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Alteration in
Elimination
Adult Health Nursing 372
Denise Hart
Anatomy of the GI System

Structure
Small Intestine
 Large Intestine


Function
Ingestion
 Digestion
 Absorption
 Elimination

Assessment of GI System

Subjective


Hx, medications, surgeries, ect.
Objective
Inspection
 Auscultation
 Percussion
 Palpation

Light Palpation of Abdomen
Fluids

Saliva


1000-1500 mLs
Gastric Secretions


2500 mLs
Small Intestine


3000 mLs
Pancreas

700 mLs
Nausea and Vomiting
Most Common GI Problem
 Assessment
regurgitation
 projectile
 vomiting
 s/s of dehydration
 fecal odor?
 color

Etiology and Pathophysiology
 Occurs
from
 GI
disorders
 Pregnancy
 Infectious diseases
 CNS disorders
 Cardiovascular problems
 Metabolic disorders
 Side effects of drugs
 Psychologic factors
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Clinical Manifestations
 Nausea
 Subjective
complaint
 Usually accompanied by anorexia
 Vomiting
 Dehydration
can rapidly occur when prolonged.
 Water and essential electrolytes are lost. Metabolic
alkalosis—from loss of gastric HCl
 Metabolic acidosis—from loss of bicarbonate if the
contents from the small intestine are vomited
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Assessment
 Determine
 Careful
underlying cause and treat
history
When vomiting occurs
 Precipitating factors
 Contents of emesis

 Differentiate
among vomiting, regurgitation, and
projectile vomiting
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Assessment
 Fecal
odor and bile indicate a lower intestinal
obstruction.
 Color of emesis aids in determining presence and
source, if bleeding.
 Time of day occurring
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Medications
 Drug
therapy
 Drug
therapy depends on cause of problem.
 Antiemetics act on CNS in CTZ to block chemicals
that trigger nausea and vomiting.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing Care
*Treat underlying cause

Symptomatic relief


Medications
Nondrug therapy




Acupuncture
Ginger
Peppermint oil
Position/Breathing




NPO
N/G tube
IV fluids
Progress diet slowly
What are our Nursing Goals associated with the patient
experiencing Nausea/Vomiting?
GOALS
Anatomy
Gastroesophageal Reflux Disease
GERD
Acid Reflux
Primary Factor
 Incompetent LES
Common Cause
 Hiatal Hernia
Etiology and Pathophysiology
Obesity is a risk factor.
 Pregnant women are at
increased risk.
 Cigarette and cigar
smoking can contribute
to GERD.
 Hiatal hernia is a
common cause of
GERD.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Symptoms of GERD
 Heartburn
Most common clinical manifestation
 Burning, tight sensation felt beneath the lower
sternum and spreading upward to throat or jaw
 Felt intermittently
 Relieved by milk, alkaline substances, or water

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Symptoms of GERD



Dyspepsia
Hypersalivation
Non cardiac chest pain
Clinical Manifestations
 Individual
may also report
 Wheezing
 Coughing
 Dyspnea
 Hoarseness
 Sore
throat
 Lump in throat
 Choking
 Regurgitation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Clinical Manifestations
 Regurgitation
 Effortless
return of food or gastric contents from
stomach into esophagus or mouth
 Described as hot, bitter, or sour liquid coming into
the mouth or throat
 Can
mimic angina
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Diagnostic Procedures






History and Physical Exam
Upper GI endoscopy with biopsy
Barium Swallow
Motility Studies
pH monitoring
Radionuclide Studies
Nursing Management
 Lifestyle
 Avoid
modifications
triggers
 Nutritional
therapy
 Decrease
high-fat foods.
 Take fluids between rather than with meals.
 Avoid milk products at night.
 Avoid late-night snacking or meals.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing Management
 Nutritional
therapy (cont’d)
 Avoid
chocolate, peppermint, caffeine, tomato
products, orange juice.
 Weight reduction therapy
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing Management
 Elevation
of HOB 30 degrees
 Not lying down for 2 to 3 hours after eating
 Avoidance of late-night eating
 Evaluation of effectiveness of medications
 Observing for side effects of medications
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
GERD Management

Lifestyle Changes
High protein, Low fat diet
 consumption of foods that  LES pressures


Chocolate, peppermint, coffee, tea, & tomatoes
Small, frequent meals
 No or decrease ETOH consumption
 Stop smoking
 Weight reduction (if overweight)

GERD Management

Lifestyle Changes




HOB elevated 4-6 inch
blocks
Weight reduction
(if needed)
Consume fluids between
meals
Chew gum

Avoid




Late night meals or
snacks
Lying flat after meals
Milk at bedtime
Tight clothing
Drug Therapy




Cholinergic
Prokinetic
Antacids
Antisecretory
Proton Pump Inhibitors
 H2-receptor blockers


Cytoprotective
Complications




Scar Tissue
Dysphasia
Barrett’s Esophagus
Cancer
Barrett’s Esophagus
Collaborative Care
 Surgical
therapy
 Necessary
if
Conservative therapy fails
 Medication intolerance
 Barrett’s metaplasia
 Esophageal stricture and stenosis
 Chronic esophagitis
 Hiatal hernia

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Surgical Intervention
Nissen Fundoplication
Nissen Fundoplication
Fig. 42-5. A, Normal esophagus. B, Sliding hiatal hernia.
C, Rolling or paraesophageal hernia.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Goals of Postoperative care
 Prevention
of respiratory complications
 Maintenance of fluid/electrolyte balance
 Prevention of infection
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Postoperative Assessment
 Respiratory
assessment
 Respiratory
rate/rhythm
 Pulse rate/rhythm
 Signs of pneumothorax
 Dyspnea
 Chest pain
 Cyanosis
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Postoperative Nursing Care
 Deep
breathing techniques
 Accurate I/O
 Observing for fluid/electrolyte
imbalance
 Pain medication
 Medications to prevent
nausea/vomiting
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Postoperative Nursing Care
 When
peristalsis returns, only fluids
given initially
 Solids added gradually
 Normal diet gradually resumed
 Patient must avoid gas-forming foods
and must chew foods thoroughly.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Hiatal Hernia
…is herniation of a portion of
the stomach into the
esophagus through an
opening in the diaphragm
Hiatal Hernia



Often asymptomatic
Cause unknown
Contributing Factors
obesity
 pregnancy
 acites
 intense physical exertion

Hiatal Hernia

Signs/Symptoms
none
 reflux when lying supine
 waist bending may cause esophageal burning
(relieved when standing)

Hiatal Hernia

Complications
GERD
 Esophagitis
 Hemorrhage
 Aspiration
 Stenosis
 Ulcerations
 Ischemia

Management






Antacids
Antisecretory agents
Loose fitting clothing
Avoid heavy lifting/straining
No smoking or ETOH
Weight reduction (if indicated)
Surgical Management

Surgery

Nissan Fundoplication
Nursing Management





Assess respiratory function
Maintain fluid and electrolyte
balance
Possible chest tube
N/G tube: maintain patency!!
Regular Diet 6 weeks post op
Peptic Ulcer Disease

Erosion of the GI
mucosa resulting
from the digestive
action of HCl and
pepsin
Peptic Ulcers
Peptic Ulcer Disease

Causes




Stress
Medications
Helicobacter pylori (HP)
Surface Mucosa is
renewed Q 3 days
Peptic Ulcers

Clinical Manifestations
no pain
 epigastric discomfort 1-2hours after
meals



food may aggravate
back pain 2-4 hours after meals
food may improve
 antacids improve

Complications

Hemorrhage

Perforation
(most lethal)

Gastric Outlet
obstruction
Management

Conservative





Rest
6 Small meals per Day
NO smoking
Medications
Decrease Stress

Acute






NPO
N/G Suction
Bedrest
NO Smoking
IVF
Medications
Upper GI Bleeding

Obvious

Hematemesis
Bright red
 “Coffee ground”


Melena
Black, tarry stools
 Foul odor


Occult
Emergency Assessment


Identify cause!
Assessment
B/P
 Pulse
 Peripheral perfusion
 Neck vein distension?
 Respiratory status
 Bowel sounds?

Management



History
Laboratory studies
IV lines
Lactated Ringers
 Packed RBCs



Foley catheter
PPI Therapy
Abdominal PAINS

Acute Abdomen





PAIN
Nausea
Vomiting
Diarrhea
Constipation




Flatulence
Fatigue
Fever
Increased abdominal girth
Diagnostic Studies


Complete history and
physical
Pain assessment

Note patient position

Lab





CBC
U/A
x-ray
CT scan
Pregnancy test
Emergency Management




Maintain a patent airway
Administer Oxygen
Initiate IV access
Obtain lab work




CBC, electrolytes, U/A
Insert foley catheter
Insert N/G tube
Anticipate surgical intervention
Post operative Care

Possible Laparotomy procedure
NPO- progress diet slowly
 N/G to low suction
 I/O
 IV Fluids
 Monitor Lab values
 Early ambulation

…….an inflammation of the appendix
APPENDICITIS
Appendicitis

Periumbilical Pain
RLQ-McBurney’s point
 Rebound tenderness





Anorexia
Nausea
Vomiting
Elevated WBC
Complications



Rupture
Peritonitis
Abscess
Inflammatory Bowel Disease

Crohn’s

Ulcerative
Colitis
Ulcerative Colitis





Colon & Rectum
15-40 years of age
Either sex
Involves mucosa and submucosa
Begins distally and progresses
upward
Complications





Intestinal Hemorrhage
Strictures
Perforation
Toxic Megacolon
>10years higher risk for
Colon cancer
Crohn’s Disease





Non specific
Skips segment of bowel
Terminal ileum, jejunum
and colon
Cobblestone appearance
Fistula formation
common
Complications




Scar Tissue
Strictures
Obstruction
Impaired absorption


Terminal ileum
Fistulas
Rectovaginal
 Detrussor

Goals of Treatment







Bowel Rest
Control inflammation
Control Infection
Correct Malnutrition
Alleviate Stress
Symptomatic Relief
Improve quality of life
Medications





Aminosalicylates (5-ASA)
Antimicrobials
Corticosteroids
Immunosuppressants
Biologic and targeted therapy

Surgical Intervention
75% of patients with Crohn’s
Strictureplasty
 Resection


25%-40% of patients with UC

Total Colectomy
Ileostomy
 Continent Ileostomy (Koch Pouch)
 Ileoanal Reservoir

Management

Acute
Hemodynamic stability
 Pain Control
 F/E balance
 Nutritional Support
 Emotional Support

Patient Education







Rest
Diet
Perianal care
Meds
Symptoms of recurrent disease
Decrease stress
When to contact MD
Parenteral Nutrition

Administration
Central Line
 Peripheral


Risk for Infection
Discard after 24 hours
 Use a 0.22 micron Millipoire filter
 Change IV tubing after 24 hours
 Change central line dressing per agency PP

Nursing Management






Administer IV fluids
Provide comfort measures
Provide restful environment
N/G
Oral care
Anticipate surgical intervention
INTESTINAL OBSTRUCTION
Intestinal Obstruction

Mechanical
Adhesions
 Hernias
 Tumors


Non-mechanical
Paralytic Ileus
 Vascular

Nursing Management

Assessment
Abdominal pain
 s/s Dehydration
 Vomitus
 Bowel function
 Bowel sounds
 Renal function
 Electrolytes

Nursing Management



V/S
Daily Wt
LAB





Blood Glucose Levels Q 6 hours
Electrolytes
CBC
Protein
BUN & Creatinine