GASTROINTESTINAL DISORDERS (GI)

Assessing a Patient With Gastrointestinal Disorders

 

Gastrointestinal Disorders

 

Review the gastrointestinal system in your anatomy and physiology book. Obtain a health history from the patient, assessing for any chronic or new symptoms. Conduct an abdominal exam, listening for bowel sounds, palpating the abdomen, assessing for pain, and assessing for constipation, nausea, or vomiting.

Gastrointestinal Diagnostics

Lab Work: WBCs, CBC, CMP, liver enzymes, hemoglobin, hematocrit, BUN/Cr, liver function tests, amylase, and lipase.

Abdominal X-ray/Kidney, Ureter, and Bladder (KUB): This is used to obtain images of the abdomen.

Endoscopy: This is the insertion of a scope to view the upper GI tract.

Colonoscopy: This is the insertion of a scope to view the lower GI tract.

Sigmoidoscopy: This is the insertion of a scope in the sigmoid colon.

Abdominal CT Scan or Ultrasound: This produces images of the abdomen.

Barium Studies: Barium is swallowed and highlights the abdomen using an x-ray.

Stool Culture: Stool is tested for blood and other pathogens.

Gastrointestinal Disorders: Gastroesophageal Reflux Disease (GERD)

Definition: In GERD, a decrease in function of the pyloric sphincter causes the gastric contents to push back into the esophagus, leading to heartburn and discomfort. For those who suffer from GERD, lay off the tacos and spicy foods!

Signs and Symptoms: Pain and burning sensation in the chest and stomach, difficulty swallowing, pain after eating, nausea and vomiting.

Diagnostics: pH levels, esophagoscopy, and presentation of symptoms.

Complications: Aspiration pneumonia and dental erosion from the gastric acid.

Drug Therapy: Histamine H2 receptor antagonists such as ranitidine (Zantac), cimetidine (Tagamet), and famotidine (Pepcid); proton pump inhibitors such as omeprazole (Prilosec) and pantoprazole (Protonix); and antacids such as TUMS or Maalox are commonly prescribed. The surgical procedure fundoplication can be performed to decrease reflux.

Nursing Care: To prevent GERD, patients should maintain a bland diet. Spicy and fatty foods, caffeine, and sodas can increase symptoms. Patients are instructed to take an antacid before eating and remain sitting up for an hour after eating. Avoid drinking 2 hours before bedtime. Administer medication as ordered.

 

Gastrointestinal Disorders: Ulcerative Colitis

Definition: This is an inflammation of the bowel and digestive tract.

Signs and Symptoms: Abdominal pain, bloody stool, severe diarrhea, weight loss, loss of electrolytes, and dehydration.

Diagnostics: Stool sample, CT of the abdomen, colonoscopy, and WBC for infection.

Complications: Perforated bowel or severe dehydration.

Drug Therapy: Antibiotics, probiotics, immunosuppressants, analgesics, antidiarrheals, anti-inflammatories, and corticosteroids to decrease inflammation.

Surgical Measures: Protocolectomy, ileostomy, and colostomy may be needed if symptoms become severe or chronic.

Nursing Care: Assess labs and stool, and monitor for bloody stools. Administer medications as ordered. Intravenous fluids may be administered. Patients should maintain a low-fiber diet, while trying to avoid alcohol, caffeine, and spicy foods. Stress can worsen ulcerative colitis. If surgery is needed, preoperative and postoperative teaching is necessary.

Gastrointestinal Disorders: Crohn’s Disease

Definition: This is a chronic inflammation of the GI system and a type of inflammatory bowel disease.

Signs and Symptoms: Diarrhea, abdominal pain, fatigue, mouth sores, weight loss, and fever.

Diagnostics: MRI or CT of the abdomen, colonoscopy, small bowel series, capsule endoscopy, sigmoidoscopy, and lab work for bleeding and infection.

Complications: Severe dehydration and worsening of symptoms.

Drug Therapy: Oral 5-aminosalicylates such as sulfasalazine (Azulfidine) and mesalamine (Pentasa). Corticosteroids are used to decrease inflammation. Immunosuppressant medications, antidiarrheals, antibiotics, and nutritional supplements are ordered.

Nursing Care: Monitor hydration status and correct fluid and electrolyte losses due to diarrhea. A high-calorie diet is needed to treat weight loss. Administer medications as ordered. Flare-ups can occur, which can be painful and severe. Monitor bowel for bloody stools. Intravenous fluids may be administered.

Gastrointestinal Disorders: Diverticulitis/Diverticulosis

Definition: Diverticulitis is an inflammation of sac-like herniations in the bowel lining. Diverticulosis is the condition of having diverticuli.

Signs and Symptoms: Abdominal pain, abdominal distension, nausea, vomiting, fever, tarry stools, and constipation.

Diagnostics: CT or ultrasound of the abdomen, barium enema, and lab work (WBCs/CRP).

Complications: Perforated or obstructed bowel.

Drug Therapy: Antibiotics, analgesics, IV fluids, pain medications, and anticholinergics.

Nursing Care: Keep patient NPO until symptoms resolve. Patients with diverticulitis should avoid eating foods with seeds such as strawberries or sesame seeds. Administer medications as ordered. Surgery may be needed if a complication arises.

Gastrointestinal Disorders: Gastroenteritis

Definition: This is an inflammation of the stomach and small bowel. It can be caused by E. coli or staph infection.

Signs and Symptoms: Abdominal cramping, abdominal distension, nausea, vomiting, diarrhea, weight loss, and fever.

Diagnostics: Stool culture and CT of the abdomen.

Complications: Worsening of the symptoms.

Drug Therapy: Antibiotics, antiemetics, pain medication, and intravenous fluids.

Nursing Care: Administer medications as ordered. Keep patient NPO until symptoms resolve. Obtain bowel specimens.

Gastrointestinal Disorders: Clostridium difficile (C. diff)

Definition: A bacterial infection caused by the organism C. difficile, which attacks the intestines.

Signs and Symptoms: Severe diarrhea, watery stool, foul-smelling stool, fever, weight loss, dehydration, and pain.

Diagnostics: Stool sample and culture, WBCs, and monitoring electrolytes.

Complications: Severe dehydration and worsening of infection.

Drug Therapy: IV antibiotics such as metronidazole (Flagyl) or vancomycin are used. A peripherally inserted central catheter (PICC) or midline catheter may need to be placed if vancomycin will be administered. Probiotics should be given as well.

Nursing Care: These patients are placed on contact precautions! C. diff is contagious and is transmitted through contact. Wash hands with soap and water; hand sanitizer does not remove the C. diff organism from the hands. Wear a gown and gloves when treating these patients. Administer antibiotics as ordered.

Gastrointestinal Disorders: Small Bowel Obstruction

Definition: This is an obstruction in the duodenum or jejunum. Small bowel obstruction can be caused by a hernia, volvulus, adhesions, tumors, and ileus.

Signs and Symptoms: Severe nausea and vomiting (bilious emesis), fever, hypoactive bowel sounds, constipation, abdominal distension, and abdominal pain.

Diagnostics: CT of the abdomen, KUB, and small bowel series.

Complications: Sepsis, perforation of the bowel, and aspiration pneumonia.

Drug Therapy: Aggressive antibiotics such as IV Cipro or Flagyl. Antiemetics, analgesics, and pain medications.

Nursing Care: If severe nausea or vomiting is persistent, an NGT may be placed to decompress the bowels. Administer medications as ordered. Assess for aspiration pneumonia. The head of the bed (HOB) should be kept at a 30° to 45° angle. Keep patients NPO until symptoms resolve. Administer intravenous fluids. Assess for dehydration. Surgical measures such as a bowel resection may be needed. Preoperative and postoperative teaching is needed.

Gastrointestinal Disorders: Peptic Ulcer Disease

Definition: In this condition, gastric secretions cause erosion of the GI tract, resulting in ulcerations. There are two types of ulcers: (a) gastric and (b) duodenal. Causes include stress, NSAIDs, alcohol abuse, gastritis, and the bacteria H. pylori.

Signs and Symptoms:

Gastric ulcers present with symptoms of left midepigastric pain that radiates to the back and upper abdomen 1 to 2 hours after eating. Other symptoms include nausea, vomiting, weight loss, and burning sensation.

Duodenal ulcers present with symptoms of midepigastric pain that occurs 2 to 4 hours after eating and is relieved when antacids are taken. Other symptoms include burning, cramping, nausea, and vomiting.

Diagnostics: Stool culture, barium studies, abdominal x-ray, esophagogastroduodenoscopy (EGD), and colonoscopy.

Complications: Perforation, obstruction, and hemorrhage.

Drug Therapy: Antibiotics, antacids, H2 antagonists, proton pump inhibitors, anticholinergics, and cytoprotective agents.

Surgical Measures: Partial gastrectomy, gastric resection, vagotomy, or pyloroplasty may be performed to decrease acid production in the abdomen. A complication that can arise from gastrectomy is dumping syndrome. In this syndrome, there is fluid accumulation in the intestine. Symptoms are weakness, epigastric fullness, and cramping, and it occurs right after eating. Prevention involves avoiding large meals and fatty foods.

Nursing Care: Patients with peptic ulcer disease are encouraged to eat a bland diet. They should avoid foods that are fatty or spicy, and caffeinated beverages. Smoking cessation is advised. Administer medications as ordered. Use of antacids after eating may help relieve symptoms. An NGT and IVF may be administered to decompress the bowel and treat nausea/vomiting. Never clamp an NGT without a physician order. Placement of the NGT should be checked at every shift. Monitor output from the NGT. Surgery may be needed, and patient preoperative and postoperative teaching is needed.

Gastrointestinal Disorders: Appendicitis

Definition: Appendicitis is inflammation or obstruction of the appendix.

Signs and Symptoms: Abdominal cramping, nausea, vomiting, fever, positive McBurney’s sign (right lower quadrant pain) and Rovsing sign (right lower quadrant pain that worsens when the other quadrants are palpated), rebound tenderness, and weight loss.

Diagnostics: Presentation of symptoms, abdominal x-ray and ultrasound, and lab work (increased WBCs).

Complications: Ruptured appendix, peritonitis, hemorrhage, perforation, and sepsis.

Drug Therapy: Antibiotics, intravenous fluids, and pain medications.

Surgical Measures: Appendectomy and exploratory laparoscopy to diagnose appendicitis.

Nursing Care: Prepare patient for surgery. Administer medications as ordered, and keep patient NPO until surgery occurs. Try to promote bed rest to decrease pain level. Never apply heat to the abdomen; apply ice for comfort. Sudden relief or pain can mean that the appendix has ruptured. It is important to diagnose appendicitis before administering pain medication. Postoperatively, patients remain NPO, and IV fluids are administered. Dressing changes are needed. Patients may have a Jackson-Pratt (JP) drain at the incision site to drain excess fluid. Assess the incision, and drain every 4 hours. Monitor intake and output. Diet should be resumed slowly postoperatively. Assess for infection.

Gastrointestinal Disorders: Cholecystitis

Definition: Cholecystitis is inflammation of the gallbladder, which can be caused by gallstones.

Signs and Symptoms: Bloating, nausea/vomiting, pain that occurs 2 to 4 hours after eating, increased heart rate, fever, claycolored stools, positive Murphy’s sign, and fever.

Diagnostics: Abdominal CT scan, ultrasound of the abdomen, hepatobiliary iminodiacetic acid (HIDA) scan, and lab work (elevated WBCs).

Complications: Perforation of the gallbladder and sepsis.

Drug Therapy: Antibiotics, antiemetics, analgesics, and intravenous fluids.

Surgical Measures: A cholecystectomy (removal of the gallbladder) may need to be performed. An NGT may be ordered.

Nursing Care: Patients with cholecystitis may remain NPO until surgery. An NGT may be inserted until surgery. IVF are administered for hydration. Administer pain medication and antibiotics as ordered. Preoperative and postoperative teaching is needed.

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Gastrointestinal Disorders: Pancreatitis

Definition: Inflammation of the pancreas, which can be caused by alcohol abuse, gallstones, or infection.

Signs and Symptoms: Abdominal pain in the left lower quadrant, dyspnea, nausea, vomiting, tachycardia, jaundice (skin/sclera), positive Cullen’s sign (discoloration of the abdomen), positive Turner’s sign (blue spotting on flank), weakness, abdominal distension, and fatigue.

Diagnostics: Lab work including pancreatic enzymes, MRI of the abdomen, CT of the abdomen, and urine tests.

Complications: Sepsis.

Drug Therapy: Antibiotics, H2 antagonists, anticholinergics, and pain medications.

Nursing Care: Patient may be kept NPO until symptoms resolve. IVF and nutritional support may be needed. Smoking and alcohol cessation may be needed. Assess for symptoms of infection. Administer medications as ordered.

Gastrointestinal Disorders: Liver Cirrhosis

Definition: This is necrosis and degeneration of the liver commonly caused by alcohol abuse.

Signs and Symptoms: Jaundice (skin/sclera), anemia, weight loss, fever, peripheral edema, shallow respirations, ascites, abdominal distension, nausea, vomiting, shortness of breath, fatigue, electrolyte imbalance, increased ammonia levels, decreased potassium levels, cardiac changes, asterixis (tremor of the hands), and fetor hepaticus (fruity odor on the breath).

Diagnostics: Ultrasound of the abdomen, liver function tests, bilirubin levels, and biopsy of the liver.

Complications: Portal hypertension, encephalopathy, peripheral edema, renal failure, seizures, coma, or death if left untreated.

Drug Therapy: Diuretics, antibiotics, pain medications, lactulose (to promote bowel movements, which decrease ammonia levels), vasopressin, albumin, and enteral nutrition.

Nursing Care: Daily weights and strict intake and output monitoring are needed. Maintain a low-sodium/low-protein diet. Fluid restriction is ordered. Treat edema and ascites. Provide comfort with pain medication and positioning. Bed rest is required to conserve energy. Alcohol cessation is needed. Monitor signs of withdrawal, and medicate as needed. Measure abdominal girth. Monitor stool output for patients receiving lactulose. Monitor for complications. A paracentesis (drainage of abdominal fluid through needle aspiration) may be performed to treat ascites.

Gastrointestinal Disorders: Hepatitis

Definition: Hepatitis is the inflammation of the liver, which can be caused by liver necrosis, viruses, and bacteria. There are several types of hepatitis (A-G). The most common types are hepatitis A, B, and C.

Types of Hepatitis:

Hepatitis A is transmitted through the fecal–oral route and contaminated foods.

Hepatitis B is transmitted through IV needles, sexual activities, bodily fluids, and blood products.

Hepatitis C is transmitted through IV needles and from mother to child.

Signs and Symptoms: Jaundice, fever, weight loss, abdominal cramping, and fatigue. Symptoms occur in stages—preicteric, icteric, and posticteric.

Diagnostics: Lab work such as hepatitis panel, LFTs, and CBC.

Drug Therapy: Antiviral medications and lactulose.

Nursing Care: Diagnostics are used to determine the type of hepatitis. Avoid giving Tylenol to patients who have hepatitis. Monitor for liver failure and other complications. Administer medications as ordered. Monitor liver function tests. A low-fat/high-carbohydrate diet is needed.

Gastrointestinal Disorders: Types of Ostomies

An ostomy is a surgical procedure in which the bowel is diverted to an opening in the abdomen so that fecal matter is released through a stoma.

Types of common colostomies:

Colostomy: Opening of the colon through the abdominal wall through a stoma. When assessing the stoma, it should appear pink/red and moist. Stool is released through the stoma, and a colostomy bag is placed to collect the stool.

Ileostomy: Opening of the ileum to the abdominal wall, where stool is drained through a stoma. When assessing the stoma, it should appear pink/red and moist. Stool is released through the stoma, and a colostomy bag is placed to collect the stool.

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