NCLEX: Gastrointestinal disorders

Gastrointestinal disorders: Treatments

Focus topic: Gastrointestinal disorders

GI dysfunction presents many treatment challenges. After all, it stems from various pathophysiologic mechanisms that may exist separately or simultaneously. These mechanisms include tumors, hyperactivity and hypoactivity, malabsorption, infection and inflammation, vascular disorders, intestinal obstruction, and degenerative disease. Treatments for these disorders include drug therapy, surgery, and related measures that call for effective nursing care.

Gastrointestinal disorders: Drug therapy

Focus topic: Gastrointestinal disorders

The most commonly used GI drugs include antacids, digestants, histamine-2 (H2) receptor antagonists, proton pump inhibitors, anticholinergics, antidiarrheal agents, laxatives, emetics, and antiemetics. Some of these drugs, such as antacids and antiemetics, provide relief immediately. Other drugs, such as laxatives and H2-receptor antagonists, may take several days or longer to solve the problem.

Gastrointestinal disorders: Surgery

Focus topic: Gastrointestinal disorders

The patient who has undergone GI surgery may need special postoperative support because he may have to make permanent and difficult changes in his lifestyle. For example, besides teaching a colostomy patient about stoma care, you’ll also have to help him adjust to changes in his body image and personal relationships. Another patient may have to endure a bowel training program for weeks or even months, which can be a frustrating and embarrassing experience. You’ll have to draw on your own emotional strengths to help the patient come to terms with these feelings. Still another patient may have great difficulty complying with dietary restrictions. He’ll need to be convinced of the firm link between such measures and a full recovery.

Esophageal surgeries
Surgery may be necessary to manage an emergency, such as acute constriction, or to provide palliative care for an incurable disease such as advanced esophageal cancer.

Gastrointestinal disorders: So many surgeries!

Focus topic: Gastrointestinal disorders

Major esophageal surgeries include cardiomyotomy, cricopharyngeal myotomy, Nissen fundoplication, esophagectomy, esophagogastrostomy, and esoph ago myotomy. The surgical approach is through the neck, chest, or abdomen, depending on the location of the problem.

Patient preparation
Explain the procedure to the patient. Tell him that, when he awakes from the anesthetic, he’ll probably have an NG tube in place to aid feeding and relieve abdominal distention. Warn him of the risk of pneumonia and the importance of good  pulmonary hygiene during recovery to prevent it. Demonstrate coughing and deep-breathing exercises, and show the patient how to splint his incision to protect it and minimize pain. Discuss possible postoperative complications and measures to prevent or minimize them.

Monitoring and aftercare
After surgery, follow these steps:
• Place the patient in semi-Fowler’s position to help minimize esophageal reflux.
• Provide antacids as needed for symptomatic relief.
• If surgery involving the upper esophagus produces hypersalivation, the patient may be unable to swallow the excess saliva. Control drooling with gauze wicks or suctioning. Encourage the patient to spit into an emesis basin placed within his reach.

Gastrointestinal disorders: Head’s up!

Focus topic: Gastrointestinal disorders

• To reduce the risk of aspiration pneumonia, elevate the head of the patient’s bed and encourage him to turn frequently. Carefully monitor his vital signs and auscultate his lungs. Encourage coughing and deep-breathing exercises.
• Watch for developing mediastinitis, especially if surgery involved extensive thoracic invasion (as in esophagogastrostomy). Note and report fever, dyspnea, and complaints of substernal pain. If ordered, administer antibiotics to help prevent or correct this complication.
• Watch for signs of leakage at the anastomosis site. Check drainage tubes for blood, test for occult blood in stool and drainage, and monitor hemoglobin levels for evidence of slow blood loss. If the patient has an NG tube in place, don’t handle the tube because this may damage the internal sutures or anastomoses. For the same reason, avoid deep suctioning in a patient who has undergone extensive esophageal repair.

Home care instructions
Provide these instructions to the patient:
• Advise him to sleep with his head elevated to prevent reflux. Suggest that he raise the head of his bed on blocks.
• If the patient smokes, encourage him to stop. Explain that nicotine adversely affects the LES. Advise the patient to avoid alcohol, aspirin, and effervescent over-the-counter products (such as Alka- Seltzer) because they may damage the tender esophageal mucosa.
• Advise the patient to avoid heavy lifting, straining, and coughing, which could rupture the weakened mucosa.
• Tell him to report any respiratory signs and symptoms, such as wheezing, coughing, and nocturnal dyspnea.

Gastric surgeries
If chronic ulcer disease doesn’t respond to medication, diet, and rest, gastric surgery is used to remove diseased or malignant tissue, to prevent ulcers from recurring, or to relieve an obstruction or perforation.

Gastrointestinal disorders: Drastic gastric surgery

Focus topic: Gastrointestinal disorders

In an emergency, gastric surgery may be performed to control severe GI hemorrhage or perforation. Surgery may also be necessary when laser endoscopic coagulation for control of severe GI bleeding isn’t possible.
Gastric surgery can take various forms, depending on the location and extent of the disorder. For example, a partial gastrectomy reduces the amount of acid-secreting mucosa. A bilateral vagotomy eliminates vagal nerve stimulation of gastric secretions and may help relieve ulcer symptoms. A pyloroplasty improves drainage and prevents obstruction. Most commonly, however, two gastric surgeries are combined, such as vagotomy with gastroenterostomy, or vagotomy with antrectomy. Although controversial in cases of morbid obesity, gastric reduction surgery may be performed to aid in weight loss.

Gastrointestinal disorders

Patient preparation
Before surgery, implement these measures:
• Evaluate and begin stabilizing the patient’s fluid and electrolyte balance and nutritional status — both of which may be severely compromised by chronic ulcer disease or other GI disorders.
• Monitor intake and output, and draw serum samples for hematologic studies.
• Prepare the patient for abdominal X-rays.
• On the night before surgery, administer laxatives and enemas as necessary.
• On the morning of surgery, insert an NG tube as ordered.

Monitoring and aftercare
Follow these steps after surgery:
• Place the patient in low or semi-Fowler’s position. Either position will ease breathing and prevent aspiration if he vomits.
• Maintain tube feedings or total parenteral nutrition (TPN) and I.V. fluid and electrolyte replacement therapy as ordered. Monitor blood studies daily. If you perform gastric suctioning, watch for signs of dehydration, hyponatremia, and metabolic alkalosis. Weigh the patient daily, and monitor and record intake and output, including NG tube drainage.

When bowel sounds rebound

Focus topic: Gastrointestinal disorders

• Auscultate the abdomen frequently for bowel sounds. When they return, notify the practitioner, who will order clamping or removal of the NG tube and gradual resumption of oral feeding. During NG tube clamping, watch for nausea and vomiting; if they occur, unclamp the tube immediately and reattach it to suction.
• Throughout recovery, have the patient cough, deep-breathe, and change position frequently. Encourage incentive spirometry. Teach the patient to splint his incision while coughing to help reduce pain. Assess his breath sounds frequently to detect atelectasis.
• Assess the patient for other complications, including vitamin B12 deficiency, anemia (especially common in patients who have undergone total gastrectomy), and dumping syndrome, a potentially serious digestive complication marked by weakness, nausea, flatulence, and palpitations that occurs within 30 minutes of a meal.

Home care instructions
Provide these instructions for the patient:
• Advise the patient to seek medical attention immediately if he develops any signs of life-threatening complications, such as hemorrhage, obstruction, and perforation.

• Explain dumping syndrome and how to avoid it. Advise the patient to eat small, frequent, nutritious meals evenly spaced throughout the day. He should chew his food thoroughly and drink fluids between meals rather than with them. In his diet, he should decrease intake of carbohydrates and salt while increasing fat and protein. After a meal, he should lie down for 20 to 30 minutes. If the patient is being discharged on tube feedings, teach him and his family how to give the feeding.
• If the practitioner has prescribed a GI anticholinergic to decrease motility and acid secretion, instruct the patient to take the drug 30 minutes to 1 hour before meals.
• Encourage the patient to avoid smoking because it alters pancreatic secretions that neutralize gastric acid in the duodenum.

Bowel surgery with ostomy
In bowel surgery with ostomy, the surgeon removes diseased colonic and rectal segments and creates a stoma on the outer abdominal wall to allow fecal elimination. This surgery is performed for such intestinal maladies as inflammatory bowel disease, familial polyposis, diverticulitis, and advanced colorectal cancer if conservative surgery and other treatments aren’t successful or if the patient develops acute complications, such as obstruction, abscess, and fistula.

Take your pick

Focus topic: Gastrointestinal disorders

The surgeon can choose from several types of surgery, depending on the nature and location of the problem.
• Intractable obstruction of the ascending, transverse, descending, or sigmoid colon requires permanent colostomy and removal of the affected bowel segments.
• Cancer of the rectum and lower sigmoid colon commonly calls for abdominoperineal resection, which involves creation of a permanent colostomy and removal of the affected portion of the colon, rectum, and anus.
• Perforated sigmoid diverticulitis, Hirschsprung’s disease, rectovaginal fistula, and penetrating trauma commonly require temporary colostomy to interrupt the intestinal flow and allow inflamed or injured bowel segments to heal. After healing occurs (usually within 8 weeks), the divided segments are anastomosed to restore bowel integrity and function.
• In a double-barrel colostomy, the transverse colon is divided and both ends are brought out through the abdominal wall to create a proximal stoma for fecal drainage and a distal stoma leading to the nonfunctioning bowel.
• Loop colostomy, done to relieve acute obstruction in an emergency, involves creating proximal and distal stomas from a loop of intestine that has been pulled through an abdominal incision and supported with a plastic or glass rod.
• Severe, widespread colonic obstruction may require total or near-total removal of the colon and rectum and creation of an ileostomy from the proximal ileum. A permanent ileostomy requires that the patient wear a drainage pouch or bag over the stoma to receive the constant fecal drainage. In contrast, a continent, or Kock, ileostomy doesn’t require an external pouch.

Patient preparation
Before surgery, implement these measures:
• Arrange for the patient to visit with an enterostomal therapist, who can provide more detailed information. The therapist can also help the patient select the best location for the stoma.

Sharing insights

Focus topic: Gastrointestinal disorders

• Try to have the patient meet with an ostomy patient (from a group such as the United Ostomy Association), who can share his personal insights into the realities of living with and caring for a stoma.
• Evaluate the patient’s nutritional and fluid status. The patient may receive TPN to prepare him for the physiologic stress of surgery.
• Record the patient’s fluid intake and output and weight daily, and watch for early signs of dehydration.
• Expect to draw periodic blood samples for hematocrit and hemoglobin determinations. Be prepared to transfuse blood if ordered.

Monitoring and aftercare
Follow these steps after surgery:
• Monitor intake and output, and weigh the patient daily. Maintain fluid and electrolyte balance, and watch for signs of dehydration (decreased urine output, poor skin turgor) and electrolyte imbalance.
• Provide analgesics as ordered. Be especially alert for pain in the patient with an abdominoperineal resection because of the extent and location of the incisions.
• Note and record the color, consistency, and odor of fecal drainage from the stoma. If the patient has a double-barrel colostomy, check for mucus drainage from the inactive (distal) stoma. The nature of fecal drainage is determined by the type of ostomy surgery; generally, the less colon tissue that’s removed, the more closely drainage will resemble normal stool. For the first few days after surgery, fecal drainage probably will be mucoid (and possibly slightly blood-tinged) and mostly odorless. Report excessive blood or mucus content, which could indicate hemorrhage or infection.

Searching for sepsis

Focus topic: Gastrointestinal disorders

• Observe the patient for signs of peritonitis or sepsis, caused by bowel contents leaking into the abdominal cavity. Remember that immunocompromised patients or those receiving TPN are at an increased risk for sepsis.
• Provide meticulous wound care, changing dressings often. Check dressings and drainage sites frequently for signs of infection (purulent drainage, foul odor) or fecal drainage. If the patient has had an abdominoperineal resection, irrigate the perineal area as ordered.
• Regularly check the stoma and surrounding skin for irritation and excoriation, and take corrective measures. Also observe the stoma’s appearance. The stoma should look smooth, cherry red, and slightly edematous; immediately report any discoloration or excessive swelling, which may indicate circulatory problems that could lead to ischemia.

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Air those anxieties

Focus topic: Gastrointestinal disorders

• During the recovery period, encourage the patient to express his feelings and concerns; reassure an anxious or depressed patient that these common postoperative reactions should fade as he adjusts to the ostomy. Continue to arrange for visits by an enterostomal therapist.

Home care instructions
Provide these instructions to the patient:
• If the patient has a colostomy, teach him or a caregiver how to apply, remove, and empty the pouch. When appropriate, teach him how to irrigate the colostomy with warm tap water to gain some control over elimination. If appropriate, reassure him that he may be able to regain continence with dietary control and bowel retraining.
• Instruct the colostomy patient to change the stoma appliance as needed, to wash the stoma site with warm water and mild soap every 3 days, and to change the adhesive layer. These measures help prevent skin irritation and excoriation.

• If the patient has an ileostomy, instruct him to change the drainage pouch only when leakage occurs. Also, emphasize meticulous skin care and use of a protective skin barrier around the stoma site.
• Discuss dietary restrictions and suggestions to prevent stoma blockage, diarrhea, flatus, and odor. Tell the patient to stay on a low-fiber diet for 6 to 8 weeks and to add new foods to his diet gradually. Suggest that the patient use an ostomy deodorant or an odor proof pouch if he includes odor-producing foods in his diet.
• Trial and error will help the patient determine which foods cause gas. Gas-producing fruits include apples, melons, avocados, and cantaloupe; gas-producing vegetables include beans, corn, broccoli, and cabbage.

Bring on the bouillon

Focus topic: Gastrointestinal disorders

• The patient is especially susceptible to fluid and electrolyte losses. He must drink plenty of fluids, especially in hot weather or when he has diarrhea. Fruit juice and bouillon, which contain potassium, are particularly helpful.
• Warn the patient to avoid alcohol, laxatives, and diuretics, which increase fluid loss and may contribute to an imbalance.
• Tell the patient to report persistent diarrhea through the stoma, which can quickly lead to fluid and electrolyte imbalance.

A nice, warm bath…

• If the patient had an abdominoperineal resection, suggest sitz baths to help relieve perineal discomfort.

Bowel resection and anastomosis
Resection of diseased intestinal tissue (colectomy) and anastomosis of the remaining segments helps treat localized obstructive disorders, including diverticulosis, intestinal polyps, bowel adhesions, and malignant or benign intestinal lesions. This is the preferred surgical technique for localized bowel cancer but not for widespread carcinoma, which usually requires massive resection and a temporary or permanent colostomy or an ileostomy.
Unlike the patient who undergoes total colectomy or more extensive surgery, the patient who undergoes simple resection and anastomosis usually retains normal bowel function.

Patient preparation
Before surgery, as ordered, administer antibiotics to reduce intestinal flora and laxatives or enemas to remove fecal contents.

Monitoring and aftercare
Follow these steps after surgery:
• For the first few days after surgery, monitor the patient’s intake, output, and weight daily. Maintain fluid and electrolyte balance through I.V. replacement therapy, and check regularly for signs of dehydration, such as decreased urine output and poor skin turgor.
• Keep the NG tube patent. Warn the patient that he should never attempt to reposition a dislodged tube himself because doing so could damage the anastomosis. Perform frequent mouth care.
• Observe the patient for signs of peritonitis or sepsis caused by leakage of bowel contents into the abdominal cavity. He’s at increased risk for sepsis if he’s immunosuppressed or receiving TPN.

An attack of hot flashes

Focus topic: Gastrointestinal disorders

• Provide meticulous wound care, changing dressings when needed. Check dressings and drainage sites frequently for signs of infection (purulent drainage, foul odor) and fecal drainage. Also, watch for sudden fever, especially when accompanied by abdominal pain and tenderness.
• Regularly assess the patient for signs of post-resection obstruction. Examine the abdomen for distention and rigidity, auscultate for bowel sounds, and note the passage of any flatus or stool.
• After the patient regains peristalsis and bowel function, help him avoid constipation and straining during defecation, both of which can damage the anastomosis. Encourage him to drink plenty of fluids, and administer a stool softener or other laxative, as ordered. Note and record the frequency and amount of all bowel movements as well as characteristics of the stool.
• Encourage regular coughing and deep breathing to prevent atelectasis; remind the patient to splint the incision site as necessary.
• Assess pain and provide analgesics, as ordered.

Home care instructions
Provide these instructions to the patient:
• Instruct the patient to record the frequency and character of bowel movements and to tell the practitioner if he notices any changes in his normal pattern. Warn him against using laxatives without consulting his practitioner.

Feeling the strain

Focus topic: Gastrointestinal disorders

  • Tell the patient to avoid abdominal straining and heavy lifting until the sutures are completely healed and the practitioner gives permission to do so.
  • Encourage the patient to maintain the prescribed semi-bland diet until his bowel has healed completely (usually 4 to 8 weeks after surgery). Stress the need to avoid carbonated beverages and gasproducing foods.
  • Because extensive bowel resection may interfere with the patient’s ability to absorb nutrients, emphasize the importance of taking prescribed vitamin supplements.

Appendectomy
With rare exception, the only effective treatment for acute appendicitis is to remove the inflamed vermiform appendix. A common emergency surgery, an appendectomy aims to prevent imminent rupture or perforation of the appendix. When completed before these complications occur, an appendectomy is usually effective and uneventful. A perforated appendix carries a greater risk of mortality. If the appendix ruptures or perforates before surgery, its infected contents spill into the peritoneal cavity, possibly causing peritonitis. Most appendectomies are now done laparoscopically, except in cases where rupture is suspected.

Patient preparation
Before surgery, implement these measures:
• Reduce the patient’s pain by placing him in Fowler’s position.
• Avoid giving analgesics, which can mask the pain that heralds rupture.

Risking rupture

Focus topic: Gastrointestinal disorders

• Never apply heat to the abdomen, give cathartics or enemas, or palpate the abdomen; these measures could trigger rupture.

Monitoring and aftercare
Follow these steps after surgery:
• Carefully monitor vital signs and record intake and output for 2 days after surgery.
• Auscultate the abdomen for bowel sounds, which signal the return of peristalsis.
• Regularly check the wound dressing for drainage, and change it as necessary. If abdominal drains are in place, check and record the amount and nature of drainage, and maintain drain patency.
• Check drainage from the NG tube, and irrigate as needed.
• Encourage ambulation within 12 hours after surgery if possible. Assist the patient as needed.

• Encourage coughing, deep breathing, use of an incentive spirometer, and frequent position changes to prevent pulmonary complications.
• On the day after surgery, remove the NG tube and gradually resume oral foods and fluids as ordered.
• Assess the patient closely for signs of peritonitis. Watch for and report continuing pain and fever, excessive wound drainage, hypotension, tachycardia, pallor, weakness, and other signs of infection and fluid and electrolyte loss. If peritonitis develops, expect to assist with emergency treatment, including GI intubation, parenteral fluid and electrolyte replacement, and antibiotic therapy.

Home care instructions
Provide these instructions to the patient:
• Tell the patient to watch for and immediately report fever, chills, diaphoresis, nausea, vomiting, or abdominal pain and tenderness.
• Instruct the patient to avoid strenuous activity (heavy lifting, stooping, and pushing or pulling) for up to 1 month following surgery.
• Encourage the patient to keep scheduled follow-up appointments to monitor healing and diagnose complications.

Gallbladder surgery
When gallbladder and biliary disorders fail to respond to drugs, diet therapy, and supportive treatments, surgery may be required to restore biliary flow from the liver to the small intestine. Gallbladder removal, or cholecystectomy, restores biliary flow in gallstone disease (cholecystitis or cholelithiasis) and relieves symptoms. It’s one of the most commonly performed surgeries. Conventional cholecystectomy requires an incision several inches long, produces considerable discomfort, and results in weeks of recovery time.

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