Medical Surgical Nursing

Diarrhea - risk for

GASTROINTESTINAL (GI) SYSTEM
 Also called “digestive system”
 Consists of the GI tract & associated organs &
glands
o Mouth, esophagus, stomach, small and
large intestine, rectum, & anus.
dehydration;
o Nutritional stuff, stomach ulcers,
intestines & diarrhea
increase
o Liver, pancreas, gallbladder – MS2
FUNCTION OF GI SYSTEM
Eating enough, issues w/ what pt is eating, absorbing
fiber/fluids,
the nutrients that pt is intaking
N/V = risk for dehydration antidiarrheals
Assess N/V - risk
 Ingestion
 Digestion
 Absorption
 Elimination
 Factors affecting function: for dehydration
Bowel sounds -
o Emotional
- Stress
o Organic
- Anatomy
o Physical
- Diet, habits
active,
 Elderly considerations
hyperactive,
GENERAL GI ASSESSMENT
hypoactive
Assess N/V - risk
Constipation -
for dehydration
increase
Bowel sounds -
fiber/water
active,
Diarrhea - risk for
hyperactive,
dehydration;
hypoactive
increase
Constipation -
fiber/fluids,
increase
antidiarrheals
fiber/water
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Assess N/V - risk

 Diagnostic data
RIGHT UPPER QUADRANT (RUQ)
 Liver

for dehydration  Gallbladder

 Ascending/Transverse colon
LEFT UPPER QUADRANT (LUQ)
Bowel sounds -  Pancreas
 Spleen

active,  Transverse/Descending colon

RIGHT LOWER QUADRANT (RLQ)
 Appendix

hyperactive,  Ascending colon

 Right ovary

hypoactive
LEFT LOWER QUADRANT (LLQ)
 Descending colon
 Left ovary

Constipation - STRUCTURES & FUNCTIONS OF GI SYSTEM

Physiology Of Digestion

increase
 Physical and chemical breakdown of food into
absorbable nutrients
 Starts w/ saliva in the mouth

fiber/water  Protein is broken down by pepsin in the

stomach
 Carbohydrates, fats, & protein are broken
Diarrhea - risk for down in the small intestine
Absorption

dehydration;  Transfer of the end products of digestion

across the intestinal wall into the circulation
 Mostly occurs in the small intestine

increase Elimination
 Large intestine/colon

fiber/fluids,
o Cecum, colon, rectum, anus
o Absorption of water & electrolytes
o Forms & stores fecal mass

antidiarrheals o Secretes mucus

o Defecation – Valsalva maneuver
Assess N/V – risk for dehydration DIAGNOSTIC STUDIES OF THE GI SYSTEM
Bowel sounds – active, hyperactive, hypoactive Radiologic Studies
Constipation – increase fiber/water  Upper GI series
Diarrhea – risk for dehydration; increase fiber/fluids,  Lower GI series
antidiarrheals o COLONOSCOPY
 Subjective data Endoscopy (EGD)
o Dietary recall  Upper GI diagnostic
o Weight gain/loss  Numb back of throat, put scope wherever the
o Changed in appetite/eating issue is (esophagus, stomach)
o Pain  NPO after midnight or up to 6 hrs.
o Indigestion & intestinal gas  Lidocaine on back of throat can impair
o N/V swallowing; assess gag reflex
o Change in bowel habits  Direct visualization of GI structure
 Objective data
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 Endoscopic retrograde o
Sliding hiatal hernia – bulge causes food
cholangiopancreatography (ERCP) to come back up
o Paraesophageal hernia
GASTROESOPHAGEAL REFLUX DISEASE (GERD)  Heartburn, dysphagia
Etiology & Pathophysiology – STOMACH problem  50% are asymptomatic
Clinical Manifestations  Occurs more in women than men
 Heartburn (pyrosis)  Medical management
o Most common clinical manifestation  May require surgery
o Burning, tight sensation felt beneath the Clinical Manifestations
lower sternum & spreading upward to the Same S/S as GERD, but in a different place
throat or jaw  May be asymptomatic
- Feels like chest is on fire,  Symptoms include
uncomfortable o Heartburn
o Felt intermittently - After meals or when lying supine
o Pt might think they’re having a heart o Dysphagia
attack  Heartburn + dysphagia – hiatal hernia
o If pt takes an antacid & it goes away, its Conservative Therapy
heartburn if not it could be heart attack  Lifestyle modifications
 GERD-related chest pain o Eliminate alcohol
o Described as burning, squeezing & o Elevate HOB
radiating to back, neck, jaw, or arms o Smoking cessation
o Can mimic angina o Avoid lifting/straining
o More common in older adults who have o Reduce weight, if appropriate
GERD o Use anti-secretory agents & antacids
o Relieved w/ antacids
Collaborative Care STOMACH & SMALL INTESTINAL DISEASES
 Nutritional therapy – how we prevent GASTRITIS
heartburn Gastritis: inflammation of gastric mucosa resulting in
o Decrease high-fat foods the breakdown of the normal gastric mucosal barrier.
- Fat causes heartburn Erosion of stomach wall 1st stage of wearing down of
o Take fluids between rather than w/ meals mucosal wall
o Avoid milk products at night Gastritis develops into an ulcer – if not treated –
- Milk curdles in the stomach chronic ulcer – perforation
o Avoid late-night snacking or meals
o Avoid chocolate, peppermint, caffeine, Withing peptic ulcer diseases, we have 2 types –
tomato products, orange juice gastric and duodenal
o Weight reduction therapy PEPTIC ULCER DISEASE (PUD)
o Chewing gum & oral lozenges – Types of Peptic Ulcer Disease:
sometimes helps o Acute
o Elevated HOB flo o Chronic
- If pt ate bad or ate late PUD = erosion of stomach lining
o Avoid lying down for 2-fl hrs. after a meal Etiology
– bed blocks o Lifestyle – what you eat
o Medicines
ESOPHAGEAL DISORDERS o Helicobacter pylori
HIATAL HERNIA Clinical Manifestations
Weakened diaphragm – allows acid to back up in  May be asymptomatic
esophagus  Mid-to-high epigastric or back pain
 Enlarged esophagus passes through opening  Dull gnawing burning pain 2-fl hrs. after meals
in diaphragm & enlarges  Bloating
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 Heartburn o PPIs
 N/V o Antibiotics
 Melena o Antacids
 Coffee ground emesis = coagulated blood o Anticholinergics
 Possible seasonal trend o Cytoprotective therapy
Collaborative Care
 Lifestyle Proton Pump Inhibitors (PPIs)
o Rest  Bad thing = they can cause C. diff
o Stress reduction o If pt takes Prilosec & pt is having a lot of
o BRATT diet diarrheas, put pt on contact
 Bananas precautions/enteric precautions – call MD
 Rice & test stool
 Apple sauce  Promote esophageal healing in 80-ft0% of pts
 Tea  Take before first meal of the day
 Toast  Decrease incidence of esophageal structures
 Helps to calm down GI system  Example: omeprazole (Prilosec)
 Can also use for pts w/ a lot of  Most common side effect = headache
diarrheas  Long-term use or high doses of PPIs may
o Smoking cessation increase the risk of fractures of the hip, wrist,
 Pharmacologic & spine
o H2 blockers  PPIs are associated w/ an increased risk of C.
o PPls diff infection in hospitalized pts
o Antacids
o Cytoprotective Histamine-2 Receptor (H2R) Blockers
 Complete healing may take 3-9 weeks  Sometimes allergens cause increased acid
o Should be assessed by means of x-rays or production
endoscopic examination  Decreases secretion of HCI acid
 Aspirin & nonselective NSAIDs may be  Reduces symptoms & promotes esophageal
stopped for 4-6 weeks healing in 50% of pts
Interventions  Example: cimetidine (Tagamet)
 Acute exacerbation w/out complications  Side effects are uncommon
o NPO Acid Protective
o NGT to suction  Used for cytoprotective properties
- NG tube will suck out extra stuff that’s  Example: sucralfate (Carafate)
causing irritation & will decompress o Helps protect the gut by coating the gut
the stomach o Take before meals
o Rest Cholinergic
o IV fluids  Increase LES pressure
- Important because suctioning can  Improve esophageal emptying
dehydrate  Increase gastric emptying
- Add in potassium because suctioning  Example: bethanechol (Urecholine)
pulls out electrolytes Prokinetic Drugs
o Pharmacologic treatment  Promote gastric emptying
o Lifestyle changes  Reduce risk of gastric acid reflux
 Nursing Management  Example: metoclopramide (Reglan)
o Evaluating effectiveness of meds o Helps w/ N/V
o Observing for side effects of meds o Helps w/ gastric emptying, speeds up GI
Drug Therapy tract
 Use of: o Empties stomach quicker so there’s not
o H2 blockers so much acid production
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Antacids  Smoking
 Quick but short-lived relief Duodenal Ulcer
 Neutralize HCI acid  Most common
 Taken fi-fl hrs. after meals or at bedtime  Well nourished
 Example: Maalox, Mylanta  Pain 2-3 hours after meals
 Food may lower the pain
Stress Ulcer
 Physiological stress
Three Major Complications  Shock
Complications happen when you don’t do  Cushing’s Ulcer – brain injury
interventions for ulcers  Curling’s Ulcer – extensive burns
All are considered emergency situations
1. Hemorrhage: most common complication GASTRIC ULCERS
a. How do you know if pt is In the stomach
hemorrhaging  Age >50 y/o
- Coffee ground emesis,  Female
throwing up blood  Pain 30 mins-1 hr. AFTER meals
b. Bleeding can turn into perforation  Food can aggravate
2. Perforation: most lethal complication o Putting more stuff in = more acid =
a. Clinical manifestations include more aggravation
i. Sudden dramatic onset o Results in nausea, burning
ii. Severe upper abdominal  Pt will not want to eat, stop
pain spreads throughout eating, then lose weight
abdomen  S/S include
iii. Tachycardia, weak pulse; o Pain typically happens EARLY
low BP – hypovolemic
o Burning
shock
o N/V
iv. Rigid, board-like
o Gassy pressure in upper epigastric
abdominal muscles
area
v. Absent bowel sounds –
o Weight loss
listen for 2 mins
vi. N/V – hypovolemic shock
DUODENAL ULCERS
b. Interventions:
 Age 5-45 y/o
i. NPO
 Male
ii. Suction
iii. O2  Pain 2-3 hrs. AFTER food
iv. Fluid first then blood  Food can relieve
v. Position = reverse o Will usually have weight gain
Trendelenburg  S/S include
3. Gastric Outlet Obstruction o Pain typically happens LATER
Gastric Ulcer o Burning
 Weight loss o N/V
 HCL – normal or hyposecretion o Cramping across mid epigastric area
 Pain ½ - 1 after meals
 Vomiting PERITONITIS
 Eating may arise pain  S/S include
Common Risk Factors o Fever
 Stress o N/V
 Helicobacter pylori o Absent bowel sounds
 Alcohol  Treatment includes

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o Antibiotics  Surgical therapy – taking out parts of the
o IV fluids colon
 Prevent septic shock which Nutritional Therapy
happens from hypovolemia  Elemental/parenteral
which can happen from  High calorie, vitamin, protein, low residue diet
infection  Dietary consultant
Septic shock = low BP, high pulse; give IV fluids at fast  Goals of diet management include
rate because we need pt back at hemodynamic o Provide adequate nutrition w/out
stability because low BP means no perfusion. exacerbating symptoms
INFLAMMATORY BOWEL DISEASE (IBD) o Correct & prevent malnutrition
Horrible GI/motility issues o Replace fluid and electrolyte losses
 Characterized by chronic, recurrent o Prevent weight loss
inflammation of the intestinal tract Drug Therapy
o Periods of remission are interspersed Amino salicylates
w/ periods of exacerbation Antimicrobials
o Exact cause is unknown  Decrease inflammation
o There is no cure  Used to achieve remission
Etiology  Helpful for acute flare-ups
 Autoimmune process Corticosteroids
 Infectious agents  Because there is autoimmune & inflammatory
 Genetics process
 Environmental causes  Decrease inflammation
 NSAIDs  Used to achieve remission
 Allergies  Helpful for acute flare ups
Clinical Manifestations Immunosuppressants
 Diarrhea  Suppress immune response
 Bloody stools  Maintain remission after corticosteroid
 Weight loss induction therapy
 Abdominal pain  Require regular CBC monitoring
 Fever  Biologic therapies
 Fatigue
Diagnosis
 History & physical
 Rule out other diseases
 Laboratory
o CBC, protein, albumin
 Stool cultures
 Imaging
o barium x-ray studies, CT
 Endoscopy/capsule endoscopy
Collaborative Care
 Rest the bowel
 Control inflammation
 Combat infection
 Correct malnutrition
o If pt is not eating or has not eaten in a
while
 Alleviative stress
 Symptomatic relief
 Improve QQL
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