1. Symptoms of GERD
    • Heartburn (dyspepsia)
    • Regurgitation (lead to aspiration/bronchitits)
    • Coughing, hoarseness or wheezing at night
    • Dysphagia
    • Pyrosis
    • Globus
    • Belching, Flatulence
    • Epigastric or retrosternal pain
  2. Diagnosic test for GERD
    • 24hours gastric pH monitoring
    • Esohageal manometry (rarely used)
    • Endoscopy:
    • requires conscious sedation
    • Informed consent
    • NPO prior to procedure
  3. Medical management for GERD
    Diet therapy
    Lifestyle changes
    • Goal:
    • Relief of symptoms and prevent complications

    • DT:
    • Restrict caffine, tomatoe, chocolate, fatty foods, and spicy
    • DO NOT eat before bedtime
    • Limit amount ( volume) of food eaten at each meal

    • LC:
    • Elevate head of bed, sleep on left side
    • Avoid smoking, alcohol
    • Weight reduction program
  4. Drug therapy for GERD
    • Histamine receptor antagonists (h2 blockers)
    • Reduces acid secretions, promote healing of infamed esophagus, control symptoms titrate
    • Tagamet, Pepcid, Zantac
    • Proton Pump inhibitor (PPI)
    • MAIN drugs used for effective long term use by inhibiting proton pump of parietal cells thus reducing acid
    • Prilosec, Nexium, Prevacid, Protonix

    • Acid protectives- Carafate
    • -cytoprotective properties
    • Cholinergic- Urecholine
    • -increases LES pressure
    • Prokinetic drugs- Reglan
    • - Mobility enhanceing
  5. GERD surgical interventions
    • Endoscopic therapy and surgery
    • -BESS procedure, stretta procedure or enteryx procedure
    • Delivers radiofrequency energy to smooth musle of LES
    • -Induces collagen contration: forms a barrier against reflux
  6. Cause:
    High gastric acid secretion, rapid empty of food reduces buffering- allows large acid bolus into the duodenum- penetrates the mocosa and into the muscle layer.
    H. pylori
    Chronic renal failure
    Smoking and alcohol use
    Duodenal ulcer
  7. Cause:
    Unknown mechanism but there is apresence of elevated levels of hydrocoric acid, ischemia, and erosive gastritis seen.
    Stress Ulcer
  8. Examples of destryers of mucosal barrier
    • Aspirin and nsaids
    • H. pylori
    • Corticosteroids
    • Lipid-soluble cytotoxic drugs
    • Increased vagal nerve stimulation
    • Chronic alcohol abuse
    • Bile reflux
    • Nicotine
  9. Symptoms of Gastric ulcer
    • Intermittent dull, gnawing pain
    • Burning epigastric
    • Pyrosis (heartburn)
    • Pain occurs 1-2 hours post meal
    • rare @ night
    • Weight loss
  10. Symptoms of doudenal ulcer
    • Pain improves after eating but returns a few hours later or in the middle of the night
    • A change in appetite with weight gain
    • Mid-epigastric pain
    • Back pain
    • 2-4 hours after meals
  11. Diagnostic tests for ulcers
    • History and physical especially with family
    • Upper GI
    • Endoscopy (EGD)
    • Stool for occulet blood
    • H pylori test (carbon urea breath test)
    • Gastric secretion studies
    • Biopsy
  12. Laboratory analysis for ulcers
    • CBC
    • *anemia
    • Urinalysis
    • Liver enzyme studies
    • Serum amylase determination
    • *pancreatic function
    • Stool examination
    • *positive blood
  13. Medical management for ulcers
    • Drug thereapy: goals to prevent recurrence, heal ulcers, treat infection and provide pain relief
    • Diet therapy: aimed at decrease acid and increase motility. Bland non-irritating diet
    • Eat small frequent meals
    • No smoking, alcohol, caffeine
  14. Surgical intervention for ulcers
    • Removal of ulcer
    • Pyloroplasty and vagotomy (V/P)
  15. Drug therapy for Ulcer
    • H2 blockers
    • Cytoprotective
    • Proton pump inhibitors
    • Antibiotic for H pylori
    • Antiacids
    • Anticholinergics
  16. Tagamet
    H2 blockers
  17. Cytotec
    • Antisecretory and cytoprotective
    • -given to prevent gastric ulcers in chronic nsaid users
  18. Carafate

    • - give 30 min before or after an antiacid
    • - if mixed with cimetidine, digoxin, coumadin, dilantin, and tetracyclin, it binds with them and reduced bioavailibitlty
  19. Prevacid
    generic names all end with -zole
    • Proton pump inhibitors
    • -more effective than h2 blockers
  20. amocicillin
    metroniadzole (flagyl)
    clarithromycin (biaxin)
    • Antiboiotics for h. pylori
    • -use concurrently with h2 blockers or ppi
  21. Baselijel
    alka seltzer
    • Antiacids
    • -increase pH neutralizing acid
    • -titralac ( higher sodium) caution in older patient or with liver cirrosis, hypertension, heart failure, and renal disease
    • -magnesium preparations should not be prescribed for patient with renal faiulre becuase risk of mag. toxticity.
  22. signs and symptoms of mag toxitcity?
  23. Nursing interventions with Ulcers
    • Assessment of symptoms and family history
    • Encourage smoking and alcohol cessation
    • medication education
    • assess for complications
    • monitor labs (CBC)
    • Monitor pain management
    • monitor nutritiional status
  24. Signs of Gastrointestinal bleeding
    Coffee ground emesis, bright red emesis, melena, signs of hypotension, decreased HCT and HgB, confusion, syncope, vertigo
  25. Signs of Gastric perphoration
    • Ulcer is so deep entire thickness is wore out
    • Sudden, shrarp pain midepigastric and spreads all over abdomen
    • Abdomen is tender and rigid "board like"
    • Client assumes the fetal postition
    • Absent bowl sounds
  26. Signs of pyloric obstruction
    • caused by scarring, edema, inflammation
    • vomiting and abdominal distention
  27. Complication treatments
    GI bleed
    • find the cause intitially thru endoscopy
    • monitor amoutn and frequency of bleeding
    • fluid management: IVF's and blood transfusions
    • Monitor serial CBC , bleeding studies
    • Endoscpic ablation, clot stabilizer (somatostatin)
    • NGT with pt NPO, may lavage if ordered with cool salin to eliminate clots
  28. Treatment fo perforation
    • NPO
    • pain monitoring
    • surgical intervention to prevent peritonitis
  29. Treatment fo pyloric obstruction
    • NGT compression
    • fluid volume replacement
    • surgical intervent if needed
    • NPO until no vomiting
    • IVF's
  30. Treatment of duodenal ulcers: eliminates acid secreting stimulus to gastric cells and dcreases responsiveness of parietal cells
  31. Widens the exit of pylorus, facilitates stomach emptying
  32. Partial resections of the stomach
  33. Billroth I:
    • Gastroduodenostomy
    • Distal stomach removed, remainder anastomosed to duodenum
  34. Bilroth II
    • Gastrojejunostomy
    • Lower stomach removed, remainder anastomosed to jejunum.
  35. Post operative management fixing ulcers
    • Assess vitals- will be hypotensive, increased heartrate
    • Monitor pain
    • Monitor gastric decompression and output
    • Monitor labs (CBCand electroyltes)
    • Montior for coninued illeus
    • monitor for gastric empty delay and recurrent ulcerations
    • make sure they deep breath
    • Replacement therapy: for every ml put out will replace half every 4 hours in addition to regular maintence IV fluids
  36. Normal HGb
    • w: 11.7-15.5
    • M: 13.2-17.3
  37. Normal Hematocrit
    • W: 35-47%
    • M: 39-50%
  38. Dumping syndrome
    Early manifestations
    • Vertigo
    • tachcardia
    • syncope
    • sweating
    • pallor
    • desire to lay down
  39. Dumping syndrome
    Late manifestations
    • intestinal manifestations
    • dixxiness
    • lightheadedness
    • palpitations
    • diaphoresis
    • confusion
  40. Treatment for dumping syndrome
    • Decreasing amount of food eaten at one time
    • Decrease eating time
    • Sit up when eating
    • High protein, low to moderate carbs, and high fat diet
    • Administer Sandostatin (may prevent syndrome)
  41. Sandostatin
  42. What can you expect patients to have to have once stomach take once stomach surgery?
    • B12 shots
    • because no longer has intrensic factor
  43. Diverticula
    Congenital pouch like mucosal herniations of small intestins or colon
  44. Diverticulosis:
    Many pouches (herniations) in the wall of the intestins
  45. Divericulitis:
    Inflammation of one or more diverticula/ results when diverticulum perforates and local abscess form
  46. Symptoms of diverticulitis
    • Typically not seen until problem arises
    • abdominal pain, tenderess to palpation
    • elevated temperature > 101, may have chills
    • Abdominal guarding, rebound tenderness
  47. How is diverticulitis confirmed
    • CT scan
    • Flat plate of abdomen
    • EGD (endoscopy)
  48. What must you not adminster to a patient with active untreated diverticulitis
    Barium enema (will turn into cement and cause a rupture
  49. Nonsurgical medical management of diverticulites
    • Broad spectrum antibiotics (flagyl, zipro)
    • IVF's ( watch k+)
    • Anticholinergics- slow down
    • NPO until able to tolerate clear liquids then increase
    • stop fiber therapy until attack is limited
    • NO enemas or laxatives
  50. Surgical medical management for diverticulitis
    Done for rupture with peritonitis, fistula formation, bleeding, bowel obstruction, or unresponsive to medical management
  51. Nursing interventions for diverticulitis
    • Healthy teaching:
    • Diet:A high fiber diet, mainly fruits and vegetable and decreased intake of fat and red meat
    • Weight reduction
    • Avoid strating at stool, vomiting, bending, lifting, and tight restrictive clothes.
    • symptom recognition,
    • activity
  52. Post operative management
    Nursing interventions
    • monitor colostomy is present
    • monitor vitals, urine output, wound condition
    • Ambulation- the sooner the better, that day or next
    • Psychosocial adjustment to stoma
  53. stool from colostomy
    formed mushy stool with regular bowel movements
  54. stool for iliostomy
    • liquid drainage always draining
    • green/brown
    • at risk for skin breakdown
  55. Chronic inflammatory process affection mucosal lining of colon or rectum
    Ulcerative colitis
  56. Diffuse inflammation fo intestinal mucosa, loss of surface epithelium causing ulcerations and abscess formations
    ulcerative colitis
  57. Starts normally at the rectuma dn progresses towards cecum (bowel can become shorter and narrower due to fibrosis)
    ulcerative colitis
  58. Inflammatory diseas of small intestins or colon or both, terminal ileum is the most common site
    Crohn's disease
  59. Chronic nonspecific inflammation of entire intestinal tract, formation of deep fissures and ulcerations thru ALL layers
    Crohn's disease
  60. Causing thickening of boewl wall resulting in narrowing of lumen and strictures
    Crohn's disease
  61. Crohn's disease late disease
    Granulomas form with ulcerations which may become cancer
  62. Symptoms of Ulcerative colitis
    • 10-20 liquid blood stools per day
    • Tenesmus (straining uncontrolled)
    • Low grade fever (late)
    • Anemia
    • fatigue
    • LLQ pain/ cramping
    • Weight loss
    • Rebound tenderness
    • guarding
  63. Symptoms of Crohn's
    • 5-10 fatty stools per day (steatorrhea)
    • Flatulence
    • malabsorption
    • weight loss
    • diffuse bilateral lower quadrant pain
    • fever with perforation or fistula
    • fluid and electrolyte and vitamin dficits- high
  64. Diagnostic tests for ulcerative colitis
    • CBC
    • electoylte panels
    • Stools for O&P, occult blood and C&S
    • Colonoscopy or sigmoidoscopy
    • Barium studies - only if not in acute phase
    • CT scans
  65. Diagnostic test for crohns
    • CBC
    • electrolyte anels
    • viatmin, folic acid levels
    • ALBUMIN and nutritional labs
    • barium studies
    • Colonoscopy
  66. TPN contents
    who is it for?
    Things to remember
    • dextrose and amino acids (protein)
    • Massive deficency
    • Only in picc or central (diluted if in peripheral)
    • everything changed every 24 hours
    • Filtered
    • check every component in the bag
  67. Medical Management of Ulcerative colitis
    Drug therapy
    • Aminosalicylates Inhibits prostaglandins to reduce inflammation
    • Corticosteriods Suppress immune system
    • Reduce inflammation
    • Immunomodulators Help reduce amount of steriod use
    • Overrides body immune system
    • Antibiotics Use with acute flair ups that may be prone to infections
    • Antidiarrheals Symptomatic relief of severe diarrhea
  68. Medical Management of Crohn's
    Drug therapy
    • Aminosalicylates- inhibits prostaglandins to reduce inflammation
    • Corticosteriods- Suppress immune system, reduce inflammation
    • Inmmunomodulators- Help reduce amount of steriod use, overrides body immune system
    • Biologic therapy- Given to those who have not responded to conventional therapy, reduces number of fistulas, works with tumor necrosis factor alpha
    • Antibiotics- common for abscess
  69. Diet therapy for ulcerative colitis
    • NPO if severe symptoms
    • TPN for long NPO
    • Elemental formula
    • Low fiber foods
    • Lactose free products
    • No caffeine, spices, alcohol, smoking
  70. Diet therapy Crohns
    • TPN for long term use
    • Nutritional supplements
    • elemental supplements
    • NO caffeine or carbonated beverages
    • No alchohol
    • Probiotics (non-digestive food ingredients)
  71. Surgical Management for ulcerative colitis
    • "Curable"
    • Total colectomy with permanent ileostomy
    • -colon, rectum and anus removed
    • Total colectomy with contient ileostomy
    • -kock's pouch
    • -J pouch- removes the colon and rectum but sutures the ileum to anal canal-forms a ileoanal reservoir NO STOMA
  72. Surgical management for crohns
    • surgery isnt a cure
    • repair of fistulas
    • release of intestinal obstructions
    • partial resection with primary anastomosis
    • ileostomy- most end up with one
    • Remember crohns can come back in the unaffected part of the bowel
    • May require many surgeries
  73. Nursing interventions for uc and crohns
    • Nutritional assesssment
    • monitoring fluid and electroytes
    • monitoring lab valures
    • monitor for complications
    • montior weight
    • psychological assessment
    • post op care
  74. nurisng care for uc and crohns
    • Adminster and monitor tpn and ppn
    • provide adequate nutrition: pre-medicate as ordered
    • Assess stools: quality, frequency, amount , and pain issure with stooling
    • assess vitals
    • teach relaxation techniques
    • Educate for ileostomy and colostomy for both client and family
    • eliminate factors that cause diarrhea and pain
    • chronic pain management
    • Provide small frequent meal with specific dietary preferences
    • detailed adominal assessment
  75. Complications of Ulcerative colitis
    • coagulation problems
    • hemorrage
    • bowel perforation
    • colon cancer
    • toxic megacolon
  76. Complications for crohns
    • intestinal obstruction
    • fistulas (can be extraintestinal)
    • malabsorption sydrome
    • liver and biliary disease
    • kidney stones
    • arthritis
  77. Characterized by intermittent and recurrent abdominal pain and stool pattern irregularities
    altered intestinal colonic motility
    alteredd responce to stress
    may be due to alterations in the enteric nervous system and/or autonomic nervous system
    Irritable bowel syndrome
  78. Diagnostic test for IBS
    • Review signs and symptoms
    • screening and colonscopy
    • lab tests and stool testing -rule out physilogic cause
    • stress evaluation
    • lifestyle evaluation
    • get what pattern they are doing? Constipated or diahrrea?
  79. Symptoms of IBS
    • Diarrhea
    • Constipation
    • Alternating diarrhea/constipation
    • abdominal distention
    • excessive flatulence
    • bloating
    • continual defecation urge, urgency
    • sensation of incomplete evacuation
  80. Medical management of IBS
    • Diet
    • Fiber therapy (20 g/day)
    • Antispasmodics
    • -Dicyclomine (Bentyl)
    • -Laxatives
    • -Serotonergic agents
    • -5-HT3 receptor blockers
    • *Alosetron (Lotronex)
    • -Antidepressants
  81. Dicyclomine (Bentyl)
    • -Dicyclomine (Bentyl)
    • -reduce colonic motility after meals
    • -take before meals
    • -side effects
    • *dry mouth, urinaty retention, tachycardia
  82. Over use of laxatives
    will deplete k+, Na+ and decreased Magnesisum
  83. 5-HT3 receptor blockers
    • Decrease urgency, pain, and diarrhea in diarrhea-prominent women
    • -Alosertron (Lotronex)
    • *FDA approved for WOMEN only
    • *Must be monitored due to potential side effects
  84. Nursing Management of IBS
    • Establish a trusting relationship
    • Monitor nutrition
    • Monitor stress levels
    • Teach relaxation techniques
    • Medication education and compliance
    • Herbal and alternative thereapies
    • Finding the causative factor
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