NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Gastrointestinal System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Gastric Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Dyspepsia Indigestion

Focus topic: Medical–Surgical Nursing

Definition: Indigestion is caused by diseases of the gastrointestinal system, eating too rapidly, emotional problems, inadequate chewing, eating improperly cooked foods, systemic diseases, food allergies, and altered gastric secretion or motility.

Assessment
A. Assess for heartburn.
B. Assess for flatulence.
C. Observe for nausea.
D. Observe for eructations.
E. Identify feeling of fullness.

Implementation
A. Based on the cause of the disorder.
B. Antacids and bland diets.
C. Antispasmodics and tranquilizers.
D. Altered eating habits.

Medical–Surgical Nursing: Anorexia Nervosa

Focus topic: Medical–Surgical Nursing

Definition: Underlying emotional disorders cause psychogenic aversion to food, with resulting emaciation. Usually occurs in females during the late teens or early twenties. Onset is often associated with a stressful life event. Client often has fear of obesity, body-image distortion, and disturbed self-concept. This eating disorder may be life-threatening. Death can occur from starvation or electrolyte imbalance.

Assessment
A. Assess weight—loss of one-fourth to one-half or more of the body weight occurs with this disorder.
B. Check for amenorrhea for at least three consecutive periods.
C. Observe for vomiting when food is forced.
D. Assess for hypotension, decreased temperature and pulse.
E. Evaluate for anemia.
F. Assess for hypoproteinemia.
G. Compulsive exercising.
H. Loss of appetite or refusal to eat.
I. Perfectionism and overachievement.
J. Self-administered enemas or self-induced vomiting.
K. Dry and scaly skin.
L. Sleep disturbances.
M. Gastrointestinal upsets.
N. Deterioration of gums and teeth.
O. Degeneration of bone.

Implementation
A. Give supportive care.
B. Administer tube feedings if necessary.
C. Monitor psychiatric treatment.

  • Set firm limits.
  • Monitor eating patterns.

Medical–Surgical Nursing: Acute Gastritis

Focus topic: Medical–Surgical Nursing

Definition: An inflammation of the stomach by a local irritant.

Characteristics
A. Ingestion of an infectious, corrosive, or erosive substance (such as alcohol, aspirin, or food poisoning).
B. Acute systemic infections.
C. Radiotherapy or chemotherapy.

Assessment
A. Assess for pain.
B. Evaluate nausea and vomiting pattern.
C. Check for malaise.
D. Observe for hemorrhage.
E. Assess for anorexia.
F. Check for headache.
G. Assess for dehydration.

Implementation
A. Remove cause and treat symptomatically.
B. Monitor drugs that include antacids and phenothiazines.
C. Correct fluid and electrolyte balance; NPO during acute phase, then graduate to bland diet with fluid replacement.

Medical–Surgical Nursing: Chronic Gastritis

Focus topic: Medical–Surgical Nursing

Definition: Unrelated to acute gastritis, a nondescript, upper abdominal distress with vague symptoms. Other causes should be explored.

Characteristics
A. Type A: autoimmune component affecting people of Northern European heritage.

  • Antibodies destroy gastric mucosal cells—results in tissue atrophy, loss of hydrochloric acid (HCl) and pepsin.
  • Intrinsic factor not present, so low absorption of B12 leads to pernicious anemia.

B. Type B: more common, with incidence increasing with age.

  • Caused by chronic infection of gastric mucosa by Helicobacter pylori.
  • Infection is associated with increased risk of peptic ulcer disease.

Assessment
A. Assess for dyspepsia, anorexia, and eructations.
B. Check for foul taste in mouth.
C. Assess for nausea and vomiting.
D. Assess for pain and mild epigastric tenderness.
E. Observe for complications.

  • Hemorrhage.
  • Scarring of mucosa.
  • Ulcer formation.
  • Malnutrition.

Implementation
The same as for peptic ulcer disease (PUD).

Medical–Surgical Nursing: Peptic Ulcer Disease

Focus topic: Medical–Surgical Nursing

Definition: An ulceration in the mucosal wall of the stomach, pylorus, or duodenum, occurring in portions that are accessible to gastric secretions. Erosion may extend through the muscle to the peritoneum.

Characteristics
A. Pathophysiology.

  • Any condition that upsets the balance between digestion and protection.
    a. No longer thought to be only caused by excess stomach acid. It can contribute to ulcer formation if too much acid is secreted.
    b. Bacterial invasion of mucosa caused by Helicobacter pylori bacterium (H. pylori).
    c. Ingestion of certain drugs such as steroids, aspirin (ASA), and nonsteroidal antiinflammatory drugs (NSAIDs).
    d. Smoking is a risk factor.
  • Ulcers tend to occur in lesser curvature of stomach near the pylorus (15%).
  • Duodenal ulcers account for 80% of peptic ulcers. (See Table 8-1.)

B. Diagnostic evaluation.

  • Medical history and symptoms.
  • Key test is endoscopy to locate ulcer.
  • Gastric biopsy to detect H. pylori.

Assessment
A. Assess pain.

  • Location and intensity—duodenal ulcer symptoms usually occur 1–3 hours after eating, worse at end of day and during the night.
  • Duration.
  • Aggravating factors.

B. Evaluate vital signs to establish a baseline to monitor for bleeding.
C. Evaluate laboratory results.
D. Check stool for blood.
E. Observe for hemorrhage.

  • Dark, granular (coffee ground) emesis is a result of acid digestion of blood in the stomach.
  • Tarry, black stools result when blood is completely digested.
  • Hematemesis (vomiting of bright red blood).
  • Bright red blood from rectum. Occurs when bleeding originates from high in the gastrointestinal tract and there is concurrent, rapid gastrointestinal motility.

Implementation
A. Administer and monitor medications.

  • Antimicrobial therapy—antibiotics (Amoxil [amoxicillin]), tetracycline.
    a. One course of therapy treats ulcers caused by H. pylori infection.
    b. Combined with proton-pump inhibitor, bismuth preparations, traditional antacids, H2 antagonists, and Flagyl (metronidazole) results in a full cure with fewer complications.
    c. Levaquin (levofloxacin)-based triple therapy is treatment of choice for persistent H. pylori infection.
  • Antacids.
    a. Action: Reduces gastric acidity; given for pain.
    b. Taken 1 hour after meals; effects last longer.

c. Side effects: diarrhea and constipation.
d. Types of nonabsorbable antacids.
(1) Calcium carbonate is most effective but may cause hypercalcemia, hypercalciuria (high urine calcium), and constipation.
(2) Magnesium oxide is more potent than either magnesium trisilicate or magnesium carbonate.
(3) Aluminum hydroxide: high sodium (Na) content and constipation are disadvantages.
(4) Sodium bicarbonate is absorbed and should be avoided to prevent systemic alkalosis.

  • Histamine H2-receptor antagonists.
    a. Tagamet (cimetidine), Zantac ( ranitidine), Pepcid (famotidine), and Axid ( nizatidine), PO or IV.
    b. Action: Blocking action reduces production of gastric acid and allows ulcers to heal.
    c. Drugs were 90% effective when taken PO for 8 weeks; now often replaced by antibiotics.
    d. Minimal side effects: headache and skin rash.
  • Carafate (sucralfate).
    a. Action: Adheres to ulcer surface, stimulates release of prostaglandins; reinforces mucosal barrier.
    b. Duration is 5 hours; administer 1 hour before or after meals and at bedtime on an empty stomach.
    c. Prescribed when drug interactions or side effects negate use of H2 antagonists.
    d. Side effects: constipation, nausea, and vomiting.
  • Anticholinergic drugs.
    a. Used only for clients with severe pain in the early morning.
    b. Drug action increases risk of gastric outlet syndrome.
  • Proton-pump inhibitors block release of HCl from parietal cells—very effective result with over 90% healing in 4 weeks.
    a. Prilosec (omeprazole).
    b. Prevacid (lansoprazole).
  • Synthetic prostaglandin.
    a. Cytotec (misoprostol).
    b. Particularly useful for persons using long-term NSAIDs.
    c. Protects stomach lining from erosive action of gastric acid. (This drug may induce abortions.)

Comparison of Duodenal and Gastric Ulcer

Medical–Surgical Nursing

B. Provide dietary control of symptoms until ulcer is cured.

  • Ensure three nutritious meals.
  • Avoid black pepper, foods that cause distress until ulcer is cured (e.g., highly seasoned, rough, greasy, gas-forming, or fried).
  • Avoid prolonged use of milk and cream, as they stimulate acid production.
  • Avoid alcohol, as it releases gastrin, stimulates the parietal cells, and may damage the mucosa.
  • Avoid tea, coffee, and cola, because caffeine stimulates gastric secretion.
  • Do not provide any snacks, even at bedtime (stimulates acid secretion).
  • Provide iron and ascorbic acid to promote healing.

C. Reduce stressful situations if client is hospitalized.

  • Allow client to care for important business obligations.
  • Eliminate visitors or duties that increase stress.
  • Teach autogenic methods of stress reduction, relaxation, tension-releasing activities.

D. Promote rest.

  • Adequate sleep is strongly advised.
  • Business and social responsibilities should be curtailed during acute phase.
  • Hospitalization may be required if therapy is not effective in 1 week.
  • Sedatives and tranquilizers may be helpful for the anxious, tense client.

E. Provide client and family teaching regarding diet, activity level, medications, risk factors (smoking), and potential complications.
F. Observe for complications.

  • Hemorrhage, ranging from slight blood loss (revealed by occult blood in stool) to massive blood loss, which may lead to shock.
    a. Promote bed rest.
    b. Observe vital signs.
    c. Observe consistency, color, and volume of vomitus and stools.
    d. Provide nasogastric suction to empty the stomach of clots and blood, and to watch the rate of bleeding.
    e. Monitor blood, plasma, or IV fluids to support blood volume.
    f. Administer narcotics and/or tranquilizers to reduce restlessness and to relieve pain.
    g. Gavage with ice water to increase vasoconstriction.
  • Perforation: Occurs almost exclusively in males 25–40 years of age.
    a. Monitor acute onset of severe, persistent pain that increases in intensity and can be referred to the shoulder.
    b. Examine for tender, boardlike rigidity of the abdomen.
  • Pyloric obstruction caused by scarring, edema, or inflammation at the pylorus.
    a. Monitor for the following signs: nausea and vomiting, pain, weight loss, and constipation.
    b. Be aware that persistent vomiting can lead to alkalosis.
  • G. For surgical interventions, see Surgical Implications
    under Gastric Cancer.

Medical–Surgical Nursing: Surgical Intervention

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Gastric Cancer

Focus topic: Medical–Surgical Nursing

Definition: Carcinoma of the stomach is a common cancer of the digestive tract.

Characteristics
A. A significant cause of death because of low cure rate.
B. Occurs twice as often in males as in females, and more often in African Americans than in other races.
C. Found frequently in conjunction with pernicious anemia and atrophic gastritis.
D. Worldwide incidence varies.
E. Early carcinoma causes no symptoms.

Assessment
A. Assess for weight loss and anorexia.
B. Check for feeling of vague fullness and sensation of pressure.
C. Assess for anemia from blood loss.
D. Examine stools for occult blood.
E. Assess vomiting if pylorus becomes obstructed.
F. Observe for late symptoms: ascites, palpable mass, and pain from metastasis.
G. Evaluate for metastasis.

  • Occurs by direct extension into surrounding tissue.
  • Spreads through lymphatic and hematogenous systems.

Implementation
A. Provide postoperative care for surgical resection.
B. Monitor chemotherapy—response has not been consistent; may shorten life span if toxic effects occur.

Medical–Surgical Nursing: Postoperative Period

Focus topic: Medical–Surgical Nursing

Assessment
A. Observe color, amount, and consistency of nasogastric drainage.
B. Evaluate patency of nasogastric tube.
C. Evaluate type and severity of pain.
D. Evaluate client’s ability to deep-breathe and cough.
E. Assess intravenous site for possible complications.
F. Listen for bowel sounds.
G. Assess all systems for possible complications.

Implementation
A. After anesthesia recovery, place in modified Fowler’s position for comfort and easy stomach drainage.
B. Prevent pulmonary complications—medicate before turning, coughing, or hyperventilating.
C. Institute nasogastric suction; drainage contains some blood for the first 12 hours, then colored brown to dark green.

  • Physician inserts tube.
  • Keep patent by irrigating with sodium chloride.

D. See that client is NPO (no peristalsis).
E. Give intravenous fluids as ordered.
F. After nasogastric tube is out, give small sips of water. (Do not use a straw.)

  • Do not give cold fluids (cause distress); give warm, weak tea.
  • Offer bland foods so that client eats six small meals a day and drinks 120 mL fluid between meals.

G. Promote ambulation on first postoperative day unless contraindicated by physician.

H. Check drainage tubes if inserted. (Serosanguineous
drainage is normal.)
I. Observe for postoperative complications.

  • Shock (from hypovolemia).
  • Vomiting—usually due to blood left in stomach. (Patent nasogastric tube prevents vomiting.)
  • Hemorrhage.
  • Pulmonary complications.
  • Large fluid and electrolyte losses.
  • Dumping syndrome.
  • Diarrhea—complication of vagotomy (use Kaopectate).
  • Vitamin B12 deficiency.
    a. Production of “intrinsic factor” is halted. (The gastric secretion is required for the absorption of vitamin B12 from the gastrointestinal tract.)
    b. Unless supplied by parenteral injection throughout life, client suffers vitamin B12 deficiency.

Medical–Surgical Nursing: Inflammatory Bowel Disease

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Regional Enteritis (Regional Ileitis, Crohn’s Disease)

Focus topic: Medical–Surgical Nursing

Definition: An inflammatory disease of the small intestine that is chronic and relapsing. It results in thickening, scarring, and granulomas of intestinal tissues, which causes narrow lumen, fistulas, ulcerations, and abscesses. The etiology is unknown but may be related to altered immunologic reactivity.

Characteristics
A. Occurs at all ages.
B. Usually observed in second and third decades of life.
C. High incidence of familial occurrence.
D. High incidence in those of Jewish descent; low incidence in African Americans.

Assessment
A. Continuous or episodic diarrhea and cramplike pain after meals.
B. Evaluate for weight loss.
C. Check for malnutrition.
D. Assess for secondary anemia.
E. Check for abdominal pain and tenderness.
F. Evaluate temperature.
G. Assess for complications: acute perforation, generalized peritonitis, and massive melena, which are sometimes present at onset.
H. Fever.
I. Electrolyte imbalance.

Implementation
A. Provide appropriate diet: high calorie, high protein, low residue, bland, with iron and vitamin supplements (including B12); elimination of all milk and milk products.
B. Administer medications.

  • Anti-inflammatory drugs to reduce swollen membranes (corticosteroids, Azulfidine [sulfasalazine]).
  • Antidiarrheal agents to control diarrhea.
  • Sedatives and narcotics to reduce apprehension and pain.
  • Antibiotics such as Flagyl (metronidazole) may be given to control infection.
  • Oral aminosalicylates (Asacol).
  • Immunosuppressives to prevent relapses.
  • Total parenteral nutrition (TPN) to maintain nutritional status is often prescribed.

C. Provide postoperative care for surgical intervention (ileostomy).

Medical–Surgical Nursing: Ulcerative Colitis

Focus topic: Medical–Surgical Nursing

Definition: A chronic ulcerative and inflammatory disease that affects the mucosa and submucosa of the colon and rectum; commonly begins in the rectum and sigmoid colon and spreads upward. The disease is characterized by periods of exacerbations and remissions.

Characteristics
A. Cause unknown, but theories include autoimmune factor, allergic reaction, specific vulnerability of the colon, emotional instability, and bacterial infection.
B. Most common in young adulthood and middle life. More prevalent among those of Jewish descent; less common in African Americans than in Caucasians.

Assessment
A. Assess for gradual onset.

  • Malaise.
  • Early—vague abdominal discomfort.
  • Later—cramplike abdominal pain.
  • Bowel evacuation—pus, mucus, and blood.
  • Stools scanty and hard.
  • Painful straining with defecation.

B. Assess for abrupt onset.

  • Severe diarrhea (15–20 watery stools a day that may contain blood and mucus).
  • Fever.
  • Anorexia.
  • Weight loss.
  • Abdominal tenderness.
  • Rectal and anal spasticity.
  • Consistency of stools varies with areas of colon involved.

C. Assess for complications.

  • Dehydration.
  • Magnesium and calcium imbalances.
  • Anemia and malnutrition—malabsorption and iron and vitamin K deficiency.
  • Perforation, peritonitis, and hemorrhage.
  • Abscesses and strictures.
  • Carcinomatous degeneration (if more than 10 years’ duration).
  • Toxic megacolon and colon perforation.
  • Bleeding tendency.

D. Evaluate results of client’s history and diagnostic tests.

  • Medical history.
  • Clinical manifestations.
  • Lower GI series.
  • Stool and blood examinations.
  • Sigmoidoscopy.
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Implementation
A. Major objective—prevent acute episodes and/or manage complications.
B. Maintain nutritional status.

  • High-protein, high-calorie, high-fiber diet.
  • Avoid certain spices (pepper), gas-forming foods, and milk products (client may be lactose intolerant).
  • All foods should be cooked to reduce cramping and diarrhea.
  • Vitamins (A and E), minerals (zinc, calcium, and magnesium), and iron supplements.
  • Eating may increase diarrhea and anorexia.
  • Total parenteral nutrition (TPN) may be indicated.

C. Replace fluid and electrolytes lost due to diarrhea.

  • 3–4 L/day.
  • Potassium chloride may need to be added.

D. Manage psychological disturbances.

  • Allow client to ventilate feelings; accept client as he or she is.
  • Help client live with chronic disease (a change in lifestyle may be necessary).
  • Avoid emotional probing during periods of acute illness.
  • Provide client and family with instructions about pathology of the disease and rationale for treatment.

E. Administer drugs as ordered.

  • Steroid therapy for inflammation, toxicity, and emotional symptoms.
    a. Induces remissions.
    b. Given IV in acute episode.
    c. Given rectally for long term.
  • Anti-infectives.
    a. Routine sulfonamides to reduce severity of attack.
    b. Antibiotic therapy for secondary bowel inflammation and systemic infections.
  • Immunosuppressives to prevent relapses.
  • Oral aminosalicylates have proven very effective (used with caution in clients with renal dysfunction).
  • Tranquilizers (e.g., Luminal [phenobarbital]) to relieve anxiety and decrease peristalsis.
  • Anticholinergics.
    a. Relieve abdominal cramps.
    b. Assist in controlling diarrhea.
  • In acute stages cathartics contraindicated, as they may lead to megacolon or perforation.

F. Maintain bed rest during acute phase.
G. Prepare client for surgery, if necessary.

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