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Gastrointestinal System

Med Surg Overview and Certification Review Course Kristi E. Cone
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Kristi Cone

on 27 June 2013

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Transcript of Gastrointestinal System

Nursing interventions
Teach importance of fiber.
Relief of constipation with stool softeners or bulk-forming cathartics.
Postop teaching of colostomy care.
The Gastrointestinal System
Med Surg Overview and Certification
Review Course

Kristi E. Cone
Anatomy
Assessment
Pathophysiology
Review
Components
Oral Cavity
Esophagus
Stomach
Small Intestine
Colon
Accessory Organs

Pancreas
Biliary System
Liver
History
Physical
Diagnostic
Chief Complaint
Present Illness
Medical, Family, and Social History
Change in appetite
Heartburn
Pain
Nausea/Vomiting
Constipation
Diarrhea
Stool Characteristics
Symptoms
Use of medications
When Started
Associated Symptoms
Precipitating factors
Alleviating factors
Location
Radiation
Intensity
Duration
Frequency
Prescription
Over-the-counter
Herbal
Vitamin/nutritional supplements
Laxatives
History of other GI disorders, surgery, or trauma
Family history of disorders with a hereditary link
(colon cancer, ulcers, Chron's, ulcerative colitis)
Work,exercise, diet, use of recreational drugs and alcohol
1. Inspection
2. Auscultation
3. Percussion
4. Palpation
Radiology
Contrast studies of upper and lower tracts and gallbladder.
Angiography
Endoscopy (most reliable)
Ultrasonography (of abdomen and hepatobiliary system)
Nuclear imaging
Ct Scans
Liver Biopsy
Gastric or fecal analysis
Laboratory Tests
24-48 pH testing
Fecal studies
Blood, c-diff, pathogens,
bile pigments.
Peritoneal fluid analysis
Urine tests
Bilirubin and urobilinogen
Stool colors
Tan- Hepatic duct of gallbladder blockage, hepatitis, or cancer

Red- colon or rectal bleeding (or some drugs)

Yellow or green- severe, prolonged diarrhea

Black- Gi bleed, iron supplements or raw to rare meat.

Pasty or greasy- high fat content intestinal mal-absorption or pancreatic disease.
Cholecystitis
Cirrhosis of the liver
Diverticular Disease
GERD
Gastrointestinal Bleeding
Hepatitis
Large and Small Bowel Obstruction
Peptic Ulcer Disease
Definition- Acute or chronic inflammation of the gallbladder.
Commonalty associated with cholelithiasis (gallstones)
Causes- Bacterial infection or gallstones.
Signs and Symptoms-
Sharp abdominal pain usually right upper quadrant. Can also be referred to the right shoulder.
Pain associated after eating especially after ingestion of fatty foods.
Abdominal tenderness and muscle rigidity on palpation.
Flatulence, nausea, and vomiting.
Positive Murphy's sign (painful inspiration due to severe tenderness)
Jaundice (if common bile duct is obstructed.
The 5 f's
Fair
Female
Forty
Fat
Fertile
Diagnosis
Ultrasound showing enlarged gallbladder and/or gallstones.
HIDA scan shows gallbladder function. No narcotics 6 hours before test.
Elevated lipase, amylase, total bilirubin, alkaline phosphate, lactate dehydrogenase.
Treatment
Low fat diet
Anticholinergic (decreases spasms of the CBD.
Analgesic
Antibiotic
Chenodeoxycholic acid or ursodeoxycholic acid can dissolve gallstones but must be taken up to 2 years to be effective.
Lithotripsy
Laparoscopic or open cholecystectomy
Nursing interventions
Preop
Monitor pain administer pain medications.
Check skin and sclera for obstructive jaundice.
Postop
Monitor bowel sounds
Monitor wound
Monitor drainage from t-tube (present if gallstones were in the CBD
Administer antibiotics and pain medications as ordered. (pain in shoulders is common from gas used to inflate the abdomen.)
Patient can advance to a regular diet since the gallbladder removal increases the patient's tolerance to fatty foods.
Encourage progressive ambulation.
Definition-
Chronic, progressive disease.
Extensive degeneration and destruction of parenchymal liver cells.
Types-
Micronodular- (Laennec's) alcohol induced.
Macronodular- (postnecrotic, toxin-induced) chemical, bacteria, viral. (Hepatitis B & C)
Biliary- caused by irritating biliary products. (autoimmune or genetic possibly)
Cardiac- caused by right sided heart failure and chronic liver disease. (from hepatic congestion)
Signs and symptoms
Enlarged liver
Liver nodules
Jaundice
Hepatic encephalopathy
Anemia and thrombocytopenia
Fever and malaise
Anorexia and weight loss
Constipation or diarrhea
Dull abd pain and heaviness
Flatulence
Nausea and vomiting
Ascites
Esophageal varices
Peripheral edema
Petechiae, purpura, and spider angiomas
Dry skin
Pruritus
Asterixis (hand-flapping tremor in hepatic coma)
lethargy
mental changes
slurred speech
Peripheral neuropathies
Gynecomastia, impotence (men) amenorrhea (women)
Diagnosis
History
Physical examination
Liver bx
Liver function studies
Ultrasound
CT scan
MRI
CBC, Electrolyte levels, PT
Treatment
Paracentesis
Peritoneovenous shunt
Potassium-sparing diuretic
Antiemetic
Vitamin K
Lactulose (decreases ammonia)
Vasopressin and b-blockers
Sengstaken-blakemore tube
(for esophageal varices)
Blood transfusions
Diet (high calorie, high protein, low fat, low sodium, fluid restriction)
Nursing Interventions
Observe for changes in level of consciousness
Administer antiemetics, diuretics
Maintain bed rest as ordered
Daily weights, measurement of abdominal girth
Monitor for bleeding
Diet teaching
Oral hygiene (prevention of stomatitis)
Teach to avoid straining to lessen pressure on varices or hemorrhoids.
Instruct to avoid spicy or irritating foods, NSAIDs, and aspirin
Encourage use of community agencies (for alcohol induced)
Description-
Characterized by diverticula (bulging pouches) in the GI wall that push the mucosal lining through the surrounding muscle
Types
Diverticulosis (mild to no symptoms)
Diverticulitis (Inflammation can cause obstruction, infection, or hemorrhage.
Causes
Low fiber diet
Defects in wall strength
decreased colonic motility
increased intraluminal pressure
Mild
Moderate LLQ abd pain.
Low Grade Fever.
Leukocytosis.
Severe
Rigidity
Severe LLQ pain
Diminished or absent bowel sounds.
High fever and chills
Hypotension from sepsis
Chronic
Constipation/diarrhea
Ribbon like stools
Signs and symptoms of obstruction
Process
High intraluminal pressure on an area or weakness.
Retained undigested food and bacteria accumulate.
Blood supply is cut off leading to inflammation, perforation, abscess, peritonitis, obstruction or hemorrhage
Diagnosis
Patient History
Barium Enema
Colonoscopy
Treatment
High residue (fiber) diet after pain subsides.
Antibiotics
Analgesics
Colon Resection (could need temp colostomy)
Causes-
Alcohol
Smoking
Hietal hernia
Obesity or pregnancy
Medications
NG tube >4 days
Weakened Esophageal sphincter
Signs and Symptoms
Burning pain epigastric area
Can radiate to arms and chest.
Usually after a meal or when lying down.
Feeling of fluid accumulation in throat without sour taste
Description-
Back flow of gastric and/or duodenal contents past the lower esophageal sphincter into the esophagus without associated belching or vomiting.
Diagnosis
History of heartburn
Esophagoscopy
Barium swallow
Upper GI series
Esophageal acidity test
Acid perfusion test
Treatment
Small Frequent meals.
Upright posture after eating and while sleeping.
Antacids, PPI's, H-2 receptor antagonists, Cholinergic agents
Smoking cessation
Lap Nissen fundoplication
85% UGI
Causes-
Disrupted mucosal-epithelial barrier
Ruptured artery or vein
PUD
Esophageal varices
Diverticular disease
Tumors
Ulcerative colitis
Signs and symptoms
Bloody or coffee ground emesis
Bloody, maroon-colored, or black, tarry stools.
Cramping
Anemia
S/S of hypovolemic shock
Diagnosis
Physical exam
History
Colonoscopy
EGD
CBC, Coags Liver function tests.
Treatment
Volume replacement
Lavage with NGT
Cauterization or sclerotherapy
Treatment of H-pylori
Blood products/ components
Nursing interventions
Monitor for bleeding and hypovolemic shock
Intake and output
Maintain NPO status
Insert two large-bore IV lines
Placement and patentcy of NG tube
While vasopressin administration continuous EKG and BP
Teach how to prevent recurrence.
Diagnosis
History and exam
Abdominal x-rays
Abdominal series
Barium enema
Colonoscopy/endoscopy
Gastric analysis
Signs and symptoms
Abdominal pain
Distention
Anorexia
Nausea and/or vomiting (may have fecal odor)
Constipation or diarrhea
High pitched or absent bowel sounds
Dehydration
Weight loss
S/S of shock
Treatment
NPO
IV therapy
NGT
Analgesic
Antibiotic
Bowel output
TIME!!!
Surgery
Nursing interventions
Maintain NPO status while acute phase
Advancement of diet. High protein low fiber at first.
Small frequent meals.
Monitor for electrolyte imbalances
Check NG for placement and patentcy
Pancreatitis
80% history of ETOH abuse
Description-
Inflammation accompanied by the release of digestive enzymes resulting of autodigestion of the organ.
Causes-
ETOH abuse, trauma, infection, drug toxicity, and obstruction of the biliary tract.
Diagnosis-
History including alcohol intake and use of prescription and nonprescription drugs.
Amylase, bilirubin, glucose, lipace, WBC, decreased serum Ca levels (possibly from fat necrosis)
x-ray, CT, MRI, ERCP
Positive Cullen's and Grey Turner's signs
Treatment-
NPO
TPN
IV fluids
Electrolyte replacement
Glucose control
Analgesic
Antibiotic
Surgical intervention to treat underlying cause.
Nursing interventions-
Maintain NPO status
Then bland, low fat, high-protein diet, small frequent meals
Monitor for s/s of Ca deficiency
Educate to avoid alcohol, caffeine, and spices
Reference:
Judith A. Schilling McCann.(2007) A Springhouse
Review for Medical-Surgical Nursing
Certification. Philadelphia. Lippincott
Williams & Wilkins.
1. A patient with peptic ulcer disease secondary to chronic NSAID use is prescribed misoprostol (Cytotec). The nurse would be most accurate in informing the patient that the drug:
A. Reduces the stomach's volume of hydrochloric acid.
B. Increases the speed of gastric emptying.
C. Protects the stomach's lining.
D. Increases LES pressure
2. The nurse is caring for a patient with active upper-GI bleeding. What's the appropriate diet for this patient during the first 24 hours after admission?
A. Regular diet
B. Skim milk
C. Nothing by mouth
D. Clear liquids
3. A patient is scheduled to have a descending colostomy. He's anxious and has many questions concerning the surgery, the care of a stoma, and lifestyle changes. It would be most appropriate for the nurse to refer the patient to which member of the health care team?
A. Social worker
B. Registered Dietitian
C. Occupational therapist
D. Enterostomal nurse therapist.
4. The nurse is planning care for a female patient with acute hepatitis A. What is the primary mode of transmission for hepatitis A?
A. Fecal contamination and oral ingestion
B. Exposure to contaminated blood
C. Sexual activity with an infected partner
D. Sharing a contaminated needle or syringe
5. A patient experiences an exacerbation of ulcerative colitis. Test results reveal elevated serum osmolality and urine specific gravity. What's the most likely explanation for these test results.
A. Renal insufficiency
B. Hypoaldosteronism
C. Diabetes insipidus
D. Deficient fluid volume
Description-
Erosions of the lining cells of the stomach or small intestine.
20% Gastric
80% Duodenal
Causes-
H. Pylori
NSAIDs
Both disrupt the normal mucosal defense making the mucosa more susceptible to the effects of gastric acid.
Signs and Symptoms
Anorexia, dizziness, eructation, light-headedness or syncope
History of Peptic ulcer disease, ASA or NSAID's
Cigarette, alcohol, or caffeine use
Stress
Diagnosis-
History and Physical exam
EGD
Barium test
Upper GI series
Gastric analysis
gastric cytology
serologic studies
testing for H. pylori
Stool tests for occult blood
Treatment-
Histamine blocker (Pepcid)
PPI (Protonix)
Carafate
Misprostol (prevention protects gastric mucosa)
Antibiotic (if H. pylori)
Stress reduction techniques
Smoking cessation
Surgical repair
Description-
Regional ileitis (Chron's disease) Inflammatory disease of the small bowel that can also affect the large intestine. Typically begins in the ileum but can affect all areas of the small intestine and even the esophagus.
Ulcerative colitis- Chronic inflammatory disease of the large intestine, commonly in the sigmoid and rectal areas.
Regional ileitis vs. ulcerative colitis
Treatment-
Restriction of raw fruits and vegetables as well as fatty and spicy foods.
For debilitated patients TPN may be required.
Anticholinergic to manage intestinal spasms.
Anti-diarrheal
Anti-inflammatory
Antimicrobial
Corticosteroid
Immunosuppressant
Surgery if fistula, obstruction, perforation, hemorrhage, or disease greater than 10 years.
Ileostomy is curative.
Nursing interventions
Purpose and effects of medications
Pre and post op care
Teaching about colostomy/ileostomy (change wafer if leaking, make sure opening around stoma is no more than 1/8")
Description-
Caused by acute or chronic inflammation of the liver.
Caused by viruses, bacteria, trauma, immune disorders, or exposure to chemicals (vinyl chloride and hydrocarbons)
Hepatitis A: Careful hand washing, good personal hygiene, environmental sanitation, screening and control of food handlers, enteric precautions, and ISG administration.
Follow standard precautions, Use gloves and gown if touching soiled or infective material, private room for infected patient with poor personal hygiene and continue for 7 days after jaundice appears.
Description-
Can occur in any part of the large or small bowel or in multiple areas.
May result from infection, tumor, or adhesions.
Complications- Hypovolemic shock, peritonitis, rupture, septicemia, and death.
Nursing interventions-
Administer prescribed medications
Identify foods that cause distress
Teach about disease, treatment, and stress reduction.
Encourage patient to stop smoking.
Provide post op care as needed.
Cullen's
Crohn's and
Ulcerative colitis
Signs and symptoms-
Prodromal or preicteric phase (1-2 days)
May cause: arthralgia, anorexia, aversion to cigarettes, constipation or diarrhea, decreased senses of taste and smell, dislike of dietary protein, elevated serologic test results, headache, hepatomegaly, low-grade fever, lymphadenopathy, malaise, nausea, vomiting, weight loss RUQ pain/ discomfort, splenomegaly, and hives.
Clinical phase (1-2 weeks)
May cause: Bilirubinuria, dark urine, fatigue, hepatomegally, jaundice, light colored stools, lymphadenopathy, puritus, right upper quad tenderness, and weight loss.
Posticteric or recovery phase
(averages 2-12 weeks)
May result in easily fatigued, hepatomegaly, malaise, resolving jaundice, and resolving liver tenderness and enlargement.
Diagnosis-
History
Physical exam (hepatomegaly)
Liver function tests
Antibody tests for surface or cellular antigens
Positive reaction for HBV surface antigen.
Treatment-
Rest including possible bed rest
Vit B, C, K administration
High cal, high carb, moderate to high protein, and moderate fat.
Nursing interventions-
Standard precautions
Balance rest and activity
Monitor for changes in symptoms
Monitor intake and output and electrolyte imbalances
For Hep A & B administer immune serum globulin
Consult dietitian for prescribed diet
Prevention
Hepatitis B and C:
Careful hand washing, screening of blood donors, use of disposable needles, registration of carriers,passive immunization for exposures and vaccine administration for health care providers. Gloves and gown if touching soiled materials.
Grey Turner's
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