GI Presentation University of San Francisco USF by mikesanye


									        Gastrointestinal Disorders
N635 Medical Surgical - Disease Management II

                         Maria M. Stone
                         Alicia Talavera
                         Amy Davidson
                         Amanda Durazo
                         Timothy Wong
                Gastrointestinal Disorders
                   Review at a Glance

•   Barrett’s epithelium: esophageal epithelial tissue that has undergone
    change as a result of repeated exposure to gastric juice and is more
    resistant to erosion, but is premalignant.

•   Body mass index (BMI): estimates total body fat stores in relation to
    height and weight.

•   Bulk-forming agents: high-fiber supplements that increase fecal bulk.

•   Cholecystitis and Choleithiasis:
     •   Cholecystitis: an acute inflammation of the gallbladder.
     •   Cholelithiasis: The formation or presence of stones in the gallbladder.

•   Cirrhosis: Degeneration of liver tissue causing enlargement, fibrosis,
    and scarring.

•   Crohn’s Disease (Regional Enteritis): Subacute, chronic inflammation
    extending throughout the entire intestinal mucosa (most frequently
    found in terminal ileum).

•   Chyme: stomach contents – partially digested food mixed with
    gastric juice.
               Gastrointestinal Disorders
                  Review at a Glance
•   Colostomy: surgical diversion of large intestine fecal contents to an
    external collection device.

•   Diarrhea: increase in frequency, amount or liquidity of stool that is a
    change from the individual’s normal pattern.

•   Diverticular Disease: manifested in two clinical forms – 1)
    Diverticulosis and 2) diverticulitis.
          1.   Diverticulosis: bulging pouches in the GI wall (diverticula) push the mucosa
               lining through the surrounding muscle.
          2.   Diverticulitis: inflamed diverticula, (may cause obstruction, infection, and/or

•   Dumping syndrome: complication of gastric resections where there
    is a rapid emptying of stomach contents into the jejunum causing
    physiologic manifestations.

•   Esophagogastroduodenoscopy (EGD): direct visualization of
    esophagus, stomach, and duodenum through a fiberoptic endoscope
    and used to diagnose disorders of aforementioned structures.

               Gastrointestinal Disorders
             Review at a Glance - continued

•   Esophagogastric tube: also known as the Sengstaken-Blakemore and
    Minnesota tube, consisting of a tube with several lumens used to
    inflate a gastric balloon, esophageal balloon and drain stomach

•   Fistula: abnormal pathway been structures or from an internal organ
    to an outside surface.

•   Gastroesophageal reflux: the backward flow of gastric contents into
    the lower portion of the esophagus.

•   Gavage: referring to intermittent feeding through a tube in the
    stomach or jejunum.

•   Hepatitis: Widespread inflammation of liver cells usually caused by a
•   Hernia: referring to a protrusion of an organ through a weakness in

•   Hiatal Hernia: herniation of the stomach and other abdominal viscera
    through an enlarged esophageal opening in the diaphragm. Etiology
               Gastrointestinal Disorders
             Review at a Glance - continued

•   Esophagogastroduodenoscopy (EGD): direct visualization of
    esophagus, stomach, and duodenum.

•   Ileostomy: surgical diversion of fecal contents at the level of the
    ileum to an external collection device.

•   Inflammatory Bowel Diseases: consists of Crohn’s disease and
    ulcerative colitis.

•   Intestinal Obstruction: Partial or complete blockage of the intestinal
    flow (fluids, feces, gas).

•   Intestinal tube: long tube, 6 to 10 feet in length, used to decompress
    the intestines.

•   Lavage: irrigation of the stomach using a tube inserted into the
               Gastrointestinal Disorders
             Review at a Glance - continued

•   Lower esophageal sphincter (LES): the sphincter located at the
    esophageal gastric junction.

•   Nasogastric (NG) tube: a tube inserted through the nose and into the
    stomach and used to drain contents or for feeding.

•   Non-steroidal anti-inflammatory drugs (NSAIDs): medications
    usually used for analgesia and to reduce inflammation.

•   Pancreatitis: Nonbacterial inflammation of the pancreas.

•   Peptic Ulcer Disease (PUD): ulceration which penetrates the mucosal
    wall of the GI tract.

•   Ulcerative Colitis: disease which affects the superficial mucosa of the
    colon, causing the bowel to eventually narrow, shorten, and thicken
    due to muscular hypertrophy. Occurs in the large bowel and rectum.

•   Zollinger-Ellison syndrome: disorder in which a pancreatic tumor
    secretes gastrin, which then stimulates secretion of acid and pepsin.
                   Gastrointestinal Disorders
                          Case Study

    MW, a 47-year-old female, is admitted to the hospital to rule out
     chronic gastro esophageal reflux disease (GERD) versus peptic ulcer
     disease (PUD). You are the nurse assigned to care for this client.

1.   What diagnostic tests should you anticipate being ordered to
     differentiate her diagnoses?

             Gastrointestinal Disorders
         Case Study – Answer and Rationale

•   An upper-GI series will probably be ordered and can show lower
    esophageal sphincter (LES) function as well as ulceration. An
    esophagogastroduodenoscopy can be more diagnostic because it is
    a direct visualization of the tissue of the esophagus and can show
    inflammation. The gastric and duodenal mucosa are also visualized
    directly and ulcerations are evident. The advantage of endoscopy
    over an upper-GI series is that tissue samples can be obtained for
    determining the presence of cancer, Barrett’s epithelium, or H.
    pylori. Gastric analysis may also be used to determine the pH and
    acid output of the stomach.

                    Gastrointestinal Disorders
                           Case Study

    MW, a 47-year-old female, is admitted to the hospital to rule out
     chronic gastro esophageal reflux disease (GERT) versus peptic ulcer
     disease (PUD). You are the nurse assigned to care for this client.

1.   What are the priorities of care after these tests?

             Gastrointestinal Disorders
         Case Study – Answer and Rationale

•   An upper-GI series usually involves the ingestion of barium, which is
    constipating. The client should be encouraged to drink fluids and
    ambulate. Aspiration of barium during the procedure is a possibility,
    so the nurse should assess lung sounds and monitor for signs of
    aspiration such as fever, cough, and dyspnea. For the client after
    esophagogastroduodenoscopy, it is extremely important to assess
    for return of swallowing and the gag reflex since the throat is
    anesthetized for the procedure, therefore, general safety measures
    should be instituted (side rails up, bed in low position).

                   Gastrointestinal Disorders
                          Case Study

    MW, a 47-year-old female, is admitted to the hospital to rule out
     chronic gastro esophageal reflux disease (GERT) versus peptic ulcer
     disease (PUD). You are the nurse assigned to care for this client.

1.   What instructions about lifestyle changes should you give MW if she
     has gastro esophageal reflux disease (GERD)?

             Gastrointestinal Disorders
         Case Study – Answer and Rationale

•   Lifestyle and diet modifications are key to controlling GERD. The
    client should be instructed to avoid eating within 2 hours of bedtime
    and should remain in an upright position after eating. Tight clothing
    (belts, tight waistbands), straining (weight lifting, bending over,
    lifting heavy objects), and vigorous physical activity increase intra-
    abdominal pressure aggravate GERD and should be avoided. A
    reduction in dietary fat and an increase in complex carbohydrates
    encourage more rapid gastric emptying and reduction in symptoms
    of GERD. The client should be instructed to avoid substances that
    decrease LES tone such as caffeinated beverages, chocolate,
    peppermint, spearmint, smoking, and fried foods. The client should
    be encouraged to elevate the head of the bed about 12 inches to
    prevent reflux at night

                   Gastrointestinal Disorders
                          Case Study

    MW, a 47-year-old female, is admitted to the hospital to rule out
     chronic gastro esophageal reflux disease (GERT) versus peptic ulcer
     disease (PUD). You are the nurse assigned to care for this client.

1.   What instructions about signs and symptoms of complications of GERD
     and PUD should you provide to MW?

             Gastrointestinal Disorders
         Case Study – Answer and Rationale

•   The complications of GERD are limited to the development of
    Barrett’s epithelium, cancer, and esophageal stricture. Symptoms
    include dysphagia, pain, and more systemic symptoms such as
    fatigue, dyspnea, and activity intolerance. Complications of PUD are
    perforation, hemorrhage, gastric cancer (gastric ulcer), and pyloric
    obstruction. The client should be instructed to report any of the
    following symptoms: vomiting, hematemesis, black tarry stools,
    pain, rapid heart rate, abdominal rigidity, and fever as they may
    indicate a complication.

                   Gastrointestinal Disorders
                          Case Study

    MW, a 47-year-old female, is admitted to the hospital to rule out
     chronic gastro esophageal reflux disease (GERT) versus peptic ulcer
     disease (PUD). You are the nurse assigned to care for this client.

1.   If MW asks you about the possibility of developing cancer, how would
     you respond?

             Gastrointestinal Disorders
         Case Study – Answer and Rationale

•   Clients with GERD may develop Barrett’s epithelium and be at a
    greater risk for cancer if GERD remains untreated, so it is important
    that the client follow the treatment regimen. If the client has a
    duodenal ulcer, the risk for developing cancer as a result are
    minimal; however, there is an increased incidence of gastric cancer
    in people with gastric ulcers. Continued follow-up is therefore
    important in this population.

                Gastrointestinal Disorders
                       HESI Hints
•   A Fowler’s or semi-Fowler’s position is beneficial in reducing the amount
    of regurgitation as well as preventing the encroachment of the stomach
    tissue upward through the opening in the diaphragm.

•   Stress can cause or exacerbate ulcers. Teach stress reduction methods
    and encourage those with a family history of ulcers to obtain medical
    surveillance for ulcer formation.

•   Clinical manifestations of GI Bleeding:
               Pallor: conjunctival, mucous membranes, nail beds.
               Dark tarry stools
               Bright red or coffee-ground emesis.
               Abdominal mass or bruit.
               Decreased BP, rapid pulse, cool extremities

•   The GI tract usually accounts for only 100 to 200ml fluid loss per day,
    although it filters up to 8 liters per day. Large fluid losses can occur if
    vomiting and/or diarrhea exists.

•   Opiate drugs tend to depress gastric motility. However, they should be
    given with care, and those receiving them should be closely monitored
    because distended intestinal wall accompanied by decreased muscle
    tone may lead to intestinal perforation.                        17

                   GI – Hesi Review Question

•   Which of the following assessments is essential for the nurse to
    make when caring for a client who has just had an
    esophagogastroduodenoscopy (EGD)?

    1.   Auscultate bowel sounds
    2.   Check gag reflex
    3.   Monitor gastric pH
    4.   Measure abdominal girth


Answer is 2.

•    The posterior pharynx is anesthetized for easy passage of the
     endoscope into the esophagus. The return of the gag reflex
     indicates that normal function is returning and the client is able to
     swallow (option 2). Bowel sounds (option 1) and abdominal girth
     (option 4) are associated with caring for a client with a nasogastric
     tube in place. Gastric pH (option 3) is related to the client with
     peptic ulcer disease.

                   GI – Hesi Review Question

•   The client is admitted to the hospital with ulcerative colitis. The
    nurse should assess the client for which sign that indicates a
    complication of the disease?

    1.   Low hemoglobin and hematocrit
    2.   Low platelet count
    3.   Epigastric or right-sided pain following a high-fat meal
    4.   Presence of fat in the stools


Answer is 1.

•    Hemorrhage and bleeding are a common feature of ulcerative
     colitis, and over time this can lead to significant loss of RBCs, the
     client should be assessed for possible anemia (option 1).
     Steatorrhea is seen in malabsorption syndrome (option 4).
     Thrombocytopenia may occur if the client is treated with
     immunosuppressants (option 2) to control the disease. Signs of
     cholelithiasis are unrelated to ulcerative colitis (option 3).

                   GI – Hesi Review Question

•   A client is admitted to the hospital with a bowel obstruction. Which
    of these findings by the nurse would indicate that the obstruction is
    in the early stages?

    1.   High-pitched tinkling bowel sounds
    2.   Low rumbling bowel sounds
    3.   No bowel sounds auscultated
    4.   Normal bowel sounds heard in all four quadrants


Answer is 1.

•    Early in a bowel obstruction, the bowel attempts to move the
     contents past the obstruction, and this is heard as high-pitched
     tinkling bowel sounds (option 1). As the obstruction progresses,
     bowel sounds will diminish and may finally become absent (option
     3). Bowel sounds in all four quadrants (option 4) and rumbling
     bowel sounds (option 2) are normal.

                  GI – Hesi Review Question

•   A client with gastroesophageal reflux disease (GERD) is prescribed
    famotidine (Pepcid). In order to provide effective teaching, the
    nurse must include which information about the action of the drug?

    1.   It improves motility
    2.   It coats the distal potion of the esophagus
    3.   It increases the gastric pH
    4.   It decreases the secretion of gastric acid


Answer is 4.

•    Famotidine is a histamine-2 receptor antagonist and reduces the
     secretion of gastric acid (option 4). This class of drugs does not have
     a direct effect on reflux or GI motility. Metoclopramide improves GI
     motility (option 1). Sucralfate coasts the ulcer (option 2). Antacids
     neutralize the hydrochloric acid in the stomach (option 3).


                   GI – Hesi Review Question

•   A 65-year old man presents to the Emergency Department
    complaining of recurring burning chest pain after eating. His history
    consists of obesity, type-II diabetes, sedentary behavior, and
    commonly takes TUMS on a regular basis. As his ED nurse, which
    nursing diagnosis would be suitable for this patient?

    1.   At risk for severe pain related to an angina attack.
    2.   At risk for hyperglycemic hyperosmolar nonketotic syndrome
         related to poorly controlled diabetes.
    3.   Deficient knowledge related to GERD.
    4.   Possible nutritional deficiency related to overuse of antacids.


Answer is 3.

•    Chest pain only after eating is a common complaint of
     Gastroesophaegeal reflux disease (GERD). Chest pain before eating
     is related to Peptic Ulcer Disease. Commonly taking TUMS is another
     indication of acid reflux.

                  GI – Hesi Review Question

•   Name the three causes of intestinal obstruction.

    1.   Constipation, neurogenic, and vascular.
    2.   Mechanical, neurogenic, and vascular.
    3.   Mechanical, diverticulitis, and vascular.
    4.   Mechanical, constipation, and diverticulitis.


Answer is 2

•    The three main causes of intestinal obstruction are due to
     Mechanical (adhesions, hernias, volvulus [twisting of the gut],
     intussusceptions, tumors), neurogenic (paralytic illeus, lesions on
     the spinal cord), and vascular causes (artery occlusions).

                  GI – Hesi Review Question

•   A patient is being admitted to post-op recovery for a hip
    replacement. It is 12-hours post-op and she is complaining that she
    has not eaten in 24 hours and wants some ice cream to soothe her
    irritated throat. What is the next nursing intervention for this

    1.   Give her the ice cream right away to soothe her irritated throat
         and document the amount on her I&O’s.
    2.   Tell her she cannot have any liquids or food until she
         ambulates for the first time.
    3.   Contact doctor to increase IV fluids because her output is
    4.   Ascultate for bowel sounds, if bowel sounds are heard, allow
         her to eat some ice cream.


Answer is 4

•    After surgery, it is important to determine if the intestines have
     begun to move or are still paralytic. The nurse must determine, via
     auscultation of the abdomen, if bowel sounds have returned. If food
     and liquid is given too early, an intestinal obstruction may occur.

                  GI – Hesi Review Question

•   A 45-year old woman presents in your outpatient facility concerned
    with her family history of colorectal cancer. What interventions
    would be suitable to suggest for this woman?

    1.   Eat more cruciferous vegetables.
    2.   Tell her that there is nothing she can do; this type of cancer
         cannot be prevented.
    3.   Decrease fiber intake, and increase more foods from animal
    4.   Begin colonoscopy examinations every year after 50.


Answer is 1

•    The only valid answer is to eat more cruciferous vegetables
     (broccoli, cauliflower, etc…). Preventative screening is important.
     Rectal examinations should be given every year after age 40, and
     colonoscopies/sigmoidoscopies should only be given every 3 -5
     years after age 50. Fiber intake should increase, and foods from
     animal sources should decrease for preventive measures.

                  GI – Hesi Review Question

•   A client is to receive gavage feeding through a nasogastric (NG)
    tube. Which of the following nursing actions should be performed
    to prevent complications?

    1.   Flush with 20 mL of air
    2.   Place client in high Fowler’s position
    3.   Advance tube 1 cm
    4.   Plug the air vent during feeding

Answer is 2. Keeping the client in a high Fowler’s position minimizes the
    risk of aspiration (option 2). Flushing with air (option 1) will increase
    abdominal distention and increase discomfort and risk of aspiration.
    Advancing the tube (option 3) is only relevant if it is a nasoduodenal
    tube that has not advanced beyond the pylorus. Plugging the air
    vent (option 4) is unnecessary.

Strategy: The NG tube bypasses the oropharynx and the gag reflux, which
     concludes that the airway is compromised. Select the answer that
     protects the airway.
                  GI – Hesi Review Question

•   The nurse should question the client with gastroesophageal reflux
    disease (GERD) about the use of which type of medications that
    decrease lower esophageal sphincter (LES) tone?

    1.   Antidepressants
    2.   Calcium channel blockers
    3.   Antiestrogen agents
    4.   Alpha-adrenergic blocking agents

Answer is 2. Many common substances contribute to decreased LES tone
    including fatty foods, caffeinated beverages, nicotine, beta-
    adrenergic blocking agents, calcium channel blockers (option 2),
    nitrates, theophylline, alcohol, and anticholinergic drugs.
    Antidepressants, antiestrogen agents, and alpha adrenergic blockers
    have no effect on LES tone.

Strategy: Identify how the lower esophageal sphincter contributes to the
     symptoms of GERD and select the drug that increases that effect.
                  GI – Hesi Review Question

•   The client with irritable bowel syndrome (IBS) asks the nurse what
    causes the disease. Which of the following response by the nurse
    would be most appropriate?

    1.   This is an inflammation of the bowel caused by eating too
         much roughage.
    2.   IBS is caused by a stressful lifestyle
    3.   The cause of this condition if unknown
    4.   There is thinning of the intestinal mucosa caused by ingestion
         of gluten

Answer is 3. There is no known cause of IBS, and diagnosis is made by
    excluding all other diseases that cause the symptoms (option 3).
    There is no inflammation of the bowel (option 1). Some factors
    exacerbate the symptoms (option 2), including anxiety, fear, stress,
    depression, some foods (options 1 and 4) and drugs, but these do
    not cause the disease.

Strategy: Know the different forms of inflammatory bowel disease and
     causative factors vs exacerbating factors.
                   GI – Hesi Review Question

•   A client with Crohn’s disease (regional enteritis) who is taking
    sulfasalazine (Azulfidine) asks the nurse why this medication is
    necessary. When information should the nurse include in her

    1.   The drug decreases abdominal cramping by slowing peristalsis.
    2.   The drug decreases prostaglandin production in the bowel so it
         decreases inflammation.
    3.   The drug inhibits neurotransmission of pain impulses.
    4.   The drug stimulates the release of endorphins so pain is

Answer is 2. Sulfasalazine is a GI anti-inflammatory medication that
    exerts its action by decreasing prostaglandin production in the
    bower (option 2). Peristalsis is decreased by anticholinergic agents
    (option 1). Analgesics affect pain impulses (options 3 and 4).

Strategy: Review the goals of treatment for inflammatory bowel disease
     and select the answer that directly decreases the inflammatory
                            Question #1
•    Colace works by?

1.   Stimulating muscles and nerves in the bowels to help move stool
2.   Forming bulk that absorbs liquid to produce a soft bulky stool,
     stimulating bowel normally by the presence of the bulk
3.   Encouraging bowel movements by drawing water into the bowel
     from surrounding body tissues, providing soft stool mass and
     increased bowel action
                              Answer is 2

•   Rationale: Colace is a bulk-forming laxative.
•   Nursing Intervention:

We should encourage our patients to increase their fluid intake during
   their use of Colace because water is being lost to the colon.
                              Question #2

•    When a client has peptic ulcer disease, the nurse would expect a
     priority intervention to be?

1.   Assisting in inserting a Miller-Abbott tube
2.   Assisting in inserting an arterial pressure line
3.   Inserting a nasogastric tube
4.   Inserting an IV
                                Answer is 3

•    Insert a NG tube

•    Rationale:
    NG tube needs to be inserted to determine the presence of active GI
     bleeding. A Miller-Abbott tube is a weighted, mercury-filled
     ballooned tube used to resolve bowel obstructions. There is no
     evidence of shock or fluid overload in the client; therefore an arterial
     line is not indicated and an IV is optional.
                              Question #3

•    A 55 year old patient with severe epigastric pain due to acute
     pancreatitis has been admitted to the hospital. The client’s activity
     at this time should be?

1.   Ambulation as desired
2.   Bedrest in supine position
3.   Up ad lib and right side-lying position in bed
4.   Bedrest in Fowler’s position
                               Answer is 4

•    Bedrest in Fowler’s position

•     Rationale:
    The pain of pancreatitis is made worse by walking and by laying in the
      supine position. The client is more comfortable sitting up and leaning
                             Question #4
•    A client has had a cystectomy and ureteroileostomy (ileal conduit).
     The nurse observes this client for complications in the postoperative
     period. Which of the following symptoms indicates an unexpected
     outcome and requries priority care?

1.   Edema of the stoma
2.   Mucus in the drainage appliance
3.   Reddness of the stoma
4.   Feces in the drainage applance
                              Answer is 4
•    Feces in the drainage appliance

•     Rationale:
    The ileal conduit procedure incorporates implantation of the ureters
      into a portion of the ileum which has been resected from its
      anatomical position and now functions as a reservoir or conduit for
      urine. Feces should not be draining from the conduit. Edema a red
      color of the stoma are the expected outcomes in the immediate post-
      op period, as is mucus from the stoma.
                               Question #5

•    Most cleft palates are repaired at what age?

1.   Immediately after birth
2.   1 to 2 months
3.   3 to 4 months
4.   1 to 2 years
                               Answer is 4

•    1 to 2 years

•    Rationale:
    Most surgeons will correct the cleft at 1 to 2 years old before faulty
     speech patterns develop to take advantage of palatal changes during
                             Question #6

•    To clear Dr. B out of the classroom as quickly as possible, so we can
     all go home, we should have all eaten which food for lunch?

1.   Beans
2.   Donuts
3.   Wine and cheese
4.   Pizza
            Question #6 Answer

Do you really need the answer and rationale?

           We are done people!

              Let’s go home!

     Thank you for your participation!!

               The GI Group

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