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CARE OF THE CLIENT WITH

PROBLEMS RELATED TO THE


GASTROINTESTINAL SYSTEM,
LIVER AND BILIARY TREE

Earl Francis R. Sumile, RN


Instructor, College of Nursing
University of Santo Tomas
Nursing Assessment
• Anorexia, nausea or vomiting
• Dysphagia
• Dyspepsia (indigestion)
• Pyrosis (heartburn)
• Diarrhea or constipation
• Regurgitation
• Bleeding- hematemesis, melena, hematochezia,
• flatulence, aerophagia, borborygmus
• Abdominal rigidity
• Hiccup
• Jaundice (obstructive)
• Acholic stools
Diagnostic Assessment:
2. Hematologic liver function studies
a. To determine excretory function
• Serum bilurubin T=0.1-1 mg/dl
• Serum alkaline phosphatase 2-5 bodansky unit
• SGOT Serum Glutamic Oxalo Transaminase or AST Aspartate
Aminotransferase N= 7-40 U
• SGPT Serum Glatamic Pyruvic Transaminase or ALT Alanine
Aminotransferase N= 10-40 U
b. To determine metabolic function
• Serum protein- albumin, globulin
• Serum ammonia- N= 20-150 ug/ 100ml
• Serum amylase N= 4-25 u/ml
• Prothrombin time N=11-16 secs
c. To determine detoxifying function
• BSP- Bromosulphthalein- NPO- dye injected IV on one arm, after 45
mins. Blood extracted from other arm
1. Roentgenography or Fluoroscopy
• Barium swallow (UGIS)- x-ray of esophagus, stomach, and
duodenum
• Barium enema (LGIS)- x-ray of small and large intestines
Prep- light evening meal, catharties at bedtime, NPO x *hrs
cleansing enema in am
• Oral Cholecystography- x-ray of visualization of the gall
bladder after introduction of dye
Telepaque tablets- to be taken one at a time at 5 minutes
interval, with a total of 240 ml of water
• Cholangiography- x-ray visualization of common bile duct
after giving of contrast medium (intravenous, operative and t-
tube) contrast medium- hypaque
1. Direct visualization- endoscopy and position during
a. Esophagoscopy- recumbent with head and elevated shoulder
b. Gastroscopy- right side lying
c. Duodenoscopy- right side lying
Prep- NPO x 6-8 hrs; anticholinergic, sedative, narcotic, topical
anesthetic are given
Post- NPO until gag reflex is back (x4hrs)
d. Anoscopy
e. Proctoscopy
f. Sigmoidoscopy
g. Colonoscopy
Prep- cleansing enema; clear liquid diet; laxative; position
• Liver biopsy- done with a fine needle aspiration (FNAB); during the
procedure- instruct patient to hold breath, position after- right sims with a
small pillow or rolled towel at costal margin
• Analytic examination
• Gastric Analysis- to determine hydrochloric acid in the stomach
Prep- NPO then NGT is inserted
give gastric stimulant (histamine phophate to stimulatehydrochloric
acid production)
antidote histamine reaction- epinephrine or adrenalin
• Gastric Tubeless Analysis
diagnex, blue or azuresin + 1g water
no medications NPO 6-8 hrs
urine saved after 2 hrs (n= blue color)
3. Cultures and stool specimens- hemoccult, hematest and guaiac
Alternative Feeding:
• Enteral hyperalimentation- delivery of nutrients directly to the GI
tract.
a. Short- term- esophagostomy; nasogastric tube
b. Long- term- gastrostomy; jejunostomy

Indications of NGT:
• Gavage- to deliver nutrients; for feeding purposes
• Lavage- to irrigate the stomach
• Decompression- to remove stomach contents or air
Nursing Care in NGT:
2. Check placement of feeding tube
• Aspirate 10-20 ml of gastric secretions (measure gastric residual and return
to stomach)
• Measure the pH of aspirated fluid
• Inject 10-30 ml of air into feeding tube and auscultate over the epigastric
area with stethoscope
• Place patient on high fowler’s if permitted
• Hang or elevate the feeding bag or syringe about 18 inches above the
patient’s head
• Flush tube with 30-50 ml of water in the end of the feeding
• Care of nares with NGT- apply water soluble lubricant to prevent irritation
• Reposition tube to insure patency
• If tube is for decompression, observe signs and symptoms for metabolic
alkalosis
• Hyperalimentation (total parenteral nutrition)- method of giving highly
concentrated solutions intravenously to maintain a patient’s nutritional
balance when oral or enteral nutrition is possible

Nursing Managements:
• Filter is used in the IV tubing to trap bacteria
• Solution and administration equipment should be changed every 24 hours
• Dressing changes every 48-72 hrs with antibiotic ointment to catheter
insertion
• Medication is never administered in a TPN line
• Do not abruptly discontinue TPN
• Observe for complications
• Infection
• Venous thrombosis
• Hyperglycemia
Common Diseases:
A. Peptic Ulcer Disease
- break in the continuity of gastric mucosa that comes in contact with
hydrochloric acid and pepsin
Predisposing Factors
- emotional stress, irregular meals excessive smoking, drinking coffee
or alcohol, drugs; genetics
Incidence
- more in men with emotional stress; type O blood
Duodenal
• 10x more frequent than gastric ulcer, occurs within 1.5cm of the
pylorus
• characterized by hypersecretion of acid due to increased rate of
gastric emptying
• more common among young men
• smoking, alcohol, abuse, psychogenic stress

Signs and symptoms


- gnawing, burning, cramping, epigastric pain (right side) 3-4 hrs after
meals
Gastric
• most common at antrum
• gastric secretions and emptying normal
• rapid diffusion of gastric acid to gastric mucosa
• gnawing, burning, cramping, epigastric pain in epigastric (left side) 1
or 2 hrs p.c.
• smoking, alcohol abuse, emotional stress, drugs
• men with low socio- economic groups
Nursing Management

• rest
• bland diet- no caffeine, alcohol and spicy foods
• stress nursing management
• if with hemorrhage- gastric lavage
•Medications

•Antacids-neutralizes hydrochloric acid and relieves pain; give 1-


2 hrs after meals
•Mucousal barrier fortifier- to protect mucousal barrier
sucralfate; given 1 hr before meals (empty stomach)
•Hyposecretory agents- reduce secretions
• H2 (histamine) receptor antagonists- inhibits gastric
secretions; given 1 hour a.c.
•Anticholinergics- decreases motility and volume of gastric
secretions; give 30 min a.c.
•Prostaglandin analogs- cytotec
•PPI- Proton Pump Inhibitor- losec
•Surgery

•gastrectomy- removal of stomach- anastomosis of esophagus


and duodenum
•Billroth I- gastroduodenostomy
•Billroth II- gastrojejunostomy
•Vagotomy- resection of vagus nerve to inhibit vagal stimulation
and decrease motility and gastric secretions
•Pyloroplasty- enlargement of pyloric sphincter to permit passage
of chyme
Complication:
1. Dumping Syndrome
-rapid emptying of food especially concentrated carbohydrates int the
duodenum; food draws fluid from the blood stream- hypovolemia

Signs and Symptoms Nsg Management:


•faintness a. Small frequent meals
•dizziness b. Chew food thoroughly
•sweating c. Avoid high carbohydrate diet
•nausea and vomiting d. Avoid liquid within meals
•palpitations e. Lying down after meals-
flat for 5-30min p.c.
2. IBD- Inflammatory Bowel Disease

a. Regional enteritis (Crohn’s disease)- nonspecific inflammatory


disease in any segment of the alimentary tract (usually ileum);
thickening of intestinal wall with scar tissue formation; characterized by
remissions and exacerbations

Signs and symptoms


•3-5 large semisolid stools per day
•stools contains mucus and possibly pus but rarely blood
•steatorrhea if with small bowel affectation
•right lower quadrant pain (mimics appendicitis)
B. Ulcerative colitis
- chronic ascending inflammation of rectumand colon; may be
psychophysiologic- related to personality traits of perfectionism,
rigidity, insecurity, dependence on a mother figure

Signs and symptoms


•profuse watery diarrhea (15-20 stools per day)
•stool contains blood, mucus and possibly pus
•abdominal cramping with BM (tenesmus)
•loss of sodium, calcium, potassim, bicarbonate
Nursing Management of IBD:

a. pharmacotherapeutics- sulfonamide or aspirin; corticosteroids;


immunosuppressive drugs
b. diet- cannot cause IBD; for patient comfort
•high calorie and high protein diet
•bland low residue
•limit dairy products
•multivitamin and mineral supplement
•liberal fluid intake of 2.5-3 liters/ day
•TPN
c. surgery- ileostomy
C. Colorectal Cancer
80%- distal portion from sigmoid to anus
Early detection:
a. digital rectal exam annually after age 40
b. occult blood test yearly after age 50
c. proctosigmoidoscopy every 5 years after age 50

Signs and symptoms


a. ascending colon- anemia and unexplained GI bleeding
b. descending colon and sigmoid colon- change in bowel habits and
rectal bleeding, tenesmus
Management:

1. APR (Abdomino Perineal Resection)- Mile’s with colostomy site


of permanent colostomy- lower descending colon
Types of colostomy
a. single barrel- usually permanent
b. loop- with bowel inflammation; segment is brought to the
abdomen for temporary colostomy held in place with rubber tubing
connected to a glass rod and left until healed (10 days); usually
temporary
c. double barrel- if tumor at ascending or transverse colon
(proximal stoma- evacuates feces, distal- mucus); usually
temporary
Preop bowel prep:
•reduce bacteria in the intestinal tract to prevent postop complications
or infections
•antibiotics- neomycin and kanamycin
•reduce colon content- low residue diet, laxatives, enema
•decompress gastrointestinal tract
•cathartics-
•stimulants- increases motility
•saline cathartics- contraction and movement of osmotic
activity
•lubricants- facilitates passage of stools
•bulk forming
Colostomy Care:

a. skin care- use of effective skin barriers or wafers to prevent skin


irritation; cleanse with mild soap and water using cotton cloth
b. odor control- avoid foods known to cause odor; lessen with yogurt,
cranberry juice and buttermilk; use of pulvorized charcoal, sodium
bicarbonate, spray disorders
c. control of gas-avoid carbonated beverages and gas forming foods
d. diet- avoid overeating; chew food thoroughly; prevent diarrhea or
constipation
e. colostomy irrigation- to stimulate peristalsis; to establish a regular
pattern of evacuation
Nursing Consideration:

•starts on 5th or 6th postop day


•done at the same time everyday, preferably after a meal
•patient sits on the commode
•prime the stoma with little finger
•hang the irrigating bag (use lukewarm solution) 18-20 inches above
the stoma
D. Liver Cirrhosis
-scaring of the liver

Causes:
a. Laennec- alcohol ingestion or malnutrition
b. Post hepatitis- fibrosis
c. Biliary obstruction
Normal and altered liver function in cirrhosis:

1. Maintenance of normal size and drainage of blood from


gastrointestinal tract- gastrointestinal symptoms like nausea and
vomiting
2. Metabolism of carbohydrates- decreased energy
3. Metabolism of fats- hepatomegaly (fatty liver); decreased energy
production; weight loss
4. Protein metabolism- decreased albumin production- edema and
ascitis; decreased production of clotting factors- bleeding; anemia
5. Detoxification of exogenous substances- decreased metabolism of
sex hormones- loss of sex characteristics; decreased metabolism of
aldosterone- edema or ascites; increased K or H2 excretion
(hypokalemia or alkalosis); decreased metabolism of ammonia-
hepatic encephalopathy
6. Detoxification of exogenous substances- decreased metabolism of
drugs- altered effects, increased toxicity and side effects
7. Metabolism and storage of vitamins and minerals- decreased stores
of vitamins and minerals- anemia and decreased energy production
8. Bile production and excretion- obstruction of bile flow; decreased vit.
K absorption- decreased clotting factors- bleeding
9. Bilurubin metabolism- decreased uptake from circulation- jaundice
and pruritus; decreased conjugation- increased urine bilurubin (dark
urine); decreased GI excretion- acholic stools
Nursing Management:
1. Correct electrolyte imbalance
2. Reduction of ammonia formation- formed in intestines by intestinal
bacteria in protein
a. NGT suction
b. Neomycin sulfate
c. Lactulose
d. Protein restriction
e. Tap water enema
f. Potassium
g. Active ROM contraindicated since ammonia is
formed during muscle contraction
3. Omission of all sedatives (detoxified by liver)
4. Butter ball diet- foods rich in carbohydrates are protein sparing
nutrients- they are used by the body for energy in place of protein
5. Abdominal paracentesis
Complications:

1. Hepatic encephalopathy and coma


2. Portal hypertension- pressure >25-30 cm. Of saline
3. Bleeding esophagastric varices
Nursing Management:
1. IV fluids
2. Antiemetics
3.Blakemore- Sengstaken Tube (esophageal balloon tamponade)
Nursing Interventions:
a. Keep a pair of scissors at bedside- in the event of acute
respiratory distress cut across tubing to deflate
balloon
b. deflate esophageal balloon for 5 minutes at 8-10 hrs
interval to prevent necrosis
4. Porta- Systemic Shunting
a. Porta caval (portal vein to inferior vena cava)
b. Splenorenal shunt (splenic to renal)

5. Diet high calorie, low to moderate protein, high carbohydrate, low


fat with vitamins ABCDK
E. Cholelithiasis- stone formation in the gall bladder
Cholecystitis- inflammation of gall bladder usually precipitated by
gallstones
Choledocholithiasis- stone formation at the common bile duct

Incidence: (5 F’s)
a. Female
b. Forty (age- 40 years and above)
c. Fair complexion
d. Fertile
e. Fat
Nursing Management:

a. Pain control- demerol (drug of choice)


b. Anticholinergic- atropine
c. ESWL Extracorporeal Shock Wave Lithotripsy- shock waves used
to disintegrate gallstones