GASTRITIS

§ Inflammation of the gastric or stomach mucosa
§ Gastritis may be:
ú Acute
lasting several hours to a few days
ú Chronic
resulting from repeated exposure to irritating agents or recurring episodes of acute gastritis

Causes of Gastritis
Acute Gastritis
o Dietary indiscretion
o Overuse of aspirin and NSAID
o Excessive alcohol intake
o Bile reflux
o Radiation therapy
o Ingestion of strong acid or alkali

Chronic Gastritis
o Benign or malignant ulcers of the stomach
o Helicobacter pylori
o Autoimmune diseases (Pernicious Anemia)
o Use of medications, especially NSAID
o Alcohol
o Smoking
o Reflux of intestinal contents into the stomach.

Signs and Symptoms

Acute Gastritis
Ø Abdominal discomfort
Ø Headache
Ø Lassitude
Ø Anorexia
Ø Nausea and vomiting

Chronic Gastritis
Ø Anorexia
Ø Heartburn after eating
Ø Belching
Ø Sour taste in the mouth
Ø Nausea and vomiting
Ø Mild epigastric discomfort
Ø Intolerance to spicy or fatty foods
Ø Slight pain that is relieved by eating

Assessment and Diagnostic Findings

§ Gastritis is sometimes associated with:
ú Achlorhydria (absence of HCl)
ú Hypochlorhydria (low levels HCl)
ú Hyperchlorhydria (high levels of HCl)

Diagnosis can be determined by:
ú Endoscopy
ú Upper GI radiographic studies
ú Histologic examination of a tissue specimen obtained by biopsy
ú Determine the presence of H. Pylori by serologic testing for antibodies against the H. pylori antigen
ú H. Pylori test (Urea-Breath test)

Medical Management

§ Antibiotic
ú Amoxicillin
ú Action
a bactericidal antibiotic that assist with eradicating H. Pylori bacteria in the gastric mucosa.
ú Side effects
vaginal itching or discharges
headache
swollen tongue
oral thrush (white patches inside the mouth or throat)
nausea, vomiting, stomach pain
ú Nursing Consideration
May cause diarrhea
Should no be used in patient allergic to penicillin

§ Antidiarrheal
ú Bismuth subsalicylate
ú Action
Suppress H. Pylori bacteria in the gastric mucosa and assist with healing of mucosal ulcer
ú Side effect
Stools may appear gray-black in color
ú Nursing consideration
Given concurrently with antibiotic to eradicate H. pylori infection
Should be taken on empty stomach

§ Histamine2 Receptor Antagonist
ú Cimetidine
ú Action
Decreases amount of HCl produced by stomach by blocking the action of histamine on histamine receptors of parietal cells in stomach
ú Side effect
Long term use may cause diarrhea
Dizziness
Gynecomastia
ú Nursing Consideration
May cause confusion
Agitation
Coma in the elderly for those with renal or hepatic insufficiency

§ Proton pump inhibitor
ú Omeprazole
ú Action
Decreases gastric acid secretion by allowing hydrogen potassium adenosine triphospate pump on the surface of the parietal cells in the stomach
ú Side effects
Headache
Diarrhea or constipation
Flatulence
Nausea and vomiting
Dry mouth
ú Nursing consideration
Taken before meal

§ Prostaglandin E1 Analog
ú Sucralfate
ú Action
Create a viscous substance in the presence of gastric acid that form a protective barrier, binding to the surface of the ulcer, and prevents digestion by pepsin
ú Side effects
Constipation
Flatulence
Headache
Hypophosphatemia
Dry mouth
ú Nursing consideration
Should be taken without food but with water
Other medication should be taken hours before or after his medication
May cause constipation and nausea

Nursing Management

I. Assessment
• History taking
• Signs and symptoms
allergies
• Medication taken
• Past medical history
• Last oral intake
• Events leading to illness
• Signs to note during physical examination
• Abdominal tenderness
• Dehydration
• Evidence of any systemic disorder that might be responsible for the symptoms of gastritis

II. Nursing Diagnosis
• Anxiety related to treatment
• Imbalanced nutrition, less than body requirements, related to inadequate intake of nutrients
• Risk for imbalanced fluid volume related to insufficient fluid intake and excessive fluid loss subsequent to vomiting
• Deficient knowledge about dietary management and disease process
• Acute pain related to irritated stomach

III. Planning and Goals
§ The major goals for the patient include:
§ Reduce anxiety
§ Avoidance of irritating food
§ Adequate intake of nutrients
§ Maintenance of fluid balnce
§ Increase awareness of dietary management
§ Relief of pain

IV. Nursing Interventions
• Reducing anxiety
• Important to explain all procedures and treatment base on the patients level understanding
• Promoting optimal nutrition
• Help the patient manage the symptoms including nausea, vomiting heartburn and fatigue
• The patient should take no foods or fluids by mouth until the acute symptoms subside allowing the gastric mucosa to heal
• If IV therapy is necessary, the nurse monitors intake and output along with serum electrolyte values
• If IV therapy is necessary, the monitors intake and output along with serum electrolyte values
• Offer ice chips until symptoms subside followed by clear
• As food is introduced, the nurse evaluates and reports and symptoms that suggest a repeated episode of gastritis
• Discourage intake of alcohol and caffeinated beverages to because its is as CNS stimulant that increases gastric activity and pepsin secretion
• Discourage cigarette smoking because nicotine reduces the secretion of pancreatic bicarbonate, which inhibits the neutralization of gastric acid in the duodenum.
• Promoting fluid balance
• Detect early signs of DHN (minimal urine output of 30 ml/hr or minimal intake of 1.5 L/day
• If NPO, IVF are prescribed
• Assess electrolyte values q24H (Na, K, Cl)
• Alert indicators of hemorrhagic gastritis (hematemesis, tachycardia and hypotension) if this occurs notify physician immediately.
• Relieving
• Instruct the patient to avoid foods and beverages that may be irritating to the gastric mucosa
• Instruct the patient about the correct use of medication to relieve chronic gastritis
• Promoting home and community based
• Self care teaching
• Stress management
• Diet
• Medication
• Continuing care
• Ongoing assessment on patient symptoms
• Lifelong Vit. B12 injection
• Emphasized the importance of follow up appointments

V. Evaluation
• Exhibit low level of anxiety
• Avoid eating irritating food or drinking caffeine beverages or alcohol
• Maintain fluid balance
ü Oral fluid intake of at least 1.5 L a day
ü Drink 6-8 glasses of water daily
ü Has a urinary output of approximately 1L daily
ü Display adequate skin turgor
• Adhere to medical regimen
ü Select non-irritating foods and beverages
ü Take medication as prescribed
• Maintain appropriate weight
• Report less pain

Nurse Patient Interaction

1.) Name of patient: Marie Ann Orzame

N: Hello po nay good morning po, Orzame po ba ang apelyido niyo?

P: Oo

N: Ah, ako po si Analyn Mendoza , nursing student po ng Wesleyan, ako po yung magiging nurse nyo mula ngayong umaga hanggang mamayang alas tres po... Ano po yung pangalan nyo?

P: Marie Ann Orzame

N: Taga saan po ba kayo?

P: Sa Guimba.

N: Ang layo naman po bakit ditto kayo naadmit?

P: Eh ditto kasi ako nirefer ng doktora ko eh.

N: Ganun po ba? Anu po ba ang nangyari sa inyo? Bakit po kayo naadmit?

P: Eh kasi my deal na kami ni Doktora dahil malaki na yung bata, mahihirapan daw ako magnormal, 28,000 daw ung caesarean  ditto.

N: Ah eh nasan na po yung baby niyo?

P: Nasa taas eh.

N: Sa pedia po? Pang ilang anak niyo nap o bay un?

P: Pangatlo na.

N: Pangatlong pagbubuntis nyo din po yun?

P: Oo, nahihirapan na nga ako kasi ang babata pa nung mga kapatid niya, isang 8 years old tsaka 5 years old. Nagpaligate na nga ako para hindi na masundan eh.

N: Mainam po niyo yung kakayahan niyo para matutukan niyo yung paglaki ng mga anak ninyo.

P: Oo nga eh, di ko na kaya ng madami ang hirap manganak, nahirapan talaga ako ditto sa pjg.

N: Ay bakit po?

P: Kasi akala ko pagdating ko ditto bibiyakin na yung tyan ko dahil may deal na nga kami ni doktora, dahil hirap na hirap na rin ko, hindi pala ganun, pagdating ko ditto pinaglabor pa din nila ako. Nakikiusap na nga ako sa doctor na ics na ko dahil di ko na kaya, magbabayad naman ako, ayaw pa din nila biyakin yung tyan ko. Tapos nalaman naming nakatae na yung bata sa tyan ko, tsaka pa lang nila biniyak.

N: Ganun po ba? Kamusta naman na po yung baby nyo ngayon?

P: Medyo ok naman na sya kaso naiinis talaga ko dahil nadoble pa ako ng gastos ditto dahil dun sa nangyari sa bata, dapat kasi biniyak na nila yung tyan ko bago pa dumumi yung bata.

N: Hindi din po siguro inexpect ng doctor na ganun, di bale po ang mahalaga eh ok po kayo ng anak ninyo.

P: Oo nga eh makakauwi na rin kami bukas.

N: Mabuti naman po, nay pag may kailangan po kayo tawagin niyo lang po ako ha, magpahinga na po muna kayo.

P: Sige, salamat.

2.) Name of patient: Margie Leal

N: Good morning po, kayo po ba si Margie Leal?

P:Ay, oo.

N: Ako po si Analyn Mendoza, ako po yung nurse ninyo ngayong araw. Nay kukuhanan ko lang po kayo ng vital signs.

P: Ano bay un?

N: Eto po yung BP o yung presyon o grado, yung pulso po tsaka yung temperature ninyo para malaman po natin kung ayos po ang katawan ninyo.

P: Sige nga at baka high blood na ko.

N: Taga saan po ba kayo nay?

P: Sa San Jose pa.

N: Ang layo naman po nay?

P: Oo nga eh, hindi naman talaga ko pumunta ditto sa Cabanatuan para magpaospital, dinalaw ko lang yung kapatid ko dyan sa may Aduas, ok pa yung pakiramdam ko nun.

N: Tapos ano po ang nagyari?

P: Biglang humilab yung tyan ko tapos ang daming lumabas na dugo, ayon sinugod na ako ditto.

N: Buti po nagkataon na andito kayo sa Cabanatuan?

P: Oo nga eh, hindi naman kasi talaga ako sanay na nanganganak sa ospital lahat ng anak ko sa bahay lang ipinanganak nakakaya ko naman.

N: Ay ganun po ba, ilang po ba lahat ng anak niyo?

P: Lima na, 19 ung panganay, yung sumunod eh 18 tapos 16, 15 tapos 12 na yung bunso ko, puro babae lahat, hindi ko nga inaasahang mabubuntis pa ko e.

N: Hindi po kayo nahirapan sa bahay niyo ipinanganak lahat?

P: Hindi, sanay na ko eh,tsaka hilot kasi yung kapitbahay naming kaya makakarating agad, di nga ako nagpapacheck up.

N: Naku nay mahalaga po ung pre natal check up, para po malaman yung kalagayan ninyo tsaka nung anak niyo.

P: Yun nga pinagsisisihan ko eh siguro kung nagpapacheck up ako hindi mamamatay yung bata, pero tanggap ko naman nay un ang gustong mngayari ng Diyos eh. Mabubuntis pa kaya ako mag foforty na ko eh?

N: Delikado nap o kasing magbuntis yung ganyag edad hanggat maari po eh huwag na dahil baka po magkaroon kayo ng malalang komplikasyon.

P: Ganun ba, sayang talaga yung bata.

N: Ang mahalaga ho eh ligtas kayo.

P: Sabi nga din ng aswa ko hayaan na lang, ayan na pala yung asawa ko eh.

N: Sige po maiwan ko nap o muna kayo, ayos naman po nay yung presyon niyo wala po ba kayong nararamdaman?

P: Wala naman, Sige salamat.

N: Opo salamat din po pag may kailnagn po kayo pakitawag na lang po ako.

P: Oo sige.

3.) Name of Patient: Rose Enriquez

N: Good morning po, kayo po ba si Rose Enriquez?

P: Oo, Ako nga.

N: Ako po si Analyn Mendoza ako po yung magiging nurse ninyo ngayon. Ilang taon na po kayo?

P: 38 na.

N: tag ditto po ba kayo sa Cabanatuan?

P: Hindi, taga Malate ako, sa Palayan.

N: Ah, bakit po ba kayo naadmit ditto?

P: Eh niraspa nga ako.

N: Kailan pa po ba kayo ditto?

P: Kahapon lang, gusto ko na ngang umuwi eh pwede na kaya akong umuwi?

N: Depende pos a kalagayan niyo na nakikita ng doctor, raspa lang naman po yun makakauwi din po kayo kaagad siguro.

P: Buti naman ala kasing nag-aalaga sa mga anak ko eh.

N: Ala naman po ba kayong nararamdaman?

P: Medyo masakit lang yung ulo ko.

N: Medyo mataas po kasi yung bp ninyo. Maliban pos a sakit ng ulo ala nap o kayong nararamdaman?

P: Wala na.

N: Sige po magpahinga na ang po muna kayo, mag-unan po kayo para makahiga kayo ng mas mataas yung ulo ninyo kaysa sa katawan para medyo bumaba yung bp ninyo.

P: Sige salamat.

N: Pag may kailangan po kayo pakitawag na lang po ako.

4.) Name of Patient: Dorezen Cruz

N: Good morning po, kayo po ba si Dorezen Cruz?

P: Oo, Ako nga.

N: Ako po si Analyn Mendoza ako po yung magiging nurse ninyo ngayon. Ilang taon na po kayo?

P: 27.

N: Taga saan po ba kayo?

P: Taga Obrero ako eh.

N: Kailan pa po ba kayo ditto?

P: Kagabi lang ako sinugod ng asawa ko ditto eh.

N: Ganun po baa nu po ba nangyari sa inyo?

P: Eh dinugo kasi ako akala ko nga makukunan na ako.

N: Ilang buwan na po ba yung dinadala niyo ?

P: 5 buwan na.

N: Pang ilang anak niyo po nap o bay an?

P: Una pa lang.

N: Unang beses niyo din pong nagbuntis?

P: Oo, natatakot nga ako baka duguin nanaman ako.

N: Mag ingat na lang po kayo, hanggat maari magpahinga na lang po kayo sa higaan, wag po kayong magpapagod.

P: Oo, doble ingat na nga din ako eh.

N: Anu po ba naramdaman niyo nung bago kayo isugod ditto?

P: Napakasakit ng balakang at tyan ko, hindi ko maintindihan tapos may dugo na, takot na takot nga yung asawa ko.

N: Eh ngaon po ayos na ang pakiramdaman niyo?

P: Oo, hindi na ko nahihirapan huminga.

N: Kailan po ba yung huling pagbibigay sa inyo ng oxygen?

P: Kaninang tanghali lang, o hapon ata, basta mga 1pm siguro.

N: Mag ooxygen po kayo ulit maya maya nay mga alas singko po.

P: Pwede bang hindi na?

N: Bakit po?

P: Okay naman na yung pakiramdam ko eh?

N: Sigurado po kayo?

P: Oo wag na siguro.

N: Kasi kung ayaw niyo nap o papapirmahin kop o kayo ng consent na katunayang ayaw niyo na pong mag-oxygen, ayaw niyo napo ba hanggat andito kayo o ngayong oras lang po na ito?

P: Mmm. Ngayun lang.

N: Eh mamayang gabi na lang po kami maglalagay ng oxygen sa inyo?

P: Oo, sige mamayang gabi na lang.

N: Sige po, pag may naramdaman kayo sabihin niyo na lang pos akin hano po?

P: Sige salamat.

N: Sige po.

Diagnostic Tests fo Gastro Intestinal Function

DIAGNOSTIC TESTS

I. LABORATORY TESTS

Laboratory tests for GI disorders include stool testing for blood (Hemoccult), other stool tests, and a variety of blood tests, such as hematocrit and hemoglobin for monitoring GI bleeding.

A. Hemoccult Guaiac Tests (Hemoccult)

Commercially available guaiac-impregnated slides or wipes present a simple, inexpensive, and aesthetically acceptable method of testing feces for blood.

Nursing and Patient Care Considerations
Advise patient as to the test preparation procedure. For 3 days before the test and during the stool collection period:
• Diet should have a high-fiber content.
• Avoid red meat in the diet.
• Avoid foods with a high peroxidase content, such as turnips, cauliflower, broccoli, horseradish, and melon.
• Avoid iron preparations, iodides, bromides, aspirin, NSAIDs, or vitamin C supplements greater than 250 mg/day.
• Avoid enemas or laxatives before the stool specimen collection.
NURSING ALERT
Certain protocols may specify to avoid aspirin and NSAIDs for at least 1 week before Hemoccult testing to prevent bleeding. Vitamin C (ascorbic acid) can cause a false-negative reading.
Procedure
• A wooden applicator is used to apply a stool specimen to the slide, or a special wipe is used and placed in the packet. Three stool samples are taken because of the possibility of intermittent bleeding and false-negative results.
• Slides (or wipes) applied inside a packet can be brought or mailed to the health care provider or laboratory.
• When hydrogen peroxide (denatured alcohol-stabilizing mixture) is added to samples, any blood cells present liberate their hemoglobin, and a bluish ring appears on the electrophoretic paper. Read precisely at 30 seconds.
• A single positive test is an indication for further diagnostic evaluation for GI lesions. False-positive results occur in about 10% of tests. Test may become false-negative in 10% of specimens tested 4 or more days after streaking on paper.
Community and Home Care Considerations
• Nonadherence to the diet/medication restrictions can cause false-positive or false-negative readings.
• The stool must not be contaminated with urine or toilet tissue.
• The stool guaiac specimen packets do not require refrigeration.
• Stool specimen packets should be submitted for laboratory testing within 6 days.

B. Stool Specimen

The stool is examined for its amount, consistency, and color. Normal color varies from light to dark brown, but various foods and medications may affect stool color. Special tests may be made for fecal urobilinogen, fat nitrogen, food residue, and other substances. Fecal leukocytes are tested by Wright’s stain, and stool cultures are obtained to identify bacteria, virus, or ova and parasites.
 Nursing and Patient Care Considerations
• Use a tongue blade to place a small amount of stool in a disposable waxed container.
• Save a sample of fecal material if unusual in appearance, contains worms or blood, blood streaked, unusual color, or excess mucus; show to health care provider.
• Specimens for parasitology must be collected in vials containing special preservatives. For accurate specimen results, the vials must be sent to the laboratory as soon as possible. The vials should be refrigerated if unable to submit quickly to the laboratory.
• Send specimens to be examined for parasites to the laboratory immediately so the parasites may be observed under microscope while viable, fresh, and warm.
• Test for occult blood or to confirm grossly visible melena or blood—Hemoccult guaiac test.
• Consider that barium, bismuth, mineral oil, and antibiotics may alter the results.

C. Hydrogen Breath Test
• The hydrogen breath test is used to evaluate carbohydrate absorption.
• A radioactive substance is ingested, and, after a certain time period, exhaled gases are measured.
• The test measures the amount of hydrogen produced in the colon, absorbed in the blood, and then exhaled in the breath.
• This test is used as a diagnostic test for short bowel syndrome, lactose intolerance, and bacterial overgrowth of the intestine (blind loop syndrome, Crohn’s disease, distal ileal disease).
Nursing and Patient Care Considerations
• The patient should be nothing-by-mouth (NPO) for 12 hours before the procedure.
• The patient should not smoke after midnight before the test.
• Antibiotics and laxative/enemas should not be used for 1 week before the test. These products may alter the laboratory results.
• Appropriate diet instructions should be given before discharge if the test is positive.

D. Helicobacter pylori Testing
• Laboratory tests for H. pylori include a serum immunoglobulin G antibody test and an H. pylori breath test.
• A positive antibody test may not differentiate between active and inactive disease.
• A negative test can be interpreted to mean no antibodies or antibodies present at a lower level than detectable.
Nursing and Patient Care Considerations
• Symptomatic patients and patients with an active or past history of ulcer disease should be tested for H. pylori. Endoscopy may be necessary for patients with symptoms of weight loss, anemia, occult blood loss, and patients older than age 50.
• It is recommended that negative H. pylori test results in a patient with ulcer-related complications be confirmed by a second test.
• Contact laboratory for the type of serologic test being performed for H. pylori and the appropriate tube for blood.
• Due to the potential for false-negative H. pylori breath test, preparation includes stopping treatment 2 weeks before testing.
• False-positive results from H. pylori breath testing may be caused by achlorhydria or urease production associated with other GI disorders.

II. RADIOLOGY AND IMAGING STUDIES

A. Upper GI Series and Small-Bowel Series
• Upper GI series and small-bowel series are fluoroscopic X-ray examinations of the esophagus, stomach, and small intestine after the patient ingests barium sulfate.
• As the barium passes through the GI tract, fluoroscopy outlines the GI mucosa and organs.
• Spot films record significant findings.
• Double-contrast studies administer barium first followed by a radiolucent substance, such as air, to produce a thin layer of barium to coat the mucosa. This allows for better visualization of any type of lesion.
Nursing and Patient Care Considerations
• Explain procedure to patient.
• Instruct patient to maintain low-residue diet for 2 to 3 days before test and a clear liquid dinner the night before the procedure.
• Emphasize nothing by mouth after midnight before the test.
• Encourage patient to avoid smoking before the test.
• Explain that the health care provider may prescribe all opioids and anticholinergics to be withheld 24 hours before the test because they interfere with small intestine motility. Other medications may be taken with sips of water, if ordered.
• Tell the patient that he will be instructed at various times throughout the procedure to drink the barium (480 to 600 mL).
• Explain that a cathartic will be prescribed after the procedure to facilitate expulsion of barium.
• Instruct the patient that stool will be light in color for the next 2 to 3 days from the barium.
• Instruct patient to notify health care provider if he has not passed the barium in 2 to 3 days because retention of the barium may cause obstruction or fecal impaction.
• Note that water-soluble iodinated contrast agent (such as Gastrografin) may be used for a patient with a suspected perforation or colonic obstruction. Barium is toxic to the body if it leaks into the peritoneum with perforation. It can also worsen an obstruction, thus is not used if an obstruction is suspected.

B. Barium Enema
• Fluoroscopic X-ray examination visualizing the entire large intestine is administered after the patient is given an enema of barium sulfate.
• Can visualize structural changes, such as tumors, polyps, diverticula, fistulas, obstructions, and ulcerative colitis.
• Air may be introduced after the barium to provide a double-contrast study.
Nursing and Patient Care Considerations
• Explain to the patient:
o What the X-ray procedure involves.
o That proper preparation provides a more accurate view of the tract and that preparations may vary.
o That it is important to retain the barium so all surfaces of the tract are coated with opaque solution.
• Instruct the patient on the objective of having the large intestine as clear of fecal material as possible:
o The patient may be given a low-fiber, low-fat diet 1 to 3 days before the examination.
o The day before examination, intake may be limited to clear liquids (no drinks with red dye).
o The day before the examination, a oral laxative, suppository, and/or cleansing enema may be prescribed.
• The patient will be NPO after midnight the day of procedure.
• An enema or cathartic may be ordered after the barium enema to cleanse bowel of barium and prevent impaction.
• Inform the patient that barium may cause light-colored stools for several days after the procedure.
NURSING ALERT
If barium enema and upper GI series are both ordered, the upper GI series is done last so barium traveling down the digestive tract does not interfere with the results of the barium enema.

C. Ultrasonography (Ultrasound)
• A noninvasive test focuses high-frequency sound waves over an abdominal organ to obtain an image of the structure.
• Ultrasound can detect small abdominal masses, fluid-filled cysts, gallstones, dilated bile ducts, ascites, and vascular abnormalities.
• Ultrasound with Doppler may be ordered for vascular assessment.
Nursing and Patient Care Considerations
• If indicated, prepare the patient before the procedure with a special diet, laxative, or other medication to cleanse the bowel and decrease gas.
• Abdominal ultrasound usually requires the patient to be NPO for at least 6 hours before the procedure.
• Change position of patient, as indicated, for better visualization of certain organs.

D. Computed Tomography Scan
• This is an X-ray technique that provides excellent anatomic definition and is used to detect tumors, cysts, and abscesses.
• The computed tomography (CT) scan can also detect dilated bile ducts, pancreatic inflammation, and some gallstones.
• It identifies changes in intestinal wall thickness and mesenteric abnormalities.
• Ultrasound and CT can be used to perform guided needle aspiration of fluid or cells from lesions anywhere in the abdomen. The fluid or cells are then sent for laboratory tests (such as cytology or culture).
• A newer technique of focused appendiceal CT can be used to diagnose appendicitis.
o Rectal contrast media is given so the colon is opacified quickly without waiting for oral contrast to reach the appendix.
o The right lower quadrant is focused on to visualize the appendix, so the procedure is quick.
Nursing and Patient Care Considerations
• Instruct the patient that fasting for 4 hours before the procedure and an enema or cathartic may be necessary. This is to clean the bowel for better visualization.
• Ask the patient if she is pregnant. If yes, do not proceed with scan and notify health care provider.
• Ask if there are known allergies to iodine or contrast media. A contrast medium may be given I.V. to provide better visualization of body parts. If allergic, notify the technician and health care provider immediately.
• Instruct the patient to report symptoms of itching or shortness of breath if receiving contrast media, and observe patient closely.

CREDITS TO MR. RELIE CASTRO

Assessment of Digestive and Gastrointestinal Function

GI

Assessment of Digestive and Gastrointestinal Function

Health History and Clinical Manifestations
• The nurse begins by taking a complete history, focusing on symptoms common to GI dysfunction.
• These symptoms include:
– Pain
– Indigestion
– Intestinal gas
– Nausea and Vomiting
– Changes in bowel habits and stool characteristics.

Pain
• Pain can be a major symptom of GI disease. The character, duration, pattern, frequency, location, distribution of referred pain, and time of the pain vary greatly depending on the underlying cause. Other factors, such as meals, rest, defecation, and vascular disorders, may directly affect this pain.

Assessing Pain
• Characteristics
– Can you describe the pain (sharp, dull, superficial, or deep)?
– Is the pain intermittent or continuous?
– Was the onset sudden or gradual?
– Can you point to where the pain is located?
– What makes the pain better, worse?
• Associated factors
– Are there other symptoms associated with the pain fever, nausea, vomiting, diarrhea, constipation, anorexia, weight loss, dyspepsia?
• History
– Any family history of GI cancer, ulcer disease, inflammatory bowel disease?
– Any previous history of tumors, malignancy, or ulcers?

Indigestion
• Upper abdominal discomfort or distress associated with eating.
• The basis for this abdominal distress may be the patient’s own gastric peristaltic movements.
• Indigestion can result from disturbed nervous system control of the stomach or from a disorder in the GI tract or elsewhere in the body.

Intestinal Gas
• The accumulation of gas in the GI tract may result in belching or flatulence.
• It is through belching that swallowed air is expelled quickly when it reaches the stomach.
• Usually, gases in the small intestine pass into the colon and are released as flatus.

Assessing Indigestion and Intestinal Gas
• Characteristics
– Have you experienced any of the following symptoms:
• feeling of fullness
• heartburn
• excessive belching
• flatus
• nausea
• a bad taste
• mild or severe pain

• Associated factors
– Is there nausea, vomiting, blood in bowel movements, or diarrhea?
– Is there a history of alcohol, nonsteroidal anti-inflammatory drug (NSAID), or aspirin use?
– History
– Any family history of cancer, inflammatory bowel disease?
– Any history of bowel obstruction?
– Any previous abdominal surgeries?

Nausea and Vomiting
• Vomiting is another major symptom of GI disease.
• Vomiting is usually preceded by nausea, which can be triggered by odors, activity, or food intake.
• The emesis, or vomitus, may vary in color and content. It may contain undigested food particles or blood (hematemesis).

Nature of Vomitus
1. Yellowish or greenish – May contain bile
2. Bright red (arterial) – Hemorrhage, peptic ulcer
3. Dark red (venous) – Hemorrhage, esophageal or gastric varices
4. Coffee grounds – Digested blood from slowly bleeding gastric or duodenal ulcer
5. Undigested food – Gastric tumor, Ulcer, Obstruction
6. Bitter taste – Bile
7. Sour or acid – Gastric contents
8. Fecal components – Intestinal obstruction

Change in Bowel Habits and Stool Characteristics
• Changes in bowel habits may signal colon disease.

Diarrhea
– An abnormal increase in the frequency and liquidity of the stool or in daily stool weight or volume.
– Commonly occurs when the contents move so rapidly through the intestine and colon that there is inadequate time for the GI secretions to be absorbed.

Assessing Diarrhea
• Characteristics
– How long has the diarrhea been present?
– Determine the frequency, consistency, color, quantity, and odor of stools.
– Is there blood, mucus, pus, or food particles in the stools?
• Associated factors
– Any fever, nausea, vomiting, abdominal pain, abdominal distention, flatus, cramping, urgency with straining?
– Is the patient taking antibiotics?
– Has there been any recent travel to foreign countries?
– Is the patient experiencing emotional stress or anxiety?

Causes of Diarrhea
– Infectious agents (Escherichia coli, Salmonella, Shigella, Campylobacter)
– Food poisoning
– Drugs (antibiotics, magnesium)
– Fecal impaction
– Bowel disease (ulcerative colitis)
– Malabsorption syndromes (lactose intolerance, celiac sprue, fat malabsorption)
– Short bowel syndrome
– Malignant syndromes (Zollinger-Ellison syndrome)

Constipation
– A decrease in the frequency of stool, or stools that are hard, dry, and of smaller volume than normal.
– May be associated with anal discomfort and rectal bleeding.

Assessing Constipation
• Characteristics
– What is the frequency, consistency, color of the stools?
– Have there been dietary changes?
– Is there blood or mucus in the stools?
– Any laxative use?

• Associated factors
– Are there periods of diarrhea?
– Is there abdominal pain or distention?
– Is the patient experiencing stress?
– Is there a change in activity level?
– Does the patient have a regular time for defecation?
– Does the patient use antacids containing calcium or an anticholinergic?
• Causes of Constipation
– Inadequate fluid intake
– Psychological factors
– Electrolyte imbalances
– Hormonal abnormalities
– Mechanical bowel obstruction, ileus
– Drugs (laxative abuse, anticholinergic agents, opiates)
– Loss of innervation (Hirschsprung’s disease)
– Neuromuscular (paralysis, spinal cord injury or sacral lesion, multiple sclerosis)
– Anorectal disorders (hemorrhoids, fecal impaction, cancer, abscess, fissures)

Characteristics of Stool
• The appearance of blood in stool may be characteristic of its source.
– Upper GI bleeding, tarry black (melena)
– Lower GI bleeding, bright red blood (hematochezia)
– Lower rectal or anal bleeding blood streaking on surface of stool or on toilet paper
• Other characteristics of stool may indicate a particular GI problem.
– Bulky, greasy, foamy, foul smelling, gray with silvery sheen steatorrhea (fatty stool)
– Light gray clay-colored (due to absence of bile pigments, acholic) biliary obstruction
– Mucus or pus visible (chronic ulcerative colitis, shigellosis)
– Small, dry, rocky-hard masses (constipation, obstruction)

Physical Assessment
• The physical examination includes assessment of the mouth, abdomen, and rectum.
• The mouth, tongue, buccal mucosa, teeth, and gums are inspected
• Ulcers, nodules, swelling, discoloration, and inflammation are noted.

Assessment of the Abdomen
• The patient lies supine with knees flexed slightly for inspection, auscultation, palpation, and percussion of the abdomen.

Inspection
– The nurse performs inspection first
– noting skin changes and scars from previous surgery.
– It also is important to note the contour and symmetry of the abdomen, to identify any localized bulging, distention, or peristaltic waves.

Auscultation
• The nurse performs auscultation before percussion and palpation (which can increase intestinal motility and thereby change bowel sounds) and notes the bowel sounds:
– character
– location
– frequency

• The nurse assesses bowel sounds in all four quadrants using the diaphragm of the stethoscope; the high-pitched and gurgling sounds can be heard best in this manner.
• It is important to document the frequency of the sounds, using the terms:
– Normal
• sounds heard about every 5 to 20 seconds
– Hypoactive
• one or two sounds in 2 minutes
– Hyperactive
• 5 to 6 sounds heard in less than 30 seconds
– Absent
• no sounds in 3 to 5 minutes

Percussion
– The nurse notes tympany or dullness during percussion.

Palpation
– Use of light palpation is appropriate for identifying areas of tenderness or swelling;
– The nurse may use deep palpation to identify masses in any of the four quadrants.
– If the patient identifies any area of discomfort, the nurse can assess for rebound tenderness.
• To elicit rebound tenderness, the nurse exerts pressure over the area and then releases it quickly.
• It is important to note any pain experienced on withdrawal of the pressure.

CREDITS TO MR. RELIE CASTRO