Nursing Document 002, Study notes of Nursing

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GI & Hepatic Disorders

Created by: Charlotte M. Wood, PhD, MSN, MBA, RN

Colon cancer is more prevalent among African Americans and smokers.

Gastrointestinal (GI) Disorders

Contributing Factors:

1. Alcohol
2. Autoimmune
3. Diet history
4. Genetics
5. NSAIDS
6. Older Adults
7. Obesity
8. Smoking
9. Sedentary lifestyle
10. Stress
11. A history of recent travel may help pinpoint an infectious source for the client’s diarrhea. A colonoscopy will not cause acute diarrhea. Trouble swallowing is not related to diarrhea. Allergic reactions do not typically cause acute diarrhea.

Gastrointestinal (GI) Disorders

Diagnostic Tests a. Hepatic and Pancreatic laboratory profiles

1. Albumin & Pre-Albumin
2. Ammonia
3. Bilirubin
4. Cholesterol
5. Liver enzymes SGOT, SGPT, LDH, Ammonia,
6. Pancreatic enzymes Amylase Lipase
7. Stool and Occult Samples b. Abdominal Ultrasound c. Endoscopy
8. Colonoscopy
9. Virtual colonoscopy
10. Sigmoidoscopy
11. Esophagogastroduodenoscopy (EGD)
12. Endoscopic retrograde cholangiopancreatography (ERCP) a. Barium Series b. Liver Biopsy c. Paracentesis

Gastrointestinal (GI) Disorders

Diagnostic Tests

3. Sigmoidoscopy-Exam of rectum and sigmoid colon Clear liquid diet 24 hours before procedure Laxative the evening before the procedure Enema the morning of the procedure Sedation is not required Tissue biopsy may be performed Report excessive bleeding

4. Esophagogastroduodenoscopy (EGD)-Exam of the esophagus, stomach, & duodenum (identify bleeding, Crohn’s disease, colitis) NPO 6-8 hours Avoid anticoagulants, aspirin, or NSAIDS for several days before test Atropine to dry secretions IV sedation Local anesthetic is sprayed to inactivate gag reflex Prevent aspiration Monitor for signs of perforation, pain, bleeding, or fever. Comfort measures for hoarseness or sore throat (several days). Post Procedure: The back of the throat is numbed for the EGD, impairing the gag reflex. Therefore the client is initially NPO postoperatively. The nurse should check the gag reflex before offering any type of liquid to the client. The client may be given ice chips or sips of fluids once the gag reflex has returned.

5. Endoscopic retrograde cholangiopancreatography (ERCP)- Exam of the liver, gallbladder, bile ducts, and pancreas NPO 6-8 hours prior to procedure Avoid anticoagulants, aspirin, or NSAIDS for several days before test Assess for allergies to x-ray dye. IV sedation May have colicky abdominal discomfort Monitor for severe pain, fever, nausea, or vomiting (indicates perforation)

Gastrointestinal (GI) Disorders

Barium Series: x-ray visualization from the mouth to the duodenojejunal junction; may include a small bowel follow-through Liver Biopsy: Needle inserted through abdominal wall to obtain sample for biopsy or tissue examination; performed under fluoroscopy. Obtained informed consent Assess coagulation studies (PT, PTT, INR, platelet count) NPO 8-10 hours Position on affected side to promote hemostasis Monitor for bleeding complications Paracentesis: Needle inserted through abdominal wall into peritoneal cavity, withdrawing fluid accumulated due to ascites. Have client void Obtain baseline vitals Position upright Administer mild sedation Administer prescribed IV fluids or albumin to restore fluid balance (as much as 4 L of fluid is slowly drained from the abdomen). Monitor vitals Record Pre & Post procedure Weight Assess lab profile pre & post procedure: albumin, amylase, protein, BUN, creatinine.

Gastrointestinal (GI) Disorders

Ascites A nurse assessing for the presence of ascites would palpate the abdomen for a fluid wave and shifting dullness. Abdominal girth is measured at the end of exhalation, at the level of the umbilicus, while the client lies flat. To ensure that measurements are taken in the same place each time, the nurse should mark the client’s abdomen and flanks with pen.

Gastrointestinal (GI) Disorders

Cirrhosis

1. Cirrhosis frequently results in impaired production of clotting factors, with increased PT and partial thromboplastin time (PTT). Serum albumin is decreased with cirrhosis because protein formation within the liver is impaired.

GI Therapeutic Procedures

Tube Purpose Nursing Interventions Nasogastric Levin: Single Lumen Salem Sump: Double Lumen (1) suction, aspiration, (2) vent Decompress stomach (ileus, gastric atony, or intestinal obstruction) Obtain specimens for analysis (pH of gastric fluid and the presence of blood) Elevate head of bed Verify placement Frequent mouth care Maintain NPO Miller-Abbott: Double-Lumen (1) aspiration, (2) Inflate balloon at tip Small bowel suction Reposition q1 hour Do NOT tape tube to nose Monitor advancement of tube Assess color of gastric contents Sengstaken-Blakemore: triple lumen-(1) esophageal balloon, (2) gastric balloon, (3) suction, irrigation For treatment of esophageal varices; can cause potential trauma and complications for the client, such as rebleeding, pneumonia, and respiratory obstructions Monitor for respiratory distress (most clients have ETT) Keep scissors at bedside Monitor signs of shock

Indications for Tube Feeding Use

A tube feeding, in which nutrition

is delivered through a tube into the

GI tract (called enteral nutrition),

is used for individuals who have a

functioning gastrointestinal (GI)

tract but cannot ingest enough

nutrients orally to meet their

current needs.

Tube feedings can be used as the

sole source of nutrition or in

combination with oral intake. In

certain situations, tube feeding is

indicated

Volume of Formula

The volume of enteral formula that

a person needs varies depending

on individual requirements.

Caloric and protein requirements

of a TF patient are calculated the

same as for any other patient.

Fluid Needs of Tube Fed Patients

Fluid needs are important to

consider for TF patients. Specific

water needs for an individual can

be calculated as 1 ml/kcal or 35

ml/kg usual body weight (UBW).

Patients who have large water

losses through perspiration or

oozing wounds may require more

fluids.

Methods to administer tube feedings:

Continuous Drip Feeding

The continuous drip method is most

commonly used. Continuous drip is

administered via gravity or a pump and is

usually tolerated better than bolus feedings.

Bolus Feedings

Bolus feedings allow for more mobility

than continuous drip feedings because there

are breaks in the feedings, allowing the

patient to be free from the TF apparatus for

activities such as physical therapy.

Combination

A combination of continuous drip (at night)

and bolus feedings (during the day) can be

used.

Enteral Feeding Tubes

Tube Feeding Tutorial: http://www.csun.edu/~cjh78264/tubefeeding/introduction .html

Total Parenteral Nutrition

I. Definition: IV administration of a hypertonic intravenous solution made up of glucose, insulin, minerals, lipids, electrolytes, and other essential nutrients. Total parenteral nutrition (TPN) must be administered through a central venous line. Used to correct severe nutritional deficiencies and minimize adverse effects of malnourishment. A potential complication of TPN is dry mouth, frequent urination, and blurred vision all symptoms of hyperglycemia. II. Contributing Factors: a. Gastrointestinal mobility disorders b. Inability to achieve or maintain adequate nutrition for body requirements c. Short bowel syndrome d. Chronic pancreatitis e. Severe burns f. Collaborative Care III. Nursing Interventions:  Confirm placement by cx-ray  Monitor central line insertion site for local infection  Maintain strict surgical asepsis for dressing change (every 72 hours)  Change tubing and remaining TPN every 24 hours  Monitor for signs of systemic infection  Monitor client’s glucose, electrolytes, and fluid balance  Prevent air embolism  Use infusion pump  Keep 10% dextrose/water available

Total Parenteral Nutrition

Managing GI Bleeding Signs of bleeding in the digestive tract depend where it is and how much bleeding there is. Signs of bleeding in the upper digestive tract include

• Bright red blood in vomit
• Vomit that looks like coffee grounds
• Black or tarry stool
• Dark blood mixed with stool Signs of bleeding in the lower digestive tract include
• Black or tarry stool
• Dark blood mixed with stool
• Stool mixed or coated with bright red blood GI bleeding is not a disease, but a symptom of a disease. There are many possible causes of GI bleeding, including hemorrhoids, peptic ulcers, tears or inflammation in the esophagus, diverticulosis and diverticulitis, ulcerative colitis and Crohn's disease, colonic polyps, or cancer in the colon, stomach or esophagus. The test used most often to look for the cause of GI bleeding is called endoscopy. It uses a flexible instrument inserted through the mouth or rectum to view the inside of the GI tract. A type of endoscopy called colonoscopy looks at the large intestine.

Managing GI Bleeding A type of endoscopy called colonoscopy looks at the large intestine.