GASTROINTESTINAL

• An increase in bilirubin level indicates liver damage or biliary obstruction
• Normal reference intervals for bilirubin levels:

  • Total: 0.3 to 1.0 mg/dL (5.1 to 17 mc mol/L)
  • Indirect: 0.2 to 0.8 mg/dL (3.4 to 12 mc mol/L)
  • Direct: 0.1 to 0.3 mg/dL (1.7 to 5.1 mc mol/L)
• Increased values for amylase and lipase levels indicate pancreatitis
• Normal reference intervals for amylase: 60 to 120 Somogyi units/dL (100 to 300 U/L)

  • Lipase: 0 to 160 U/L (0 to 160 U/L)
• • Advise a low-fat, high-fiber diet and avoiding eating/drinking 2 hours before bedtime
  • Recommend small, frequent meals and not lying down after eating
  • Avoid anticholinergics, NSAIDs, calcium channel blockers
  • Educate on prescribed medications like antacids, H2-receptor antagonists, proton pump inhibitors
  • Instruct on prokinetic medications if prescribed
  • Surgery may be required in extreme cases, involving fundoplication
• Gastroesophageal Reflux Disease (GERD):

  • Description: Backflow of gastric and duodenal contents into the esophagus
  • Risk factors: Incompetent lower esophageal sphincter (LES), pyloric stenosis, motility disorder, overweight or obesity
  • Assessment: Heartburn, epigastric pain, chest pain, voice hoarseness, chronic dry cough, dyspepsia, nausea, regurgitation, pain and difficulty with swallowing, globus, hypersalivation
  • Interventions:
  • Instruct client to avoid factors that decrease LES pressure or cause esophageal irritation
• • Acute gastritis: Withhold food/fluids until symptoms subside, then progress to clear liquids and solid food
  • Monitor for signs of hemorrhagic gastritis and notify healthcare provider
  • Instruct client to avoid irritating foods/substances
  • Administer prescribed medications like antibiotics for H. pylori and antacids
  • Provide information on vitamin B12 injections if deficiency is present
• Gastritis:

  • Description: Inflammation of the stomach or gastric mucosa
  • Acute causes: Contaminated food, overuse of aspirin or NSAIDs, excess alcohol intake, bile reflux, radiation therapy
  • Chronic causes: Benign or malignant ulcers, H. pylori bacteria, autoimmune diseases, dietary factors, medications, alcohol, smoking, reflux
  • Assessment: Includes symptoms like gnawing, sharp pain in the midepigastric region, anorexia, nausea, vomiting, headache, hiccupping, reflux, dyspepsia
  • Interventions:
• Peptic Ulcer Disease:

  • Description: Ulceration in the mucosal wall of the stomach, pylorus, duodenum, or esophagus
  • Most common ulcers: Gastric and duodenal ulcers
  • Gastric ulcers:
  • Involves ulceration of the mucosal lining extending to the submucosal layer
  • Predisposing factors: Stress, smoking, corticosteroids, NSAIDs, alcohol, gastritis history, family history, H. pylori infection
  • Complications: Hemorrhage, perforation, pyloric obstruction
  • Interventions:
  • Monitor vital signs and signs of bleeding
• • Administer blood transfusions as prescribed
  • Prepare to assist with medications to reduce bleeding
  • Surgical interventions: Total gastrectomy, vagotomy
• • Administer small, frequent bland feedings during the active phase
  • Use H2-receptor antagonists, proton pump inhibitors, antacids, anticholinergics, mucosal barrier protectants, prostaglandins as prescribed
  • Treat H. pylori infection if indicated
  • Educate on lifestyle changes and medication adherence
  • Interventions during active bleeding:
  • Monitor vital signs closely
  • Assess for signs of hemorrhage, dehydration, shock, sepsis, respiratory insufficiency
  • Maintain NPO status, administer IV fluid replacement, monitor hemoglobin/hematocrit
• Gastric Ulcers:

  • Gnawing, sharp pain in or to the left of the midepigastric region occurs 1 to 2 hours after a meal (food ingestion accentuates the pain)
  • Hematemesis is more common than melena
• • Some postoperative interventions include monitoring vital signs, placing the client in a Fowler's position for comfort, administering fluids and electrolyte replacements intravenously, assessing bowel sounds, monitoring NG suction as prescribed, maintaining NPO status for 1 to 3 days until peristalsis returns, progressing the diet from NPO to sips of clear water to six small bland meals a day, and monitoring for postoperative complications
• Duodenal Ulcers:

  • Burning pain occurs in the midepigastric area 2 to 5 hours after a meal and at specific times during the day
  • Melena is more common than hematemesis
  • Pain is often relieved by the ingestion of food
  • Risk factors and causes include infection with H. pylori, alcohol intake, smoking, stress, caffeine, and the use of aspirin, corticosteroids, and NSAIDs
  • Complications include bleeding, perforation, gastric outlet obstruction, and intractable disease
• Dumping Syndrome:

  • The rapid emptying of the gastric contents into the small intestine that occurs following gastric resection
  • Symptoms occurring 30 minutes after eating include nausea and vomiting, feelings of abdominal fullness and abdominal cramping, diarrhea, palpitations and tachycardia, perspiration, weakness and dizziness, and borborygmi (loud gurgling sounds resulting from bowel hypermotility)
• Bariatric Surgery:

  • Surgical reduction of gastric capacity or absorptive ability that may be performed on a client with morbid obesity to produce long-term weight loss
  • Thorough psychological assessment and testing to detect depression, substance abuse, or other mental and behavioral health problems that could interfere with success after surgery is necessary
  • Surgery can prevent the complications of obesity, such as diabetes mellitus, hypertension, and other cardiovascular disorders, or sleep apnea
• • Postoperative interventions include care similar to that for clients undergoing laparoscopic or abdominal surgery, introducing clear liquids slowly once bowel sounds have returned, progressing the diet from liquids to puréed foods, monitoring for symptoms of anastomotic leaks, and assessing for abdominal pain, restlessness, unexplained tachycardia, and oliguria
• • Interventions include medical and surgical management similar to those for gastroesophageal reflux disease, providing small frequent meals, limiting the amount of liquids taken with meals, and following specific dietary guidelines
• Hiatal Hernia:

  • A portion of the stomach herniates through the diaphragm and into the thorax
  • Complications include ulceration, hemorrhage, regurgitation and aspiration of stomach contents, strangulation, and incarceration of the stomach in the chest with possible necrosis, peritonitis, and mediastinitis
  • Assessment includes heartburn, chest pain, regurgitation or vomiting, dysphagia, feeling of fullness, and worsening of symptoms when lying down
• Preventing Dumping Syndrome:

  • Encourage the client to consume a well-balanced diet and make lifestyle changes as indicated
  • Advise the client not to recline for 1 hour after eating
  • Avoid anticholinergics, which delay stomach emptying
• Cholecystitis Description:

  • Inflammation of the gallbladder that may occur as an acute or chronic process
  • Acute inflammation is associated with gallstones (cholelithiasis)
  • Chronic cholecystitis results from inefficient bile emptying and gallbladder muscle wall disease causing a fibrotic and contracted gallbladder
  • Acalculous cholecystitis occurs in the absence of gallstones and is caused by bacterial invasion via the lymphatic or vascular system
• Cholecystitis Assessment:

  • Nausea and vomiting
  • Indigestion
  • Belching
  • Flatulence
  • Epigastric pain that radiates to the right shoulder or scapula
  • Pain localized in the right upper quadrant triggered by a high-fat or high-volume meal
  • Guarding, rigidity, and rebound tenderness
  • Mass palpated in the right upper quadrant
  • Murphy’s sign (cannot take a deep breath when the examiner’s fingers are passed below the hepatic margin because of pain)
  • Elevated temperature
  • Tachycardia
  • Signs of dehydration
• Bariatric Surgery Dietary Measures:

  • Avoid alcohol, high-protein foods, and foods high in sugar and fat
  • Eat slowly and chew food well
  • Progress food types and amounts as prescribed
  • Take nutritional supplements as prescribed, which may include calcium, iron, multivitamins, and vitamin B12
  • Monitor and report signs and symptoms of complications such as dehydration and gastric leak (persistent abdominal pain, nausea, vomiting)
• Care of a T-Tube:

  • Place the client in semi-Fowler’s position to facilitate drainage
  • Monitor the output amount and the color, consistency, and odor of the drainage
  • Report sudden increases in bile output to the primary health care provider (PHCP)
  • Monitor for inflammation and protect the skin from irritation
  • Keep the drainage system below the level of the gallbladder
  • Monitor for foul odor and purulent drainage and report its presence to the PHCP
  • Avoid irrigation, aspiration, or clamping of the T-tube without a PHCP’s prescription
• • As prescribed, clamp the tube before a meal, and observe for abdominal discomfort and distention, nausea, chills, or fever; unclamp the tube if nausea or vomiting occurs
• Monitor intake and output and electrolyte balance
• Weigh client and measure abdominal girth daily
• Monitor level of consciousness; assess for pre-coma state (tremors, delirium)
• Monitor for asterixis, a coarse tremor characterized by rapid, nonrhythmic extensions and flexions in the wrist and fingers
• Fluid and Electrolyte Disturbances:

  • Ascites
  • Decreased effective blood volume
  • Hypokalemia
  • Peripheral edema
  • Water retention
  • Hypocalcemia
  • Dilutional hyponatremia or hypernatremia
• Gastrointestinal (GI) Findings:

  • Abdominal pain
  • Anorexia
  • Clay-colored stools
  • Diarrhea
  • Esophageal varices
  • Hiatal hernia
  • Hypersplenism
  • Malnutrition
  • Nausea
  • Small nodular liver
  • Vomiting
  • Fetor hepaticus
  • Gallstones
  • Gastritis
  • Gastrointestinal bleeding
  • Hemorrhoidal varices
  • Hepatomegaly
• Hematological Findings:

  • Anemia
  • Disseminated intravascular coagulation
  • Impaired coagulation
  • Splenomegaly
  • Thrombocytopenia
  • Asterixis
  • Paresthesias of feet
  • Peripheral nerve degeneration
  • Portal-systemic encephalopathy
  • Reversal of sleep-wake pattern
  • Sensory disturbances
• Neurological Findings:

  • Axillary and pubic hair changes
  • Caput medusae (dilated abdominal veins)
  • Ecchymosis; petechiae
  • Increased skin pigmentation
  • Jaundice
  • Palmar erythema
  • Pruritus
  • Spider angiomas (chest and thorax)
• Monitor for fetor hepaticus, the fruity, musty breath odor of severe chronic liver disease
• Maintain gastric intubation to assess bleeding or esophagogastric balloon tamponade to control bleeding varices as prescribed
• Administer blood products as prescribed
• Monitor coagulation laboratory results; administer vitamin K if prescribed
• Administer antacids as prescribed
• Administer lactulose as prescribed, which decreases the pH of the bowel, decreases production of ammonia by bacteria in the bowel, and facilitates the excretion of ammonia
• Administer antibiotics as prescribed to inhibit protein synthesis in bacteria and decrease the production of ammonia