1
Q
What are the general signs and symptoms for a client with an upper gastrointestinal disorder?
A
- nausea and vomiting
- gastric reflux
- upper abdominal pain
- coffee-ground emesis (blood in the vomit)
2
Q
What are the general signs and symptoms for a client with a lower gastrointestinal disorder?
A
- lower abdominal pain and cramping
- diarrhea
- melena (blood in the stool)
3
Q
What medications are given for nausea and vomiting?
A
Antiemetics:
- ondansetron
- metoclopramide
- promethazine
4
Q
What is the typical diet for a client with an acute gastrointestinal disorder with inflammation?
A
NPO (nothing by mouth) and IV fluids are started to prevent dehydration.
This is to decrease inflammation and preparation for possible surgery.
5
Q
What is the typical diet for a client going for a gastrointestinal procedure or test?
A
NPO (nothing by mouth) for at least 4-8 hours. Some clients are taught to have a clear liquid diet only the day before some diagnostic tests.
This is to clean out the bowels and decrease the risk of aspiration.
6
Q
Describe:
Peritonitis
(Immediate complication)
A
It is when the bowel perforates causing infection and eventually sepsis if not treated.
7
Q
What are the characteristic signs and symptoms of peritonitis?
A
- rigid, hard abdomen and pain
- pain that suddenly goes away
- distended abdomen
- no bowel sounds/no flatus
- temperature and chills
- restlessness, tachycardia, and tachypnea
- increased WBCs
8
Q
Interventions:
Peritonitis
A
- IV antibiotics
- NPO
- drain any fluid - surgery/NG tube
- possible surgery to repair perforation
- TPN
9
Q
What is an endoscopy?
A
A test where a flexible tubing with a camera on the end is inserted into the nose or mouth to visualize the digestive tract.
10
Q
What are the interventions for an endoscopy?
A
- NPO for at least 4-6 hours
- will be sedated
- check for gag reflux afterward
- assess for signs of perforation afterward
11
Q
What is a barium test?
A
It is when the client drinks barium or gets an enema with barium to visualize the GI tract.
The barium is white and x-rays are taken while the barium is administered.
12
Q
What are the interventions before a barium swallow test?
A
- NPO for at least 8 hours
- inform client that stools will be chalky white
13
Q
What are the interventions after a barium test?
A
Goal is to prevent constipation: administer laxatives and increase fluids.
14
Q
What is a capsule endoscopy procedure?
A
It is when the client swallows a capsule that has a small camera in it to look for abnormalities in the intestines. The client wears a belt that records the images.
Make sure the client is NPO 3 hours before and 3 hours after swallowing the capsule.
15
Q
What is an endoscopic retrograde cholangiopancreatography (ERCP)?
A
An ERCP is a scope that is inserted into the esophagus to look at the liver, gall bladder, and bile ducts - the hepatobiliary system.
Client will be getting dye, so assess for allergies.
16
Q
What is a paracentesis?
A
It is when a needle is used to get fluid out of the peritoneal cavity.
It’s commonly done for clients with liver failure who have ascites.
17
Q
What are the interventions before a paracentesis?
A
- ensure that informed consent is signed
- get a set of vital signs and weight to assess for fluid shifts
- have client empty bladder to avoid puncture
18
Q
What are the interventions after a paracentesis?
A
- assess for shock and fluid and electrolyte imbalances
- record output
- get a sample and send to lab for analysis
- monitor for pink or bloody urine due to possible bladder puncture
19
Q
What is a liver biopsy?
A
It is when a needle is inserted through the skin into the liver to get a liver tissue sample for laboratory analysis.
20
Q
What are the interventions before a liver biopsy?
A
- Assess PT, PTT, and platelets - if high, there is risk for bleeding and procedure may be held
- give a sedative
- place in a supine or left lateral to access the right side
21
Q
What are the interventions after a liver biopsy?
A
Goal is to prevent bleeding:
- assess for bleeding and peritonitis
- place on right side for at least 2 hours
- no coughing or straining
- teach that there is no heavy lifting for at least 2 weeks
22
Q
What is the most common reason a stool specimen is collected?
A
To check for occult blood (blood that is not obvious to the naked eye).
23
Q
Describe:
Gastroesophageal reflex disease (GERD or “reflux”)
A
GERD is excess stomach acid that goes up the esophagus.
It is caused by excessive relaxation of the lower esophageal sphincter (LES).
24
Q
Who is most at risk of getting GERD?
A
Clients with a hiatal hernia or clients who are overweight.
Both conditions increase intra-abdominal pressure pushing the acid back up.
25
# Describe:
Hiatal hernia
It is when a **portion of the stomach herniates up through the diaphragm**.
## Footnote
It has the same symptoms of GERD and symptoms occur when laying down.
26
What are the severe **complications** of untreated GERD?
1. **Barrett's esophagus** - The damaged lining of the esophagus gets replaced with precancerous cells.
2. **Esophageal stricture** - The damaged lining of the esophagus gets replaced with scar tissue leading to difficulty swallowing.
27
What **substances** should a client with GERD avoid?
* caffeinated drinks
* chocolate
* citrus fruits, tomatoes
* smoking
* peppermint
* alcohol
* fatty foods
* large meals
## Footnote
These substances increase gastric acid production.
28
What is the **characteristic symptom** of GERD?
**dyspepsia** (heartburn)
## Footnote
The epigastric pain is due to acid entering the esophagus. These symptoms typically get worse when the client bends over.
29
What other **disease** can the symptoms of severe GERD imitate?
Myocardial infarction.
## Footnote
Many clients will visit the ER thinking they are having a "heart attack" when it is actually GERD. It is important to rule out a severe cardiac issue first.
30
What are the **diagnostic tests** for suspected GERD?
* **barium swallow** to check for esophageal problems like hiatal hernia
* **upper endoscopy** to look at the esophagus for abnormalities
* **pH monitoring exam** for 24 hours (a scope is placed in the esophagus and the pH is monitored)
31
# Teaching:
Lifestyle changes with GERD
* Limit or avoid foods that cause esophageal irritation
* Avoid smoking and drinking alcohol
* Avoid large meals, especially before sleep
* Sleep with the head of the bed elevated
* Avoid constrictive clothing, bending over and heavy lifting
32
# Medications:
GERD
1. **Antacids** - neutralizes stomach acid
2. **H2 receptor blockers**
* end in _-dine_
3. **Proton pump inhibitors** (PPIs) - prevents stomach acid from forming
* end in _-prazole_
33
What is the **last resort treatment** for a client with GERD?
Fundoplication surgery.
## Footnote
The gastric fundus is wrapped around the sphincter area of the esophagus.
34
# Describe:
Gastritis
Inflammation of the stomach or gastric mucosa.
## Footnote
It is caused by many reasons.
35
# Cause:
Gastritis
From **irritation of the gastric mucosa:**
* infection (such as H. pylori)
* spicy foods
* overuse of aspirin or NSAIDs
* alcohol and smoking
* acid reflux
* radiation
36
# Signs and symptoms:
Gastritis
**Upper GI symptoms:**
* abdominal discomfort
* nausea/vomiting
* acid reflux and burping
37
Which **vitamin deficiency** is associated with chronic gastritis?
**Vitamin B12 deficiency** (which can result in anemia).
## Footnote
Healthy gastric mucosa is needed to absorb vitamin B12.
38
# Interventions:
Gastritis
* assess for bleeding
* NPO or small, bland meals during acute phase
* treat the cause
39
# Medications:
Gastritis
1. **to decrease acid secretion**
* antacids
* H2-receptor blockers (famo**_tidine_**)
* proton-pump inhibitors (pantopr**_azole_**)
2. **antibiotics** to treat *H. pylori*
3. **Vitamin B12** injections
40
What is the **last resort treatment** for gastritis?
**Gastric resection** (Billroth I procedure)
## Footnote
A part of the stomach is removed.
41
# Describe:
Peptic ulcer disease
Are ulcers anywhere from the esophagus to the duodenum.
42
What is the **major complication** if gastritis or peptic ulcer disease isn't treated?
**Perforation and bleeding**
Assess for bleeding and provide interventions:
* check vital signs
* check hemoglobin and hematocrit
* start IV fluids and give blood
43
# Risk factors:
Peptic ulcer disease
**Substances that irritate the mucosa:**
* infection of H. pylori
* overuse of aspirin, NSAIDs, corticosteroids
* alcohol and smoking
* acid reflux
* stress
44
What are the **characteristic signs and symptoms** of a gastric ulcer?
* **pain in the stomach** 30 - 60 minutes after a meal
* **hematemesis** (vomiting of blood)
45
What are the **characteristic signs and symptoms** for a duodenal ulcer?
* **pain in the stomach** 1.5 - 3 hours after a meal and during the night
* **melena** (blood in the stool)
* pain is relieved by eating
46
# Interventions:
Peptic ulcer
* asses for bleeding
* small, frequent and bland meals
* treat the cause
47
# Medications:
Peptic ulcers
**To protect stomach:**
1. Take before meals:
* mucosal barriers such as sucralfate or bismuth subsalicylate
* proton pump inhibitors (ome**_prazole_**)
2. H2 blockers (rani**_tidine_**) at bedtime
3. antacids 2 hours after meals
4. antibiotics for H. pylori
48
# Teaching:
Gastritis and Peptic ulcer disease
**Avoid substances that cause stomach irritation:**
* alcohol, caffeine, and chocolate
* aspirin and NSAIDs
* don't smoke and try to reduce stress - smoking and stress release gastric acid
49
What is the **last resort treatment** for peptic ulcers and gastritis if meds and lifestyle changes don't work?
Surgery to **remove the stomach or part of the intestine** including:
* **gastrectomy**: removal of the entire stomach
* **gastric resection**: removal of the lower half of stomach
* **gastroduodenostomy or gastrojejunostomy**: removal of part of the stomach and then reconnected to the small intestine
50
What is a **gastrectomy**?
The removal of the entire stomach.
51
What is a **gastroduodenostomy**?
A **partial removal of the stomach** with the remaining part connected to the duodenum.
## Footnote
Also called a Billroth I.
52
What is a **gastrojejunostomy**?
A **partial removal of the stomach** with the remaining part connected to the jejunum.
## Footnote
Also called a Billroth II.
53
What is a **pyloroplasty**?
It **widens the pylorus** (lower part of the stomach) to reduce obstruction.
## Footnote
This allows stomach content to empty into the small intestine.
54
What is **Dumping syndrome**?
Can occur after gastric surgery where **food leaves the stomach quickly** due to lack of a stomach.
55
# Signs and symptoms:
Dumping syndrome
Symptoms occur **10 - 30 minutes after a meal**:
1. nausea/vomiting/diarrhea/cramping/pain/diarrhea
2. hot, sweaty, palpitations, dizzy
3. pale, cold, clammy - due to fluid and electrolyte shifts
4. borborygmi (loud bowel sounds)
56
# Teaching:
Dumping syndrome
1. eat a high-protein, high-fat, low-carb diet - may eat laying on left side because delays gastric emptying
2. eat small meals and don't drink fluids with meals
3. lie down after meals
## Footnote
This prevents food from metabolizing too quickly.
57
What is **bariatric surgery**?
It is used with obese clients to **reduce the size of the stomach** by several different ways.
## Footnote
Clients will need psychological interventions to agree to change their lifestyle and keep the weight off.
58
What is **gastric banding**?
A type of bariatric surgery where a **band is placed around the stomach to reduce its size**.
59
What is a **Roux-en-Y gastric bypass**?
It is when a **small pouch is created on the upper part of the stomach**. Then the small intestine is directly connected to it.
60
What are the **postoperative** **interventions** after most gastric surgeries?
* monitor vital signs for signs of hemorrhage and fluid and electrolyte imbalances
* place in Fowler's position to promote drainage and comfort
* keep client on NG tube suction
* NPO status for 1 to 3 days until peristalsis returns
61
Why should the NG tube **_NOT_** be removed after a gastric surgery unless prescribed by the health care provider?
As it might result in the **disruption of the gastric sutures**.
62
How should the **diet** progress after a client has had gastric surgery?
* NPO 1 - 3 days
* clear liquids
* then full liquids as tolerated
## Footnote
After bariatric surgery, the client will be limited to liquids or pureed foods for 6 weeks.
63
# Describe:
Cholecystitis
**Inflammation of the gallbladder**, usually caused by gallstones.
64
What are the **characteristic signs and** **symptoms** of cholecystitis?
* **epigastric pain** that radiates to the right shoulder or scapula
* **pain in the right quadrant** after a high-fat meal
* **Murphy's sign** (can't take a deep breath when pressed on the right quadrant)
65
What is a **biliary obstruction**?
It is when one of the ducts that carry bile from the liver to the intestine via the gallbladder **becomes blocked**. Gallstones can cause this.
## Footnote
If left untreated, this blockage can lead to sepsis.
66
# Signs and symptoms:
Biliary obstruction
1. **from bilirubin in the blood**
* yellow skin (jaundice)
* dark orange and foamy urine
2. **toxins getting on skin**
* itchy skin (pruritus)
3. **from bilirubin not entering the intestines**
* fat in feces (steatorrhea)
* clay/pale-colored feces
67
# Interventions:
Acute cholecystitis
**Focus on preventing nausea and vomiting:**
* NPO
* NG tube decompression (suction)
* antiemetics
* analgesics
68
What **diet** should a client with **chronic cholecystitis** follow?
A diet consisting of **small portions and low-fat meals**.
69
What is a **choledocholithotomy**?
The removal of gallstones.
70
What is a **cholecystectomy**?
The removal of the gall bladder.
## Footnote
"Lap choly" is a common term that means removal of the gall bladder by laparoscopic surgery.
71
What is a **T-tube**?
It is placed in the bile duct after a cholecystectomy to **drain the bile** while the edema subsides.
72
What are the **interventions** for a T-tube?
* semi-Fowler's and keep tube below level of gallbladder to help with drainage
* monitor, empty and record output
* avoid getting bile on skin - it's irritating
* report to HCP for any sudden increase in drainage or signs of infection
73
What is done with the T-tube **before meals**?
It is **clamped before meals** so that the bile can be used for digesting food.
## Footnote
If the client gets abdominal discomfort or nausea/vomiting, unclamp the tube.
74
Why is CO2 gas inserted into the abdomen for a laproscopic cholecystectomy?
For better visualization.
75
Where can pain radiate to when CO2 gas is inserted into the abdomen?
The shoulders
* encourage ambulation
* apply a heat pack to shoulders
## Footnote
This helps to dissipate the gas.
76
# Describe:
Cirrhosis
**Liver damage usually caused by chronic alcohol use or Hepatitis C**. The healthy tissue is replaced with scar tissue.
## Footnote
There are many complications associated with it because the liver has many functions.
77
What are the **major complications** associated with cirrhosis?
* **ascites** (fluid overload in the abdomen)
* **esophageal varices** (bleeding)
* **coagulation problems** (bleeding)
* **encephalopathy** (confusion and coma)
78
What are the **characteristic signs and symptoms** of cirrhosis?
* ascites/edema
* jaundice
* asterixis (coarse hand flapping)
* fetor hepaticus (a fruity, musty breath)
* high ammonia level
* high AST and ALT (liver labs)
79
# Interventions:
Ascites and cirrhosis
**Fo****cus on preventing fluid overload:**
* restrict fluids and sodium
* diuretics
* monitor intake and output
* weight daily and abdominal girth
* paracentesis
80
# Interventions:
Bleeding and cirrhosis
* monitor PT/INR and give vitamin K if bleeding
* insert an NG tube with a balloon tamponade if has esophageal varices
* administer blood products
81
# Interventions:
Encephalopathy and cirrhosis
Focus on **decreasing toxins in blood** and **monitoring for coma:**
* give lactulose to decrease ammonia levels in blood
* fall precautions
82
What **diet** is recommended for a client with **cirrhosis**?
1. if there are no ascites and no signs of an impending coma, give **a high protein diet with supplemental vitamins**
* B complex, vitamins A, C, and K, folic acid and thiamine
2. if there are ascites and possible impending coma, **give a low protein diet**
## Footnote
Protein breaks down into ammonia.
83
Which **medicines are avoided** for clients with cirrhosis?
* **acetaminophen** - it's hepatotoxic
* **sedatives** - due to risk of coma
84
# Describe:
Hepatitis A and E
An infection of the liver transmitted by the fecal-oral route and person-to-person contact.
## Footnote
Prevent by washing hands and foods thoroughly before eating.
85
# Describe:
Hepatitis B, C, and D
An infection of the liver transmitted by body fluids, especially the blood.
## Footnote
Prevent by having protected sex, no IV drug use, and not accidentally sticking self with a needle.
86
How can hepatitis be prevented?
Get vaccinated.
87
# Symptoms:
**Preicteric (1st)** stage of hepatitis
**"flu-like" symptoms:**
* fatigue
* nausea/vomiting/diarrhea
* headache and muscle aches
* increased bilirubin
88
# Symptoms:
**Icteric (2nd)** stage of hepatitis
**Caused by increased bilirubin in the blood:**
* jaundice
* dark or tea-colored urine
* clay-colored stools
* pruritis (itching)
89
# Symptoms:
**Posticteric (3rd)** stage of hepatitis
**Client starts to go back to normal:**
* jaundice decreases
* urine and stool goes back to normal
* minimal GI symptoms
* bilirubin returns to normal
90
What are the **diagnostic tests** for hepatitis?
Client is **positive** for hepatitis if there are **antibodies or antigens** in the blood specific to the type.
## Footnote
Example: + for hepatitis A: **HAV** antibodies in blood
91
What are the **complications** for **untreated Hepatitis**?
* cirrhosis
* if pregnant: fetal death
92
What is the **treatment** if a client is suspected of having hepatitis A or hepatitis B?
Give **immune globulin** to prevent hepatitis from occurring.
## Footnote
Hepatitis B is the most common disease nurses get from accidentally sticking themselves with a dirty needle.
93
# Medications:
Hepatitis C
Antivirals
94
# Treatment:
Hepatitis D
It is typically a mild disease and **there is no specific treatment.**
## Footnote
Hepatitis D infection occurs with Hepatitis B.
95
# Teaching:
Hepatitis
* wash hands a lot!
* don't share personal items, especially for hygiene
* don't prepare food for others
* no alcohol or acetaminophen and sedatives (bad for the liver)
* no blood donation
* small meals that are high carb and low fat
96
# Describe:
Acute pancreatitis
An inflammation of the pancreas usually caused by alcoholism or gallstones.
97
What are the **characteristic signs and symptoms** of acute pancreatitis?
* mid-epigastric or left upper quadrant pain
* pain aggravated by a fatty meal or alcohol
* Cullen's sign
* Turner's sign
98
What **labs** are elevated with acute pancreatitis?
* amylase and lipase
* white blood cell count
* bilirubin
99
# Interventions:
Acute pancreatitis
**Focus on preventing release of enzymes that can damage the pancreas:**
* NPO and IV fluids
* TPN if severely malnourished
* possible NG tube for suction
* Teach to not drink alcohol
100
# Medications:
Acute pancreatitis
1. **Opioids**: to decrease pain
2. **H2 Receptor blockers and proton pump inhibitors**: to prevent increased acid and enzyme release
101
# Describe:
Irritable bowel syndrome
Chronic episodes of diarrhea and constipation.
## Footnote
The cause is unknown.
102
# Interventions:
Irritable bowel syndrome
* If client is experiencing diarrhea, **give antidiarrheals**
* if client is experiencing constipation, **increase fiber and fluids**
103
# Describe:
Ulcerative colitis
An inflammatory bowel disease that occurs in one portion of the colon.
## Footnote
It is an autoimmune disorder.
104
What is the **characteristic symptom** with ulcerative colitis?
Severe diarrhea that may contain blood and mucus.
105
# Describe:
Crohn's disease
An inflammatory bowel disease that can occur anywhere in the GI tract.
## Footnote
The cause is unknown but thought to be autoimmune.
106
What is the **characteristic symptom** with Crohn's disease?
Diarrhea, which may contain mucus and pus.
107
# Medications:
Ulcerative colitis and Crohn's disease
* corticosteroids
* immunosuppressants
* antidiarrheals
## Footnote
Possible ostomy creation if medications don't work.
108
What is the diet for ulcerative colitis and Crohn's disease?
* NPO or low fiber diet when having diarrhea
* Avoid diary products after symptoms have subsided
## Footnote
Dairy products can cause more diarrhea.
109
What is a **colostomy** and **ileostomy**?
**A colostomy** connects the colon to the abdominal wall.
**An ileostomy** connects the small intestine (ileum) to the abdominal wall.
## Footnote
These operations are done because the bowel may have to be rerouted through an artificially created hole (stoma) in the abdomen so that stool can still leave the body.
110
What is the **difference in stool** between a colostomy and an ileostomy?
A _colostomy_ is made from the colon and puts out **more solid stool**.
An _ileostomy_ is made from the small intestine and **puts out more liquidy stool**, putting the client at a higher risk of fluid and electrolyte imbalances.
111
What are the **preoperative interventions** for an ostomy (stoma)?
* work with client to identify optimal placement of stoma (don't want it at the beltline)
* address body concerns and feelings
112
What are the **post-operative interventions** for a stoma?
1. assess stoma
* it should be pink or bright red and shiny
* if pale or purple-black stoma, notify HCP
2. empty when bag is 1/3 full
3. don't let stool get on skin - it's irritating
4. assess for fluid and electrolyte imbalances
## Footnote
Pale stoma indicates a low hemoglobin and hematocrit; purple-black stoma indicates that no blood is getting to it.
113
What types of foods should be avoided for clients with an ileostomy or colostomy?
Avoid gassy foods such as:
* broccoli
* Brussel sprouts
* cabbage
* bean/lentils
* garlic
## Footnote
These foods cause the bag to expand and then possible break.
114
What is a **colostomy irrigation**?
It is when **an enema (warm tap water) is given through the stoma to stimulate a bowel movement**.
## Footnote
Usually done around the same time each day, 1 hour after eating.
115
# Describe:
Appendicitis
An **inflammation of the appendix**. It is usually caused by impacted stool.
## Footnote
If not treated, it can rupture causing peritonitis and sepsis.
116
What are the **characteristic symptoms** of appendicitis?
* abdominal pain most intense at **McBurney's point**
* **rebound tenderness** at McBurney's point
* laying in a side-lying position with legs flexed due to extreme pain.
117
# Treatment:
Appendicitis
**Appendectomy** - removal of the appendix
118
What should **_NOT_ be placed on the abdomen** for a client with appendicitis?
**Never apply a heating pad**; it can cause rupture of the appendix.
119
# Describe:
Diverticulosis and Diverticulitis
_Diverticulosis_ is an **outpouching of the intestinal mucosa**.
_Diverticulitis_ is when that **intestinal mucosa becomes inflamed** from fecal matter getting impacted in the pouches (diverticula).
120
What is the **characteristic symptom** of diverticulitis?
**Left lower quadrant pain** that increases with straining.
121
# Interventions:
Diverticulitis
* NPO and analgesic until inflammation subsides
* assess for perforation
* possible colon resection and colostomy
122
# Teaching:
Diverticulosis
* eat a **high fiber diet**
* drink **2500 - 3000 mL of fluids daily** to prevent constipation
* **do not eat seeds, nuts, or popcorn** since it can get trapped in the diverticula and cause inflammation
* take **bulk-forming laxatives**
123
# Describe:
Hemorrhoids
Dilated veins coming out of the anus.
## Footnote
They are caused by increased abdominal pressure, pregnancy or straining with bowel movements.
124
What is the **characteristic symptom** of hemorrhoids?
Bright red bleeding with bowel movements.
125
# Interventions:
Hemorrhoids
* cold packs and witch hazel soaks to decrease inflammation
* sitz bath for comfort
* possible hemorrhoidectomy
126
# Teaching:
Hemorrhoids
**Focus on preventing constipation:**
* high fiber diet and fluids to prevent constipation and straining
* stool softeners when needed
NCLEX-PN (5) Adult Health
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