GIT

1. Gastrointestinal AssessmentPhysical Exam1

2. Health History and Clinical Manifestations1. Complete history focusing on GI dysfunction.Pain - major symptom of GI disease

3. Note the character, duration, pattern, frequency, location, distribution and time of the pain.

4. Aggravating factors – meals, rest, defecation, and vascular disorders may directly affect the pain

5. Indigestion - upper abdominal discomfort or distress associated with eating.

6. Most common symptom of patients with GI dysfunction.

7. Gastric peristaltic movements may or may not relieve the pain

8. Can result form disturbed nervous system control of the GI tract or elsewhere in the body

9. Fatty foods tend to cause discomfort as well as coarse vegetable and highly seasoned foods.

10. Health History and Clinical ManifestationsIntestinal gas – accumulation of gas in the GI tract.

11. May result to belching or flatulence

12. Complain of bloating, distention or being “full of gas”

13. Excessive flatulence – maybe symptom of gallbladder disease or food intolerance.

14. Nausea and vomiting - Another major symptom of GI disease.

15. Vomiting (emesis) is usually preceded by nausea

16. Can be triggered by odors, activity or food intake.

17. Vomitus may vary in color and content

18. May contain undigested food particles or blood (hematemesis)

19. When vomiting occurs soon after hemorrhage – bright red

20. If blood has been retained in the stomach – coffee-ground appearance because of digestive enzymes

21. Hematemesis – Vomiting of bloodHealth History and Clinical ManifestationsChanges in bowel habits – a signal of colon diseaseDiarrhea – abnormal increase in frequency and liquidity of the stool or daily stool weight or volume.Occurs when contents move so rapidly through the intestine and colon with inadequate time for absorption of GI contents.

22. Sometimes associated with abdominal pain or cramping and nausea and vomitingHealth History and Clinical ManifestationsConstipation – decrease in the frequency of stool or stools that are hard, dry and smaller volume than normal.- May be associated with anal discomfort and rectal bleedingStool characteristics

23. Normally light to dark brown

24. Indigestion of certain foods and medications can change the appearance of stool.Foods and Medications That Alter Stool ColorCOLORDark brownGreenRedDark red or brownYellowBlackMilky whiteALTERING SUBSTANCESMeat proteinSpinachCarrots and beetsCocoaSennaBismuth,iron,licorice & charcoalBarium

25. Health History and Clinical ManifestationsBlood in the stool

26. Melena – black tarry stool is produced if blood is shed into the upper GI tract.

27. Blood entering the lower portion of the GIT or passing rapidly through it will appear bright or dark red.

28. Lower rectal or anal bleeding if there is streaking of blood on the surface of the stool or noted on toilet tissueHealth History and Clinical ManifestationsOther Common abnormalities in stool characteristics

29. Bulky, greasy, foamy stools foul in odor, gray with a silvery sheen.

30. Light gray or clay-colored stool-caused by absence of urobilin

31. Stool with mucus threads or pus

32. Small, dry, rock-hard mass called scybala, streaked with blood from rectal trauma

33. Loose, watery stool that may or may not be streaked with blood.Health History and Clinical ManifestationsPrevious GI diseasePast and current medication usePrevious treatment or surgeryDietary historyUse of tobacco and alcohol – type and amountChanges in appetite or eating patternsUnexplained weight gain or loss over the past yearPsychosocial factors – Stress and anxietySpiritual factors -ReligionCultural factors – Beliefs and Tradition

34. sequenceInspectionAuscultationPercussionPalpation 11

35. PHYSICAL ASSESSMENTMouthInspection of the mouth, tongue, buccal mucosa, teeth and gums

36. Ulcers, nodules, swellling, discoloration and inflammation are noted

37. Dentures should be removed.

38. PHYSICAL ASSESSMENT2. Abdomen a. Inspection - note for skin changes and scars from previous surgery, contour and symmetry, localized bulging, distention or peristaltic waves. b. Auscultation - notes the character, location and frequency of bowel sounds. - Assess bowel sounds in all four quadrants using the diaphragm of the stethoscope (high pitched and gurgling sounds) - Bowel sounds (Borborygmi sound) NORMAL – Sounds heard every 5-20 seconds HYPOACTIVE – 1-2 sounds in 2 minutes HYPERACTIVE – 5-6 sounds heard in less than 30 seconds ABSENT – no sound in 3-5 minutes

40. PHYSICAL ASSESSMENT c. Palpation > Light palpation may identify areas of tenderness or swelling > Deep palpation may identify masses in any four quadrants. > Identify direct and rebound tenderness…HOW? > Identify findings in relation to surface landmarks (xiphoid process, costal margins, ASIS, symphysis pubis) and four quadrants (RUQ,RLQ,LUQ,LLQ) d. Percussion - Note for tympany or dullness

41. PHYSICAL ASSESSMENT3. Anus and Perineal Area > Inspect and palpate areas of excoriation or rash, fissures or fistula openings or external hemorrhoids > Digital rectal examination may note areas of tenderness or mass.

42. DIAGNOSTIC ASSESSMENTBlood TestsStool TestsBreath TestsAbdominal UltrasonographyDNA TestingImaging StudiesComputed Tomography (CT) ScanMagnetic Resonance Imaging (MRI)ScintigraphyEndoscopic ProceduresManometry and Electrophysiologic StudiesGastric Analysis, Gastric Acid Stimulation Test and pH MonitoringLaparoscopy (Peritoneoscopy)

43. GENERAL NURSING INTERVENTIONS FOR PATIENTS HAVING GI DIAGNOSTIC ASSESSMENTProvide general information about a healthy diet and nutritional factors that can cause GI disturbancesProviding information about the test and the activities required of the patientAlleviating anxietyHelp patient cope with discomfortEncourage family members to offer emotional support to patient during the testAssess for adequate hydration before, during and immediately after the procedure and provide education about maintenance of hydration

44. DIAGNOSTIC ASSESSMENTBlood TestsCBC, CEA, Liver function tests, serum cholesterol, and triglycerides

45. May reveal alterations in basal metabolic function and severity of a disorderStool TestsInspect specimen for consistency and color, occult blood (Hematest), fecal urobilinogen, fat, nitrogen, parasites, pathogens, food residues and other substances.

46. Quantitative 24-72-hour collections must be kept refrigerated until taken to the laboratory

47. What stool test is most frequently used in cancer screening programs and for early cancer detection?DIAGNOSTIC ASSESSMENTFalse positive HEMATEST may result if patient eat

48. Rare meat, liver, poultry, turnips, broccoli, cauliflower, melons, salmon, sardines or horseradish within 7 days before testing

49. Medications: aspirin, ibuprofen, indomethacin, colchicine, corticosteroids, cancer chemotherapeutic agents and anticoagulants

50. False negative result: ingestion of Vit. C supplements or foodDIAGNOSTIC ASSESSMENTOther occult blood tests that yield more specific and more sensitive readings include:

51. Hematest II SENSA

52. HemoQuant OTHER TESTS:Immunologic tests are more specific to human hemoglobin

53. Hemoporphyrin assays detect the broadest range of blood derivatives

54. Immunochemical test using antihuman antibodies that are extremely sensitive to human hemoglobin are available.DIAGNOSTIC ASSESSMENTBreath TestsHydrogen breath test – evaluate carbohydrate absorption and diagnosis of bacterial overgrowth in the intestine and short bowel syndrome.

55. Determines the amount of hydrogen expelled in the breath after it has been produced in the colon and absorbed into the blood.

56. Urea breath test – detect presence of Helicobacter pylori which causes peptic ulcer disease.4. Abdominal UltrasonographyNoninvasive diagnostic technique which uses high-frequency sound waves.

57. Used to indicate the size and configuration of abdominal structures.

58. Useful in detection of cholelithiasis, cholecystitis, and appendicitis and acute colonic diverticulitis.

59. Advantages: No ionizing radiation, no noticeable side effects, relatively inexpensive.

60. Disadvantage: It cannot be used to examine structures that lie behind bony tissue….

61. Endoscopic ultrasonography – gives direct imaging of a target area.

62. Nursing Interventions:

63. Patients fasts for 8-12 hours before the test

64. If gallbladder studies is to be done, patient should be fat-free the evening before the test

65. If barium studies are to be performed, nurse should make sure they are scheduled after this test…..why?5. DNA Testing – Pre clinical diagnosis to identify persons who are at risk for certain GI disorders (gastric cancer, lactose deficiency, inflammatory bowel disease, colon cancer).6. Imaging StudiesX-ray and contrast studies Upper GI series or barium swallow> Double contrast studies – administration of thick barium suspension followed by tablets that release carbon dioxide in the presence of water. (Early superficial neoplasms are identified)> Enteroclysis – a double contrast study of the entire small intestine by infusing continuously of 500-1000ml of thin barium sulfate suspension followed by methylcellulose and observed through fluoroscopy. Up to 6 hours. For diagnosis of Partial small-bowel obstructions or diverticula.

66. 7. Upper GI series or Barium SwallowNursing InterventionsPatient need to maintain low-residue diet for several days before the test.

67. NPO after midnight before the test.

68. Physician may prescribe laxative

69. Discourage smoking on the morning before the examination

70. Withholds all medications

71. Follow up care after the procedure, fluids must be increased, monitor patient’s stool color, laxative or enema may be needed.8. Lower Gastrointestinal Tract StudyBarium Enema

72. Barium is instilled rectally to visualize the lower GI tract.

73. To detect presence of polyps, tumors and other lesions of small intestine and demonstrate abnormal anatomy or malfunction of the bowel.

74. Takes about 15-30 minutes

75. Double contrast studies – barium enema with instillation of air.

76. Lower Gastrointestinal Tract StudyNursing Interventions:Emptying and cleansing the lower bowel.

77. Low residue diet 1-2 days before the test

78. Clear liquid diet and laxative the evening before

79. NPO after midnight

80. Cleansing enemas until returns are clear the following morning

81. Barium enemas should be scheduled before any upper GI studies.

82. Contraindications: Signs of perforations or obstruction, GI bleeding prohibit the use of laxatives and enemas

83. Administers enema or laxative after test to facilitate barium removal, Increase fluid intake.9. Computed Tomography (CT) ScansProvides cross-sectional images of abdominal organs and structures. Multiple x-ray images are taken for many different angles.Nursing Interventions:Patient should not eat or drink for 6-8 hours before the test.

84. Physician may prescribe an IV or oral contrast agent. Dye allergy history should be asked.

85. Barium studies should be performed after CT scanning.10. Magnetic Resonance Imaging (MRI)Noninvasive technique that uses magnetic fields and radio waves to produce an image of the area being studied.

86. Useful in evaluating abdominal soft tissues as well as blood vessels, abscesses, fistulas, neoplasms, and other sources of bleeding.

87. Contraindications: patients with permanent pacemakers, artificial heart valves and defibrillators, implanted insulin pumps or implanted transcutaneous electrical nerve stimulation devices, with internal metal devices (aneurysm clips) or intraocular metallic fragments.

88. Nursing Interventions:

89. Patient should not eat or drink for 6-8 hours before the test.

90. Remove all jewelry and other metals

91. Warn patients on the close-fitting scanners which may induce feelings of claustrophobia and the machine will make a knocking sound during the procedure.11. Scintigraphy (Radionuclide imaging)Use radioactive isotopes (technitium,iodine and indium) to reveal displaced anatomic structures, changes in organ size and presence of neoplasms, cysts or abscesses.

92. Scintigraphic scanning measure the uptake of tagged red blood cells and leukocytes which will define areas of inflammation, abscess, blood loss.

93. A sample of blood is removed, mixed with a radioactive substance and reinjected into the patient.

94. Abnormal concentrations of blood cells are detected at 24 and 48 hours intervals12. Gastrointestinal Motility StudiesUsed to assess gastric emptying and colonic transit time.

95. After meal, patient is positioned under a scintiscanner and measures the passage of radioactive substance out of the stomach.

96. For evaluation of diabetic gastroparesis and dumping syndrome, chronic constipation and obstructive defecation syndrome

97. Abdominal x-rays are taken every 24 hours until all markers are passed

98. The process takes 4-5 days but in severe constipation may take as long as 10 days.

99. If with chronic diarrhea, may be evaluated at 8-hour intervals. 13. Endoscopic ProceduresFibroscopy/ EsophagogastroduodenoscopyAnoscopyProctoscopySigmoidoscopyColonoscopySmall-bowel enteroscopyEndoscopy through ostomy

100. Gastroscopy

101. ENDOSCOPIC PROCEDURESEGDAfter the patient is sedated, the endoscope is lubricated with a water-soluble lubricant and passed smoothly and slowly along the back of the mouth and down into the esophagus.Biopsy forceps to obtain tissue specimens or cytology brushes to obtain cells for microscopic study can be passed through the scope.Patients may experience nausea, choking or gagging.

102. ENDOSCOPIC PROCEDURESEGDUse of oral anesthetics and moderate sedation makes it important to monitor and maintain the oral airway during the after the procedure.Monitor oxygen saturation by means of pulse oximeters, and supplemental oxygen may be administered if necessary

103. ENDOSCOPIC PROCEDURESEGD: Nursing InterventionsThe patient should not eat or drink for 6 to 12 hours before the examination.Help the patient spray or gargle with a local anesthetic.Administer a sedative such as midazolam intravenously just before the scope is introduced.The nurse may also administer atropine to decrease secretion, and glucagon to relax smooth muscle.

104. ENDOSCOPIC PROCEDURESEGD: Nursing InterventionsPosition the patient on the left side to facilitate saliva drainage and provide easy access for the endoscope.Instruct the patient not to eat or drink until the gag reflex returns.Place the patient in the Simms position until he or she is awake, and then place the patient in the semi-Fowler’s position until ready for discharge

105. ENDOSCOPIC PROCEDURESEGD: Nursing InterventionsAfter gastroscopy, observe for signs of perforation: bleeding, unusual dysphagia, fever.Monitor the pulse and blood pressure for changes that can occur with sedation.Test the gag reflex. Relieve minor throat discomfort by giving lozenges, saline gargle and oral analgesics

106. Colonoscopy

107. Fiberoptic ColonoscopyDirect visual inspection of the colon to the cecum.Used commonly as a diagnostic and screening device.Tissue biopsies can be obtained as needed, and polyps can be removed and evaluated.May also be used to evaluate diarrhea of unknown cause, occult bleeding, or anemia

108. Fiberoptic ColonoscopyUsually performed while the patient is lying on the left side with the legs drawn up toward the chest.Discomfort may result from instillation of air to expand the colon or from insertion and moving of the scope.Potential complications include cardiac dysrhythmias and respiratory depression resulting from the medications administered, vasovagal reactions and circulatory overload or hypotension as a result of under- or over hydration.

109. Fiberoptic ColonoscopyAdequate colon cleansing provides optimal visualization and decreases the time needed for the procedure.Patient should limit the intake of liquids for 24 to 72 hours before the examination.Prescribe laxatives for two nights before the examination and a Fleet’s or saline enema until the return runs clear on the morning of the test.Clear liquid diet starting at noon the day before the procedure.

110. Fiberoptic ColonoscopyPatient ingests lavage solutions orally at intervals over 3 to 4 hours.Cardiopulmonary clearance prior to test for patients with known or suspected cardiac and pulmonary conditions, and in patients over the age of 40 years.NSAIDs, aspirin, ticlopidine and pentoxifylline must be discontinued before the test and for 2 weeks after the procedure.Informed consent must be obtained.

111. Fiberoptic ColonoscopyNPO after midnight before the test.Monitor for changes in oxygen saturation, vital signs, color and temperature of the skin, level of consciousness, abdominal distention, vagal response and pain intensity during the test.After the procedure, patients who were sedated are maintained on bed rest until fully alert.Abdominal cramps are common as a result of increased peristalsis stimulated by air insufflated into the bowel during the procedure

112. Fiberoptic ColonoscopyImmediately after the procedure, observe the patient for signs and symptoms of bowel perforation.If midazolam was used, the nurse should explain its amnesic effect; it is important to provide written instructions, because the patient may be unable to recall verbal information.Instruct the patient to report any bleeding to the physician.

113. Flexible Fiberoptic Sigmoidoscopy

114. Anoscopy, Proctoscopy and SigmoidoscopyVisualize the lower portion of the colon to evaluate rectal bleeding, acute or chronic diarrhea, or change in bowel patterns, and to observe for ulceration, fissures, abscesses, tumors, polyps, or other pathologic processes.Rigid or flexible fiberoptic scopes can be used.Anoscopes are rigid scopes that are used to examine the anus and lower rectum.Proctoscopes and sigmoidoscopes are rigid scopes used to inspect the rectum and sigmoid colon.

115. Anoscopy, Proctoscopy and SigmoidoscopyFor rigid scopes, the patient assumes the knee-chest position at the edge of the bed or examining table.Keep the patient informed about the progress of the examination and to explain that the pressure exerted by the instrument will create the urge to have bowel movement.

116. Anoscopy, Proctoscopy and SigmoidoscopyFor flexible scope procedures, the patient assumes a comfortable position on the left side, with the right leg bent and placed amteriorly.It is important to keep the patient informed throughout the examination and to explain the sensations associated with the examination.These examinations require only limited bowel preparation, including a warm tap water or Fleet’s enema until returns are clear.

117. Anoscopy, Proctoscopy and SigmoidoscopyDietary restrictions usually are not necessary, and sedation usually is not required.Monitor the vital signs, skin color and temperature, pain tolerance and vagal response during the procedure.After the procedure, the nurse monitors the patient for rectal bleeding and signs of intestinal perforation.On completion of the examination, the patient can resume regular activities and dietary practices.

118. DIAGNOSTIC ASSESSMENT Manometry and Electrophysiologic Studies. Gastric Analysis, Gastric Acid Stimulation Test and pH Monitoring Laparoscopy (Peritoneoscopy)

119. Gastrointestinal AssessmentLaboratory Procedures54

120. 55Foods and MedicationsColorAltering SubstanceDark brownMeat proteinGreenSpinachRedCarrots and beetsDark red or brownCocoaYellowSennaBlackBismuth, iron, licorice and charcoalMilky whiteBariumHealth History and Clinical Manifestations

121. COMMON LABORATORY PROCEDURESFECALYSISExamination of stool consistency, color and the presence of occult blood.Special tests for fat, nitrogen, parasites, ova, pathogens and others56

122. COMMON LABORATORY PROCEDURESFECALYSIS: Occult Blood TestingInstruct the patient to adhere to a 3-day meatless dietNo intake of NSAIDS, aspirin and anti-coagulantScreening test for colonic cancer57

123. COMMON LABORATORY PROCEDURESUpper GIT study: barium swallowExamines the upper GI tractBarium sulfate is usually used as contrast58

124. COMMON LABORATORY PROCEDURESUpper GIT study: barium swallowPre-test: NPO post-midnightPost-test: increase pt fluid intake, instruct that stools will turn white, monitor for obstruction, laxative is also ordered59

125. 60

126. 61

127. COMMON LABORATORY PROCEDURESLower GIT study: barium enemaExamines the lower GI tractPre-test: Clear liquid diet and laxatives, NPO post-midnight, cleansing enema prior to the test62

128. COMMON LABORATORY PROCEDURESLower GIT study: barium enemaPost-test: Laxative is ordered, increase patient fluid intake, instruct that stools will turn white, monitor for obstruction63

129. 9/19/201164

130. COMMON LABORATORY PROCEDURESGastric analysisAspiration of gastric juice to measure pH, appearance, volume and contentsPre-test: NPO 8 hours, avoidance of stimulants, drugs and smokingPost-test: resume normal activities65

131. COMMON LABORATORY PROCEDURES EGD(esophagogastroduodenoscopy)Visualization of the upper GIT by endoscopePre-test: ensure consent, NPO 8 hours, pre-medications like atropine and anxiolytics66

132. 67

133. COMMON LABORATORY PROCEDURESEGDesophagogastroduodenoscopyIntra-test: position : LEFT lateral to facilitate salivary drainage and easy access68

134. COMMON LABORATORY PROCEDURESEGD (esophagogastroduodenoscopy)Post-test: NPO until gag reflex returns, place patient in SIMS position until he awakens, monitor for complications, saline gargles for mild oral discomfort69

135. COMMON LABORATORY PROCEDURESLower GI- scopyUse of endoscope to visualize the anus, rectum, sigmoid and colonPre-test: consent, NPO 8 hours, cleansing enema until return is clear70

136. 71

137. COMMON LABORATORY PROCEDURESLower GI- scopyIntra-test: position is LEFT lateral, right leg is bent and placed anteriorlyPost-test: bed rest, monitor for complications like bleeding and perforation72

138. 9/19/201173

139. COMMON LABORATORY PROCEDURESCholecystographyExamination of the gallbladder to detect stones, its ability to concentrate, store and release the bilePre-test: ensure consent, ask allergies to iodine, seafood and dyes; contrast medium is administered the night prior, NPO after contrast administration9/19/201174

140. COMMON LABORATORY PROCEDURESCholecystographyPost-test: Advise that dysuria is common as the dye is excreted in the urine, resume normal activities75

141. COMMON LABORATORY PROCEDURESParacentesisRemoval of peritoneal fluid for analysis76

142. COMMON LABORATORY PROCEDURESParacentesisPre-test: ensure consent, instruct to VOID and empty bladder, measure abdominal girth77

143. COMMON LABORATORY PROCEDURESParacentesisIntra-test:Upright on the edge of the bed, back supported and feet resting on a foot stool78

144. DIAGNOSTIC EVALUATION: Computed TomographyProvides cross-sectional images of abdominal organs and structures.The patient should not eat or drink for 8 hours before the test.The practitioner may prescribe an intravenous or oral contrast agent.Obtain a history and ask about allergies.Should be performed before barium studies.79

145. DIAGNOSTIC EVALUATION: Computed Tomography80

146. DIAGNOSTIC EVALUATION: MRIUsed in gastroenterology to supplement ultrasonography and CT scanning.Noninvasive technique that uses magnetic fields and radio waves to produce an image of the area being studied.Physiologic artifacts of heartbeat, respiration and peristalsis may create a less-than-clear image.81

147. DIAGNOSTIC EVALUATION: MRIThe patient should not eat or drink for 8 hours before the test.The patient must remove all jewelry and other metals.Warn patients that the close-fitting scanners used in many MRI facilities may induce feelings of claustrophobia and that the machine will make a knocking sound during the procedure.82

148. DIAGNOSTIC EVALUATION: MRI83

149. COMMON LABORATORY PROCEDURESLiver biopsyPretestConsentNPOCheck for the bleeding parameters84

150. COMMON LABORATORY PROCEDURESLiver biopsyIntratestPosition: Semi fowler’s LEFT lateral to expose right side of abdomen85

151. COMMON LABORATORY PROCEDURESLiver biopsyPost-test: position on RIGHT lateral with pillow underneath, monitor VS and complications like bleeding, perforation. Instruct to avoid lifting objects for 1 week86

152. The NURSING PROCESS in GIT DisordersAssessmentHealth history Nursing HistoryPELaboratory procedures87

153. GASTRIC GAVAGE: Nursing InterventionGastric gavage is the introduction of liquid feedings directly into the stomach.Purpose:Effective in persons who have difficulty in swallowing, prolonged unconsciousness, or anorexia.Useful when there is oral or esophageal obstruction or trauma.Life-saving in one who is debilitated or who has had surgery on some part of the GIT that does not permit normal ingestion of food.

154. GASTRIC GAVAGE: Nursing InterventionAvenues:Nasogastric/orogastricEsophagotomy – a stoma (temporary or permanent) may be created at one of several sites along the esophagus.GastrostomyJejunostomy

155. GASTRIC GAVAGE: Nursing InterventionFeeding Methods:GravityDrip-regulated (a Murphy drip is connected by tubing to a receptacle or Kelly flask) which hangs on an IV pole.Motor pump

156. GASTRIC GAVAGE: Nursing InterventionContinuous Nursing AssessmentRecognize that even though nutritional deficits are corrected, some other problems may arise.Cleanse all containers and tubings thoroughly.Aspirate the tubing prior to feeding to verify that the tube is inside the patient’s stomach.Avoid air bubbles in the system.Provide oral and nasal hygiene before and after orogastric and nasogastric feedings for comfort or prevent infection.

157. GASTRIC GAVAGE: Nursing InterventionContinuous Nursing AssessmentFollow each feeding with water to flush tubing for cleansing and to promote fluid balance.Monitor patient for signs of fluid and electrolyte imbalance.Record amount of feeding and water; indicate patient’s participation and acceptance.

158. GASTRIC GAVAGE: Nursing InterventionPatient EducationSince tube should be changed every 2 to 3 days, the patient may be taught how to do it.The patient should learn how to feed himself.Skin requires special care.

159. Total Parenteral Nutrition (TPN)Intravenous administration of a hypertonic solution of glucose, nitrogen and other nutrients to achieve tissue synthesis and anabolism. Lipids may be given as a supplement.

160. Provides 3,000 – 4,000 calories per day.TPN/ PPNIV Hyperalimentation

161. Method of supplying nutrients to the body via IV route

162. Goal: to improve nutritional status, promote weight gain & enhance healing processIndications: Severe burns, malnutrition, sepsis, cancer, paralytic ileus, bowel obstruction, anorexia nervosa, acute pancreatitis, bowel surgery

163. Solution: 25% glucose and synthetic amino acids

164. Site: Subclavian vein going to SVCComplications:Pneumothorax

165. Air embolism

166. Clotted line

167. Displacement

168. Sepsis

169. Hyperglycemia

170. Fluid overload

171. Rebound hypoglycemiaNURSING ALERT! Continous uniform infusion in 24-hour period

172. Weigh daily

173. Prevent infection

174. Change dressings aseptically twice a week

175. Infusion rate NOT too fast nor too slow Indication for use: Inability of the gastrointestinal tract to absorb nutrients adequately.

176. Inability to take food by mouth

177. Excessive nutritional needs that cannot be met by the usual methods

178. *1000 cc D5W provides only 200 calories and no protein; adult energy requirements can reach 2,500 to 3,000 calories in some situations such as burnsNursing Intervention

179. CXR immediately after subclavian line insertion

180. Assess weight, baseline electrolytes, blood glucose, zinc and copper levels before treatment begins

181. Maintain aseptic technique during dressing changes

182. Maintain infusion rate

183. Monitor for complications - Infection - Pneumothorax during insertion - Hypoglycemia - Zinc deficiency - Hyperglycemia - Fluid overload - Air embolism - Hyperglycemic, hyperosmolar nonketotic coma

184. Ileostomy stomaProtrudes so that the liquid stool does not burn the skin.

185. Located on the right hand side of the tummy.

186. Colostomy stoma

187. Note how it is flusher with the skin

188. Located on the left hand side of the tummyColostomy and IleostomyNursing InterventionPreoperative Care - Emotional support - Client-teaching concerning impending surgery ileostomy/ colostomyPostoperative Care - General postoperative care - Psychological support - Observe stoma, surrounding tissues, and type of excretion - Teach client of self care * Type of equipment to use and how * Skin care * Diet * Irrigation

189. Colostomy CareAssess every shift for 3 days post opNormal stoma: pinkAbnormal: cyanotic; dusky color, black/brownInitially it protrudes 1 inch outwardCheck bowel sounds q 4Begins functioning after 48 hrsAvoid gasforming foods/ high fiber

190. Colostomy CareStoma irrigations: 500-1000ml of warm or tepid waterNsg. Alert :Prior to 1st irrigation, insert gloved finger to note direction of stomaHang bag 12-14 inches above the stomaLubricate and insert 3-4 inchesInfuse for 15 minsExpect return after 15-20 mins

191. The ABDOMINAL examinationThe sequence to follow is:InspectionAuscultationPercussionPalpation103

192. Most Common GIT SymptomAbdominal PainMajor symptom of GI disease.CharacterDurationPatternFrequencyLocationDistribution of referred painTime of the painIs it?Medical Abdomen?Surgical Abdomen?When to refer?104

193. IndigestionUpper abdominal discomfort or distress associated with eating.Most common symptom of patients with GI dysfunction.Fatty foods tend to cause the most discomfort.Coarse vegetables and highly seasoned foods can also cause considerable distress.105

194. Intestinal GasThe accumulation of gas in the GIT may result in belching or flatulence.Patients often complain of bloating, distention, or “being full of gas.”106

195. Nausea and VomitingVomiting is usually preceded by nausea, which can be triggered by odors, activity, or food intake.Emesis, or vomitus, may vary in color and content.Hematemesis refers to bloody vomitus.107

196. Change in Bowel Habits and Stool CharacteristicsThese may signal colon disease.Diarrhea (abnormal increase in the frequency and liquidity of the stool or in daily stool weight or volume) occurs when the contents move so rapidly through the intestine and colon.Constipation (decrease in the frequency of stool, or stools that are hard, dry, and of smaller volume than normal) may be associated with anal discomfort and rectal bleeding.108

197. Change in Bowel Habits and Stool CharacteristicsStool is normally light to dark brown.Ingestion of certain foods and medications, as well as the presence of blood, can change the appearance of stool.Bulky, greasy, foamy stools that are foul in odor; stool color is gray with a silvery sheen (fat malabsorption).Light gray or clay-colored stool (absence of urobilin).Mucus threads or pus in stools (infection).109

198. Change in Bowel Habits and Stool CharacteristicsScybala (small, dry, rock-hard masses) often seen in narrowing of the colonic lumen.Loose, watery stool that may or may not be streaked with blood (inflammatory conditions).110

199. PHYSICAL ASSESSMENTAssessment of the mouth, abdomen and rectum.Mouth, tongue, buccal mucosa, teeth and gums are inspected, and ulcers, nodules, swelling, discoloration, and inflammation are noted.Patients with dentures should remove them during this part of the examination to allow good visualization.111

200. PHYSICAL ASSESSMENT: The AbdomenPatient lies supine with knees flexed slightly for inspection, auscultation, palpation and percussion.The nurse performs inspection first, noting skin changes and scars from previous surgery.It is also important to note the contour and symmetry of the abdomen, to identify any localized bulging, distention, or peristaltic waves.112

201. Abdominal Assessment: AuscultationCharacter, location and frequency of bowel sounds.Assess bowel sounds in all four quadrants using the diaphragm of the stethoscope.Categorize and document frequency of bowel sounds into normal (5 to 6/min), hypoactive (1 sound/min), hyperactive (5 to 6 sounds in less than 30 seconds), or absent (no sound in 3 to 5 minutes).113

202. Abdominal Assessment: Percussion and PalpationTympany or dullness.Light palpation for identifying areas of tenderness or swelling.Deep palpation to identify masses in all four quadrants.If any area of discomfort is identified, the nurse can assess for rebound tenderness.114

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