INTERVENTIONS FOR CLIENTS WITH GASTROINTESTINAL PROBLEMS

1. INTERVENTIONS FOR CLIENTS WITH GASTROINTESTINAL PROBLEMS PEPTIC ULCER CHOLYCYSTITIS PANCREATITIS 2010

2. HOW DO ULCERS DIFFER? • PEPTIC ULCER • GASTRIC ULCER • DUODENAL ULCERS • STRESS ULCER

3. PAIN COMPARED • Gastric Ulcer: occurs 30-60 min after a meal, rarely at night, accentuated by food • Duodenal Ulcer: Occurs 1 1/2 - 3 hours after a meal, often awakened at night between 1-2 AM, relieved by ingestion of food

4. COMPLICATIONS OF ULCERS • HEMORRHAGE • PERFORATION • PYLORIC OBSTRUCTION

5. Assessment indicating hemorrhage • Hematemesis • Melena • Coffee Ground Emesis • Black stool • Hematochezia • Profuse upper GI hemorrhage

6. Assessment indicating Perforation • Sudden sharp pain • Apprehension • Abdominal assessment • Client position • peritonitis • Bowel sounds • MEDICAL EMERGENCY, LIFE THREATENING

7. Assessment indicating Obstruction PYLORIC OBSTRUCTION: Nausea/Vomiting GASTRIC OUTLET OBSTRUCTION: • Abdominal bloating • Nausea/Vomiting • F & E imbalances

8. Assessment indicating Obstruction PYLORIC OBSTRUCTION: Nausea/Vomiting GASTRIC OUTLET OBSTRUCTION: • Abdominal bloating • Nausea/Vomiting • F & E imbalances

9. TEACHING CAUSE • Use of certain drugs • Bacterial infection • Genetics

10. ASSESSMENT • HISTORY • Physical assessment • What is the most common symptom? • Where is pain? • How is the pain described? • How is the pain different from gastric to duodenal ulcer? • What other symptom is associated?

11. LABORATORY ASSESSMENT • Hgb, Hct • Stool specimen • Ba enema • Upper right abdomen series • ***EGD (esophagogastroduodenoscopy) • Biopsy

12. ASSESSMENT CONTINUED SMOKING CESSATION: • smoking decreases the secretion of bicarbonate from the pancreas into the duodenum • Acidity of the duodenum is higher when one smokes

13. Assessment Continued SMOKING CESSATION: • smoking decreases the secretion of bicarbonate from the pancreas into the duodenum • Acidity of the duodenum is higher when one smokes

14. NURSING DIAGNOSIS • Knowledge deficit RT • Imbalanced nutrition RT • Disturbed sleep RT • Risk for falls RT • Fatigue RT • Nausea RT • Ineffective Health Maintenance RT • Fear RT

15. DRUG THERAPY GOALS: DRUGS for H. pylori bismuth compound or proton pump inhibitor and two antibiotics BISMUTH: Pepto-Bismol PROTON PUMP INHIBITORS: omeprazole (Prilosec) COMBINATION OF ANTIBIOTICS: metronidazole (Flagyl) & Tetracycline clarithromycin & amoxicillin CHALLENGE WITH THIS REGIMEN?

16. HYPOSECRETORY DRUGS • Reduces gastric acid secretions • 1. antisecretory agents • 2. H2 receptor antagonists • 3. Prostaglandin analogues

17. ANTISECRETORY AGENTS Or PROTON PUMP INHIBITORS EXAMPLES: • omeprazole (Prilosec) • lansoprazole (Prevacid) • rabeprazole (Aciphex) • pantoprazole (Protonix) • esomeprazole magnesium (Nexium)

18. H2 Receptor Antagonists • Block histamine stimulated gastric secretions • OTC Examples: • rantidine (Zantac) • famotidine (Pepcid) • nizatidine (Axid)

19. PROSTAGLANDIN ANALOGUES • HOW: reduce gastric acid secretion and enhance gastric mucosal resistance to tissue injury • EXAMPLES: • Misoprostol (Cytotec)

20. DRUGS CONTINUED Hyposecretory Drugs antisecretory Agents H2 receptor antagonist Prostaglandin analogues Antacids

21. ANATACIDS • HOW: • buffer gastric acid and prevent the formation of pepsin • Speeds up healing of duodenal ulcers EXAMPLES: • Mylanta (magnesium containing) • Maalox (aluminum containing) • TUMS (calcium containing) • Simethicone Combination products: Gelusil & Mylanta Problems: INTERACTION WITH DRUGS & • HIGH SODIUM CONTENT

22. MUCOSAL BARRIER FORTIFIERS • Forms a protective coat • EXAMPLE: • Sucralfate (Carafate) • INSTRUCTIONS FOR ADMINISTRATION:

23. DIET • CONTROVERSY • What is known about food? • Instruct client about foods that increase gastric acid secretion

24. SURGICAL INTERVENTION • Seen in 10-15% of pts INDICATIONS FOR SURGERY: • life threatening bleeding • Perforation • Obstruction TYPE OF SURGERY: • GASTRIC RESECTION: remove the gastrin producing portion of the stomach

25. ADDITIONAL SURGERY: BILROTH I AND II • Used to remove ulcers and cancer, not for peptic ulcer disease • Bilroth I (gastroduodenostomy): fundus of stomach anastomosed to duodenum • Bilroth II (gastrojejunostomy) duodenum is closed, fundus of stomach anastomosed into the jejunum • Heineke-Mikulicz pyloroplasty: enlarges pyloric stricture (most common)

26. ASSESSMENT POSTOP • Observe for blood from NGT • Observe for abdominal distention • REPORT TO SURGEON • IRRIGATION OF NGT: not done

27. POSTOP PROBLEMS RELATED TO BILROTH PROCEDURES DUMPING SYNDROME: vasomotor symptoms after eating after Billroth II procedure RESULTS from rapid emptying of gastric contents into the small intestine which shifts fluid into the gut causing abdominal distention • EARLY S&S seen 30 min after eating:vertigo, tachycardia, syncope, sweating, pallor, palpitations and desire to lie down • LATE S&S: 90 min-3hrs after eating caused by excessive amt of insulin: dizziness. • Light headedness, palpitations, diaphoresis, confusion

28. TREATMENT OF DUMPING SYNDROME • 6 small meals a day high in protein and fat and low in CHO; avoid fluids during meals • Avoid refined or concentrated CHO because they leave the stomach quickly • Eat slowly • Vitamins for nutritional deficiencies • Anticholinergics: decrease stomach motility • Somatostatin analogue: octreotide (Sandostatin) Synthetic form of the hormone found in GI tract used to inhibit dumping syndrome

29. OTHER COMPLICATIONS • Alkaline Reflux gastropathy or bile reflux gastropathy • Delayed gastric emptying • Afferent loop syndrome • Recurrent ulceration REVIEW ALL OF THESE: see page 1303-1304

30. NUTRITIONAL PROBLEMS POSTOP • deficiencies of : • vitamin B12 • folic acid • iron • impaired calcium metabolism • reduced absorption of calcium &vitamin D • WHY? • WHAT ASSESSMENTS? • WHAT TREATMENT?

31. BILIARY DISORDERS

32. DEFINITIONS • CHOLECYSTITIS: Inflammation of GB • CHOLELITHIASIS: caused by presence of stones • ACALCULOUS CHOLECYSTITIS: inflammation of the GB without stones • CALCULOUS CHOLECYSTITIS: Follows obstruction of the cystic duct by a stone creating an inflammation • CHOLANGITIS: infection of the bile ducts • CHOLEDOCHOLITHIASIS: common bile duct stones

33. CHOLECYSTITIS WITH CHOLELITHIASIS STONES composed of cholesterol, bile pigment and calcium • INCIDENCE: higher in women over age 40 • PREDISPOSING FACTORS: Runs in families, obesity, middle age, multiparity, use of birth control pills, pregnancy, diabetes, after rapid weight loss, alcholism

34. NON-SURGICAL APPROACH • Low fat diet • Replacement of fat soluable vitamins (A, D, E, K), bile salts • Weight reduction • NGT for uncontrolled vomiting • Broad spectrum antibiotics (ampicillin, tetracycline, cephalosporins) • Dissolution therapy (chenodeoxycholic acid or CDCA; ursodeosycholic acid or UDCA) • Lithotripsy • Endoscopic Retrograde Cholangiopancreatography (ERCP)

35. NON-SURGICAL APPROACH CONTINUED DRUG THERAPY: • Meperidine hydrochloride (Demerol): pain AVOID USE OF MORPHINE (causes spasm and constriction of the sphincter of Oddi) • atropine sulfate (Atropine): anticholinergic • dicyclomine (Bentyl, Lomine): antispasmodic

36. ASSESSMENT OF CHOLECYSTITIS AND CHOLELITHIASIS • Abdominal pain, usually in the right upper quadrant, may radiate to back or right shoulder • Pain triggered by high fat/high volume meal • Full feeling • Eructation • Dyspepsia • Flatulence • Nausea/Vomiting • Low grade fever

37. ASSESSMENT CONTINUED: done by MD and NP • Blumberg’s sign • Murphy’s sign

38. ASSESSMENT CONTINUED FOR CHRONIC CHOLECYSTITIS • Jaundice • Clay-colored stools • Dark urine • Steatorrhea

39. Serum alkaline phosphatase AST (aspartate aminotransferase) LDH (lactate dehydrogenase) Direct serum bilirubin Indirect serum bilirubin DIAGNOSTIC ASSESSMENT

40. WBC: Serum amylase Serum lipase DIAGNOSTIC ASSESSMENT CONTINUED

41. DIAGNOSTIC ASSESSMENT Ultrasound of right upper quadrant: Hepatobiliary Scan:

42. SURGICAL TREATMENT • CHOLECYSTECTOMY: removal of gallbladder and cystic duct • CHOLEDOCHOSTOMY: opening into the common bile duct through the abdominal wall with insertion of T-tube to keep duct open for healing • LAPAROSCOPIC CHOLECYSTECTOMY: removal of gallbladder via umbilical incision

43. POST-OP NURSING CARE FOR LAP CHOLECYSTECTOMY • May be same day surgery/ or 1-2 hospital stay • Must be able to tolerate food, ambulate, and have stable vital signs to be discharged • Mild to moderate pain for two days postop • Mild discomfort for one week • No lifting heavier than 5 lbs • Normal activity in 1-3 weeks

44. POSTOP NURSING CARE FOR PT WITH OPEN CHOLECYSTECTOMY • PCA for severe postop pain (avoid morphine) • Low to semi Fowler’s position • C &DB • Change dressing (usually off in 24 hrs) • IV fluids/NPO • Advance from low fat clear liquids to low fat bland diet as tolerated; many clients don’t need special diet • Antiemetics • Surgical drain for 24 hours • T-tube (placed to keep the common bile duct open)

45. COMPLICATIONS OBSTRUCTION: • Clay colored stool or steatorrhea means no bile in intestinal track • CALL SURGEON! HEMORRHAGE: • Check VS, incisions, tubes, increased tenderness or rigidity of abdomen • CALL SURGEON!

46. COMPLICATIONS INFECTION • Pain • fever DISRUPTION OF GI TRACT FUNCTION: • Vomiting, abdominal distension, increased pain

47. PATIENT EDUCATION • Care of T-tube When to call MD: • Jaundice, dark urine, pale colored stools, pruritus (signs of obstructed bile flow) • Pain or fever (signs of infection)

48. PATIENT EDUCATION • Teach patient to expect loose bowel movements for a few weeks to several months • Teach about low fat diet: trim fat from food, lean meats, remove skin from poultry, limit use of eggs, no frying goods, use skim milk, low fat cottage cheese, no sauces, gravies or rich desserts, increase fish and seafood.

49. T TUBE • T-tube: biliary drainage tube Avoid tension and obstruction of tubing • Keep pt in semi Fowler’s position • Drains to bile bag kept below the level of the GB • Initially blood tinged immediately postop, then changes to green-brown bile • Assess q 2-4 hours initially then q 8 hours after 1st 24 hrs

50. T TUBE • BILE OUTPUT: about 400 + ml/day with gradual decrease in output • REPORT DRAINAGE AMOUNTS IN EXCESS OF 1000 ml/DAY TO MD • REPORT SUDDEN INCREASES IN BILE OUTPUT AFTER NORMALLY DECREASING PATTERN