Nursing Interventions/Tx GI

Oral Cancer
1.Airway management
2•Cough Enhancement
3•Aspiration Precautions
Medical:
1. Oral examination for lesions &Palpation of cervical nodes
2•Biopsy of oral lesions which do not heal in two weeks
3•Surgical resection
4•Radiation Therapy
5•Chemotherapy
6•Combination of above 3

GERD Diagnosis (3)
-Rule out cardiac pain
-Diagnosis demonstrated reflux
1. 24-hour ambulatory pH monitoring (most accurate method of dx) (small catheter placed into distal esophagus that continuously monitors and records pH while client keeps a diary of activities and symptoms
2. Endoscopy/esophagogastroduodenoscopy (EGD) (requires conscious sedation)
3. Esophageal manometry: water filled catheter inserted through nose or mouth and slowly withdrawn while LES pressure and peristalsis measurements are recorded
-Labs

GERD Teaching (9)
1•Avoid foods & medication that reduce LES tone
2•Avoid eating within 3 hours of bedtime or lie flat after eating
3•Avoid restrictive clothing
4•Avoid large meals
5•Elevate HOB 6-12 inches for sleeping
6•Smoking cessation
7•Caffeine in moderation
8•Consult with dietician for weight loss
9•Avoid heavy lifting & straining or working bent-over

GERD Surgery tx

done if medical doesn’t work

1. Laparoscopic NissenFundoplication- done by laproscopy-A portion of the gastric fundus is wrapped around the sphincter area of the esophagus.
2. Nissen Fundoplication
3. Hill Repair
4. Belsy Repair (Mark IV)
5. Angelchic Prosthesis

Hiatal Hernia tx
1.Lifestyle Modification
Weight loss, small frequent meal, Avoid eating 2-3 hours before bedtime or lying down after meals, Avoid straining and vigorous exercise, Smoking cessation, Elevate HOB
2. Medications: Antacids, Histamine H 2-receptor antagonist, & Proton Pump Inhibitors

Hiatal Hernia surgery

done if severe, non-responsive, & if ulceration/necrosis is suspected

Surgery similar to that done for GERD-
-NissenFundoplication most common: fundus of stomach is brought up and wrapped around esophagus; stitched into place providing a one-way valve to control reflux; may be done laparascopically
-Complications include hemorrhage, infection, dysphagia, obstruction, perforation, fistula, pulmonary embolus

Achalasia tx
Aimed at relief of symptoms
•Elevate HOB
•Pain relief-Antacids, H2 receptor antagonists, and Proton pump inhibitors
•Calcium channel blockers and nitrates reduce LES pressure
•Botox injections to esophagus -Inhibits contraction of smooth muscle (90% improve, but requires repeated dosing; long-term effects are unknown)

Achalasia dx
-Barium Swallow: visualizes the esophagus and will show dilation with a narrowing at the terminal esophagus (hallmark)
-CXR: shows a distorted and dilated tubular esophagus, the absence of a gastric bubble, and occasionally a tubular mediastinalmass next to the aorta.
-Endoscopy: to evaluate the appearance of esophageal mucosa
-Manometry: usually reveals increased LES pressure and incomplete sphincter relaxation when swallowing

Achalasia Surgery
1. Esophageal dilation of LES- Usually done on outpatient basis, Local anesthesia used, 75% success rate
2. Esophagomyotomy -enlarging the LE sphincter by incising the circular muscle fibers down to the mucosa

Esophageal Tumors dx
-Esophagogastroduodenoscopy (EGD) with biopsy
-Bronchoscopy to determine metastasis to trachea

Esophageal tumor tx
1.Nutrition consult due to malnourishment or risk for malnourishment.
2.Speech pathologist consult to assist with oral exercise for improved swallowing.
3.Radiation therapy is used for inoperable tumors to manage symptoms or to provide palliation of symptoms by shrinking tumor.
4.Chemotherapy either alone or in combination with radiation and/or surgery.

Esophageal tumor surgery
1-Esophagectomy-removal of all or part of the esophagus and replacement with a Dacron graft or a portion of colon or small intestine
2-Esophagogastrostomy-resection of a portion of the esophagus and anastomosis of remaining portion to stomach
3-Palliative gastrostomy done for purpose of feeding client

Zenker Diverticulum tx/dx
Diagnosis: Esophagogastroduodenoscopy (EGD)

•Collaborate with Dietician for best food options
•Semisoft meals, small, frequent meals
•Sleep with HOB elevated
•Avoid being supine for at least 2 hours after eating
•Avoid excessive exercise after meals
•Avoid tight clothing
•Limit stooping and bending
•Surgical removal of diverticulum
-NPO for several days to promote healing
-IV fluids and possible tube feedings
-NG tube placement

Gastritis Acute tx (7) & Chronic (4)
Directed toward identification of and removing the cause and treating the symptoms
1.NPO until N/V abate
2.Bland diet progressing to regular diet as tolerated
3.Administer medications as ordered
4.Antiemetic for n/v
5.Antacids, H2 receptor antagonists, Proton Pump Inhibitor for gastric pain
6.Anti-diarrheal if a problem with diarrhea
7.Replacement IV fluids if dehydration is a problem

Chronic same as acute but add
1.R/O Gastric Cancer
2•Vitamin B12
3•Treat H. pylori
4•Stress reduction techniques

PUD tx
Treatment similar regardless of location
1. Medications
-Antimicrobials: Clarithromycin(Biaxin), Metronidazole(Flagyl), Amoxicillin(Amoxil), Tetracycline(Sumycin)
-PPI or H2 blocker
-Antacids or Bismuth
-Coating agents
-Gastrointestinal Prostaglandin-misoprostol(Cytotec)
2. Dietary modification
-Small frequent meals
-Avoid irritants/foods that promote gastric secretion, such as caffeine, milk, coffee, alcohol
3.Lifestyle modification
-Smoking cessation
-Stress reduction
-Exercise

PUD Complication: Hemorrhage tx (11)
Goal: Stop acute bleeding & prevent re-bleeding
1.Maintain airway, breathing, & circulation.
2.Cool saline lavage via NG tube
3.Endoscopic therapy via EGD for:
4.Thermal contact using a heater probe or multielectrocoagulation
5.Injection of bleeding site with diluted epinephrine
6.Laser therapy
7.Clipping vessel with mechanical clip
8.Suppression of gastric acid (H2-receptor antagonists, PPI, antacids)
9. Replace volume/fluids to maintain vascular, cellular, and intracellular perfusion (NS, LR)
10•Promote rest-Bedrest with limited visitors
11•Monitor VS, UOP, & kidney function, and neurological status
-Foley/hourly urine
-BUN/Creatinine
-Frequent neuro checks

PUD Complications: Perforation tx (5)
1•Keep NPO
2•Fluid/electrolyte replacement
3•Antimicrobial
4•Nasogastric suction
5•Emergency Surgery
-Hemigastrectomy
-Pyloroplasty
-Peritoneal Cavity flushing with antimicrobial and Normal Saline

PUD complications: Obstruction tx ()
1•Nasogastric suctioning
2•IV maintenance of fluid & electrolyte balance
3•Surgical Treatment
-Gastric resection-removal of portion of stomach involved
-Vagotomy-cutting of Vagus nerve to eliminate PSN stimulation of gastric secretion
-Pyloroplasty-pylorus in incised and re-sutured to relax muscle and enlarge opening from stomach to duodenum to increase rate of gastric emptying

Stress Ulcer tx (5)
1.Prevention is best! Monitor patients at high risk & prophylactic measures
2. Remember its painless
3. Admin Meds: Antacids, H2 Blockers, PPI, Coating Agents
4-Hemorrhage care
•Gastric lavage
•Vasoconstrictive meds-Vasopressin(Pitressin) drip
•Electrocoagulation
•Vagotomy
•Gastrectomy

ZES tx
1.Therapy aimed @ suppression of acid secretion (PPI or/and H2 receptor antagonists)
2.Tumor Removal
3.Aggressive disease may be treated with chemotherapy

Gastric Cancer tx (4)
Treatment depends on stage of disease
1•Little effective medical treatment available
2•Primary treatment is surgical resection (usually palative)-Gastrectomy (Partial/Total), Vagotomy, Pyloroplasty
3•Combination of radiation and chemotherapy after surgery may be used
4•TPN for nutrition

Dumping Syndrome tx (6)
1.Decrease amount of food eaten at one time
2.Eat high protein, high fat, low carbohydrate, dry diet
3.Eat 5-6 small meals per day
4.Minimize roughage (Fiber)
5.Eat in semi-recumbent position or lie down after meals
6.Avoid fluids 1 hour before meals and for 2 hours after meals

IBS tx (5)
No specific test to diagnose
1.Diet modification
•Restrict foods which irritate condition
•Dairy
•Grains
•Sorbitol/Fructose/Lactose (1st 2 are irritants, 3rd can have intolerance)
2.Stress relief
3.Manage psychosocial impact
4.Monitor analgesic use
5. Meds
-Constipation dominate: Bulk forming laxatives (Metamucil-psyllium) at mealtime w/8 oz H20
-Diarrhea dominate: antidiarrheals (Lomotil-difenoxin/atropine, Imodium-loperamide)
-Pain dominate: Anticholinergics or antispasmodics (Bentyl-dicyclomine, Pro-Banthine-propantheline)
-Tricyclic Antidepresants
-Postprandial discomfort: take meds 30-45 minutes prior to eating

Abd Hernia tx
1.Strengthening exercises
2•Weight control
3•Mechanical reduction by a truss which is a pad made with firm material, held in place by a belt.
4. Surgery

Intestinal Obstruction tx (11)
1•NPO-bowel rest
2•NG suction
-Low continuous decompression
-Replacement of NG output with IVF
3•Treatment of primary disease
-Barium enema to dislodge intussusception
4•Disempaction if mechanical empaction
5•Fluid & Electrolyte replacement (K)
6•TPN
7•Mouth care
8•Pain management (not opiods until dx)
9•Broad spectrum antibiotics
10•Insertion of an intestinal tube to decompress and/or break up obstruction
-Miller-Abbott
-Cantor Tube
11.Sugery: Exploratory Laparoscopy/Laparotomy•Bowel resection•Primary resection and anastomosis•Temporary colostomy/ileostomy•Lysis of Adhesions

Hemorrhoids tx
1•Prevent constipation:
-Diet high in fiber to avoid constipation, Avoid prolonged sitting, Ample fluids (water), Stool softeners, Mineral oil,Exercise
2•Relieve pain
-Sitz baths 3-4x day, Witch hazel compresses, OTC preparations- locally – temporary pain relief
•Ice pack
•Bulk laxatives
•Topical anesthetics

hemorrhoids surgery

Complications: Infection, Stricture formation, Hemorrhage, Urinary retention d/t rectal spasms

•Sclerotherapy- Injecting a sclerosing agent between and around tissue and veins to cause formation of scar tissue
•Ligation-used for internal hemorrhoids-hemorrhoids are tied off with rubber bands and in 8-10 days area sloughs.
•Cryosurgery- (freezing) not common now leads to necrosis and sloughing of hemorrhoids
•Laser-hemorrhoids are burned off with laser
•Hemorrhoidectomy-Vein is excised and is left open to heal by granulation or is closed with sutures

Appendicitis tx
No medical treatment for appendicitis
Surgical intervention, removal of appendix, within 24-48 hrs. of onset of symptoms
Delay usually results in rupture of appendix and subsequent peritonitis
Surgery may be small incision or by laparoscope

Peritonitis tx (11)
1.Maintain fluid and electrolyte balance
IV fluids
Replacement electrolytes
NG tube or long intestinal tube to reduce pressure within the bowel
2.Infection control
IV antibiotic therapy with potent broad-spectrum agents
3.surgery may have to be delayed until stable:
-Surgery will Repair perforated organ as soon as possible
-Irrigate abdominal cavity with antibiotic solution to reduce bacterial count
-Wound may be packed open or drain in place so that infection can be treated
4. Bedrest in Semi-fowlers position
5. TC & DB
6. Assess respiratory status, VS
7.Strict I & O, wt, hydration
8.Assess pain, IV, NG Tube
9.Assess GI function
10.Wound Care
11.Post-Op Care

Gastroenteritis tx (8)
1. IV fluids
2.Monitor I&O, Daily wts
3.NPO, advance as tolerated
4.Water only does not replace electrolytes
5.HOLD Anticholinergics and antiemetics
6.Antibiotics (Cipro, Septra, Bactrim)
7.Rectal Care
8.Health Teaching

Ulcerative Colitis dx (5)
1.Stool Samples
2.CBC/Electrolytes: Hgb & Hct Decrease, Increased WBC
Increased ESR, Hyponatremia and hypokalemia, Hypoalbuminemia
3.CT Scan of Abdomen
4.Lower GI Series
With or without contrast (Barium) and air
5.Colonoscopy (most definitive test)

Ulcerative Colitis tx(8)
1.Maintain Remission
2.Diarrhea Management (atropine sulfate (Lomotil), loperamide (Imodium)
3.Diet Therapy
4.No Smoking
5.Rest
6.Meds- Aminosalicylates, Corticosteroids, Immunomodulatory Agents
7.Prevent Complications
8.Surgical Management
-Total protocolecotmy with permanent ileosstomy
-Total colectomy with ileoanal anastomosis; ileoanal reservoir

Crohns tx (3)
1.Drug Therapy
-Antibiotics: Metronidazole (Flagyl), Rifaximin (Xifaxan)
-Immunosupressive (Immuron)
-Biological Agents: Infliximab (Remicaide), Adalimumab (Humira), Etanercept (Embrel)

2.Manage Complication of Fistula (abnormal tract from intestine to skin or intestine to intestine)
3. Surgical Management: bowel resection, total colectomy and ileostomy

IBD: Crohns & CUC Nursing management (12)
1.Maintaining Normal Elimination patterns
2.Relieving pain
3.Maintaining Fluid Intake, Measures to promote fluid an electrolyte balance,TPN or Parenteral Nutrition
4.Promoting rest
5.Reducing Anxiety, Incorporate Stress reduction into lifestyle, Enhancing Coping Measures
6.Preventing Skin Breakdown
7.Understanding of Disease
8.Post surgical care – ileostomy, colostomy or colectomy
9.Nutritional management-Bland, low-residue(during flares), high protein, high vitamin diet, Foods to avoid
10.Medication Regimen
11.Measures to treat exacerbation of symptoms
12.Management, complications and interventions

Diverculitis tx (6)
1.Rest
2. Diet : Clear liquid until inflammation subsides, low fiber diet during acute episodes then High-fiber, low fat diet (Avoid seeds and nuts)
3.Monitor I&O: Adequate fluid intake 10 glasses/d
4.Drug Therapy:
-Antibiotics broad spectrum (Flagyl)
-IV’s
-Anticholenergics (Pro-Banthine)
-Opiod analgeisics
-Antispasmodics
5. NG Tube
6.Surgical Management: One Stage resection, Two stage resection

Cholecytis tx (8)
1.Diet:
-Avoid high-fat or high volume meals
-NGT – decompression of stomach
-Chronic: Low-fat diet to decrease stimulation to gallbladder
2.Drug therapy:
-Opioid analgesics (Demerol) relieve abd pain and spasm, morphine
-Antispasmotic agents: (Bentyl) to relax smooth muscle
-Antiemetics: (Tigan) to relieve n/v
-IV antibiotics: Ampicillin, cephalosporins, aminoglycosides
-anticholinergic medications
3. Fluid and electrolyte balance; rehydrate with IV fluids
Withhold food/fluids for N/V
4.Monitor for complications
5.Endoscopy
6.Dissolution: UDCA: ursodiol, Dissolves cholesterol
7.ESWL (extracorporeal shock wave lithotripsy)
Can have no pancreatic or liver involvement, Conscious sedation, general anesthesia or epidural
Recurrence is High
8.Surgery

choleliathisis
(Gall stones)
1.Diet therapy:Low fat,Obst bile flow decreases fat soluble vitamins (A, D, E, & K), Avoidance of large meal after fasting
2. Drug therapy:
-Opioid analgesics
-Antispasmotic or anticholinergics (Bentyl)
-Antiemetics
-Bile acid therapy – dissolve gallstones: Chenodeoxycholic acid (Chenix), Ursodeoxycholic acid (ursodiol) Reduce cholesterol stones by unsaturating bile
3.Fluid and electrolyte balance: NPO, IV fluid hydration
Careful progression of diet
4.Extracorporeal Shock wave lithotripsy-Noninvasive, outpatient, Lithotriptor generates powerful shock waves to shatter the stones, Approximately one hour; 1500 shocks, Stones are then secreted via intestines, RUQ pain is common, resolving in 2 days
5.Surgical:Cholecystotomy, Choledocholithotomy, Cholecystectomy

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