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GASTROINTESTINAL PROCEDURES

Gastrointestinal (GI) Series
GASTROINTESTINAL
PROCEDURES The introduction of barium, an opaque medium, into
the upper GI tract via the mouth, gastrostomy tube,
or nasogastric tube to visualize the area by x-ray
methods

Nursing care
1. Explain procedure to client
2. Maintain the client NPO after midnight
3. Inform client that the stool will be white or pink for
NIO C. NOVENO, RN, MAN
24 to 72 hours after procedure
4. Encourage fluids and administer cathartics as
ordered
5. Evaluate client's response to procedure

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Barium Enema
Barium Enema Nursing care

1. Explain procedure to the client
2. Prepare the client for the procedure by:
A. The introduction of a. Administering cathartics and/or enemas as
barium, an opaque ordered to evacuate the bowel
medium, into the b. Maintaining the client NPO for 8 to 10 hours prior
intestines for the to the test
purpose of x-ray 3. Inspect stool after the procedure for the
visualization for presence of barium
pathologic changes 4. Administer enemas and/or cathartics as
ordered if the stool does not return to normal
5. Encourage fluid intake
6. Evaluate client's response to procedure

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DEAN NIO C. NOVENO, RN, MAN 1
GASTROINTESTINAL PROCEDURES

Colostomy Irrigation and Care Colostomy irrigation
1. Instillation of fluid into the lower colon
via a stoma on the abdominal wall to
stimulate peristalsis and facilitate the
expulsion of feces
2. Cleansing the colostomy stoma and
collection of feces
o sigmoid colon will tend to produce formed
stools
o transverse or ascending colostomy will
produce less formed stools

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Colostomy Irrigation and Care Colostomy Irrigation and Care
Nursing care Nursing care
1. Secure a physician's order
6. Provide privacy while waiting for fecal returns or
2. Irrigate the stoma at the same time each day to permit the client to ambulate with the collection bag
approximate normal bowel habits in place to further stimulate peristalsis
3. Insert a well-lubricated catheter tip into the 7. Clean the stoma
stoma o if excoriation occurs, a soothing ointment may be
o 7 to 10 cm in the direction of the remaining bowel ordered
o as the solution is allowed to flow, the catheter may be 8. Apply a colostomy bag or gauze dressing
advanced 9. Teach the client to control odor when necessary
4. Hold the irrigating container o place two aspirin tablets (or commercially available
o height: 30.5 to 45.7 cm (12 to 18 inches) deodorizers) in the colostomy bag
o temperature: 105oF (40.5oC) o take bismuth subcarbonate tablets orally to control
5. Clamp tubing or temporarily lower the container odor
if the client complains of cramping 10. Evaluate client's response to procedure

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DEAN NIO C. NOVENO, RN, MAN 2
GASTROINTESTINAL PROCEDURES

Colostomy bag Endoscopy
The visualization of the esophagus, stomach,
gallbladder, pancreas, colon, or rectum using a
hollow tube with a lighted end

1. Gastroscopy: stomach
2. Esophagoscopy: esophagus
3. Sigmoidoscopy: sigmoid colon
4. Proctoscopy: rectum
5. Endoscopic retrograde
cholangiopancreatography (ERCP)
One-piece Two-piece

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Gastric endoscopy Endoscopy

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DEAN NIO C. NOVENO, RN, MAN 3
GASTROINTESTINAL PROCEDURES

Sigmoidoscopy Colonoscopy

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Endoscopic retrograde Endoscopy
cholangiopancreatography (ERCP) Nursing care

1. Obtain an informed consent for the procedure
2. If rectal examination is indicated, administer
cleansing enemas prior to the test
3. Restrict diet (NPO) prior to procedure
4. Following the procedure, observe for bleeding,
changes in vital signs, or nausea
5. If the throat is anesthetized (as for a
gastroscopy or esophagoscopy), check for the
return of gag reflex before offering oral fluids
6. Evaluate client's response to procedure

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DEAN NIO C. NOVENO, RN, MAN 4
GASTROINTESTINAL PROCEDURES

Enemas Enemas
1. Tap-water enema (TWE): introduction of
water into the colon to stimulate
evacuation
2. Soapsuds enema (SSE): introduction of
soapy water into the colon to stimulate
peristalsis by bowel irritation
o contraindicated as a preparation for an
endoscopic procedure
• may alter the appearance of the mucosa

3. Hypertonic enema: commercially
prepared small-volume enema that works
on the principle of osmosis
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Enemas
Enemas Nursing care

4. Harris flush or drip: introduction of water 1. Explain procedure to client
into the colon as tolerated and subsequent
repeated drainage of that water through the 2. Provide privacy
same tubing to facilitate passage of flatus o place in side-lying position
5. High colonic irrigation: introduction of 3. Obtain the correct solution
water into the upper portion of the colon to 4. Lubricate the tip of a rectal catheter
facilitate complete fecal evacuation
with water-soluble jelly
6. Instillation: introduction of a liquid (usually
mineral oil) into the colon to facilitate fecal 5. Insert the catheter 10 to 15 cm (4 to
activity through lubricating effect 6 inches) into the rectum

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DEAN NIO C. NOVENO, RN, MAN 5
GASTROINTESTINAL PROCEDURES

Enemas
Nursing care Gastric Analysis
6. Allow the solution to enter slowly 1. Analysis of stomach contents for the
o keep it no more than 30.5 to 45.7 cm (12 to presence of abnormal constituents or
18 inches) above the rectum lack of normal constituents such as
o temporarily interrupt flow if cramps occur hydrochloric acid, blood, acid-fast
7. Allow ample time for the client to expel bacteria, and lactic acid
the enema 2. Acid content is elevated in ulcers,
8. Observe and record the amount and decreased in malignant conditions of
consistency of returns the stomach, and absent in pernicious
9. Evaluate client's response to procedure anemia

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Gastric Analysis
Nursing care Gavage (Tube Feeding)
1. Explain procedure to client 1. Nasogastric
2. Maintain the client NPO prior to the test and a. Placement of a tube through the nose into the
have a nasogastric tube passed at time of stomach, securing it in place with tape
procedure b. Prepared nutritional supplements are
3. Administer histamine or caffeine to stimulate introduced through this tube
hydrochloric acid secretion prior to the
2. Intestinal
procedure if ordered
a. Placement of a tube through the nose into the
4. Obtain stomach contents, secure in an
small intestine, securing it in place with tape
appropriate container, and send to laboratory
b. There is less likelihood of aspiration because
5. Evaluate client's response to procedure
the pyloric sphincter inhibits backflow

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DEAN NIO C. NOVENO, RN, MAN 6
GASTROINTESTINAL PROCEDURES

Gavage (Tube Feeding) Gavage (Tube Feeding)
3. Surgically placed feeding tubes 4. Percutaneous endoscopic gastrostomy
a. Cervical esophagostomy: tube is sutured directly
into the esophagus for clients who have had head (PEG)
and neck surgery a. Stomach is punctured during endoscopy
procedure
b. Gastrostomy: tube is placed directly into stomach
through the abdominal wall and sutured in place b. Does not require general anesthesia or
• used for clients who require tube feeding on a laparotomy
long-term basis
c. Dressing should be changed daily
c. Jejunostomy: tube is inserted directly into the d. Although associated with reduced risks,
jejunum for clients with pathologic conditions of accidental removal and aspiration still
the upper GI tract may occur

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Gavage (Tube Feeding) Gavage (Tube Feeding)
Nursing care Nursing care

1. Verify placement of tube prior to feeding 2. Aspirate contents of stomach prior to
a. Inject a small amount of air into the tube and, feeding to determine residual
with a stethoscope placed over the epigastric
area, listen for the passage of air into the • reinstill to avoid electrolyte imbalance
stomach • withhold feeding if the residual is greater
than 150 ml
b. Aspirate for presence of stomach contents;
reinstill to avoid electrolyte imbalance

c. Test aspirate for acid pH

d. Small-bore tube placement must be verified by
x-ray examination

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DEAN NIO C. NOVENO, RN, MAN 7
GASTROINTESTINAL PROCEDURES

Gavage (Tube Feeding) Gavage (Tube Feeding)
3. Intermittent feeding cont…
3. Intermittent feeding d. Slowly administer the feeding at room or body
a. Position the client so that the head is elevated temperature
during and for 1 hour after the feeding – observe and question the client to determine
tolerance
b. Appropriately verify placement of tube
– the higher the feeding container and the
larger the lumen of the feeding tube, the
more rapid the flow
c. Introduce a small amount of water (30 ml) first to e. Administer a small amount of water to clear the
verify the patency of the tube tube at the completion of the feeding
f. Clamp the tubing and clean the equipment
– the tube should not be allowed to empty during
g. Place client in sitting position for 1 hour after
feeding so that excess air is not forced into the feeding
stomach
– place infant in right side-lying position

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Gavage (Tube Feeding) Gavage (Tube Feeding)
4. Continuous feeding cont…
4. Continuous feeding
d. Appropriately verify placement of tube when adding
a. Place prescribed feeding in gavage bag and prime additional fluid to a continuous feeding
tubing to prevent excess air from entering stomach
e. Flush tube intermittently with water to prevent occlusion
of tube with feeding
b. Set rate of flow
– rate of flow can be manually regulated by setting
f. Monitor for gastric distention and aspiration
drops per minute or mechanically regulated by
– gastric distention and subsequent aspiration are less
using an electric pump frequent

c. Position the client to keep the head elevated g. Discard unused fluid that has been in gavage
throughout the feeding administration bag at room temperature for longer than 4
hours

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DEAN NIO C. NOVENO, RN, MAN 8
GASTROINTESTINAL PROCEDURES

Gavage (Tube Feeding) Gavage (Tube Feeding)
5. Care common for all clients receiving tube feedings cont…
5. Care common for all clients receiving d. When appropriate, encourage the client to chew foods
that will stimulate gastric secretions while providing
tube feedings psychologic comfort
a. Monitor for abdominal distention – chewed food may not be swallowed

– changes in bowel sounds or diarrhea e. Provide special skin care
– if the client has a gastrostomy tube sutured in place,
the skin may become irritated from gastrointestinal
b. Discontinue feeding if nausea and/or enzymes
– if the client has a nasogastric tube, the skin may
vomiting occur become excoriated at point of entry because of
irritation

c. Provide oral hygiene f. Evaluate client's response to the procedure

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Ileostomy Care Ileostomy
The physical care of the ileostomy stoma and surrounding skin

Nursing care
1. Protect the skin from irritation, since the feces will be
liquid because of the anatomic location of the stoma
2. Explain procedure to the client and family and encourage
selfcare
3. Do not irrigate the stoma
4. Affix an appliance with an adequate seal (e.g., karaya) to
prevent accidental leakage around the stoma; the
appliance is generally changed every 2 to 4 days but
emptied every 6 hours
5. Evaluate client's response to procedure

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DEAN NIO C. NOVENO, RN, MAN 9
GASTROINTESTINAL PROCEDURES

Irrigation of Nasogastric
(Levin) Tube Gastric decompression: Levin
1. The Levin tube is commonly used for gastric
decompression
2. Purposes of insertion of a nasogastric tube
include emptying the stomach, obtaining a
specimen for diagnostic purposes, or
providing a means for nourishment
3. Irrigation is the insertion and then removal of
fluid (usually normal saline) to maintain
patency

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Irrigation of Nasogastric (Levin) Tube Irrigation of Nasogastric
Nursing Care (Levin) Tube

1. Check that the order for irrigations has 5. Instill approximately 30 ml of fluid into the
been written by the physician tube
2. Ascertain the patency of the Levin tube 6. Gently withdraw the same volume of fluid as
was instilled
attached to intermittent suction by
o if the client has undergone gastric surgery, the
observing for drainage physician will generally order instillations
 nausea or abdominal discomfort may indicate o irrigation fluid is instilled but not withdrawn
that the tube is occluded o the amount instilled must be subtracted from total
3. Assemble equipment: 30-ml syringe or gastric output
bulb syringe, irrigating solution, and 7. Chart the amount, color, and consistency of
basin for returning fluid drainage
8. Evaluate client's response to procedure
4. Verify placement

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DEAN NIO C. NOVENO, RN, MAN 10
GASTROINTESTINAL PROCEDURES

Paracentesis
Paracentesis Nursing care

The surgical puncture of the peritoneal 1. Explain the procedure; obtain consent
membrane of the abdominal cavity for 2. Have the client void prior to procedure
the purpose of removing fluid to avoid accidental trauma to the
bladder
3. Assist the client to a sitting position
4. Observe for signs of shock
• sudden fluid shifts can result in
hypotension

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Paracentesis
Paracentesis Nursing care

5. Chart the amount and characteristics
of fluid withdrawn
6. Apply a dry sterile dressing to the
puncture site
7. Properly label the specimen if required
and send to the laboratory
8. Evaluate client's response to the
procedure

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DEAN NIO C. NOVENO, RN, MAN 11
GASTROINTESTINAL PROCEDURES

Parenteral Replacement Therapy Parenteral Replacement Therapy
Peripheral parenteral nutrition (PPN) Total Parenteral Nutrition (TPN)
1. Administration of isotonic lipid and 1. Administration of carbohydrates, amino
amino acid solutions through a acids, vitamins, and minerals via a central
vein (usually the superior vena cava)
peripheral vein
2. High osmolality solutions (25% dextrose)
2. Amino acid content should not exceed are administered in conjunction with 5% to
4%; dextrose content should not be 10% amino acids, electrolytes, minerals,
greater than 10% and vitamins
3. Assists in maintaining a positive 3. Assists in maintaining a positive nitrogen
nitrogen balance balance

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Parenteral Replacement Therapy Parenteral Replacement Therapy

Intralipid therapy Total nutrient admixture (TNA or "3 in 1")
1. Infusion of 10% to 20% fat emulsion 1. Combination of dextrose, amino acids
that provides essential fatty acids and lipids in one container; vitamins
and minerals may be added
2. Provides increased caloric intake to 2. Administered through a central line

maintain positive nitrogen balance over 24 hours

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DEAN NIO C. NOVENO, RN, MAN 12
GASTROINTESTINAL PROCEDURES

Parenteral Replacement Therapy
Nursing care Parenteral Replacement Therapy

1. Infuse fluid through a large vein such 3. Precisely regulate the fluid infusion rate; an
intravenous pump should be used if available
as the subclavian because of the high
a. Rapid infusion may result in movement of the
osmolarity of the solution used in TPN fluid into the intravascular compartment
2. Ensure proper placement of the tube • dehydration, circulatory overload, and
hyperglycemia can occur
by chest x-ray examination after
insertion of a catheter; accidental b. Slow infusion may result in hypoglycemia,
pneumothorax can occur during since the body adapts to the high osmolarity of
this fluid by secreting more insulin
insertion • therapy is never terminated abruptly but is
gradually discontinued

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Parenteral Replacement Therapy Parenteral Replacement Therapy

4. Use aseptic technique when handling 6. Utilize a filter for TPN; filters cannot
the infusion or changing the dressing be used for lipids
(in many institutions, only nurses 7. Use surgically aseptic technique when
specially prepared are allowed to changing tubing
change the dressing because of the 8. Record daily weights, and monitor
high risk of infection) urinary sugar and acetone or blood
5. Consult manufacturer's instructions glucose levels frequently
about tubing when administering lipids

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DEAN NIO C. NOVENO, RN, MAN 13
GASTROINTESTINAL PROCEDURES

Parenteral Replacement Therapy Stool Specimens
8. Check laboratory reports daily, especially 1. Stool for guaiac (occult blood): specimen or smear of
stool on a commercially prepared card is analyzed for
glucose, creatine, BUN, and electrolytes the presence of blood
• serum lipids and liver function studies if lipids are • positive results indicate the presence of blood in the
administered stool
• peptic ulcer, gastritis, gastric or colonic carcinoma,
9. Monitor temperature every four hours since colitis, or diverticulitis
infection is the most common complication of
TPN 2. Stools for O and P (ova and parasites): must be sent to
• if the client has a temperature elevation, order the laboratory while still warm for microscopic
examination unless a preservative is available
cultures of blood, urine, and sputum to rule out
other sources of infection
3. Stool culture: specimen or swab of stool is sent in a
10. Evaluate client's response to procedure sterile container for identification of abnormal
bacterial growth

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Stool Specimens
Guaic’s test Nursing care

1. Explain procedure to the client
2. Collect specimen in an appropriate
container
3. Label the container with the client's
name, identification number,
physician, and room number
4. Chart that the specimen was sent and
any unusual assessment of the stool

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DEAN NIO C. NOVENO, RN, MAN 14
GASTROINTESTINAL PROCEDURES

GASTROINTESTINAL
PROCEDURES

THANK YOU!

NIO C. NOVENO, RN, MAN

DEAN NIO C. NOVENO, RN, MAN 15