Gastrostomy / Gastrectomy /

hemorrhoidectomy /
gastrointestinal bypass
Gastrostomy is the creation of an artificial external opening into the stomach for
nutritional support or gastric decompression. Typically this would include an incision in
the patient's epigastrium as part of a formal operation. It can be performed through
surgical approach, percutaneous approach by interventional radiology, percutaneous
endoscopic gastrostomy or percutaneous ultrasound gastrostomy.

Preoperative Nursing management

1. Patient Education

 Teach breathing and coughing exercises

 Encouraging mobility and active body movement (turning, change position)
leg and foot exercise.
 Explaining pain management
 Teaching cognitive coping strategies

1. Managing nutrition and fluids

 Withholding food and fluid before surgery prevent aspiration

  Fasting period of 8 hrs or more is a recommended for a meal that includes
fried or fatty foods.

1. Preparing the skin

2. Immediate pre operative nursing intervention

 Administering pre anesthetic medication.

 Maintaining the pre operative record (final checklist, consent form and
identification).

Prior to the operation, the doctor will perform an endoscopy and take x rays of the
gastrointestinal tract. Blood and urine tests will also be performed, and the patient may
meet with the anesthesiologist to evaluate any special conditions that might affect the
administration of anesthesia.

Post- operative Nursing management

1. Assessing the patient: Frequent assessment of the patient Oxygen saturation,

pulse volume and regularity, depth and nature of respiration, skin color, depth
of consciousness.
2. Maintaining a patent airway
3. Maintaining cardiovascular stability
4. Relieving pain and anxiety
5. Assessing and managing the surgical site
6. Assessing and managing gastrointestinal function.
7. Assessing and managing voluntary voiding
8. Encourage Activity

Immediately after the operation, the patient is fed intravenously for at least 24 hours.
Once bowel sounds are heard, indicating that the gastrointestinal system is working, the
patient can begin clear liquid feedings through the tube. The size of the feedings is
gradually increased.
Patient education concerning use and care of the gastrostomy tube is very important.
Patients and their families are taught how to recognize and prevent infection around the
tube; how to insert food through the tube; how to handle tube blockage; what to do if the
tube pulls out; and what normal activities can be resumed.

Post operative Complications:

 1. Infection
2. Shock
3. Hemorrhage
4. Deep Vein Thrombosis
5. Pulmonary Embolism
6. Urinary Retention
7. Intestinal Obstruction
8. Dislodgement of the tube
9. stomach bloating, nausea and vomiting

Gastrectomy

A gastrectomy is the surgical removal of all or part of the stomach. The stomach is a J-
shaped organ in the upper abdomen. It is part of the digestive system, which processes
nutrients ( vitamins, minerals, carbohydrates, fats, proteins, and water) in foods that are
eaten and helps pass waste material out of the body. Food moves from the throat to the
stomach through a hollow, muscular tube called the esophagus. After leaving the
stomach, partly-digested food passes into the small intestine and then into the large
intestine.
Gastrectomy is performed for the following conditions:
Stomach Cancer
Bleeding Gastric Ulcers
Perforation (Hole) in the Stomach Wall
Benign Polyps
Pre-operative Care

1. In the preoperative period, the nurse per- forming the patient assessment
should verify the patient’s identity and the procedure. This should be done
verbally with the patient and by checking the patient’s name band
2. Aims to prepare the patient holistically, act as the patient’s advocate by
assessing their needs and identifying symptoms, risk factors and co-
morbidity that might impact the surgery and it’s recovery.
3. Education about the surgery. Having good pre-operative education decreases
anxiety and improves post-operative outcomes.
4. Try to tailor the information according to the patient’s needs. Use written
materials, pictures, videos
5. Help alleviate anxiety and fear (breathing techniques, music therapy, further
education)
6. Post-operative planning.

 Expected pain or discomfort, and how it will be treated

 Deep breathing exercises to reduce Pulmonary Complications
 Encouraged mobility to reduce risks of DVT, and Pressure Sores

7. Nutrition and diet (Some surgeries require specific diets post-op)

8. Care of the incision
9. Lifestyle changes (in case of stomas etc.)
10. Discharge planning (if the patient requires help at home)
11. Physiology Assessment (VS, O2 sat, BP,CBG,BMI and etc.)
12. Most surgeries require scans, ECG or other tests to be done. Check for any
specific surgery tests, and make sure that the patient gets a date to have
them done.
13. Nutritional Status. As a global standard, patients need to fast at least 6 hours
before the surgery. The fasting period reduces risk of aspiration during
intubation. However, you need to check if the surgery has specific dietary
requirements such as only allowing fluids a couple of days before the surgery
(usually happens in stomach or bowel surgery). Once you have the fasting
period and specific diets sorted, you need to ensure that your patients are
still getting adequate hydration. So discuss with the medical team regarding
IVI

Immediate pre-operative nursing care

An identification bracelet
An allergy bracelet (if applicable)
Changed into the hospital gown
Removed all jewelry/ foreign teeth/ hearing aid/ contact lenses/ make-up
A marked and shaved surgical site
Not been eating or drinking for a minimum of 6hours before the surgery
Ongoing IV fluid for hydration (Specific protocols apply for diabetic patients)
The patient’s file
Make sure that your patient’s file contains:
All medical notes and treatment charts
A signed consent form
Pre-operative medical assessment
An ECG done in the last 2weeks
Blood results, and Blood type from the past 3 days (often found online)
Pre-operative checklist

Post-operative Care

1. The patient is placed in semi-fowler's position when conscious.

2. Administer Intravenous fluids, antibiotics and analgesics
3. Correction of Anemia and Electrolyte
4. Chest physiotherapy
5. Early ambulation, DVT prophylaxis
6. NG tube
7. Graded oral sips
8. Feeding

Complication
Early

1. Intragastric hemorrhage
2. Extragastric hemorrhage
3. Duodenal blow out/ stump leakage
4. Stomal obstruction
5. Afferent loop obstruction
6. Jejunal loop herniation
7. Gastric remnant necrosis
8. Post operative pancreatitis
9. Common bile duct injury
10. Omental Infarction

Late
 1. Early dumping syndrome
2. Late dumping syndrome
3. Recurrent ulcers
4. Small gastric remnant syndrome
5. Gastrojejunocolic fistula
6. Internal hernia
7. Jejunogastric Intussusception
8. Chronic afferent loop obstruction
9. Chronic efferent loop obstruction

Hemorrhoidectomy is an operation to remove severe hemorrhoids' (also known as

piles). It is usually a day procedure and is usually carried out under a general
anesthetic. The procedure is common and generally safe, but recovery after the surgery
can take a few weeks and can be painful.
Pre-operative care

1. general physical and careful anorectal-colonic examination, including

proctosigmoidoscopy, to exclude such conditions as anorectal-colonic cancer,
ulcerative colitis, regional enteritis and amebiasis, together with such
constitutional diseases as blood dyscrasia, diabetes, hepatitis and kidney
disease.
2. The patient is prepared psychologically to accept surgical treatment for
his/her hemorrhoids.
3. All questions regarding post-operative pain, the first bowel movement, and so
on, are answered frankly, and the need for co-operative effort explained.
Preparation before surgery.
4. A complete blood count and urinalysis and other necessary laboratory studies
should be done.
5. . An enema must be given.
6. Administer sedative preferably a barbiturate, as ordered to ensure a good
night's sleep.
7. The perianal area is shaved and cleansed with an antiseptic detergent.
8. Three hours before operation, the patient is asked to attempt a bowel
evacuation. He then receives a second enema.
9. Two hours before operation, the patient is given pre-anesthetic sedation
consisting of a barbiturate, followed by morphine sulfate with scopolamine or
atropine one hour later.
10. Immediately before surgery, a skin antiseptic is applied and a long-lasting oil
soluble anesthetic is injected perianally. It relieves muscle spasm-a principal
cause of postoperative pain and urinary retention.

Post-operative Care
In the Surgical Ward:

1. Instruct the patient to remain flat on bed.

2. Monitor VS till stable.
3. Inspect dressing frequently for bleeding.
4. Inform physician when excessive bleeding occur or sign of impending shock.
5. Administer pain medication when required to prevent severe pain due to
rectal spasm and prevent discomfort.
6. The patient may be given a general diet and encouraged to drink plenty of
water to keep the stool soft and easy to move.
7. Administer medication to soften the stool, allowing the patient to pass it more
easily and with less disturbance to the operative wound. This reduces the
pain and lets the wound get on with healing without stopping a normal bowel
habit.
8. Perform wound dressing daily and after each passing out of stool.
 9. Assist the patient to take a hot sitz bath in plain water and soak for at least 20
minutes three times a day. It is the most effective method of controlling pain.
10. Encourage the patient to do what feels comfortable for him/her to do after
surgery. Just do not sit for longer than 10 to 15 minutes at a time. He or she
sit on a foam pillow but avoid rubber rings or "donuts."

Complication:

 excessive bleeding
 difficulty urinating
 infection, which might cause a high temperature
 loss of control of the rectal sphincter
 narrowing or damage to the anal canal

Complication:

 excessive bleeding
 difficulty urinating
 infection, which might cause a high temperature
 loss of control of the rectal sphincter
 narrowing or damage to the anal canal

Gastric bypass is a surgical procedure that can help people with obesity to lose weight
and improve their health. It decreases the size of the stomach and changes the way the
stomach and small intestine absorb food, making it easier to lose weight. This
procedure is also called a Roux-en-Y gastric bypass.
Gastric bypass, also called Roux-en-Y (roo-en-wy) gastric bypass, is a type of weight-
loss surgery that involves creating a small pouch from the stomach and connecting the
newly created pouch directly to the small intestine. After gastric bypass, swallowed food
will go into this small pouch of stomach and then directly into the small intestine, thereby
bypassing most of your stomach and the first section of your small intestine.
Gastric bypass is one of the most commonly performed types of bariatric surgery.
Gastric bypass is done when diet and exercise haven't worked or when you have
serious health problems because of your weight.
Pre-operative Nursing Care

1. Informed patient consent and motivation. Make sure that the consent is
signed.
2. Review NPO status
3. Bowel prep if indicated
4. Baseline Vital signs
5. Review or draw labs
6. Administer Medication (IVF and Antibiotics)
7. Insert IV and Foley catheter.
8. Remove jewelries , make up, nail polish, dentures, hearing aid, glasses and
contact lenses.
9. Advised Family to stay in the waiting room.
10. Interdisciplinary risk assessment
11. Optimized physical condition and medication
12. A detailed medical history and a thorough clinical assessment of the patient’s
physical and psychological condition are of utmost importance, as it may help
to identify patient risk factors for imminent morbidity or mortality.
13. Routine diagnostic tests
  Laboratory tests
 Standard blood count
 International normalized ratio
 Activated partial thromboplastin time (aPTT)
 Concentrations of sodium, potassium, creatinine and glucose
 Electrocardiography
 Preoperative 12-channel electrocardiography (ECG) allows for screening of
as-yet undetected cardiac disorders.
 Chest radiography
 Echocardiography

Post operative Care

In the Medical-Surgical Ward

1. Assess level of sensation

2. Perform head to toe assessment
3. Monitor frequent VS
4. Assess for Nausea and Vomiting (high for aspiration risk)
5. Manage lines and drains
6. Teach how to use Patient Controlled Analgesia
7. Teach/ Demonstrate Incentive Spirometry and extended lung exercises.
8. NPO advance to diet as tolerated. (Early oral nutrition)
9. Apply sequential compression device for DVT.
10. Encourage early ambulation
11. Removal of tubes, catheters and drains
12. Assess and early detection of complication.

Complication
Risks associated with the surgical procedure are similar to any abdominal surgery and
can include:

 Excessive bleeding
 Infection
 Adverse reactions to anesthesia
 Blood clots
 Lung or breathing problems
 Leaks in your gastrointestinal system

Longer term risks and complications of gastric bypass can include:

 Bowel obstruction
 Dumping syndrome, causing diarrhea, nausea or vomiting
 Gallstones
  Hernias
 Low blood sugar (hypoglycemia)
 Malnutrition
 Stomach perforation
 Ulcers
 Vomiting

Rarely, complications of gastric bypass can be fatal.

ADMINISTERING NASOGASTRIC TUBE FEEDING

DEFINITION
Feeding a client through a nasogastric tube.

OBJECTIVE
To introduce liquid food and medications into the stomach through a tube when a patient is unable to take food into
a normal manner.

EQUIPMENT
Correct amount of feeding solution
20-50 ml syringe or Asepto syringe
Measuring glass
Water (60 ml, unless specified)
Kidney basin
Mouth wipes
Stethoscope
NG Tube

Steps Rationale Satisfactory Unsatisfactory Not Done

( 2 points) (1 point) (0 point)
1. Assess Safety of the scene

2. Provide privacy and dignity NGT feeding is embarrassing to some

clients
3. Perform Hand Hygiene

4. Introduce self and state reason for visit

5. Confirm patient’s identity

6. Check Allergies
7. Explain procedure
8. Gain consent
9. Assist client to a fowler’s position in bed
and sitting position on chair. If
contraindicated, slightly elevate head
and place in right side lying position
10. Assess tube placement
11. Assess residual feeding contents
12. Administer the feeding.
When using a bulb syringe:
a) Remove the bulb from the syringe
and connect the syringe to a pinched or
clamped NGT
13. b) Add feeding to the syringe barrel and
permit the feeding to flow in slowly
14. Rinse the feeding tube by instilling 50-
60 ml of water
These positions promote gravitational flow
of solutions and prevent aspiration of fluids
into the lungs
Ensure patency of the tube and prevent
aspiration
This is done to evaluate absorption of the
last feeding. If 50 ml or more of undigested
formula aspirated in adults and 10 ml or
more in infants, check the doctor’s order or
agency policy before giving the feeding.
To prevent excess air from entering the
stomach causing distention
A quickly administered feeding can cause
flatus, crampy pain and reflux vomiting.
Water cleans the lumen of the tube and
prevents future blocking by sticky formula.
This should be done before the feeding
solution has drained from the neck of a bulb
syringe to prevent introduction of air.
15. Clamp and cover the feeding tube. To prevent leakage and air from entering
the tube.

16. Ensure client comfort and safety Ask client to remain sitting or in fowler’s
position for 30 minutes to facilitate digestion
and prevent potential aspiration

17. Dispose of equipment appropriately.

18. Wash hands

19. Document relevant information. Feeding, time given, duration and client’s
reaction

20. Monitor client for possible problem.

Total Score (40 points)

Name of Student: _________________________________

Score: __________________________________________
Comments: ______________________________________

Rubrics

Satisfactory 2 points Performs the steps or task according to the standard procedure or guidelines
Unsatisfactory 1 point Performs the steps and task but unable to do it according to standard guidelines
Not Done 0 point Unable to perform the task
Diagnostic procedures GIT
Diagnostic Tests (Preparation,
Procedures and Care of Patient) in
GI Disturbances
Non-Invasive
1. Barium enema can be used to detect the presence of polyps, tumors, or other lesions
of the large intestine and demonstrate any anatomic abnormalities or malfunctioning of
the bowel. After proper preparation and evacuation of the entire colon, each portion of
the colon may be readily observed. The procedure usually takes about 15 to 30
minutes, during which time x-ray images are obtained.
2. Computed Tomography scan provides cross-sectional images of abdominal organs
and structures. Multiple x-ray images are taken from numerous angles, digitized in a
computer, reconstructed, and then viewed on a computer monitor.
3. Magnetic Resonance Imaging is used in gastroenterology to supplement
ultrasonography and CT. This noninvasive technique uses magnetic fields and radio
waves to produce images of the area being studied. The use of oral contrast agents to
enhance the image has increased the application of this technique for the diagnosis of
GI diseases. It is useful in evaluating abdominal soft tissues as well as blood vessels,
abscesses, fistulas, neoplasms, and other sources of bleeding.
4.Positron Emission Tomography scans produce images of the body by detecting the
radiation emitted from radioactive substances. The radioactive substances are injected
into the body IV and are usually tagged with radioactive isotopes of oxygen, nitrogen,
carbon, or fluorine (Bontrager & Lampignano, 2014).
5. Scintigraphy (radionuclide testing) relies on the use of radioactive isotopes (i.e.,
technetium, iodine, and indium) to reveal displaced anatomic structures, changes in
organ size, and the presence of neoplasms or other focal lesions such as cysts or
abscesses.
6. Abdominal Ultrasonography is a noninvasive diagnostic technique in which high-
frequency sound waves are passed into internal body structures, and the ultrasonic
echoes are recorded on an oscilloscope as they strike tissues of different densities. It is
particularly useful in the detection of an enlarged gallbladder or pancreas, the presence
of gallstones, an enlarged ovary, an ectopic pregnancy, or appendicitis.
Endoscopic Procedures
1. Fibroscopy/Esophagogastroduodenoscopy allows direct visualization of
the esophageal, gastric, and duodenal mucosa through a lighted endoscope
(gastroscope.
2. Fiberoptic Colonoscopy -Historically, direct visualization of the bowel was the only
means to evaluate the colon, but virtual colonoscopy (also known as CT colonography)
is now available. Virtual colonoscopy provides a computer-simulated view of the air-
filled distended colon using conventional CT scanning (ACS, 2015c).
3. Anoscopy, Proctoscopy, and Sigmoidoscopy. Endoscopic examination of the anus,
rectum, and sigmoid and descending colon is used to evaluate chronic diarrhea, fecal
incontinence, ischemic colitis, and lower GI hemorrhage and to observe for ulceration,
fissures, abscesses, tumors, polyps, or other pathologic processes.
Small Bowel Studies
Several methods are available for visualization of the small intestine, including
1. Capsule endoscopy allows the noninvasive visualization of the mucosa throughout
the entire small intestine.
2, Double-balloon enteroscopy has made it possible to visualize the mucosa of the
entire small bowel as well as carry out diagnostic and therapeutic interventions (ASGE,
2014).
Manometry and electrophysiologic studies are methods for evaluating patients with
GI motility disorders.
1. Manometry test measures changes in intraluminal pressures and the coordination of
muscle activity in the GI tract with the pressures transmitted to a computer analyzer.
2. Esophageal manometry is used to detect motility disorders of the esophagus and the
upper and lower esophageal sphincter
Gastric Analysis, Gastric Acid Stimulation Test, and pH Monitoring analysis of the
gastric juice yields information about the secretory activity of the gastric mucosa and the
presence or degree of gastric retention in patients thought to have pyloric or duodenal
obstruction. It is also useful for diagnosing Zollinger–Ellison syndrome or atrophic
gastritis
Laparoscopy (Peritoneoscopy) With the tremendous advances in minimally invasive
surgery, diagnostic laparoscopy is efficient, cost-effective, and useful in the diagnosis of
GI disease.

Serum Laboratory Studies

Initial diagnostic tests begin with serum laboratory studies, including but not limited to
CBC, complete metabolic panel, prothrombin time/partial thromboplastin time,
triglycerides, liver function tests, amylase, and lipase; possibly, more specific studies
may be indicated, such as carcinoembryonic antigen (CEA), cancer antigen (CA) 19–9,
and alpha-fetoprotein, which are sensitive anhepatocellular carcinomas, respectively.
Stool Tests
Basic examination of the stool includes inspecting the specimen for consistency, color,
and occult (not visible) blood. Additional studies, including fecal urobilinogen, fecal fat,
nitrogen, Clostridium difficile, fecal leukocytes, calculation of stool osmolar gap,
parasites, pathogens, food residues, and other substances, require laboratory
evaluation.
Breath Tests
The hydrogen breath test was developed to evaluate carbohydrate absorption, in
addition to aiding in the diagnosis of bacterial overgrowth in the intestine and short
bowel syndrome. This test determines the amount of hydrogen expelled in the breath
after it has been produced in the colon (on contact of galactose with fermenting
bacteria) and absorbed into the blood)

Additional tests:
1.Xray studies to include a -, flat plate of the abdomen, Ultrasound, MRI, CT scan, etc.,
laboratory tests such as T3, T4, TSH, FBS, CBG, PPBS, OGTT, IVGTT, Urine for sugar
and ketone, etc.