MEDICAL-SURGICAL NURSING 2

Care of Clients with Gastrointestinal Disorders

Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

Types of Gastrointestinal Tube

OUTLINE
i. Levin Tube
III. Common Gastrointestinal Interventions ➢ Inserted through the nose
A. Gastrointestinal Intubation into the upper alimentary
B. Nasogastric Tube Insertion canal to facilitate intestinal
C. Gastronomy/ Jejunostomy Feeding decompression.
➢ May also be used for
D. Common Problems of the Tube Feedings
E. Administering Total Parenteral Nutrition administration of medicine,
F. Administering Enemas gastric suction, and gastric
irrigation.
IV. Management of Patients with GI Disorders
A. Achalasia ➢ Has a smooth rounded tip.
B. Hiatal Hernia
C. Diverticulum
D. Gastroesophageal Reflux Disease
E. Gastritis
F. Peptic Ulcer Disease
G. Gastric Cancer
H. Appendicitis
I. Diverticular Disease ii. Salem-Sump Tube
J. Peritonitis ➢ Bi-lumen tube which
K. Chronic Inflammatory Bowel Disease facilitates safer continuous
L. Colorectal Cancer and intermittent gastric
M. Dumping Syndrome suctioning.
N. Hemorrhoids ➢ The larger lumen facilitates
suctioning of gastric
contents, irrigation, and
administration of medicine.
III. COMMON GASTROINTESTINAL INTERVENTIONS ➢ The smaller lumen allows
withdrawal of atmospheric
air in the stomach to
equalize the pressure which
Gastrointestinal Intubation prevents the suction eyelets
from sticking and damaging
➢ A process wherein a small, flexible tube the lining of the stomach.
is passed through the nose or mouth
into the stomach or in the intestines.
➢ May be used for treatment and
diagnostic purposes.

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

iii. Miller-Abbot Tube v. Sengstaken-Blakemore Tube

➢ Used to treat obstruction in ➢ A triple-lumen tube used to
the small intestine. treat bleeding esophageal
➢ Has a mercury-filled tube at varices (balloon
the bottom to assist tamponade)
decompression. ➢ The esophageal balloon is
inflated for 48 hours only to
prevent tissue necrosis

Has two balloons:

o Esophageal Balloon
▪ To Compress
bleeding
varices.
o Gastric Balloon
▪ To anchor
S-B tube in
the
stomach.
iv. Cantor Tube
➢ Single-lumen tube which
facilitates decompression of
the intestines.
➢ Has a mercury-weighted
rubber tub attached to its
perforated tip to help carry
the tube through the GI
tract.

👐 Nursing Responsibility
✓ To prevent aspiration:
o Encourage to
expectorate at
regular basis
o Suction the mouth
PRN
✓ Observe for signs and
symptoms of respiratory
obstruction
o Gastric
balloon may

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 MEDICAL-SURGICAL NURSING 2
Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

rupture and ✓ Tilt the patient’s head forward once the

esophageal balloon tube reaches oropharynx and ask to
may obstruct swallow
airway ✓ Assess the placement of the tube
(keep pair of ✓ Secure the NGT by taping it to the bridge
scissors readily of the nose
available)
✓ Provide oronasal care every
1-2 hours
✓ Lubricate nostrils with
water-soluble ointment
✓ To remove S-B tube, deflate
esophageal balloon before
the gastric balloon
to prevent upward
displacement of the
esophageal balloon
into the pharynx causing
airway obstruction

Nasogastric Tube Insertion

3. Administering feeding via NGT
1. Purposes ➢ Assist client to a Fowler’s position or
➢ To provide feeding (gastric gavage) sitting position
➢ To irrigate the stomach (gastric lavage) ➢ Assess tube placement
➢ For decompression and patency:
➢ To administer medication ✓ Introduce 5-20mL of air into the
➢ To administer supplemental fluids NGT and auscultate at the
epigastric area if
👐 2. Nursing Interventions during Insertion gurgling sound is heard
✓ Verify the doctor’s order. ✓ Aspirate gastric content, which
✓ Inform the client and explain the is yellowish or greenish in color
procedure ✓ Aspirate gastric content, which
✓ Measure the length of the NGT to be is yellowish or greenish in color
inserted (Tip of the nose to tip of the ✓ Measure the pH of aspirated
earlobe, to the xiphoid process=50cm) fluid which should be acidic
✓ Lubricate tip of the tube with water- ✓ Ask the client to speak or hum
soluble jelly ✓ Observe the client for coughing
✓ Hyperextend the neck, gently advance or choking
the tube toward the nasopharynx ✓ Radiographic verification – most
effective

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

➢ Assess residual feeding contents. If 50ml Jejunostomy

or more, verify if the feeding will be ✓ Is an opening on a skin into the
given midsection of the small intestine. A tube
➢ Introduce feeding slowly. delivers food and medicine bypassing
➢ Height of feeding is 12 inches above the the mouth, esophagus, and the
tube’s point of insertion into the client stomach.
➢ Instill 60mL of water into NGT after
feeding. To cleanse the lumen of the
tube
➢ Clamp the NGT before all of the water is
instilled
➢ Ask the client to remain in Fowler’s
position for at least 30min to prevent
potential aspiration of feeding
➢ Do after care of equipment
➢ Document

Gastronomy/ Jejunostomy Feeding

Gastronomy 👐 1. Nursing Responsibility in Administering

✓ Is an opening on a skin into the stomach Gastronomy/ Jejunostomy Feeding
which was surgically created under ✓ Verify doctor’s order
general anesthesia. ✓ Assist client to a Fowler’s position or
✓ A feeding device may be used to feed the sitting position
child straight through the stomach. ✓ Insert feeding tube into the ostomy
opening 10-15cm (4-6in) if one is not
sutured in place. (Lubricate tube before
insertion)
✓ Check the patency of the tube sutured in
place – pour 15 to 30 ml of water into
the asepto syringe
✓ Assess residual feeding contents. If 50ml
or more, verify if the feeding will be
given
✓ Introduce feeding slowly. Hold syringe 7-
15cm(3-6in) above ostomy opening
✓ Instill 30mL of water after feeding. To
cleanse the lumen of the tube
✓ Ask the client to remain in Fowler’s
position or slightly elevated right lateral
position at least 30min

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 MEDICAL-SURGICAL NURSING 2
Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

✓ Assess status of peristomal skin

✓ Document 3. Diarrhea
Causes
Common Problems of Tube Feedings i. Hyperosmolar feedings
ii. Rapid infusion/ bolus feeding
1. Vomiting iii. Cold formula
Causes
i. Medications, especially when the 👐 Therapeutic Nursing Intervention
patient is under antibiotic therapy ✓ Assess fluid balance and
ii. Change in the formula given and electrolytes of the patient & notify
the rate the physician on the findings
iii. Inadequate gastric emptying ✓ Implement changes in tube
feeding formula and its rate
👐 Therapeutic Nursing Intervention ✓ Review medications of the patient
✓ Review the medication of the
patient. 👐 Preventive Nursing Intervention
✓ Use appropriate rate of infusion
👐 Preventive Nursing Intervention and temperature of the formula
✓ Check residual, if >/= 200cc, ✓ Avoid multiple-elixirs and pro-
reinstill and recheck. motility medications
✓ Report if the residual is
consistently high.
✓ Keep the tube free from air. 4. Constipation
Causes
2. Aspiration i. Lack of fiber
Causes ii. Inadequate fluid intake/
i. Improper tube placement dehydration
ii. Vomiting with aspiration of tube iii. Use of Opiods
feeding
iii. Supine position 👐 Therapeutic Nursing Intervention
✓ Check the fiber and water content
👐 Therapeutic Nursing Intervention of the formula, notify the
✓ Assess the respiratory status of physician
the patient and notify the
physician. 👐 Preventive Nursing Intervention
✓ Administer adequate amount of
👐 Preventive Nursing Intervention hydration during flushing
✓ Implement reliable method for ✓ Consider cathartics medications
checking tube placement
✓ Keep the head of the bed elevated
at 30 degrees.

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 MEDICAL-SURGICAL NURSING 2
Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

5. Hyperglycemia promote weight maintenance or gains,

Causes and enhance healing process.
i. Glucose intolerance ➢ PN solutions contains enough calories
ii. High carbohydrate content of the and nitrogen to meet the patient’s
feeding nutritional needs.
➢ The primary purpose of TPN is to
👐 Therapeutic Nursing Intervention administer glucose (25-35% dextrose)
✓ Check the blood glucose level of
the patient routinely. Indications
✓ Consult dietitian to reevaluate the i. Inability to ingest oral food or
feeding program for the patient. fluids within 7 days

6. Abdominal Distention ii. Major GI diseases, fistulas, or

Causes inflammatory diseases
i. Air in tube
ii. Excess fiber iii. Severe trauma/ burns

👐 Therapeutic Nursing Intervention iv. Severe GI side effects from

✓ Notify the physician if distention is radiation/ chemotherapy
persistent
v. Severe malnutrition
👐 Preventive Nursing Intervention vi. Need for extensive support over
✓ Keep the tubing free from air
an extended period of time
during and after the feeding
vii. Prolonged preop and postop
nutritional needs
 Check the book for additional
complications of Enteral Feeding.

Administering Total Parenteral Nutrition

Parenteral Nutrition
➢ Is a method of providing nutrients to the
body via IV route.
➢ The nutrients are complex admixture
containing proteins, carbohydrates, fats,
electrolytes, vitamins, trace minerals,
and sterile water in a single container.
➢ The goal of this is to improve nutritional
status, establishment of positive
nitrogen balance, maintain muscle mass,

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 MEDICAL-SURGICAL NURSING 2
Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

👐 Nursing Responsibility 1. Types of Enema

✓ Usual site of TPN catheter i. Cleansing Enema
insertion is subclavian vein ➢ Water is injected through
threaded into the superior vena the rectum and held for
cava, into the right atrium. couple of minutes until the
✓ Place the client in T-burg position body automatically rids
during insertion of TPN catheter itself of the fluid.
✓ Administer TPN solution at room ➢ The purpose of it is to
temperature ensure clean colon
✓ Consumed prepared formulas especially when the patient
within 24 hours to prevent will undergo diagnostics
contamination procedures.
✓ Maintain a steady infusion rate
✓ Do not attempt to “catch up” if ii. Carminative Enema
infusion is delayed ➢ A.k.a. anti-spasmodic
✓ Monitor urine and blood enema which is used to
glucose levels remove gas accumulation in
✓ Provide good oral hygiene the abdomen.
➢ It increases the peristaltic
👐 Care of the Catheter Insertion site movements in the
✓ Practice strict aseptic technique intestines.
✓ Cleanse site with antiseptic ➢ Expulsion of flatulence
solution and change sterile
dressings daily iii. Retention Enema
✓ Monitor for signs and symptoms ➢ Solution is administered
of infection through the rectum and
intended to be held in it for
 Formula with >10% of dextrose should longer period of time.
not be administered through peripheral veins. ➢ Used for penetration and
lubrication of the feces.
➢ Uses solutions in oil-base.
Administering Enemas
iv. Return flow Enema/ Colonic
Enema Irrigation
➢ Is am administration of fluid into the ➢ Large amount of water and
lower bowel through the rectum. other solutions are flushed
➢ It is used to stimulate stool evacuation through the colon using a
wherein it helps to push the stool out of tube inserted in the rectum.
the rectum. The fluid is withdrawn by
➢ Can be used to relieve constipation. lowering the container
below the level of the
bowel.

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

v. Non-retention Enema

👐 2. Nursing Intervention in Enema

Administration
✓ Verify doctor’s order
✓ Provide privacy and relaxation
✓ Position the client properly:
o Adult- Left lateral/ Sim’s
o Infant/ Child- Dorsal recumbent
✓ Lubricate 5 cm(2in) of the rectal tube IV. MANAGEMENT OF PATIENTS WITH GI DISORDERS
✓ Allow solution to flow through the
connecting tubing and rectal tube to
expel air Achalasia
✓ Insert 7-10 cm (3-4in) of the rectal tube
gently, rotating motion Achalasia
✓ Introduce solution slowly ➢ Absent or ineffective peristalsis of
✓ Change position to distribute solution the distal esophagus accompanied
well in the colon (high enema). Remain by failure of the esophageal
in left position (low enema). sphincters to relax in response to
✓ Alternate hypotonic solution with swallowing.
isotonic solution to prevent water
intoxication
✓ If abdominal cramps occur during
introduction of solution, temporarily
stop the flow until peristalsis relaxes
✓ After introduction of the solution, press
buttocks together to inhibit the urge to
defecate
✓ Ask the client who is using the toilet not
to flush it
✓ Do perineal care
✓ Documentation

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 MEDICAL-SURGICAL NURSING 2
Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

☣ Diagnostic Test
1. X-ray
2. Barium swallow, CT scan and endoscopy
 A barium swallow test may be used
by itself or as part of an upper GI series.
This series looks at your esophagus,
stomach, and the first part of the small
intestine (duodenum).
Fluoroscopy is often used during a
barium swallow test.
3. Manometry – measures esophageal
pressure; confirmatory test

 Achalasia is a heterogeneous disease 👨 Collaborative Management

categorized into 3 distinct types based on 1. Instruct to eat slowly and drink fluids
manometric patterns: with meals.
1. Type I (classic) with minimal contractility 2. Botulinum toxin (Botox) - It inhibits the
in the esophageal body. contraction of smooth muscle
2. Type II with intermittent periods of pan decreasing pressure and improve
esophageal pressurization. swallowing.
3. Type III (spastic) with premature or 3. Pneumatic dilation - A procedure
spastic distal esophageal contractions. wherein a dilator is passed, guided by a
guide wire; when the balloon is in proper
position, it is distended by pressure
sufficient to dilate the narrowed distal
esophagus - Moderate sedation during
insertion is usually done.
4. Surgery: Esophagomyotomy, is an
incision made through the muscles of
the esophagus.

Hiatal Hernia
💉 Signs and Symptoms
✓ Dysphagia
✓ Sensation of food sticking in the lower Hiatal Hernia
portion of the esophagus ➢ A condition wherein the opening in
✓ Regurgitation the diaphragm through which the
✓ Chest pain esophagus passes becomes
✓ Heartburn (Pyrosis) Diagnostic Tests enlarged and part of the upper
stomach moves up in the lower
portion of the thorax.

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 MEDICAL-SURGICAL NURSING 2
Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

Two types: 6. Prolonged increase of intra -

1. Sliding esophageal hernia – the abdominal pressure
stomach and gastroesophageal 💉 Signs and Symptoms:
junction have moved upward and ✓ Heartburn
slide in and out of the thorax. ✓ Regurgitation
2. Paraesophageal hernia – all or part ✓ Dysphagia
of the stomach pushes through the ✓ Gastric reflux does not occur because
diaphragm next to the the gastroesophageal junction is still
gastroesophageal junction. intact.
☣ Diagnostic Test
1. X-ray
2. Barium swallow
3. Fluoroscopy

👨 Medical management
1. Pharmacologic Treatment
a. Antacids, Antiemetics, H2
blockers
b. Avoid: Anticholinergic, Ca-
channel blockers, diazepam
These drugs lower the LES (lower
esophageal sphincter) pressure

2. Surgical Treatment
➢ Nissen Fundoplication (gastric-
wrap around)
➢ Laparoscopic anti-
reflux surgery for GERD may
involve a procedure to reinforce
the lower esophageal sphincter
➢ The surgeon wraps the top of
the stomach around the lower
esophagus after reducing the
hiatal hernia, if present.
Causes
Muscle weakness in the esophageal hiatus:
1. Aging process
2. Congenital muscle weakness
3. Obesity
4. Trauma
5. Surgery

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 MEDICAL-SURGICAL NURSING 2
Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

👐 Nursing Responsibility on Diverticulum

GERD Surgery
Diverticulum
✓ Preoperative Care ➢ An outpouching of mucosa and
o Teach DBE and assist in submucosa that protrudes
the use of incentive through a weak portion of the
spirometer musculature
o Inform possible postop ➢ Zenker’s diverticulum
contraptions: NGT, (pharyngoesophagealpulsion
chest tube diverticulum or pharyngeal
✓ Postoperative Care pouch), is the most common
o Facilitate airway type.
clearance
o Semi-Fowler’s position
o DBE, incentive
spirometry, CPT
o NGT care
o Drainage is yellowish
green for the first 8-12
hours
o Clear liquids after
peristalsis returns

It may occur in one of the 3 areas of

👐 Nursing Interventions the esophagus:
✓ Modify diet: high CHON diet to enhance i. Pharyngoesophageal or
LES pressure upper esophagus
✓ Small frequent feedings; eat and chew ii. Midesophageal area
foods properly iii. Epiphrenic or lower
✓ Avoid fatty foods, cola, coffee, chocolate esophagus
and tea
✓ Advise not to recline 1 hour after eating
✓ Avoid smoking

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

💉 Signs and Symptoms

✓ Dysphagia
✓ Regurgitation of undigested food
✓ Fullness in the neck
✓ Gurgling noises after eating
✓ Belching
✓ Halitosis

☣ Diagnostic Test
1. Barium swallow
2. Manometry
3. Esophagoscopy, usually contraindicated
because of the danger of perforating Gastroesophageal Reflux Disease (GERD)
diverticulum
Gastroesophageal Reflux Disease (GERD)
👨 Collaborative Management ➢ Backflow of gastric or duodenal
1. Surgical Treatment contents into the esophagus
i. Diverticulectomy
➢ Surgical removal of the
diverticulum

ii. Myotomy
Causes:
➢ Performed to relieve
1. Incompetent lower esophageal sphincter
spasticity of the
2. Pyloric stenosis
musculature preventing
3. Motility disorder
continuation of the
4. Aging
previous symptoms
2. NGT insertion
💉 Signs and Symptoms
✓ Pyrosis (Heartburn)
✓ Odynophagia (Painful Swallowing)
✓ Dyspepsia (Indigestion)
✓ Hypersalivation
✓ Regurgitation

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

✓ Can imitate anginal attack 👨 Collaborative Management

✓ Dysphagia 1. Pharmacologic treatment - Antacids, H2
blockers, Sucralfate
☣ Diagnostic Test 2. Bland or liquid diet until pain resolves
1. Endoscopy 3. Fluid – electrolyte replacement
2. Barium swallow 4. Vitamin B12 if pernicious anemia occurs
3. Esophageal pH monitoring 5. Avoid alcohol, smoking
➢ Measure the pH or amount of acid 6. Avoid overeating
that flows into the esophagus from
the stomach during a 24-hour
period.
Gastritis
4. Bilirubin monitoring
➢ Useful to evaluate the etiology of
damaging the esophageal mucosa Gastritis
and causes of symptoms by
estimating duodenogastro- ➢ Diffuse or localized inflammation of the
esophageal reflux, which has gastric mucosa (linings of the stomach).
synergistic effect with acid.

👨 Collaborative Management
1. Pharmacologic treatment
i. Antacids or H2 blockers
[Famotidine (Pepcid), ranitidine
(Zantac)]
ii. Proton Pump Inhibitors
[Omeprazole (Omepron)]
2. Surgical treatment
a. Nissen-Fundoplication
3. Low fat diet. To enhance lower
esophageal sphincter pressure
4. Avoid caffeine, smoking, beer, milk and Types of Gastritis
cola
5. Avoid eating or drinking 2 hours before A. Acute Gastritis
bedtime ➢ Short-term (several hours to few
6. Elevate HOB 6-8” days)
7. Elevate upper body on pillows ➢ Inflammatory process due to
ingestion of chemical agents or food
☣ Diagnostic Test products that irritate and erode
1. UGI x-ray series gastric mucosa.
2. Endoscopy
3. Histologic examination B. Chronic Gastritis

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

➢ Forms the posterior roof of the 💉 Signs and Symptoms

mouth. ✓ Anorexia
➢ Resulting from repeated exposure to ✓ Nausea and vomiting
irritating agents or recurring ✓ Abdominal cramping
episodes of acute gastritis ✓ Diarrhea
✓ Epigastric pain
✓ Fever
2 Forms of Chronic Gastritis: ✓ Painless GI bleeding (due to
i. Type A ASA/NSAIDs)
➢ Autoimmune in nature,
✓ Pyrosis (heartburn)
gastric Ca, pernicious
anemia
☣ Diagnostic Tests
ii. Type B 1. UGI x-ray series
➢ Associated with H. pylori 2. Endoscopy
infection. 3. Histologic examination

👨 Collaborative Management
1. Pharmacologic treatment
➢ Antacids, H2 blockers,
Sucralfate
2. Bland or liquid diet until pain
resolves
3. Fluid – electrolyte replacement
4. Vitamin B12 if pernicious anemia
occurs
5. Avoid alcohol, smoking
6. Avoid overeating

Peptic Ulcer Disease

Causes Peptic Ulcer Disease

1. Dietary Indiscretion / Unhealthy diet ➢ Generic term for disorders characterized
2. Overuse of NSAIDs (aspirin) by excavation (hollowed-out area) in any
3. Excessive alcohol intake segment of the GI mucosal wall
4. Bile reflux (esophagus, stomach, pylorus,
5. Radiation therapy duodenum) secondary to hyperacidity.
6. H. pylori infection

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

Two Common Types:

i. Gastric Ulcer
ii. Duodenal Ulcer

Predisposing Factors
1. Stress
2. Cigarette smoking
3. Alcohol
4. Caffeine
5. Drugs (ulcerogenic drugs: ASA,
NSAIDs, Steroids)
6. H. pylori infection 👨 Collaborative Management
➢ Pancreatic Tumor (gastrinoma) 1. Pharmacologic Therapy
➢ Gastric secretion a. Hyposecretory Agents
➢ HCl secretion ➢ H2 blocker
➢ Multiple areas of ulceration (e.g. Ranitidine), given
7. Zollinger – Ellison Syndrome ac
8. Eating hurriedly and not eating ➢ Proton Pump Inhibitor
9. Fatty, spicy, highly acidic foods (e.g. Omeprazole),
10. Type A personality given ac
11. Type O blood ➢ Prostaglandin
12. Genetics analogue
(e.g. Cytotec)
💉 Signs and Symptoms
b. Antacid agents
GASTRIC ULCER DUODENAL ULCER ➢ Neutralizes HCl
Pain radiates on the left Pain radiates on the right ➢ Taken 1 -2 hrs pc
epigastrium epigastrium ➢ AlOH (Amphogel)
30min – 1hr pc 2 – 3 hrs. pc ➢ MgOH (Milk of
Aggravated by food Relieved by food Magnesia, Novaluzid)
Relieved by vomiting No vomiting occurs ➢ AlMgOH (Maalox,
Decreased HCI Increased HCl Simeco)
Hematemesis Melena
Occasionally malignant Rarely malignant c. Cytoprotective Drugs /
Barrier Fortifiers
➢ Coats ulcer
☣ Diagnostic Tests
➢ Given 1hr ac
1. Barium Swallow
➢ Carafate (Sucralfate)
2. UGI endoscopy
3. Biopsy of suspicious lesions
d. H. pylori Drug Treatment
4. Gastric Analysis
➢ Pepto-Bismul (bismuth
➢ Diagnosing achlorhydria and
compound)
ZES

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

➢ Amoxicillin / d. Subtotal Gastrectomy

Tetracycline ➢ Removal of 75% of the
➢ Flagyl (Metronidazole). distal stomach with
Avoid alcohol to Billroth I or Billroth II
prevent disulfiram-like repair.
reactions
👐 Nursing Responsibility on
2. Surgical Treatment Gastric Surgery
a. Vagotomy ✓ Preop Care
➢ Resection of the vagus o Provide psychosocial
nerve support
➢ Decreases cholinergic o Teach DBCT exercises
stimulation o Provide nutritional
➢ HCl secretion and and support
gastric motility o TPN as ordered
o Inform about postop
b. Pyloroplasty measures: NGT and TPN
➢ Surgical dilatation of until peristalsis returns
the pyloric sphincter
➢ Improves gastric ✓ Postop Care
emptying of acidic o Promote patent airway
chime and ventilation:
▪ Semi-Fowler’s
c. Antrectomies /Gastrectomy position
➢ Removal of 50% of the ▪ Reinforce DBCT
lower part of the exercises, incentive
stomach spirometer
▪ Administer
Types: analgesics before
i. Billroth I activities
(gastroduodenostomy) ▪ Splint incisions
before the patient
ii. Billroth II coughs
(gastrojejunostomy) ▪ Encourage early
o The duodenum ambulation
is bypassed to o Promote adequate
permit the flow nutrition:
of the bile from ▪ NPO until
the common peristalsis returns
bile duct. ▪ NGT care
▪ TPN care

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

o Prevent potential Causes

complications: 1. Excessive intake of nitrite-cured,
▪ Signs of Bleeding salt-cured and smoke-cured foods
▪ Dumping 2. Low fiber diet
Syndrome 3. Cigarette smoking
o Acute-angle entrance of 4. Chronic achlorhydria
the esophagus into the 5. Pernicious anemia
stomach 6. Villous adenoma
o Mucosal folds in the 7. Heredity
gastro-esophageal 8. Excessive intake of raw foods
junction 9. Atrophic gastritis
o Compression due to the
positive intra- 💉 Signs and Symptoms
abdominal pressure ✓ Progressive loss of appetite
o Pinch-cock effect due to ✓ Palpable abdominal mass
the diaphragm ✓ Gastric fullness (early (e.g. ascites,
hepatomegaly) satiety)
👐 Nursing Interventions ✓ Achlorhydria
✓ Relieve Pain ✓ Dyspepsia
✓ Promote healthy lifestyle - Avoid / ✓ Sister Mary Joseph’s nodule
prevent all predisposing factors of PUD (palpable nodules around the
✓ Quit smoking umbilicus)
✓ Stress Therapy / Coping ✓ Nausea and vomiting (sign of GI
malignancy)
Gastric Cancer ✓ Hematemesis / melena
✓ Pain induced by eating
Gastric Cancer ✓ Weight loss, fatigue, relieved by
vomiting (late anemia symptom)
➢ Cancer, which is mostly
adenocarcinomas that can occur ☣ Diagnostic Tests
anywhere in the stomach. 1. Barium x-ray of the UGIT
➢ Common in middle-age males 2. Esophagogastroduodenoscopy for
biopsy (Dx of choice)
3. Endoscopic ultrasound
4. CT scan

👨 Collaborative Management
1. Surgery
a. Total Gastrectomy
b. Radical subtotal
gastrectomy
i. Billroth I

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

ii. Billroth II 4. Rovsing’s sign (paradoxical

2. Chemotherapy pain felt on the RLQ when
3. TPN prn palpated on the LLQ)
4. Prevent Dumping Syndrome 5. McBurney’s Sign
5. Vitamin B12 per IM 6. Anorexia, nausea and
vomiting
Appendicitis 7. Low-grade fever
8. Decreased or absent bowel
Appendicitis sound
➢ Inflammation of the vermiform
appendix ☣ Diagnostic Test
➢ Appendix - a finger-shaped pouch that ✓ CBC 2. X-ray
projects from your colon on the lower ✓ UTZ, and CT scans
right side of your abdomen. ✓ Laparoscopy

👨‍⚕ Medical Management

1. Surgery – Appendectomy
➢ Surgical removal of
the appendix
➢ Spinal anesthesia
➢ If ruptured
appendicitis occurs,
a penrose drain may
be placed to drain
the abscess
Causes: 👐 Nursing Responsibility
1. Obstruction by fecalith or ✓ Flat on bed for 6-
foreign bodies, bacterias, and 8hours postop
toxins ✓ Monitor for return
2. Low fiber diet of sensation in the
3. High intake of refined lower extremities
carbohydrates ✓ NPO until peristalsis
returns
💉 Signs and Symptoms ✓ Ambulation after 24
1. Vague epigastric or hours and other
periumbilical pain that related exercises
progresses to the RLQ 2. Analgesics as ordered
(McBurney’s point) 3. Antibiotic therapy
2. Blumberg sign (rebound
tenderness)
3. Psoas sign (lateral position
with right hip flexion)

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

👐 Nursing Management 5. Abdominal distention and

✓ Bed rest tenderness
✓ NPO 6. Narrow stools
✓ Relieve pain (cold application 7. Occult bleeding
over the abdomen) 8. s/sx of peritonitis due to
✓ Avoid factors that increase development of abscess or
peristalsis, thereby rupture: perforation
o Heat application over
the abdomen
o Laxative
o Enema
✓ IVF therapy to maintain fluid
electrolyte balance

Diverticular Disease

i. Diverticulum
➢ Saclike outpouching of the
lining of the bowel that extends
through a defect in the muscle

ii. Diverticula / diverticulosis

➢ Multiple outpouching without ☣ Diagnostic Tests:
inflammation or symptoms ✓ Colonoscopy
✓ Barium enema
iii. Diverticulitis ✓ CT scan and abdominal x-ray
➢ acute inflammation and ✓ CBC
infection caused by trapped
foods, bacteria and fecal 👨‍⚕ Medical Management
material in a diverticulum 1. Diet
➢ Clear liquid, High fiber,
Causes: low fat
1. Low fiber diet 2. ℞ Pharmacologic Treatment
2. Aging ➢ Analgesics (opioid
except morphine)
💉 Signs and Symptoms: ➢ Antibiotics
1. Crampy LLQ pain ➢ Bulk-forming laxatives
2. Low-grade fever (Metamucil)
3. Chronic constipation ➢ Antispasmodics (Pro-
4. Nausea and vomiting Banthine)

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

3. Surgical Treatment • Paralytic ileus

Hartmann procedure- o is the occurrence of
Removal of area of intestinal blockage in
diverticulitis and the the absence of an actual
remaining bowel is physical obstruction.
joined end-to-end
o This type of blockage is
👐 Nursing Management caused by a malfunction
✓ Encourage high fiber diet in the nerves and
✓ Liberal fluid intake of 2,500 to 3,000 muscles in the intestine
ml/day that impairs digestive
✓ Avoid nuts and seeds which can movement.
become trapped in the diverticula
✓ If signs of infection are still present,
avoid high fiber diet to prevent GI
irritation
✓ Bed rest
✓ Weight loss to reduce
intraabdominal pressure

Peritonitis

Peritonitis
➢ Inflammation of the peritoneum caused
by the following:
i. Ruptured appendicitis ➢ Fever
ii. Perforated peptic ulcer ➢ Signs of early shock: HR, RR,
iii. Diverticulitis urine output, etc
iv. Pelvic inflammatory disease
v. UTI or trauma Diagnostic Tests
1. CBC, serum electrolytes
Peritoneum 2. Abdominal x-ray
➢ Serous membrane which lines 3. CT scan
the abdominal cavity. 4. Peritoneal aspiration and
cultures
💉 Signs and Symptoms: ➢ A peritoneal fluid
• Diffuse abdominal pain culture is a test that is
• Abdominal guarding / rigidity / performed on a small
“boardlike” abdomen sample of peritoneal
• Nausea and vomiting fluid. It may also be
• Diminished bowel sounds called an abdominal tap
or paracentesis. The

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

laboratory examines Types of Chronic Inflammatory Bowel

the fluid for any Disease
bacteria or fungi that i. Regional Enteritis (Crohn’s
may be causing an disease)
infection. ➢ A subacute and chronic
Complications inflammation of the GI
1. Sepsis tract wall that extends
2. Shock through all layers.
➢ Though all layers could
👨‍⚕Medical Management be affected, it is
1. Fluid, colloid and electrolyte commonly seen in the
replacement – IVF distal ileum and
2. Pharmacologic treatment ascending colon
a. Analgesics ii. Ulcerative Colitis
b. Massive antibiotic ➢ A recurrent ulcerative
therapy and inflammatory
3. O2 therapy disease of the mucosal
4. Surgery to drain infected and submucosal layers
materials and correct the of the colon and rectum
cause
Crohn’s Disease Ulcerative Colitis
👐 Nursing Management
Causes - Unknown - Unknown
✓ Monitor VS regularly - Familial history -Familial history
✓ Proper positioning – fetal (more common) (less common)
position - Autoimmune -Bacterial
✓ Care of drains postop and - Emotional stress infection
assessing its drainage - Immunologic
characteristics factors /
Environment
Chronic Inflammatory Bowel Disease Age 20 – 30 yrs 15 – 40 yrs
40 – 60 yrs
Stool and stool with pus and Severe; stool
Bleeding mucoid; steatorrhea with blood, pus
and mucus;
tenesmus
Diarrhea 3 – 5x a day 15 – 20x a day
Pain RLQ Generalized
crampy
abdominal pain
(LLQ)
Weight loss Present Present

Fistulas Common Rare

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Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

 Steatorrhea 3. Endoscopy, colonoscopy, intestinal

➢ is the medical term for fat biopsies
in stool i. Endoscopy
 Tenesmus ➢ It is the insertion of a long, thin
➢ refers to cramping rectal tube directly into the body to
pain. observe an internal organ or
☣ Diagnostic Test (CROHN’S DISEASE) tissue in detail (small intestine).
1. Stool Examination
➢ This is performed to test for the
presence of white blood cells
(WBCs), occult blood, routine
pathogens, ova, parasites, and
Clostridium difficile toxin.

2. Barium Study
➢ This study is a radiographic (X-ray)
examination used to diagnose
abnormalities of the GI tract
➢ This reveal “string sign” on an x-ray
image of the terminal ileum

String sign – described as a persistently

narrowed segment of intestine due to ii. Colonoscopy
structure. ➢ This will show a clear picture of
your intestines and let them
take a tissue sample to study.

iii. Intestinal Biopsy

➢ If a biopsy of the colon lining
finds clusters of inflammatory
cells, called granulomas, it will
help to confirm a diagnosis of
Crohn's disease.

4. CT Scan
➢ It can highlight bowel wall
thickening and mesenteric edema,
as well as obstructions, abscesses,
and fistulae.
➢ May help specify abscess formation
and location, guiding percutaneous
access and drainage

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

5. CBC
➢ It is performed to assess hematocrit
and hemoglobin levels (which may
be decreased) as well as the white
blood cell count (may be elevated).

☣ Diagnostic Test (ULCERATIVE COLITIS)

1. Stool Exam
➢ The stool is positive for blood

2. CBC
➢ Laboratory test results reveal low
hematocrit and hemoglobin levels in
addition to an elevated white blood
cell count, low albumin levels
(indicating malabsorptive
disorders), and an electrolyte
imbalance.

3. Abdominal x-ray
➢ It is useful for determining the cause
of symptoms.
➢ This may show massive colonic
dilatation associated with an
abnormal mucosal contour.

4. Proctosigmoidoscopy and Ba enema

i. Proctosigmoidoscopy
➢ (Proctoscopy, Sigmoidoscopy) is ii. Barium Enema
an internal examination of the ➢ is an X-ray exam that can detect
lower large bowel (colon), using changes or abnormalities in the
an instrument called a large intestine (colon)
sigmoidoscope. ➢ An enema is the injection of a
➢ Characteristic changes that can liquid into your rectum through
be seen include loss of the a small tube.
typical vascular pattern,
friability, exudates, ulcerations, 5. CT scan
and granularity in a continuous, ➢ This can identify abscesses and
circumferential pattern. perirectal involvement.

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

3. Surgical treatment – Colon Surgery

i. Ileostomy / colectomy (Crohn’s
👨 Medical Management of CIBD disease)
1. Nutritional Therapy ➢ It allows for drainage of fecal
➢ Increased oral fluids, protein, matter (i.e., effluent) from the
caloric, low-residue diet with ileum to the outside of the body.
vitamin supplement ➢ The drainage is liquid to
➢ Any foods that exacerbate diarrhea unformed and occurs at
should be avoided frequent intervals.
➢ TPN (Total Parenteral Nutrition) –
glucose + amino acids (Nutrimix)

2. Pharmacologic treatment
i. Antibiotics
➢ [e.g., metronidazole (Flagyl)]
➢ are used for complications such
as abscesses or fistula formation

ii. Corticosteroids
➢ [e.g., prednisone, hydrocortisone] ii. Ileostomy / Proctocolectomy
➢ are used to treat severe and
(Ulcerative colitis)
fulminant disease and can be given
➢ Proctocolectomy with ileostomy
orally in outpatient treatment or
(i.e., complete excision of colon,
parenterally in hospitalized
rectum, and anus) is
patients.
recommended in patients with
severe ulcerative colitis
iii. Immunomodulators refractory to medical therapy
➢ [e.g., methotrexate] with a severely diseased rectum.
➢ This have been used to alter the
immune response.
➢ are used in patients with severe
disease who have not responded
favorably to other therapies.

iv. Antidiarrheal
➢ are used to minimize peristalsis in
order to rest the inflamed bowel.
➢ They are continued until the iii. Proctocolectomy with Ileal Pouch
patient’s stools approach normal Anal Anastomosis
frequency and consistency. ➢ is the surgical procedure of
choice in cases where the
rectum can be preserved

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Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

because it eliminates the need 4. History of inflammatory bowel disease

for a permanent ileostomy. 5. High fat, high protein, low fiber diet
➢ It establishes an ileal reservoir 6. Genital cancer or breast cancer
that functions as a “new”
rectum, and anal sphincter 💉 Signs and Symptoms
control of elimination is 1. Ascending (Right) Colon Cancer
retained ➢ Occult blood in stool
➢ Anemia
➢ Anorexia and weight loss
➢ Abdominal pain above umbilicus
➢ Palpable mass
2. Distal Colon / Rectal Cancer
➢ Rectal bleeding
➢ Changed in bowel habits
➢ Constipation or diarrhea
➢ Pencil or ribbon-shaped stool
➢ Tenesmus (cramping rectal
pain)
➢ Sensation of incomplete bowel
emptying

☣ Diagnostic Tests
Colorectal Cancer 1. GUAIAC test
2. Ba Enema
3. Endoscopic Procedures
Colorectal Cancer i. Proctosigmoidoscopy
➢ Tumors of the colon and rectum are ➢ Proctoscopy,
relatively common; the colorectal area Sigmoidoscopy
(the colon and rectum combined) o is an internal
➢ The most significant risk factor for examination of the
colorectal cancer is older age. lower large bowel
(colon), using an
Causes: instrument called a
1. Aging sigmoidoscope
➢ It is most frequently diagnosed ii. Colonoscopy
in adults between 65 and 74 ➢ is the only screening test
years of age. that can also simultaneously
2. Genetics remove precancerous
➢ Approximately 20% of patients polyps, thus preventing
with colorectal cancer have a colorectal cancer.
family history of the disease. 4. Biopsy and cytology smears
3. Previous colon cancer 5. CEA studies

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Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

➢ Carcinoembryonic antigen ➢ Necessitates permanent

➢ CEA is a tumor marker that is colostomy
recommended for assessing the
presence of colorectal cancer, as
well as its progression or
recurrence.

Guidelines for Early Detection of Colorectal

Cancer
1. Digital rectal examination after age 40
2. Occult blood test yearly after age 50
3. Proctosigmoidoscopy every 5 years after
age 50, following 2 negative results of
yearly examination

👨 Medical Management 2. Chemotherapy

1. Surgery ➢ Fluorouracil is the most effective
i. Hemicolectomy drug for colorectal cancer
➢ for ascending and transverse 3. Radiotherapy
colon cancer ➢ Adjuvant treatment for rectal cancer

👐 Nursing Management
1. Colostomy Care
✓ Diet
➢ fiber diet
➢ Avoid gas-forming and foul odor –
forming foods (dairy products,
fish, CHO, cabbage, carbonated
beverages)
✓ Skin care
➢ Clean with plain soap and water
➢ Apply skin barriers
✓ Colostomy irrigation
ii. Abdomino – Perineal Resection ➢ Done to stimulate peristalsis
(APR) for rectosigmoid cancer and reestablish bowel habits
➢ There are 2 incisions: lower ➢ Done 4th – 6th day post-
abdomen incision to remove operatively
the sigmoid; perineal incision ➢ Perform colostomy irrigation
to remove the rectum after meal at the toilet
➢ T – binder is used to secure ➢ Advise to seat on the commode
perineal dressing while on irrigation

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Care of Clients with Gastrointestinal Disorders
Lecturer: Mr. Laurence Santos, MAN, RN
March 30, 2021

➢ Hang the irrigation solution 12- Collaborative Management

18 inches above the stoma 1. Eat in recumbent or semi –
➢ Clamp the tubing if abdominal recumbent position
cramps occur and continue until 2. Lie down after meal (left side)
it relaxes 3. Small, frequent feedings
➢ Allow the solution to remain for 4. Moderate fat, high protein diet. Fats
5-10min then remove the slow down gastric motility; proteins
catheter to drain for 15-20 min increase colloidal osmotic pressure
➢ Clean the stoma, apply new and prevent shifting of plasma
pouch 5. Limit carbohydrates, no simple
sugars
6. Give fluids after meals
Dumping Syndrome 7. Avoid very hot and cold foods and
beverages
Dumping Syndrome 8. Anticholinergic or antispasmodic as
ordered
➢ Rapid emptying of the hypertonic
chime of the stomach
➢ It is a physiologic response to the rapid
emptying of gastric contents into the
jejunum. The rapid transit of the food
bolus from the stomach into the small
intestines causes a rapid and exuberant
release of metabolic peptides that are
responsible for the symptoms

💉 Early signs and symptoms

1. Weakness
2. Tachycardia
3. Dizziness
4. Diaphoresis
5. Pallor
6. Feeling of fullness or discomfort
7. Nausea Hemorrhoids
8. Explosive diarrhea, abdominal cramps,
borborygmi Hemorrhoids
➢ Dilated blood vessels beneath the lining
💉 Late signs and symptoms of the skin in the anal canal
1. Hyperglycemia ➢ It develops as a result of perianal
2. increased insulin secretion vascular congestion caused by straining.
3. hypoglycemia ➢ Shearing of the mucosa during
defecation results in the sliding of the

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March 30, 2021

structures in the wall of the anal canal,

including the hemorrhoidal and vascular
tissues.

Two Types
1. External hemorrhoids – occur below
the anal sphincter
➢ are associated with severe pain
from the inflammation and
edema caused by thrombosis
(i.e., clotting of blood within the
hemorrhoid).

2. Internal hemorrhoids – occur above

the anal sphincter
➢ are not usually painful until they 💉 Signs and Symptoms
bleed or prolapse when they 1. Constipation
become enlarged. 2. Anal pain
3. Rectal bleeding
4. Anal itchiness
 Internal hemorrhoids are also classified by 5. Mucous secretion from the anus
degree of prolapse: 6. Sensation of incomplete evacuation of
i. First degree — do not prolapse and the rectum
protrude into anal canal 7. Internal hemorrhoids may prolapse
ii. Second degree — prolapse outside
the anal canal during defecation but Collaborative Management
reduce spontaneously 1. High fiber diet, liberal fluid intake
iii. Third degree — prolapsed to the 2. Bulk laxatives
extent that they require manual 3. Hot sitz bath, warm compress
reduction 4. Local anesthetic application –
iv. Fourth degree — prolapsed to the Nupercaine
extent that they may not be reduced  Nupercainal hemorrhoidal ointment
➢ used to relieve rectal pain and
Causes itching caused by hemorrhoids or
1. Chronic constipation other rectal irritations.
2. Pregnancy 5. Surgery:
3. Obesity i. Hemorrhoidectomy
4. Prolonged sitting or standing ➢ is surgery to remove internal or
5. Wearing constricting clothing external hemorrhoids that are
6. Disease conditions like liver cirrhosis, extensive or severe.
RSCHF

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March 30, 2021

ii. Cryosurgery Transcribers’ Message:

 is a type of surgery that involves This transcription is based from the
the use of extreme cold to destroy handouts provided by Sir John Paul M. Mendoza,
abnormal tissues, such as tumors. additional information provided by our lecturer Mr.
 The surgery most often involves Laurence Santos, and some information obtained in
the use of liquid nitrogen, although the book Brunner & Suddarth’s Textbook of Medical-
carbon dioxide and argon may also be Surgical Nursing (12th Edition)
used.
Please treat this transcription as an
additional reading only for the subject and not a
substitution for the modules provided by the clinical
instructors, and the textbook mentioned above.

These are the lists of new people who

collaborated in making this transcription:
1. Bondoc, Jennilyn
2. Fabian, Mary Rose
3. Refuerzo, Princess Aphrodite
4. Navarro, Jenna Joy

iii. Rubber band ligation No additional notes from lectures were

 This is a procedure in which added here because this transcription is made in
the hemorrhoid is tied off at its base advance.
with rubber bands, cutting off the blood
flow to the hemorrhoid. The
hemorrhoid then shrinks and dies and, in Reading:
about a week, falls off.
 This treatment is only for Internal Smeltzer S.C., Bare B.G., Hinkle J.L., and Cheever
hemorrhoids K.H. (2010) Brunner and Suddarth’s
Textbook of Medical-Surgical Nursing
(12th ed) C&E Publishing Inc. Volume 2

-End of Digestive Part 2-

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March 30, 2021

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