-
Nursing assessment of the GI
- Auscultation: present, absent, hypoactive, hyperactive, tinkling,
- gurgling, rushing
- Normal: High pitched
- clicks or gurgles
Absent: Rare
- Borborygmi: loud, high
- pitched gurgling –indicates
- hyperperistalsis
- Obstruction: high pitched
- tinkling sounds before obstruction;
- diminished or absent after
-
Diagnostics and Labs for GI?
- Radiologic: Upper GI
- Lower GI
- Ultrasound
- CTMRI
- Cholangiography
- Gastric emptying
- HIDA
- Endoscopic:
- Upper GI
- Colonoscopy
- ERCP
- Virtual Colonoscopy
- Capsule Endoscopy
- Miscellaneous:
- Liver Biopsy
- LFT’s
- Gastric Analysis
- Fecal Analysis
- Stool Culture
-
Labs for GI assessment
- Laboratory Studies
- Serum Albumin to hold fluids in BS
- Prealbumin
- Serum Transferrin
- C-Reactive Protein (CRP)
- Anthropometric Measurements
- --Ht/ Wt
- --Body Mass Index
- --Skin fold thickness
-
What are the SnSs of malnutrition?
- Deficit, excess, or
- imbalance in essential
- components of balanced
- diet
- - dry, scaly skin
- - brittle nails
- - decreased muscle mass
- - fatigue, no endurance
- - poor wound healing
- - depressed immune
- system
-
Assessment for malnutrition?
- Joint Commission requires screening for all patients
- within 24 hours of admission
- MNA - Mini-Nutritional Assessment (older adults)
- MDS – Minimum Data Set (Long-term care)
- OASIS – Outcome and Assessment Information Set
- Obtain accurate Height and Weight
- Assess weight loss
- Calculate BMI
-
What are some risk factors for malnutrition?
- Dementia
- Depression
- Chronic Substance Abuse
- Swallowing Disorders
- Decreased Mobility
- Nutrient loss from malabsorption, dialysis, wounds
- Drugs w/ antinutrient properties (corticosteriods)
- Hypermetabolism (fever, infection, burns, trauma)
- No oral intake
-
Nursing intervensions to support nutrtion for the pt w/malnutrition
- High-Calorie, High-Protein Diet
- Supplementation
- Milkshakes
- Pudding
- Commercially available products
- Carnation Instant Breakfast (CIB)
- Ensure
- Boost
-
Indications for enteral nutrition (tube feedings)
- Nutrition provided through GI tract via a tube, catheter or stoma that delivers nutrients distal to the oralcavity for:
- Anorexia
- Orofacial Fractures
- Head and neck cancer
- Neurologic problems
- Psychiatric conditions
- Critical Illness
- Considered safer, more physiologically efficient, less expensive than parental nutrition. Obviously, GI system has to work to be able to feed enterally.
-
Enteral nutrition
types of tubes
- Types of Tubes
- Nasogastric Tube (NGT)
- Percutaneous Endoscopic
- Gastrostomy Tube (PEG)
- Jejunostomy Tube
-
Nursing management of enteral tube feedings
- Positioning- HOB 30-45 degrees
- Tube Patency- Flush before and after
- Tube Position - Placement check
- Aspiration Risk - HOB elevation/Residual check
- Formula- strength/hang time. Do not dilute with water. May -->diarrhea.
- Administration – pump/gravity(bolus/intermittent)
- Medication Administration - crush meds well!
- General Considerations:
- --daily weights, glucose checks,
- --change tubing q24 hrs, free water
- --label w/ date/time hung, I&O
- --Gastric residual: check q 4 hrs. for 1st 48 hours then q6-8 hrs for stable patient; q4h critical pts (>200 = gastric intolerance).
-
What are some complications of enteral feedings?
- Nausea/Vomiting
- Diarrhea/Constipation
- Aspiration: keep HOB 30-45 degrees; hold TF when HOB lowered; check residuals; ambulation; gastric emptying agents, suction for any s/sx aspiration, clear airway!!!!!
- Clogged Tube: crush meds well; flush before and after meds; dilute viscous solutions; use liquid meds if available; follow hospital protocol for unclogging tube
- Displacement of tube
- Dehydration
- Infection: assess for s/sx infection; clean around site q shift with water initially then soap and water.
- Skin irritation
- Thrush: Oral care!!!!!!!
-
General info about TPN feeding
- GI tract not functioning properly
- Administration of nutrition IV:
- --Total Parental Nutrition (TPN)
- --Lipids/fat emulsions:
- --Peripheral Parental Nutrition (PPN)
- Indications:
- Severe nausea/vomiting/diarrhea
- Gastrointestinal obstruction/anomalies
- Severe injury/trauma
- Malabsorption/short bowel
- Pancreatitis
-
TPN vs. PPN
- PPN
- Short term nutritional needs
- Protein/calorie requirements low
- CVC Contraindicated-use peripheral IV
- Supplement inadequate oral intake
- Hypertonic (Glucose concentration 10%)
- TPN
- Long-term nutritional support needed
- High protein/calorie requirements
- Must be given in Central Line (CL)
- Glucose concentration (20-50%)
- Hypertonic 1600 mOsm/L (blood 280 mOsm/L)
-
Nursing management of Parenteral nutrition
- VS q 4-8 hrs.
- Daily Weight
- Labs, esp glucose.
- DSG change according to protocol
- Change label/bag/tubing/filter q 24 hours no matter how much is left in the bag or even if the condition looks fine. Just do it.
- IV site assessment:
- Signs of phlebitis: erythema, tenderness or exudate; systemic infxn: fever, chills, N/V, malaise. Cultures (x2) may be performed and line may be D/C’d with tip cultured if no source of infection can be identified. Central line usually not replaced right away r/t risk of seeding new IV with bacteria.
- Glucose q 6 hrs. risk for hyperglycemia
- Administer PN ONLY via pump!!!
- Administration routine
-
Complications of TPN
- Infection
- Fungus/ Gram +/ Gram - bacteria
- Metabolic Problems
- Hyperglycemia/hypoglycemia
- Altered Renal Function
- Electrolyte/vitamin/mineral excess or deficiency
- Refeeding Syndrome
- Mechanical Problems
- Air embolus
- Pneumothorax
- Line displacement
- Thrombosis/phlebitis
-
-
preconditions for n/v
- Etiology
- Pregnancy
- Infectious disease
- CNS disorders
- CV problems
- Metabolic disorders
- SE of drugs
- Psychologic factors
- Signs/Symptoms
- Anorexia
- Dehydration
- Electrolyte imbalances
- Metabolic alkalosis
- Metabolic acidosis
- Weight loss
Aspiration precautions!
-
assessment and intervensions for n/v
- HPI
- Precipitating factors
- When does it occur
- Description of contents
- Drug therapy
- Antimuscarinics
- Antihistamines
- Phenothiazines
- Dexamethasone
- Cannibinoids
- Prokinetics
- Serotonin antagonists
- Nutritional therapyBRAT diet
-
Upper Gastrointestinal Bleeding
- Most common sites
- --Esophagus
- Stomach
- --Stress Related
- Duodenum
-
SnSs of UGI bleed
- Severity Depends on Origin
- Overt
- --Hematemesis (bright red/coffee ground vomit)
- --Melena (black/tarry stool)
- --Hematochezia (maroon colored stool)
- Occult
- --Guaic-Positive Stools/Nasogastric Aspirate
-
Emergency Assessment and management of pt w/UGI bleed.
- VS (s/sx shock)
- Abdominal assessment
- PMH
- Blood transfusion inquiry
- Establish IV (x2 large gauge periferal)
- NGT vs. OGT
- Foley
- Labs
-
Assessment of pt w/UGI bleed
- LOC
- VS
- JVD
- Abdomen
- Distention
- Peristalsis
- Guarding
-
Collaborative care with pt/UGI bleed
- Endoscopic therapy
- --Hemostasis to coagulate bleeding
- Drug therapy
- --Injection therapy with epinephrine
- --Sclerosant
- --Vasopressin
- --H2 blockers or PPI drip via IV
- --Antacids
- --Sedatives
- Angiography
- Surgical therapy
-
Possible Nursing Diagnoses
- Risk for aspiration
- Decreased cardiac output
- Deficient fluid volume
- Ineffective peripheral tissue perfusion
- Ineffective coping
-
Pt teaching UGI bleed
- Avoid alcohol
- Quit Smoking
- Reduce Stress
- Take only prescribed meds
- Avoid Aspirin, NSAIDS-->GI bleeds, so CX.
- PPI, H2 Blocker
- Watch for bleeding
-
GERD
- What?
- Reflux of gastric contents into lower esophagus
- Who?
- 14-20% world’s population??
- Why?
- Hiatal hernia
- Incompetent LES
- Impaired esophageal motility
- Decreased gastric emptying
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