitor for signs of bowel perforation (rectal bleeding fever, abdominal pain and distention). Family member must drive pt home and nurse instructs to watch for signs of bleeding.

*****S/E are problematic in older adult because their physiological ability to compensate for fluid loss is diminished. Older adult may require reduced dosage of opioid analgesic***** o Sonography - detects cysts, tumors and stones; measures size of growth. o CT scan – gall bladder, biliary duct, pancreatic problems; used w/w/o contrast. o Pts getting gall bladder ultrasound must have low fat diet night before; increases visualization. o MRI – looks at soft tissue; metal is major contraindication

Cancer of the Mouth –  can develop in any part of the mouth or throat (lips, tongue, palate, cheeks) and is curable if detected early. Linked to smoking, ETOH use (risk increases with heavier use and combination of both).  Incidence is higher in ages 45+; more prevalent in men and African Americans. 90% of mouth cancer affects squamous cells;  majority of the tumors are on the tongue; cancer spreads very rapidly; first seen as a lesion (non-healing sore; can be white -leukoplakia or red) if doesn’t go away for 2 weeks or more see physician;  as cancer progresses pt may complain of tenderness, difficulty chewing, swallowing, speaking, cough blood-tinged sputum and enlarged cervical lymph nodes.  Collaborative care includes – biopsy, ultrasound, CT scan, radiation/surgery or both, advanced stages – surgical resection (removal of tumor and surrounding tissue to eliminate cancer cells), radical neck dissection (removal of lymph nodes in neck

area as well as the sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve.)  Surgery results in xerostomia (severe dry mouth) which may persist through life.  NI – asses nutritional status (may need enteral or parenteral feedings before and after surgery); assess pts ability to communicate other than oral due to post surgery inability to speak; post-surgery assess airway and manage secretions, pt placed in fowlers position to promote drainage and drainage tubes present; graft site monitored and doppler may be used to assess pulse at graft site; possible trach care; shoulder droop: have pt rotate neck, shrug and rotate shoulder, ROM exercise and PT; patient teaching: use soft tooth brush, dilute H2O2(as prescribed), avoid commercial mouthwashes, avoid hot/cold; modify diet. Pt may need occupational and physical therapy. GERD – Gastroesophageal Reflux Disorder - reflux of gastric contents into esophagus which has troublesome symptoms and can cause injury to the mucosal lining. o Reason for GERD include  incompetent lower esophageal sphincter - caused by foods to regurgitate back up the esophagus ex: caffeine/choc; and anticholinergics  hiatal hernia – The opening in the diaphragm through which the esophagus passes becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax.  pyloric stenosis,  motility disorder.

Incidence of GERD can happen in people with IBS, and airway disorders, peptic ulcers and angina. Alcohol, smoking, coffee and H. pylori is also associated with GERD. o Clinical manifestations include – heartburn (burning pain, tightness); hot, sour or bitter liquid in mouth, hoarseness, lump in throat, disturbed sleep patterns, dyspepsia (indigestion), regurgitation o Assessment – diagnostic testing such and endoscopy and barium swallow will be used to evaluate damage to esophagus. o Mild symptoms that occur for 5+ yrs or > than a week should be evaluated. o Management –  proton pump inhibitors PPI may help Dx. Examples: omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), ETC H2 blockers - Cimetidine (Tagamet) Ranitidine (Zantac), Famotidine (Pepcid) ****Antacids can only cover up problems – mild symptoms*******  pt should be instructed to eat a low-fat diet: avoid caffeine, tobacco, drugs, beer, milk, foods containing peppermint or spearmint, and carbonated beverages, avoid fluid w/meals  avoid eating or drinking 2 hours before bedtime; elevate HOB 30 degress  maintain normal body weight and avoid tight fighting clothes o Complications of GERD –  Changes in the mucosal lining  Esophagitis – inflammation ulcers

 Barrett’s Esophagus – Considered a pre-cancerous lesion; Occurs in 10-15% of GERD pts; pt may also complain of symptoms related to peptic ulcer. Monitor cell changes.  Respiratory: asthma, bronchitis, pneumonia Hiatal Hernia - The opening in the diaphragm through which the esophagus passes becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax.  Two Types o Sliding – (commonly associated with GERD) upper part of stomach and gastroesophageal junction are displaced upward and slide in and out of the thorax. Happens when lying supine and moves back when upright. 95 % of pts with hiatal hernias have a sliding hernia o Rolling – all the parts of the stomach push through the diaphragm next to the esophagus. Notes say into esophagus. Read page 1280-1281  Contributing Factors of hernia o Structural changes (also congenital) o Increased intraabdominal pressure – obesity, pregnancy, ascites o Other factors – age, poor nutrition, prolonged bed rest  Nursing management – Similar to GERD (meds are the same) o Eat small frequent meals and not to recline for 1 hour after meals o Elevate HOB o May need surgery (laparoscopy) o *****older adults: LES less competent/ absence of symptoms or symptoms may not be as pronounced; less pain****************************************

Esophageal carcinoma o Squamous Cell Carcinoma  Risk factors include: GERD, chronic ingestion of hot liquids or food; nutritional deficiencies; poor oral hygiene; smoking, and chronic alcohol abuse  Seen more in African American males  Spreads rapidly and harder to treat the further it spreads; 5 year survival rate  BE is precursor to squamous cell carcinoma o Adenocarcinoma  Risk factors include: GERD (obesity), smoking, alcohol  Seen more in white males  5 year survival rate; spreads rapidly and harder to treat the further it spreads  BE is precursor to squamous cell carcinoma o Clinical signs and symptoms  Generally asymptomatic in early stages  Progressive dysphagia – gets worse and worse (initially with foods then eventually with liquids)  Sensation of a mass in back of throat and painful swallowing  Regurgitation of foods and salvia occur (possible hemorrhage)  Weight loss and loss of strength  Later signs include: dull substernal pain, persistent hiccup, respiratory difficulty and halitosis o Diagnostics/Meds  Barium swallow - outline  Endoscopy with biopsy and brushing – visualization

 CT scan of chest and abdomen (metastatic disease lungs?, liver? Kidneys?)  Treatment – combination of chemo, radiation, and (primary) surgery  Squamous cell reacts better to chemo  Adenocarcinomas re...