NCLEX: Gastrointestinal disorders

Gastrointestinal disorders: Treatments

Focus topic: Gastrointestinal disorders

Gastrointestinal disorders: Laparoscope to the rescue

Focus topic: Gastrointestinal disorders

Laparoscopic laser cholecystectomy allows gallbladder removal without major abdominal surgery. This speeds recovery and reduces the risk of such complications as infection and herniation. Patients are usually discharged from the hospital and can resume a normal diet after 24 to 36 hours. Typically, patients can return to the workplace within 10 days. Laparoscopic laser cholecystectomy is contraindicated in pregnancy, acute cholangitis, septic peritonitis, and severe bleeding disorders.

Gastrointestinal disorders

Gastrointestinal disorders: A clean sweep

Focus topic: Gastrointestinal disorders

In patients who aren’t good candidates for cholecystectomy, cholecystostomy (incision into the fundus of the gallbladder to remove and drain any retained gallstones or inflammatory debris) or choledochotomy (incision into the common bile duct to remove any gallstones or other obstructions) are sometimes performed.

Patient preparation
Before surgery, implement these measures:
• Monitor and, if necessary, help stabilize the patient’s nutritional status and fluid balance. Such measures may include vitamin K administration, blood transfusions, and glucose and protein supplements.
• For 24 hours before surgery, give the patient clear liquids only.
• As ordered, administer preoperative medications and insert an NG tube.

Monitoring and aftercare
Follow these steps after laparoscopic surgery:
• Check the small stab wounds; they will be closed with staples or sutures and may have small dressings.
• Monitor for anesthesia-related nausea and vomiting.
• Apply heat to the patient’s shoulder to alleviate right shoulder pain caused by phrenic irritation from carbon dioxide under the diaphragm. To decrease discomfort, place the patient in semi- Fowler’s position. Early ambulation also helps.
• Tell the patient a light meal is usually permitted the same evening.
• The day after discharge, place a follow-up phone call to the patient’s home to check on his progress.

Gastrointestinal disorders: Nothing conventional about this care

Focus topic: Gastrointestinal disorders

Follow these steps after conventional surgery:

  • Place the patient in low Fowler’s position. If the patient has an NG tube, attach it to low intermittent suction. Monitor the amount and characteristics of drainage from the NG tube as well as from any abdominal drains. Check the dressing frequently, and change it as necessary.
  • If the patient has a T tube in place, frequently assess the position and patency of the tube and drainage bag. Make sure the bag is level with the abdomen to prevent excessive drainage. Also note the amount and characteristics of drainage; bloody or blood tinged bile usually occurs for only the first few hours after surgery. Provide meticulous skin care around the tube insertion site to prevent irritation.
  • After a few days, expect to remove the NG tube and begin introducing foods: first liquids, then gradually soft solids. As ordered, clamp the T tube for an hour before and an hour after each meal to allow bile to travel to the intestine to aid digestion.
  • Watch for signs of postcholecystectomy syndrome (such as fever, abdominal pain, and jaundice) and other complications involving obstructed bile drainage. For several days after surgery, monitor vital signs and record intake and output every 8 hours. Report unusual signs and symptoms to the practitioner, and collect urine and stool specimens for laboratory analysis of bile content.

Home care instructions
After laparoscopic laser cholecystectomy, instruct the patient on the use of oral analgesics, how to clean the surgical stab sites, and when to call the practitioner. Also, include these instructions in your teaching:
• Recommend activity as tolerated, but tell the patient to avoid heavy lifting for about 2 weeks. Assure him that patients typically return to a normal schedule within 10 days.
• Tell the patient that he’ll be given an appointment to see the practitioner or return to the clinic within 7 days for removal of the staples. Assure him that scarring is usually minimal.
• If the patient underwent the procedure as a same-day, outpatient procedure, tell him he may feel shoulder pain from the carbon dioxide used during surgery. Explain that he can relieve the pain by walking and applying heat to his shoulder.

Gastrointestinal disorders: Conventional wisdom

Focus topic: Gastrointestinal disorders

After conventional surgery, give these instructions:
• If the patient is being discharged with a T tube in place, stress the need for the patient to practice meticulous tube care.
• Tell him to immediately report any signs or symptoms of biliary obstruction: fever, jaundice, pruritus, pain, dark urine, and clay-colored stools.
• Encourage the patient to maintain a diet low in fats and high in carbohydrates and protein. Tell him that his ability to digest fats will improve as bile flow to the intestine increases. As this occurs — usually within 6 weeks — he may gradually add fats to his diet.

Liver transplantation
For the patient with a life-threatening liver disorder that doesn’t respond to treatment, a liver transplant may seem the last best hope. Even so, transplant surgery is used infrequently because of its risks and high cost, as well as the shortage of suitable donor organs. Typically, it’s used only in large teaching centers and is reserved for those terminally ill patients who have a realistic chance of surviving the surgery and withstanding postoperative complications. Candidates include patients with congenital biliary abnormalities, chronic hepatitis B or C, inborn errors of metabolism, or end-stage liver disease.

Gastrointestinal disorders: Meet the candidate

Focus topic: Gastrointestinal disorders

Careful identification of suitable candidates for referral to the transplant team is essential to the success of therapy. Criteria for referral for transplantation include:
• advanced hepatic failure with a predicted survival rate of less than 2 years
• unavailability of other medical or surgical therapies that offer long-term survival
• absence of contraindicated conditions, such as extrahepatic carcinoma, severe cardiac disease, and current active alcohol or drug addiction
• full understanding by the patient and his family of the physical, psychological, and financial aspects of the transplant process.

Gastrointestinal disorders: Waiting game

Focus topic: Gastrointestinal disorders

Many qualified transplant candidates are awaiting suitable donor organs, but few survive the wait. Also, even if a compatible healthy liver is located and transplantation performed, the patient faces many obstacles to recovery. Besides the complications accompanying extensive abdominal and vascular surgeries, liver transplantation carries a high risk of tissue rejection. Current 1-year survival rates range from 85% to 90%.

Patient preparation
Before surgery, implement these measures:
• As ordered, begin immunosuppressant therapy to decrease the risk of tissue rejection, using such drugs as cyclosporine and corticosteroids.
• Explain the need for lifelong therapy to prevent rejection.
• Address the emotional needs of the patient and his family. Discuss the typical stages of emotional adjustment to a liver transplant: overwhelming relief and elation at surviving the operation, followed by anxiety, frustration, and depression if complications occur.

Monitoring and aftercare
Focus your aftercare on four areas:
• maintaining immunosuppressant therapy to combat tissue rejection
• monitoring for early signs of rejection and other complications
• preventing opportunistic infections, which can lead to rejection
• providing emotional support to the patient throughout the prolonged recovery period.

Home care instructions
Teach the patient and his family to:
• watch for early indications of tissue rejection — including fever, tachycardia, jaundice, changes in the color of urine or stool, and pain and tenderness in the right upper quadrant, right flank, or center of the back — and notify the practitioner immediately if any of these signs or symptoms develop
• watch for and report any signs or symptoms of liver failure, such as abdominal distention, bloody stool or vomitus, decreased urine output, abdominal pain and tenderness, anorexia, and altered level of consciousness (LOC)

Gastrointestinal disorders: A wave instead of a handshake

Focus topic: Gastrointestinal disorders

• reduce the risk of tissue rejection by avoiding contact with any person who has or may have a contagious illness and report any early signs or symptoms of infection, including fever, weakness, lethargy, and tachycardia
• keep follow-up appointments, which will include regular liver function tests, complete blood count (CBC), and blood cyclo sporin levels, to evaluate the integrity of the surgical site and continued tissue compatibility
• strictly comply with the prescribed immunosuppressive drug regimen because noncompliance can trigger rejection, even of a liver that has been functioning well for years
• be aware of potential adverse effects of immunosuppressive therapy, such as infection, fluid retention, acne, glaucoma, diabetes, and cancer
• seek psychological counseling if necessary to help the patient and his family cope with the effects of the patient’s long and difficult recovery.

Liver resection or repair
Resection or repair of diseased or damaged liver tissue may be indicated for various hepatic disorders, including cysts, abscesses, tumors, and lacerations or crush injuries from blunt or penetrating trauma. Usually, surgery is performed only after conservative measures prove ineffective. For instance, if aspiration fails to correct a liver abscess, resection may be necessary.
Liver resection procedures include a partial or subtotal hepatectomy (excision of a portion of the liver) and lobectomy (excision of an entire lobe). Lobectomy is the surgery of choice for primary liver tumors, but partial hepatectomy may be effective for small tumors.

Gastrointestinal disorders: Rarely resectable

Focus topic: Gastrointestinal disorders

Even so, because liver cancer is often advanced at diagnosis, few tumors are resectable. In fact, only single tumors confined to one lobe are usually considered resectable, and then only if the patient is free from complicating cirrhosis, jaundice, or ascites. Because of the liver’s anatomic location, surgery is usually performed through a thoracoabdominal incision.

Patient preparation
Before surgery, implement these measures:
• Encourage rest and good nutrition and provide vitamin supplements, as ordered, to help improve liver function.
• Prepare the patient for additional diagnostic tests, which may include liver scan, CT scan, ultrasonography, percutaneous needle biopsy, hepatic angiography, and cholangiography.
• Explain postoperative care measures. Tell the patient he’ll awaken from surgery with an NG tube, a chest tube, and hemodynamic monitoring lines in place. Tell him to expect frequent checks of vital signs, fluid and electrolyte balance, and neurologic status as well as I.V. fluid replacement and possible blood transfusions and TPN. If possible, allow the patient to visit and familiarize himself with the intensive care unit.
• To reduce the risk of postoperative atelectasis, encourage the patient to practice coughing and deep-breathing exercises, and teach him how to use an incentive spirometer.

Monitoring and aftercare
Follow these steps after surgery:
• Frequently assess for complications, such as hemorrhage and infection. Monitor the patient’s vital signs and evaluate fluid status every 1 to 2 hours. Report any signs of volume deficit, which could indicate intraperitoneal bleeding. Keep an I.V. line patent for possible emergency fluid replacement or blood transfusion. Provide analgesics as ordered.
• At least daily, check laboratory test results for hypoglycemia, increased PT, increased ammonia levels, azotemia (increased blood urea nitrogen [BUN] and creatinine levels), and electrolyte imbalances (especially potassium, sodium, and calcium imbalances). Promptly report adverse findings, and take corrective steps, as ordered. For example, give I.M. vitamin K to decrease PT, or infuse hypertonic glucose solution to correct hypoglycemia.
• Check wound dressings often and change them as needed. Note and report excessive bloody drainage on the dressings or in the drainage tube. Also note the amount and characteristics of NG tube drainage; keep in mind that excessive drainage could trigger metabolic alkalosis. If the patient has a chest tube in place, maintain tube patency. Make sure the suction equipment is operating properly. Don’t strip the tube because the increase in negative pressure could harm the patient.

Gastrointestinal disorders: Dazed and confused

Focus topic: Gastrointestinal disorders

• Watch for signs and symptoms of hepatic encephalopathy, including behavioral or personality changes, such as confusion, forgetfulness, lethargy or stupor, and hallucinations. Also observe for asterixis, apraxia, and hyperactive reflexes.

Home care instructions
Provide these instructions to the patient:
• Tell him that adequate rest and good nutrition conserve energy and reduce metabolic demands on the liver, thereby speeding healing. For the first 6 to 8 months after surgery, he should gradually resume normal activities, balance periods of activity and rest, and avoid overexertion.
• As ordered, instruct the patient to maintain a high-calorie, high-carbohydrate, and high-protein diet during this period to help restore the liver mass. However, if the patient had hepatic encephalopathy, advise him to follow a low-protein diet, with carbohydrates making up the balance of calorie intake.

Transjugular intrahepatic portosystemic shunt insertion
Intractable ascites resulting from chronic liver failure can be controlled by diverting blood flow from the portal vein to the venous circulation with a transjugular intrahepatic portosystemic shunt (TIPS). Using angiographic techniques and contrast dye, the surgeon places an expandable metal stent to form a connection between the intrahepatic portal vein and the hepatic vein. This reduces intravascular fluid pressure in the liver by allowing blood to return to the systemic circulation. The TIPS is extremely effective in reducing sodium retention, improving renal function, and reducing cirrhosis-related esophageal and gastric variceal bleeding.

Patient preparation
Before the procedure, implement these measures:
• Explain to the patient and his family how the TIPS works.
• Tell the patient that it may be necessary to withhold medications, such as aspirin and other NSAIDs and anticoagulants, for a period of time before the procedure.
• Assess the patient for contrast dye allergies.

Gastrointestinal disorders

• Tell the patient that he’ll receive a local anesthetic during the procedure to minimize discomfort at the internal jugular catheter insertion site; he may also receive sedation during the procedure.
• Measure and record the patient’s weight and abdominal girth to serve as a baseline.
• Obtain a CBC; electrolyte, BUN, and creatinine levels; and coagulation laboratory studies to establish a baseline.

Monitoring and aftercare
Follow these steps after the procedure:
• Make the patient as comfortable as possible by placing him in low Fowler’s or semi-Fowler’s position; administer analgesics as ordered.
• Monitor the patient’s vital signs, and watch for hypervolemia or hypovolemia. Be alert for signs of heart failure and infection. Monitor his electrolyte levels.

Gastrointestinal disorders: Toxic effects

Focus topic: Gastrointestinal disorders

  • Because blood from the GI tract is shunted around the liver, the patient is at increased risk for hepatic encephalopathy from circulating toxins; monitor his mental status, and report changes to the practitioner immediately.
  • Weigh the patient and measure his abdominal girth daily. Watch for signs of shunt failure, such as gastric bleeding or increases in abdominal girth.

Home care instructions
Provide these instructions to the patient:
• Instruct the patient to weigh himself daily and to keep a log. Tell him to report increases of 2 or more pounds to the practitioner.
• Tell him he’ll need to have his shunt periodically assessed for placement and patency, typically with ultrasound.
• Explain that, if his shunt becomes stenosed, a stenting procedure can usually reestablish patency.
• Encourage the patient to keep regular follow-up appointments.

Endoscopic retrograde sphincterotomy
First used to remove retained gallstones from the common bile duct after cholecystectomy, endoscopic retrograde sphincterotomy (ERS) is now also used to treat high-risk patients with biliary dyskinesia and to insert biliary stents for draining malignant or benign strictures in the common bile duct.

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Gastrointestinal disorders: A-tisket, a-tasket, balloons or a basket

Focus topic: Gastrointestinal disorders

In this procedure, a fiber-optic endoscope is advanced through the stomach and duodenum to the ampulla of Vater. A papillotome is passed through the endoscope to make a small incision to widen the biliary sphincter. If the stone doesn’t drop out into the duodenum on its own, the doctor may introduce a Dormia basket, a balloon, or a lithotriptor through the endoscope to remove or crush the stone.

Gastrointestinal disorders: Quick, painless, and safe

Focus topic: Gastrointestinal disorders

ERS allows treatment without general anesthesia or a surgical incision, ensuring a quicker and safer recovery. It may be performed on an outpatient basis for some patients, making it a costeffective alternative to surgery.

Patient preparation
Explain the treatment to the patient:
• His throat will be sprayed with an anesthetic to prevent discomfort during the insertion and he may also receive a sedative to help him relax. Reassure him that the procedure should cause little or no discomfort.
• He’ll be positioned on the fluoroscopy table in a left side-lying position, with his left arm behind him. Encourage him to relax.

Monitoring and aftercare
Follow these steps after treatment:
• Instruct the patient to cough, deep-breathe, and expectorate regularly to avoid aspirating secretions. Keep in mind that the anesthetic’s effects may hinder expectoration and swallowing.
• Withhold food and fluids until the anesthesia wears off and the patient’s gag reflex returns.
• Check the patient’s vital signs frequently and monitor carefully for signs of hemorrhage: hematemesis, melena, tachycardia, and hypotension. If any of these signs develop, notify the practitioner immediately.

Home care instructions
Provide these instructions to the patient:
• Tell him to immediately report any signs of hemorrhage, sepsis, cholangitis, or pancreatitis.
• Encourage him to report any recurrence of the characteristic jaundice and pain of biliary obstruction. He may need repeat ERS to remove new stones or to replace a malfunctioning biliary stent.

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