MS Nursing Enrichment Class

Gastrointestinal Disorders

Diagnostic Exams
Radiographic tests
Scout film of the abdomen/flat plate
Barium Studies- barium color: ______
Nursing Considerations: drink water after procedure;
stools will be ___
Barium swallow
UGIS- NPO 6-8hrs
LGIS (Barium enema)- Clear liquid diet then NPO,
laxatives/enema
Endoscopy- check if gag reflex has returned
UGI endoscopy
LGI endoscopy : proctosigmoidoscopy
colonoscopy

Diagnostic Tests
Cholangiography
- Consent form; allergies to dye; cleansing
enema ; NPO
Liver Biopsy
- Position before and after the procedure
Lab Tests
- CBC, serum bilirubin, ammonia, amylase,
lipase, LDH, CEA, Alpha-fetoprotein
PY test
- H. Pylori infection; C-capsule given, blow
balloon, presence of gastric urease

GERD
Gastric contents flow upwards to
esophagus
Common in obese and pregnant women
Any activity that can increase intraabdominal pressure (overeating,
bending, tight clothing), foods that
relax cardiac sphincter (alcohol,
peppermint, caffeine, high fat diet),
lying down after meals

GERD

Assessment:
dyspepsia, dysphagia, odynophagia
(painful swallowing), esophagitis

Management
Avoid alcohol, peppermint, caffeine, high
fat diet
Lose weight
Avoid over-eating and tight fitting clothes
Elevate HOB during and after meals

 How

can gastric regurgitation

best be reduced?
A. eat small frequent feedings and
avoid overeating
B. small evening meals with
bedtime snacks
C. belch frequently
D. swallow air

GASTRITIS
Acute
Chronic
Causes:
-

Meds (ASA, NSAIDS, steroids)

Foods (oily, caffeine, spicy, alcohol)
Stress (ischemia of gastric mucosa)

GASTRITIS
Assessment:
-

vomiting, diarrhea,
anorexia, abdominal pain,
melena, hematemesis
CBC- anemia

PEPTIC ULCER DISEASE

Impaired

GI mucosa leading to
erosion and ulceration
May be gastric or duodenal (most
common)

 Predisposing

factors

Stress
Food (MILK included)
cigarette smoking and alcohol
caffeine
Drugs
H. pylori (90%)

PUD
Manifestations:

- Bloating, belching, n/v, pain (burning,

gnawing or aching) located in the upper
abdomen and occurring between
mealtimes or at night, pain associated
with ingestion of specific foods and
ASA, relief of pain after administration
of antacids and food
- Hematemesis, hemorrhage or melena
may occur

NURSING MANAGEMENT
Relieve

the pain
lifestyle modification
dietary modification
quit

smoking
stress therapy
pharmacotherapy
antacids

aluminum or magnesium or AlMgOH

Suppress gastric acid secretions

Histamine (H2) blockers
ranitidine, famotidine, nizatidine,
cimetidine
Proton Pump Inhibitors
omeprazole, esomeprazole, lansoprazole
Coats the ulcer
cytoprotective drugs
sucralfate

 Antibiotics
bismuth-sulfate (Pepto-bismol)
amoxicillin and metronidazole
Surgery
vagotomy
Billroth I and II- gastric resections
Gastrectomy (Pernicious anemia)

TOTAL/SUBTOTAL
GASTRECTOMY
Billroth I and Billroth II

POST-OPERATIVE CARE
AFTER
GASTRIC RESECTION
pain
management
Maintain on fowlers position for
comfort and to promote drainage
Gastric drainage system managementdont reposition NGT
Monitor dressings for drainage
(bleeding)
Assess bowel sounds; maintain on NPO
Nutritional support

DUMPING SYNDROME
rapid emptying of gastric contents into
the small intestine which has been
anastomosed to the gastric stump
Cause: Ingestion of food high in CHO and
electrolytes, which must be diluted in the
jejunum; ingestion of fluid at mealtimes
Signs
weakness, tachycardia, pallor, feeling
of fullness and discomfort, nausea and
(3Ds) dizziness, diaphoresis diarrhea
late signs maybe hypoglycemia
(pancreas secrete excessive insulin)

NURSING MANAGEMENT
Eat

in a recumbent or semi
-recumbent position
small frequent feedings
moderate fat, high protein diet
limit carbohydrates, no simple
sugars
give fluids after meals

Following a subtotal gastrectomy,

a client develops dumping
syndrome. The nurse understand
that dumping syndrome refers to:
A. nausea due to a full stomach
B. rapid passage of osmotic fluid into
the jejunum
C. reflux of intestinal contents into the
esophagus
D. buildup of feces and gas within the
large intestine

APPENDICITIS
Obstruction

of vermiform appendix

signs

acute abdominal pain (RLQ) McBurneys point

anorexia, nausea and vomiting
rigid abdomen with guarding
rebound tenderness
fever
elevated WBC count
Sudden cessation of pain means rupture

NURSING MANAGEMENT
Bed

rest
NPO
Do not give NARCOTICS initially will mask the pain
antibiotic therapy
surgery : appendectomy

PERITONITIS
Caused

by perforation of the GI tract and

hepatobiliary structures; ectopic pregnancy;
peritoneal dialysis
Spillage of chemicals and bacteria inflames the
peritoneum fluid shifts hypovolemia
shock (septic)
signs
abdominal pain and tenderness with guarding and
rigidity
paralytic ileus (absent bowel sounds)
abdominal distention (gas and fluids accumulate)
fever

PERITONITIS
Interventions:

-Maintain fluid and electrolyte balance- treat

shock, IVF and NPO with NGT to reduce
pressure
- Analgesics, paracentesis, monitor weight
- TPN and Antibiotics
Prepare for surgery- treat the cause- drains
will be placed; ATB irrigation of peritoneum,
wound care, pain
Avoid lifting and straining of abdominal
muscles x 6wks post-op

Crohns disease vs Ulcerative

Colitis

Autoimmune
Ileum and ascending
colon
Right lower quadrant
pain
Diarrhea
3-5 watery stools
mucoid stools with pus
Transmural involvement
Ileostomy
Steroids and Flagyl

Autoimmune
Rectosigmoid
Lower left quadrant
pain
Diarrhea
15-20 watery stools
bloody mucoid stools
with pus
Shallow ulcerations
Colostomy
Steroids and Flagyl

ULCERATIVE COLITIS
Interventions:
Steroids, Flagyl, antidiarrheal (Imodium,
Psyllium and antispasmodic agents)
low residue, lacto-free diet, elemental type
diet, TPN, monitor weights, I&O, stool
specimens
prepare for bowel resection (administer
antibiotic bowel prep- Neomycin)
After surgery: wound care, F&E, pain, bowel
function (paralytic ileus) , manage
ileostomy or colostomy, emotional support

CROHNS DISEASE
Interventions:
ATB, diet therapy, vitamin
supplements, stool specimens, F&E
-

Prepare for surgery if there is

obstruction

provide wound management with

skin care; fistulas may require
placement of drains, pouches, skin
barriers

SAMPLE QUESTIONS
The nurse is performing a physical
assessment of a client with ulcerative
colitis.
The finding most often associated with a
serious complication of this disorder would
be:
a. decreased bowel sounds
b. loose, blood tinged stools
c. distention of the abdomen
d. intense abdominal discomfort

A client is scheduled to have a

permanent colostomy. Before the
surgery, a low residue diet is
ordered. The nurse explains that it is
necessary to:
a. lower the bacterial count in the GI tract
b. limit production of flatus in the intestine
c. prevent irritation of the intestinal
mucosa
d. reduce the amount of stool in the large
bowel

The dietary teaching for a client diagnosed

with
ulcerative colitis with a new colostomy is:
a. food low in fiber so that there is less
stool
b. bland foods so that the intestines do
not get irritated
c. everything as long as foods that are
gas forming are avoided
d. soft foods that are easily digested and
absorbed by the large intestine

A client is scheduled to have a bowel

resection and is to receive antibiotics
preoperatively. The nurse should teach
the client that the purpose of the
antibiotics is to help:
a. prevent incisional infection
b. eliminate bacteria from the GI tract
c. avoid postoperative pneumonia
d. limit the risk of UTI

CIRRHOSIS
irreversible

chronic inflammatory
disease- massive degeneration and
destruction of hepatocytes resulting in
disorganized lobular pattern of
regeneration
Types:
- Laennecs cirrhosis, postnecrotic (viral
hepatitis), biliary and cardiac ( ___ CHF)

CIRRHOSIS

GI effects like anorexia, constipation or diarrhea,

abdominal pain, flatulence, n/v, weight loss
(increased portal pressure)
Excessive bile salts
RBC > unconjugated bilirubin > LIVER >
conjugated bilirubin > duodenum > stools (color)

LIVER damage: ________ bilirubin increases?

HYPERBILIRUBINEMIA
Bilirubin > kidneys > __________ urine
Stools > ___________ color
jaundice, tea-colored urine, acholic stools

Cirrhosis

Deamination of CHON > removing of N >

Ammonia > > LIVER > >UREA
Hepatic encephalopathy, asterixis (hand
flapping tremor in hepatic coma)
anemia, thrombocytopenia
Ascites (decreased albumin > decreased
colloidal osmotic pressure), peripheral edema,
dry skin, pruritus, peripheral neuropathies,
portal hypertension, esophageal varices
(most common cause of death), hemorrhoids,
caput medusae

ASCITES

INTERVENTIONS

- Assess for bleeding, impaired skin

-

integrity
Monitor I&O, VS and lab results
daily weight and abdominal girth
administer meds (Vit K, vasopressin if
bleeding)
IV therapy using volume expanders
Assess for breathing problems

Paracentesis
Lactulose and Neomycin - hepatic
encephalopathy- excreted in feces
Tap water enemas to remove
ammonia
Potassium sparing diuretics
High calorie diet, mod to high CHON,
moderate to low fat and low Na diet

Esophageal Varices

 Prevent

MANAGEMENT

bleeding if possible
Administer FFP aimed at increasing clotting
time
Assist with insertion of Sengstaken-Blakemore
tube- assess for esophageal necrosis ( release
pressure periodically)
- assess for aspiration pneumonia- suction prn
- prevent airway obstruction (gastric balloon
deflation or breakage)- cut asap
Provide soft diet and adequate nutrition

SENGSTAKEN BLAKEMORE
TUBE

SAMPLE QUESTIONS
A client has been treated for cirrhosis of the liver
for 3 years. Now he is hospitalized for treatment
of
recently diagnosed esophageal varices. Which of
the following should the nurse teach the client?
a. eat foods quickly so they dont get cold and
cause distress
b. avoid straining at stool to keep venous
pressure low
c. decrease fluid intake to avoid ascites
d. avoid exercise because it may cause
bleeding of the varices

A client being treated for esophageal

varices has a Sengstaken Blakemore
tube inserted to control bleeding. The
most important assessment is for the
nurse to:
a. Check that a hemostat is at the
bedside
b. Monitor IV fluids for the shift
c. Regularly assess respiratory status
d. Check that the balloon is deflated on
a regular basis

BILIARY DISORDERS
1. CHOLECYSTITIS
- ACUTE OR CHRONIC
- ASSOCIATED WITH GALLSTONE OR BILIARY OBST.
- OCCURRENCE: WOMEN 40-50 Y.O.
SEDENTARY
OBESE
- MANIFESTATIONS:
ACUTE:
NAUSEA & VOMITING
-INDIGESTION, BELCHING, FLATULENCE
-EPIGASTRIC PAIN >>SCAPULA 2-4 HRS
AFTER FATTY MEAL & LAST 4-6 HRS
-TACHYCARDIA, TACHYPNEA, FEVER
-LEUKOCYTOSIS

Demerol: Drug of Choice for pain

SURGICAL:
- CHOLECYSTECTOMY
- CHOLEDOCHOTOMY
- LAPAROSCOPIC CHOLECYSTECTOMY
- ESWL
POST-OP CARE:
- MONITOR RESPIRATORY COMP.
- MAINTAIN RESPIRATORY FUNCTION
- NPO, NGT>>SUCTION
- MEDS: ANTIEMETICS, ANALGESICS
- T-TUBE CARE (Choledocotomy)

Post operative nursing Care:

Maintain patency of NGT
2. Assess T-tube if common bile duct is
manipulated
3. position: low to SF
4. monitor dressing
5. clamp T-tube as ordered
6. IVFs and vitamin supplementation
7. deep breathing exercise
8. early ambulation
9. Fat free diet for 6 weeks
1.

Surgical interventions
Abdominal

Cholecystectomy

Laparoscopic
Cholecystectomy

Extracorporeal shock wave

(Lithotripsy)

PANCREATITIS
INFLAMMATION >>
> AUTODIGESTION BY THE
TRAPPED PANCREATIC ENZYMES
> OBSTRUCTION & EDEMA
> INTERSTITIAL HEMORRHAGE &
TISSUE NECROSIS

MANIFESTATIONS:
1. STEADY, SEVERE EPIGASTRIC
PAIN
>>BACK, AGGRAVATED BY FATTY
MEAL & RECUMBENT POSITION.
2. VOMITING
3. FEVER, TACHYCARDIA, LOW BP
4. ABDOMINAL DISTENTION
5. ELEVATED SERUM : LIPASE & AMYLASE CHARACTERISTIC INDICATORS
6. ELEVATED WBC, BLOOD SUGAR AND
BILIRUBIN

GOALS OF CARE
1. CLIENT WILL BE FREE FROM PAIN OR LESS
PAIN
- NPO PREVENTS AUTODIGESTION
- ANALGESIC: DEMEROL DRUG OF
CHOICE
* NO MORPHINE CAUSES SPASM
OF SPHINCTER OF ODDI
2. CLIENT WILL BE FREE FROM SHOCK
- IV FLUIDS

3. CLIENT WILL HAVE ADEQUATE NUTRITION

- NPO >>CLEAR LIQUIDS OR ELEMENTAL
DIET
- NGT TO DRAINAGE- DECREASE
DISTENTION &
SECRETION
- TPN & VITAMIN SUPPLEMENTS
- INSULIN AS NEEDED
4. CLIENT WILL INSTITUTE MEASURES TO
PREVENT CHRONIC PANCREATITIS
- ELIMINATE CAUSE
- ALCOHOL REHAB PROGRAM

Sample Questions

A client with a T-tube following

choledochostomy asks the nurse
why the tube is being clamped
during mealtimes. The most
accurate response by the nurse is

a.
b.
c.
d.

It will help the tube come out quickly

It causes less pain during mealtimes
It will help in the digestion of fats
It helps keep the common bile duct
open

 The

nurse planning the care

of a client admitted with
severe acute pancreatitis
would anticipate the diet
order of:
a. NPO
c. enteral feedings
b. soft low fat diet
d. TPN

You are giving health teachings to a

client who has been prescribed with
a bulk laxative for constipation.
Which dietary source should the
client take with a bulk laxative?
A. Rice B. Bananas
C. Large volumes of water D. Orange
juice

A.

B.
C.
D.

Your client is diagnosed with a gastric ulcer and

H. pylori (+) test. The client asks, Why do I
have to take 4 different medications? Which is
your most appropriate response?
Each of the medications has a purpose in the
treatment of the ulcer as well as eradicating
the causative bacteria.
Eradication of H. pylori increases the risk of
the ulcer recurring.
It is not clear which of the medications is most
beneficial, so all medications should be taken.
Your doctor has a reason for this treatment.

A.
B.
C.
D.

Which of the following is an important

component of a teaching plan for the
client recently diagnosed with peptic
ulcer disease?
Antacids and histamine-2 receptor
blockers should be taken together.
Avoid the use of NSAIDs for pain control.
Increase milk products in the diet to
enhance healing.
Limit physical activity to reduce stomach
acid.

A.
B.
C.
D.

Oral lactulose (Duphalac) is prescribed

for the client who has a hepatic disorder.
You provide instructions to your client
about this medication. Which statement
by the client indicates a need fo further
teaching?
I need to take it with milk.
I need to increase fluid intake while
taking the medication.
I need to increase fiber in my diet.
I need to notify my physician if nausea
occurs.

You are reviewing home care

instructions with a client who was
recently diagnosed with liver cirrhosis.
Which statement by the client indicates
a need for further instruction?
I will take paracetamol for discomfort.
I will eat a balanced diet.
I need to restrict fat in my diet.
I will weigh myself on a regular basis.

A client with ulcerative colitis is diagnosed

with the mild case of the disease. You are
providing dietary instructions and you
give him examples of foods to eat that
represent which of the following diets?
A. High fat with milk
B. High protein with milk
C. Low roughage without milk
D. Low roughage with milk

You are providing dietary instructions

to a client diagnosed with
cholecystitis. You should tell her to
avoid which of the following foods?
A. Fresh fruits
B. Fresh vegetables
C. Chicken breast
D. Steak with gravy

A.
B.
C.
D.

You are developing a teaching plan for

your client with viral hepatitis. Which of
the following should you include in the
teaching session?
Activity should be limited to prevent
fatigue
Diet should be low in calories.
Meals should be large to conserve energy.
Alcohol intake should be limited to 2 oz.
per day.

You are teaching a pre-operative client about

the insertion of an NGT in preparation for
surgery. You evaluate that the client
understands what you have taught him about
when the tube will be removed if he states:
A. When my gastrointestinal system is healed
enough.
B. When I can tolerate food without vomiting.
C. When my bowels begin to function again
and I begin to pass gas.
D. When the doctor says so.