GI (Callahan)

• •Past Medical History
•    -GI disorders
•    -Hepatic/biliary disorders
•    -Anemia
•    -Other medical problems

• •Family History
•    -Autoimmune diseases
•    -GI Cancer
•    -Genetic disorders

• •Medication
•    -Current or prior tx for ulcer
•    -Hepatotoxic drugs
•    -NSAIDs, ASA, APAP
•    -Goody, etc. powders
•    -Herbals/supplements
•    -Laxative/antacid use

• •Surgical procedures
•    -GI diagnostic procedures

• •Social History:
•    -ETOH use
•    -Illicit drug use
•    -Tobacco
•    -caffeine

• •Nutritional status
•    -Change in appetite
•    -Typical diet, eating patterns

• •Abdominal pain
•    -Severity, location, duration, character, alleviating and exacerbating factors
•    -Associated factors
• •N/V
•    -What foods tolerated?
• •Change in bowel patterns
•    -What is patient’s baseline normal?
•    -Diarrhea
•    -Constipation
•    -Different appearance of stool
• •Hematemesis/Melena/Hematochezia
• •Anemia
• •Jaundice
• •Swelling or protrusion
• •Bloating
• •Increased flatulence
• •Unplanned weight gain/loss

• •Mouth
•    -Moist/dry
•    -Lesions/ulcers
•    -Dentition
•    -Gingival tissue (gums)
•    -breath

• •Older Adults
•    -Decreased moisture
•    -Gingival atrophy

•Inspect

• •Auscultate
•    -4 quadrants
•    -Bowel sounds:
•        Normoactive
•        Hypoactive
•        Hyperactive (borborygmi)
•        Absent bowel sounds
•    -Always listen 5 minutes to verify
• •Light palpation
•    -Tenderness
•    -Masses
•    -Swelling
•    -Fluid wave sometimes if ascites

• •Deep palpation
•    -abdominal organs and masses
•    -Rebound tenderness

• •Requirements
•    -NPO? How long?
•    -Informed consent?
•    -Contrast?
•    -Bowel prep?

• •Special considerations
•    -older adult
•    -diabetic
•    -hydration status

• Upper GI series (with or without small bowel follow-through)
•    -Barium swallow
• Lower GI series (barium enema)
• Abdominal ultrasound
• CT scan
• MRI
•    -Virtual colonoscopy

• •Assess, diagnose and treat
• •Informed consent necessary
• •Main complication is perforation
• •Most require
•    -IV conscious sedation

• •Endoscopic procedures
•    -EGD
•    -ERCP
•    -Colonoscopy
•    -Capsule endoscopy

• Barrium Swallow
• •Manometry
•    -Lower esophagus
• •Esophageal pH monitoring

Mouth to Duodenum

• Inflammation of the gastric mucosa
•    -Acute or Chronic
•    -Diffuse or Localized

• •Drug Related- NSAIDS, ASA, Corticosteroids
• •ETOH
• •Diet- Spicy Foods
• •Smoking
• •Radiation
• •Bacteria, such as Helicobacter pylori  (H. pylori)
• •Autoimmune Atrophic Gastritis
• •Viral

• -Nausea
• -Vomiting
• -Anorexia
• -Epigastric Pain
• -Fullness and bloating
• -Bleeding can occur if severe

• Re-hydrate and rest the gastric mucosa
• •NPO, advancing diet as tolerated
• •IV Fluids for hydration
• •NG Tube may be needed to decompress

• Treat symptoms and reduce gastric mucosa irritation
• •Antiemetic
• •Antacids
• •Proton Pump Inhibitors (PPIs)
• •Histamine 2 Receptor Blockers (H2R blockers)

• Eradicating H. pylori: H. Pylori Treatment Regimen
• •Triple Therapy (7-10 days)
•    -Omeprazole, Amoxicillin, Clarithromycin
•    -Bismuth subsalicylate, tetracycline, omeprazole
•    -Lansoparole, clarithromycin, amoxicillin
• •Quadruple Therapy (10-14 days)
•    -Bismuth subsalicylate, metronidazole, tetracycline, omeprazole

• Treating pernicious anemia
•    •B12

• •Exacerbations
• •Pernicious Anemia
• •Gastric Cancer

• •Prevention Education
• •Diet Modification
• •Smoking Cessation
• •CBC Monitoring
• •Drug Regimen Adherence
• •Encourage Rest
• •Support

• -Can be gastric, duodenal or esophageal
• -Duodenal most common area
• -Causative factors:
•    NSAIDS/ASA use (decreases secretion of mucus that protects against gastric HCL)
•    H. pylori infection
•    Stress ulcers – caused by physiologic stress
• (Why many hospitalized patients are prescribed a PPI)

• •Burning or gaseous pressure in epigastrium, back, and/or upper abdomen
• •Pain immediately after eating
• •Nausea
• •Vomiting
• •Less common to have relief from pain by eating or taking antacid

• •Burning and cramping pain in midepigastrium and/or back
• •Pain 2-4 hrs after meals
• •Nighttime awakening with pain common
• •More likely to have relief from eating/antacids

• Pain Control
• NPO
• Clear Liquids/ Bland Diet

• •H. pylori Regimen
• •Antacids
• •H2- blockers
• •PPIs
• •Cytoprotective- sucralfate (Carafate) and bismuth subsalicylate (Pepto-Bismol)

• GI Bleeding:
• •Hematemesis (coffee ground) or melena (stool)
• •Monitor H/H, VS
• •NG insertion may be necessary
• •Endoscopic evaluation
• •Potential for shock

• GI Bleeding
• Perforation
• Gastric Outlet Obstruction

• •Sudden/severe abd pain, may radiate to rt shoulder
• •Boardlike abdomen
• •Tachycardia, hypotension
• •Chemical peritonitis » bacterial peritonitis
• Immediate surgical intervention

• •Smoking Cessation
• •Stress Management
• •Diet
• •Medication Adherence
• •Pre and post-op Teaching

• •Distal to pyloric sphincter
• •Spasm, edema or scar tissue
• •N/V, constipation, epigastric fullness, anorexia
• •NG tube to decompress stomach
• •Manage fluid/electrolyte balance
• •Endoscopy or surgery may be necessary to manage

• Gastritis
• Peptic Ulcer Disease

• •Decrease in stool frequency from normal pattern
• •Hard stools, straining to pass stool
• •Abdominal discomfort
•    -often “perceived” by individual
• •Inactivity, inadequate fiber intake, aging contribute
• •“functional” or idiopathic when no medical cause
• •Chronic laxative use can contribute
• •Impaction may result

• •Increase in number, volume or liquidity of movements
• •IBS, IBD, food intolerances (ex. Lactose) as causes
• •Also infectious causes
• •Antibiotic-related diarrhea (C. difficile)
• •Manage fluid and electrolyte balance
• •Chronic diarrhea can lead to metabolic acidosis
• •r/t bicarbonate loss
• •Skin assessment important! Excoration risk

• •IBS-D, IBS-C, or IBS-A
• •Chronic functional bowel disorder
• •“Diagnosis of exclusion”, Rome Criteria
• •Relationship to stress/anxiety
• •Nursing management: symptom management
• •Food/symptom diary may be helpful

• •Multiple causes
• •Often frequent, loose, bulky, foul-smelling stools
• •Fatty stools…may float (steatorrhea)
• •Also abd distension, discomfort, flatus, weight loss
• •If not diagnosed and treated can lead to malnutrition

• Inflammation of the appendix
• Peri-umbilical Pain and/or RLQ Pain
• Anorexia
• Nausea
• Vomiting
• May have fever
• Local and rebound tenderness

•NPO

•Pain Control

•Appendectomy

•Assess & re-assess Pain

•Enforce NPO Status

•Pre and Post-op Teaching

•Post-op Ambulation

• Perforation
•    •Peritonitis
•    •Abscess

• Management
• •Antibiotic therapy
• •IV Hydration therapy
• •Appendectomy

• •Diverticulosis- non-inflamed diverticula
• •Diverticulitis- infection
•    -Sigmoid colon most common

• •Mostly Asymptomatic
• •Often chronic constipation
• •No evidence of inflammation
• •Progression to diverticulitis

• •Abdominal Pain – may be severe
• •N/V
• •Fever, may have chills
• •Leukocytosis

• •Perforation
• •Peritonitis
• •Abscess
• •Fistula
• •Bowel Obstruction
• •Urethral Obstruction
• •Bleeding

• -Bacterial, fungal, mycobacterial
• -Trauma
• -Bowel perforation, ruptured appendix or diverticulitis, perforated ulcer (ALL bacterial
• perforation)

• Rigid abd, rebound tenderness, pain, ileus
• Fever
• Elevated WBC
• Can lead to sepsis, shock

drain infection, monitoring

• -Crohn’s Disease and Ulcerative Colitis
• (Autoimmune diseases...Family history of Crohns/UC/other autoimmune dz)

Inflammation of colon and rectum

•Continuous inflammation

•Involvement ranges from anorectal area to entire colon (pancolitis)

•Exacerbations

•Bloody diarrhea

•Abdominal Pain

•Removal of colon curative if pancolitis

• Occurs anywhere in the GI tract
• “skip lesions”
• Diarrhea – may be bloody
• Colicky Abdominal Pain
• Weight Loss

• Inflammation of colon and rectum
• •Perineal Abscess
• •Fistulas
• •Small Bowel Cancer

•Rest Bowel

•Control Inflammation

•Prevent Infection

•Correct Malnutrition

•Prevent Stress

•Treat Symptoms

•Improve Quality of Life

•Medications

•Surgery

• Aminosalicylates
•    (Orally for Crohn’s)
•    Pentasa, Asacol
•    (May be administered rectally in UC (Rowasa)

Corticosteroids

• Immune modulators – severe Crohn’s
•    Remicade 
•    6-mercaptopurine (6-MP)
•    Aziothrapine (Imuran)

• •Medication Adherence
• •Hydration
• •Pre and Post-op Teaching
• •Emotional Support
• •Pain Control
• •Encourage Rest
• •Maintaining normal elimination
• •Pain control
• •Fluid balance
• •Promoting rest
• •Preventing skin breakdown
• •Enhancing coping/reducing anxiety
• •Teaching self-care measures

• •Following total colectomy:
•    •Ileostomy
•    •Ileal pouch anal anastomosis
•    •Kock pouch ileal reservoir – drained by catheter

• •www.ccfa.com – Crohn’s and Colitis Foundation of America
• •Advocacy
• •Patient education

Marking stoma site by WOC nurse or surgeon

Low residue diet

Preoperative teaching on what to expect from surgery, immediately postop and with stoma

Allow patient to verbalize feelings and ask questions

Involve S/O and/or family in education

Patient may have concerns about body image/sexuality

•General post-surgical care

•Pain management

•Monitor stoma site – stoma should be shiny and pink to red in color

•Fecal drainage begins 24-48 h after surgery

•Indwelling catheter drainage for 2-3 weeks after Kock pouch

•I & O strictly monitored

Intestinal Obstruction

• •Mechanical or Non-mechanical
•    •Hernia
•    •Neoplasms
•    •Adhesions
•    •Neurologic or neuropathic (DM, MD)

• •Fluid, gas and intestinal contents accumulate above obstruction
• •Can eventually result in rupture or perforation

•Cramping abd pain r/t peristalsis

•No flatus or stool passed

•Vomiting

•Abdominal distension

•Severe fluid loss/electrolyte imbalance

•Patient NPO

•NG tube for decompression

•Maintain IV fluid therapy as ordered

•Strict I & O including IV fluids, NG drainage, urine

•Monitor electrolytes, WBC, VS

•Measuring abdominal girth may be necessary

•Pain Control

•High fiber/ fruits and vegetables

•Decrease red meat and fat

•Stool softeners

Pre and post-op teaching

•Pain Control

•Antibiotics

•NPO

•IV Fluids

•NG Tube

•Bed rest

•Surgery- Colon resection

• Hernia
•    •Umbilical
•    •Inguinal

•Commonly hernias involve a loop or section of colon

•Reducible hernia – able to push back into place manually

• •Warning signs
•    -Irreducible
•    -Warmth, redness or other signs of infection

Strangulation

•Acute Intestinal Obstruction

•Decrease in Blood Flow

•Severe Pain/ Cramping

•Necrosis

•Vomiting

•Distension

•Truss

•Skin breakdown

•Education

•Education

•Bladder Checks

•Ostomy Care

•Deep breathing only

•Splinting