Nursing Care of Patients with Dysfunction in Digestion System
Chia-Chun Tang, PhD, RN School of Nursing, National Taiwan University
Table of Content
• Assessment of digestive and gastrointestinal function
– Anatomy, blood, and nervous system – Function
– Symptoms – Lab data
• Nursing care and interventions – Procedure-related
– Tube insertion
– Disease specific: Case studies
Assessment of Digestive and Gastrointestinal Function
7m-7.9m 25 cm
1500- 2000 cc
285 cm-700 cm Duodenum- Jejunum-Ileum
Game Time- Jeopardy!
Quiz #1
Duodenum (12指腸)
A. 小腸中段
B. 最易發生潰瘍的部位
C. 小腸中最主要消化吸收處
D. 小腸中最⻑的⼀段
上腸繫膜靜脈
Portal Vein System
下腸繫膜 靜脈
About 20% of the total c/o
Nervous System
Parasympathetic Sympathetic
• Inhibitory effect
• Gastric secretion↓
• Motility ↓
• Sphincters constrict
• Blood vessels constrict
• Stimulate effect
• Gastric secretion↑
• Motility ↑
• Most sphincters relax
• Blood flow ↑
Function
• Breakdown
• Digestion
• Absorption
• Elimination
Function
Mouth
• Breakdown: chew & swallow
• Digestion: salivary amylase (starches)
Stomach
• Breakdown/disinfect: gastric secretion
• Digestion: pepsin (protein), intrinsic factor (vit B12)
Small intes.
• Digestion: amylase, trypsin, lipase, bile (starches, protein, fat)
• Absorption
Colon→
• Breakdown: bacteria
• Absorption: water & electrolytes
• Elimination
30’- hours
3-6 hours
About 12 hours – 3days after eating
Symptoms
• Pain
• Dyspepsia/indigestion
• Intestinal gas
• Nausea and vomiting
• Diarrhea (some, ＜10,＞10)
• Constipation
Signs Related to Appendicitis
Lab Data
• CBC/DC
• Complete metabolic panel
• PT/APTT
• Liver function
• Amylase
• Lipase
• Tumor marker: CEA, CA 19-9
• FOBT
Nursing Care and Interventions
Procedures
• Upper/lower gastrointestinal tract study, barium swallow/ enema, CT, MRI, PET, endoscopy, ERCP
• Preparation: NPO, substance stimulating gastric motility, medications (withhold regular medication, gascon, atropine), bowel cleaning (low-residue diet and enema), IV
• Post-procedure: NPO, fluid intake, bowel movements, gag reflex, pain, bleeding
Mid-night NPO Pre-medication: Gascon, atropine
Anesthesia Remove NG
Low Residue Diet* 2 days Exam day: cleansing enema, NPO
Intubation and Special Nutrition Modalities
• Reasons for intubation
– Decompress: remove gas and fluid – Lavage: flush with water or other fluid – Diagnose
– Medication and nutrition – Compress bleeding site
Ostomy Care
• Keep it simple
• Change: 3-7 days
• Clean: warm water with wash clothe
**stoma has no nerve ending so you won’t feel from it
• Activity: normal- shower, swim, hot tub
Goals of Nursing Care
• Prevent infection
• Fluid balance, I/O
• Monitoring nutrition status and electrolytes
• Encouraging activity
• Promoting self-care
• Stable rate
臺大醫院靜脈營養輸液 Complications related to TPN
• Catheter-related bloodstream infection
• Localized infection
• Pneumothorax
• Air embolism
• Hyperglycemia
• Refeeding syndrome
• Fluid excess/ pulmonary edema
Case Study #1-1
(modified from Rattner. Gastroesophageal Surgery Case Scenario. Massachusetts General Hospital)
• ⼀位52歲周先生已有好幾年的心灼燒
(heartburn)症狀，近⼀個⽉因感受到症狀更加 頻繁出現故於門診尋求協助。除上述症狀，周 先生主訴他躺下後常常覺得喉嚨後有液體在流 動，嚴重影響他的睡眠，以前睡前會喝的小酒 也無法再喝。
• 鑑別診斷?須 配合那些檢查/實驗室數據證實 ?
• GERD
• Ischemic heart disease/
heart attack
• Endoscopy or barium swallow
• ambulatory 12-36- h esophageal PH monitoring
What is Gastroesophageal Reflux Disease (GERD)?
• Backflow of gastric or duodenal contents into the esophagus
• Some degree of GERD is NORMAL in both adults and kids
• Excessive flow may be caused by incompetent lower esophageal sphincter or pyloric stenosis
• Incidence of GERD increase with aging
• Symptoms: burning sensation, indigestion, dysphagia or pain on swallowing, hypersalivation
24-Hour Esophageal pH Test
• Prepare:
– 7 days - stop PPI – 2 days - H2 blockers – 6 hours – antacids – 4-6 hours- NPO
• During:
– Normal activity (no bath/shower/swim) – Regular meals
(stimulate symptoms, no gums or hard candy)
– Recording symptoms and events
Case Study #1-2
(modified from Rattner. Gastroesophageal Surgery Case Scenario.
Massachusetts General Hospital)
• 周先生確診為GERD，醫師決定給予耐 適恩(Nexium)，並將病人轉介給護理 師進行衛教。護理師將告訴周先生…
• Diet: low-fat diet, avoid caffeine, tobacco, beer, milk…
• No drinking or eating within 2 hours of bedtime
• Normal body weight
• Avoid tight-fitting clothes
• Elevated the head of bed
• If take PPI- monitor infection
Case Study #2-1
Mak, Chan, & Chan (2016). Elderly Man with Dysphagia and Weight Loss: A Case Report.
iMedPub Journals, 2(1), 11
• ⼀位63歲的男性因吞嚥困難且疼痛、噁心嘔
吐及體重下降約三個⽉、營養嚴重不良而就 診入院。請問鑑別診斷之疾病及方法為何 ?
• Benign tumor
• Esophageal cancer
• GERD
• History taking
• PE
• Endoscopy, biopsy, PET-CT, Albumin, tumor markers…
Esophageal Cancer
• Men＞women
• Risk factor: chronic esophageal irritation, alcohol and tobacco
• Symptoms/signs: esophagus ulcers without symptoms, progressive dysphagia , pain, regurgitation with foul breath and hiccups, bleeding, body weight loss
• Staging
• Treatment: CCRT, surgery
• 病人確診為第二期食道癌(T2N1)，護理 照護措施之重點為…
• Procedure preparations: tracheostomy, NG or jejunostomy, CCRT, surgery
• Diet: high calorie, high fat, TPN or PPN
• Dumping syndrome:
20’ ~ post eating
Water between meals
More fat and protein, low carbo
Sit while eating and rest after eating
Case Study #2-2
Mak, Chan, & Chan (2016). Elderly Man with Dysphagia and Weight Loss: A Case Report. iMedPub Journals, 2(1), 11
Case Study #3-1
Atiq, O., & Abrams, G. A. (2014). Case study in gastroenterology & hepatology: An uncommon complication of peptic ulcer disease. Gastroenterology & hepatology, 10(5),
333.
• ⼀位44歲的陳小姐因斷續、強烈的上腹部 灼燒痛感至急診，有時疼痛亦會輻射至背 部。進⼀步了解病史，陳小姐表示曾有噁 心過⼀次，並嘔吐出少量半消化之食物，
但沒有出血的情形。其餘大小便均正常。
過去因不明原因胃痛曾自己服用過含阿斯 匹靈的止痛藥。陳小姐需要什麼要的進⼀
步檢查以釐清那些診斷 ?
• GERD, Peptic ulcers in gastric or duodenum
• Barium swallow/ endoscopy w or w/o biopsy
• 若確診為胃潰瘍，相關醫療措施及護理照護之重
點為何?
• Pharmacologic therapy: antibiotics + PPI (triple therapy) for H. pylori induced; H2 receptor anatagonists + PPI for NSAIDS induced and other
• Stress reduction and rest
• Smoking cessation
• Dietary modification: lower stimulation
• Surgery
• Recurrence rate
Case Study #3-2
Atiq, O., & Abrams, G. A. (2014). Case study in gastroenterology & hepatology: An uncommon complication of peptic ulcer disease. Gastroenterology & hepatology, 10(5),
333.
Case Study #4-1
By Cleveland Clinic Center for Continuing Education
• 50歲男性在凌晨三點因劇烈、突發性的 腹痛被送至急診，此疼痛感多在腹部中 上段，有時輻射至左肩及後背。病人候 診時多次嘔吐，嘔吐過後疼痛並未緩 解，其最不可能的診斷為 ?
A.Acute pancreatitis B.Myocardial infarction C.Penetrating ulcer D.Acute appendicitis
Pancreatitis
• Sudden inflammation of the pancreas that may be mild or life threatening
• Possible causes: gallstones, alcohol abuse
• Symptoms: severe abdominal pain (movement worsen the pain, hard to relief even with opioids), N/V, shallow and quick HR and breathing, fever, low blood pressure
• Diagnosis: blood test (amylase and lipase) and image (x-ray, ultrasound, CT)
• 理學檢查發現其血壓為110/60 mmHg，心跳每分110下，呼吸每分24 下，體溫攝氏38度。聽診肺底有輕微 羅音、無心雜音、腸音每分1-2下，觸 診腹部時腹部僵硬且身體弓起。專科護 理師協助安排的下列檢查中，何者之優 先順序可以較後面?
A.CT scan of the abdomen with contrast B.Electrocardiogram
C.Troponin
Case Study #4-2
By Cleveland Clinic Center for Continuing Education
Nursing Care for Pancreatitis
• Pain control: Demerol
• Nutrition: IV with NPO (at least a couple of days)
• Decrease stimulation: Parasympathetic, gastric secretion, NG free
drainage/decompression
• Monitor blood sugar and bleeding
• Recovery stage: low protein and fat, high carbohydrate, avoid alcohol and tobacco
Ranson’s Criteria for Predicting the Prognosis and Mortality of Acute
Pancreatitis
At admission:
• Age in years > 55 years
• WBC count > 16000 cells/mm3
• Blood glucose > 11 mmol/L (> 200 mg/dL)
• Serum AST > 250 IU/L
• Serum LDH > 350 IU/L Within 48 hours:
• Serum calcium < 2.0 mmol/L (< 8.0 mg/dL)
• Hematocrit fall > 10%
• Oxygen (hypoxemia PaO2< 60 mmHg)
• BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration
• Base deficit (negative base excess) > 4 mEq/L
• Sequestration of fluids > 6 L
Take-home Points
• Assessment:
– Four divisions: palpation and auscultation – 4 major functions: time and locations
– Symptoms: color, referral pain, murphy’s sign, Rovsing sign, psoas sign
• Nursing care and interventions:
– Cancer screening – Intubation: aims, ostomy care – Nutrition modalities: TPN, PPN
– Disease/symptom specific interventions: GERD, esophageal cancer, gastric ulcers, pancreatitis, dumping syndrome
