Nursing Management: Gastrointestinal Problems

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Nursing Management Gastrointestinal Problems

• George Ann Daniels, MS. RN

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Oral Cancer

• Involves the lip, tongue, or inside mouth
• Predisposing Factors
• Interferes with defense mechanisms
• Alcohol
• Tobacco
• Poor oral hygiene
• Trauma from jagged teeth
• Poor fitting dentures
• Malnutrition
• syphilis
• Cirrhosis
• Sun exposure
• Recurrent herpetic Lesions
• Squamous cell carcinoma

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Assessment

• Leukoplakia
• White nodular, patchy areas on the mucosa
• Smokers patch
• Erthroplasia
• Red velvety patch
• Blister
• Non-healing soregt 3 weeks
• Crusts and bleeds
• Painless hard fixed mass
• ulcerations
• Areas of constant irritation

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• Mouth and tongue
• White or yellowish ulcerated lesions
• Early stage- red or white and asymptomatic
• Feels like rough area
• Pain
• Hot/spicy foods
• Impaired speech
• Slurred
• Difficulty swallowing
• Increased salivation
• Blood tinged sputum

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Diagnostic test

• Oral exfoliative cytology
• Scrapping from lesion
• Examined microscopically
• Surgery treatment
• Small lesions
• Simple surgical excision with radiation

• Large tumors
• Total glossectomy
• Laryngectomy
• Mandibulectomy
• Hemiglassectomy
• Radial Neck
• Most common
• Followed with radiation and chemotherapy

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Pre-operative Nursing Care

• Assessment
• Nutritional, fluid, and electrolyte status
• Weight loss
• Respiratory status
• Teach
• Disfigurement
• Impairment of speaking, swallowing, and eating
• Review
• Oral suctioning
• Surgery Preparation
• NPO
• Cleanse mouth prior to surgery

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Post Operative Nursing Care

• Removal or parotid gland
• Assess for Cranial Nerve VI function
• Pain management
• Nutritional
• IV for 24-48 hours R/t edema
• May have NG or gastrostomy tube for tube feeding
• Ability to handle food/fluids
• Psychologic
• Withdraw from people
• Non-adaptive response
• Anxiety about resuming personal responsibilities

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Nursing Process

• Risk for ineffective airway clearance R/T edema,
  difficulty swallowing, increased secretions
• Pain R/T surgical tissue trauma
• Altered nutrition Less than body requirements
  R/t inability to ingest foods and fluids orally

• Impaired verbal communication R/T postoperative
  restriction on mouth movement
• Risk for body image disturbance R/T changes in
  appearance secondary to surgery.
• Risk for infection R/T location of surgical site

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Mandibular Fraacture

• Fracture of the mandible from trauma to the face
  or jaws
• Surgery
• Immobilization
• Wiring the jaws, cross wires, or rubber bands
• 4-6 weeks

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Pre-operative Care

• Teach
• Disfigurement
• Will be able to breathe, speak, and swallow
  liquids
• May have N/G tube to prevent vomiting
• May also be used as feeding tube

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Post-Operatively

• Diet
• Liquid diet
• Straw
• Gas and fatigue
• Oral hygiene
• Warm saline swishes after meals and snacks
• Keep corners of mouth moist
• Oral Communication
• Discharged with wires
• Patient concerns
• Oral care, handling secretions, diet, facing
  people

• Focus on airway
• Respiratory distress emergency
• Cut wires and bands
• Tape wire cutter and scissors to bed
• Surgeon outlines which wires to cut
• Trach and/or endotrach suction on hand
• Aspiration
• Place on side
• Elevate HOB
• Suction

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Nausea/Vomiting

• Nausea is the feeling to vomit
• Diaphoresis, increased salivation, pallor,
  tachycardia, dizziness and faintness
• Vomiting is the expulsion of gastric contents
• Reverse peristalsis and relaxation of the
  esophageal sphincter
• Types Projectile, retching (dry heaves)
• Assessment of vomit
• Condition associated with N/V
• Amount, odor
• Content- undigested food, mucus, parasites,
  foreign bodies
• Color- Green, red, coffee ground, black, brown

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• Hospital
• NPO then IVs with electrolyte replacement
• NG tube
• Keeps stomach empty
• Decreases the urge to vomit
• Bowel obstruction
• Paralytic Illus
• Drugs
• Antiemetic
• Prevention
• Start with water first
• Clear liquids, warm cola, increase in amounts if
  no vomiting
• Dry toast, crackers, bland foods
• Avoid foods that stimulate peristalsis
• High fat foods, orange juice, caffeine, high
  fiber foods.extremely hot or cold fluids

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Geriatric consideration

• Major problem with electrolyte imbalance
• Decreased level of consciousness
• Increased risk of aspirations
• May need to alter doses of antimetics
• Confusion
• Reduce for fragile adults

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Constipation

• Passage of hard, dry stool, less than the
  patients normal pattern
• Factors
• Inadequate dietary fiber, inadequate fluid
  intake, lack of exercise, irregular bowel habits,
  medications (iron).

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Assessment

• Feeling of fullness, back pain, headache,
  anorexia, and malaise, absence of stool,
  abdominal distention, decreased frequency, rectal
  pressure, straining, tenesmus, increase flatus,
  nausea, palpable mass, stools with blood, dizzy,
  and urinary retention

• Time of day , events associated with defecation
  smoking, coffee, eating, diet exercise
  medications
• (laxatives), BS, percussion for abdominal
  distention, check for hemorrhoids, fissures, or
  irritation.
• Long periods between movements
• fecal impaction

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Pediatric Considerations

• Newborn
• 1st stool meconium
• 24-36 hours old
• No stool red flag
• Meconium plug
• Atresia
• Hirschsprung
• Hypothyroidism
• Infancy
• Relates to diet
• Usually no constipation seen in Breastfed infant
• Change to cows milk or formula fed infants

• Childhood
• Environmental
• Delaying urge
• Playing
• School age
• Embarassment
• Stress and change in toileting patterns
• Lack of privacy
• Busy schedule

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Pharmacology

• Laxative types
• Bulk formers- Metamucil
• Absorbs H20 and increases bulk
• Surfactants ( stool softeners) Colace, pericolace
• Lubricates intestines and softens feces
• Contact Laxatives Dulcolax, Exlax
• stimulates peristalsis
• Saline Laxatives- Milk of Mag
• Retention of fluid causing an osmotic effect

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Prevention

• Increase fluid 3 quarts/3000mL per day
• Water, fruit juice
• Avoid caffeine
• Stimulates fluid loss-hard stools
• Increase dietary fiber 20-20 grams
• Softens stool, adds bulk, promotes evacuation
• Bran, fruits, grains
• Infants- increase cereal, add vegetables and
  fruits

• Increase exercise
• Walking, swimming, bike
• 3 times a week
• Promote normal environment
• Regular times to defecate
• Do not delay
• Avoid depending on laxatives or enemas
• Can actually cause constipation
• Normal motility of bowel is interupted
• BM slows or stops passage

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Diarrhea

• Passage of liquid stool more frequent than normal
  bowel habit
• Abdominal cramping, presence of mucus, blood, or
  fat, urgency, tenesmus, perianal discomfort,
  feeling not completely empty
• Pharmacology
• Lomotil, Imodium

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Nursing DX

• Diarrhea
• Well ventilated room, easy access to bathroom or
  bedpan, Stress free environment, Antidirrahea
  medications, NPO for 4 hours, then weak tea,
  bouillon, Jell-O, thin cooked cereal then to low
  residue diet tender beef, veal, chicken, boiled
  or steamed rice, hard boiled eggs. Avoid cold
  liquids, caffeine, and concentrated sweets
• Risk for Impaired tissue integrity
• use soft toilet paper, gently wash with gentle
  soap and warm h20, pat dry. Protective salve.
  Sitz baths for 10 minutes TID. Witch hazel
  soaked pads (Tucks)

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• Fluid Volume deficit
• IV, I O, measure all liquid stool and count in
  output. Weight daily, monitor lab values for
  electrolyte imbalance.

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Pediatric Diarrhea

• Most acute diarrhea is infectious
• Self limiting
• Less than 14 days in duration
• Chronic diarrhea
• Greater than 14 days
• Intractable diarrhea of infancy
• Fist few months
• Greater than 2 weeks
• Chronic nonspecific diarrhea (CNSD)
• Irritable bowel of childhood and toddlers
• Ages 6-54 months

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• Assessment data
• Mild diarrhea
• Few stools/day without evidence of illness
• Moderate diarrhea
• Several loose or watery stools/day
• Normal or elevated temperature
• Vomiting
• Fretful and irritable

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• Severe diarrhea
• Numerous to continuous stools
• Evident signs of dehydration
• Cry lacks vigor, often whining and high pitched
• Irritable
• Seeks comfort and attention
• Displays purposeless movements
• Inappropriate response to people/familiar things
• Lethargic, comatose, or moribund (near death)

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Goals in Management of diarrhea

• Assessment of fluid and electrolyte imbalance
• Re-hydration
• Maintenance of fluid therapy
• Re-introduction of adequate diet

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Oral Hydrating Solutions

• ORSs
• Mild to moderate diarrhea
• 60-80 mL/kg over 2 hours
• Older children
• 11 replacement ( stool amount replacement
  fluids)
• 10 mL/kg or ½ to 1 cup ORS for each diarrhea stool

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Pediatric Considerations

• Dehydration
• Total output of fluid exceeds the total intake,
  regardless of the underlying cause
• Fluid loss
• Insensible loss
• Skin and respirations
• Renal excretions
• GI tract
• Diabetes Ketoacidosis
• Extensive burns

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Extent of Dehydration

• Know the moderate and severe signs and symptoms
  located in table 24-1 on page 882 of Wong

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Pediatric Fluid Requirements

• Daily maintenance fluid requirements
• Calculate weigh of child in kilograms
• Allow 100 mL per kilogram for first 10 kg
• Allow 50 mL per kilogram for second 10 kg
• Allow 20 mL for remainder of weight in kilograms
• Total the amounts
• Divide total amount by 24 hours to obtain rate in
  mLs per hour

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Nursing Management

• Monitor I O
• Assess change in condition
• Very rapid
• VS, Skin, Mucous Membranes, Body Weight,
  Fontanels, Sensory alterations
• Interventions are specialized to specific
  disorder
• Diabetes, renal, etc.

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• Manage diarrhea with ORS
• AVOID Fruit juices, carbonated drinks and gelatin
• Avoid high carbohydrate content low electrolyte
  high osmolality
• AVOID Caffeinated soda high in caffeinediuretic
• AVOID BRAT diet
• No longer used r/t little nutritional value ( low
  in energy and protein) high in carbohydrate and
  low in electrolytes

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Hiatal Hernia

• Herniation of a portion of the stomach into the
  esophagus
• S S
• Heartburn
• Regurgitation
• Chest pain
• Dysphagia

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Types

• Sliding
• Most common
• Gastroesophageal sphincter is displaced into the
  thoracic cavity

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• Paraesophgeal (rolling)Hiatal Hernia
• Stomach fundus rolls into the thorax

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Complications

• Erosion
• Hemorrhage
• Stenosis
• Strangulation
• Regurgitation
• Aspiration

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Nursing Management

• Bland diet in small feedings
• Semi-fowlers position after eating-promotes
  movement of ingested foods
• Pain management
• Antacids
• Pyrosis
• Histimine- Blocking agents
• Tagamet
• Pepcid

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Surgical Treatment

• Fundoplication
• Wrapping the fundus of the stomach around the
  lower portion of the stomach
• Creates a one-way valve
• Post op
• NPO until peristalsis returns
• IV until peristalsis returns
• Patent N/G tube
• irrigate

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Esophagitis/GERD

• Inflammation of the esophagus
• Most common
• GERD
• Reflux of gastric secretions in the esophagus
• Incompetent LES

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Triggers

• Smoking
• Intake of alcohol or spicy foods
• Ingestion of caustic agents
• Lye/ammonia
• Reflux (GERD)
• Friction movement of sliding hiatal hernia
• Prolonged gastric intubations
• Bacterial/viral invasion

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Assessment

• Diet
• Produces Heartburn
• Feels like lump in the throat
• Food stoppage
• Dysphagia
• Solid foods
• Respiratory difficulty
• Aspiration of gastric content

• Heartburn
• Pyrosis
• Retrosternal
• Burning
• Painful swallowing
• Radiate to arms, neck, back, jaw
• Regurgitation
• belching

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Complications

• Local effects of gastric secretion irritation on
  the esophageal mucosa
• Formation of fibrosis scar tissue
• Ulcerations
• bleeding

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Management of Mild Esophagitis

• Goal- eliminate cause and promote healing
• Nutritional
• Bland diet
• Restrict spicy/acid foods
• Weight reduction

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• Prevent reflux
• Small frequent meals
• Sleep with HOB elevated
• Blocks 4-6 inches
• Do not lie down 2-3 hours post eating
• Avoid tight fitting clothing around waist
• Avoid bending over after meals
• Diet
• High protein, low fat

• Avoid
• Alcohol
• Smoking
• Caffeine
• Late night eating
• Avoid fatty foods, chocolate, peppermint,
  spearmint, alcohol, tea, coffee

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Medications

• Antacids
• Coats stomach lining that help decrease gastric
  secretions
• Between meals and HS
• 1-3 hours
• Cholinergic drugs
• Increases pressure at the LESincreased gastric
  emptying
• Reglan

• Histamine Antagonist
• Reduces gastric secretions
• Cimetidine (tagamet)
• Famotidine (Pepcid)
• Ranitidine (Zantac)
• Proton-pump inhibitors
• Lanosprazole ( Prevacid)
• Omprazole (Prilosec

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Pediatric Considerations

• Assessment
• Spitting up
• Vomiting
• Weight loss
• Gagging
• Chocking at the end of the feeding
• Respiratory problems
• Hematemesis
• Melena
• Anemia
• Heartburn
• Irritability

• Medication
• Tagment, Zantac, Pepcid, Prilosec
• Nursing Care
• 30 degree angle
• Elevate head of crib with extra bedding, wood, or
  metal frame, or wedge constructed from cardboard.

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Gastritis

• Inflammation of the gastric mucosa
• Factors
• Break down in the gastric mucosa
• Chronic alcohol abuse
• Excessive ingestion of ASA/NSAIDS
• Reflux of duodenal contests post gastric surgery

• Radiation
• Helicobacter pylori
• Staph
• Salmonella
• Smoking
• Stress
• Renal failure
• Spicy, irritating foods
• Trauma
• NG suction
• Hiatal hernia
• Endoscopic procedures

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Types

• Type A
• Autoimmune disease
• Eats away the mucosa
• Type B
• Presence of Helicobacter pylori

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Manifestations

• Anorexia
• N/V
• Epigastric tenderness
• Feeling of fullness
• Hemorrhage
• Alcohol abuse

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Management

• Bland diet
• Six small meals a day
• Antacid after meals

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Achalasia

• Peristalsis of the lower 2/3 of the esophagus is
  absent
• Food and fluid accumulate in the lower esophagus
• Results in dilation of the lower esophagus

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Assessment

• Dysphagia
• More frequent with fluids
• Substernal pain
• After meals
• Halitosis
• Inability to erucate
• Regurgiation of sour-tasting food and liquids
• Horisontal position
• Weight Loss

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Treatment

• Dilation
• Dilation of the esophagus
• Pneumatic dilation of the LES
• Balloon tipped dilator passed orally
• Surgery
• Esophagomyotomy
• Division of muscle fibers in the esophagus
• Allows pouch to form
• Swallowing with out obstruction
• Medications
• Anticholinergics, calcium channel blockers, long
  acting nitrates

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Abdominal Trauma

• Blunt
• MVA
• Penetrating
• Gunshot wounds or stab wounds
• Lacerated liver, ruptured spleen, pancreatic
  trauma, mesenteric artery tears, diaphragmatic
  rupture, urinary bladder rupture, great vessel
  tears, renal injury, and stomach or intestinal
  rupture

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Manifestations

• Guarding and splinting of the abdominal wall
• Hard, distended abdomen
• Intraabdominal bleeding
• Decreased or absent bowel sounds
• Contusions, abrasions, or bruising
• Abdominal pain
• Pain over scapula
• Hematemesis/hematuria
• Hypovolemic shock
• Cullens sign

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Nursing management
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Hirschsprung Disease

• Obstruction caused by inadequate motility of
  parts of the large intestines
• Failure of ganglion cells to migrate along the GI
  tract during gestation
• Aganglionic segments of the proximal portion of
  the large intestines and rectum
• Absence of peristalsis in a segment of the large
  intestines
• Accmulation of intestinal contents
• Megacolon

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Diagnostic Evaluation

• Based on clinical manifestations
• Barium Enema
• Anorectal biopsy with histological examination
  for absence of ganglion cells

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Clinical Manifestation

• Newborn Period
• Failure to pass meconium within 24-48 hours after
  birth
• Spitting up
• Poor feeding
• Visible bowel loops
• Bile-stained vomitus
• Abdominal distention

• Infancy
• Failure to thrive
• Constipation
• Abdominal distention
• Diarrhea and vomiting
• Explosive watery stools
• Fever
• Severe prostration

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• Childhood
• Symptoms more chronic
• Constipation
• Ribbon like foul smelling stools
• Abdominal distention
• Palpable fecal masses
• Poorly nourished

• Prognosis
• Good with corrective surgery
• Temporary colostomy

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Nursing Care

• Pre-op
• Improving nutritional status
• Low fiber, high calorie, high protein
• TPN
• Enemas
• Sterilizing colon
• Saline enemas with antibiotic solutions
• Oral antibiotics
• Psychological preparation for possible
  colostomy Parent and child
• Stress colostomy is temporary

• Post-op
• Stoma Care
• Diaper pinned below dressing to prevent
  contamination
• Possible foley
• Discharge teaching
• Colostomy care
• High fiber diet