G
Impaired Gas Exchange
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Monitor respiratory rate, depth, and ease of respiration. Watch for use of accessory muscles and nasal flaring. Normal respiratory rate is 10 to 20 breaths/min in the adult (Jarvis, 2012). EBN: A study demonstrated that when the respiratory rate exceeds 30 breaths/min, along with other physiological measures, a significant cardiovascular or respiratory alteration exists (Hagle, 2008).
• Auscultate breath sounds every 1 to 2 hours. Listen for diminished breath sounds, crackles, and wheezes. The presence of crackles and wheezes may alert the nurse to airway obstruction, which may lead to or exacerbate existing hypoxia. In severe exacerbations of chronic obstructive pulmonary disease (COPD), lung sounds may be diminished or distant with air trapping (Bickley & Szilagyi, 2009).
• Monitor the client’s behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. Changes in behavior and mental status can be early signs of impaired gas exchange. In the late stages the client becomes lethargic and somnolent (Schultz, 2011).
Monitor oxygen saturation continuously using pulse oximetry. Correlate arterial oxygen saturation blood gas results with pulse oximetry An oxygen saturation of less than 90% (normal: 95% to 100%) or a partial pressure of oxygen of less than 80 mm Hg (normal: 80 to 100 mm Hg) indicates significant oxygenation problems. Pulse oximetry is useful for tracking and/or adjusting supplemental oxygen therapy for clients with COPD (GOLD, 2011).
• Observe for cyanosis of the skin; especially note color of the tongue and oral mucous membranes. Central cyanosis of the tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in the extremities may be due to activation of the central nervous system or exposure to cold and may or may not be serious (Bickley & Szilagyi, 2009).
• Position the client in a semirecumbent position with the head of the bed at a 30- to 45-degree angle to decrease the aspiration of gastric, oral, and nasal secretions EBN: Evidence shows that mechanically ventilated clients have a decreased incidence of VAP if the client is placed in a 30- to 45-degree semirecumbent position as opposed to a supine position (Grap, 2009; Siela, 2010; Vollman & Sole, 2011).
• If the client has unilateral lung disease, position with head of bed at 30 to 45 degrees with “good lung down” for about 1 hour at a time (Marklew, 2006).
If the client is acutely dyspneic, consider having the client lean forward over a bedside table, resting elbows on the table if tolerated. Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm (Langer et al, 2009). This is called the tripod position and is used during times of distress, including when walking, leaning forward on the walker.
• Help the client deep breathe and perform controlled coughing. Have the client inhale deeply, hold the breath for several seconds, and cough two or three times with the mouth open while tightening the upper abdominal muscles as tolerated. Controlled coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective. If the client has excessive fluid in the respiratory system, refer to the care plan Ineffective Airway clearance.
Monitor the effects of sedation and analgesics on the client’s respiratory pattern; use judiciously. Both analgesics and medications that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the sympathetic nervous system discharge with physical and psychological distress that accompanies hypoxia (Brennan & Mazanec, 2011).
• Schedule nursing care to provide rest and minimize fatigue. The hypoxic client has limited reserves; inappropriate activity can increase hypoxia.
Administer humidified oxygen through an appropriate device (e.g., nasal cannula or Venturi mask per the physician’s/provider order); aim for an oxygen (O2) saturation level of 90% oxygen saturation or above. Watch for onset of hypoventilation as evidenced by increased somnolence. There is a fine line between ideal or excessive oxygen therapy; increasing somnolence is caused by retention of carbon dioxide (CO2) leading to CO2 narcosis (Wong & Elliott, 2009). Promote oxygen therapy during a COPD exacerbation. Supplemental oxygen should be titrated to improve the client’s hypoxemia with a target of 88% to 92% oxygen saturation (GOLD, 2011).
• Assess nutritional status including serum albumin level and body mass index (BMI).Weight loss in a client with COPD has a negative effect on the course of the disease; it can result in loss of muscle mass in the respiratory muscles, including the diaphragm, which can lead to respiratory failure (Odencrants, Ehnfors, & Ehrenbert, 2008).
• Assist the client to eat small meals frequently and use dietary supplements as necessary. For some clients, drinking 30 mL of a supplement such as Ensure or Pulmocare every hour while awake can be helpful.
• If the client is severely debilitated from chronic respiratory disease, consider the use of a wheeled walker to help in ambulation.
Watch for signs of psychological distress including anxiety, agitation, depression, and insomnia. Refer for counseling as needed (Corbridge et al, 2012). EBN: A study showed that COPD clients were well aware of the stigma associated with having their disease, and the prevalent blaming from others, and health care personnel related to smoking (Berger, Kapella, & Larson, 2011).
Refer the COPD client to a pulmonary rehabilitation program. Pulmonary rehabilitation is now considered a standard of care for the client with COPD (Corbridge et al, 2012; GOLD, 2011; Nici et al, 2009).
Critical Care
Assess and monitor oxygen indices such as the PF ratio (FIO2:pO2), venous oxygen saturation/oxygen consumption (SVO2 or ScVO2) (Burns, 2011; Headley & Guiliano, 2011).
If the client has adult respiratory distress syndrome with difficulty maintaining oxygenation, consider positioning the client prone with the upper thorax and pelvis supported, allowing the abdomen to protrude. Monitor oxygen saturation and turn back to supine position if desaturation occurs. EBN & EB: Oxygenation levels have been shown to improve in the prone position, probably due to decreased shunting and better perfusion of the lungs (Vollman & Powers, 2011). Prone ventilation significantly reduced mortality in clients with severe acute hypoxemic respiratory failure, but not in clients with less severe hypoxemia (Sud et al, 2010). If the client becomes ventilator dependent, refer to the care plan Impaired spontaneous Ventilation.
Geriatric:
Use central nervous system (CNS) depressants carefully to avoid decreasing respiration rate. An elderly client is prone to respiratory depression.
• Recognize that the elderly have decreased pulmonary function with age, and that results in decreased gas exchange and pulmonary reserve function. Also that the elderly are more vulnerable to develop pneumonia because of decreased immune function. EB: A study demonstrated that frail elderly are more prone to respiratory impairment shown by spirometry, and also have increased mortality (Vaz Fragoso et al, 2012).
Home Care:• Work with the client to determine what strategies are most helpful during times of dyspnea. Educate and empower the client to self-manage the disease associated with impaired gas exchange. EBN & EB: A study found that use of oxygen, self-use of medication, and getting some fresh air were most helpful in dealing with dyspnea (Thomas, 2009). Evidence-based reviews have found that self-management offers COPD clients effective options for managing the illness, leading to more positive outcomes (Kaptein et al, 2008).
Collaborate with physicians regarding long-term oxygen administration for chronic respiratory failure clients with severe resting hypoxemia. Administer long-term oxygen therapy greater than 15 hours daily for pO2 less than 55 or saO2 at or below 88% (Corbridge et al, 2012; GOLD, 2011). Long term oxygen therapy has been shown to increase survival and improve hemodynamics, hematology, exercise capacity, lung mechanics, mental status, motor speed, and hand grip strength (Corbridge et al, 2012).
• Assess the home environment for irritants that impair gas exchange. Help the client to adjust the home environment as necessary (e.g., install an air filter to decrease the level of dust).
• Assist the client with identifying and avoiding situations that exacerbate impairment of gas exchange (e.g., stress-related situations, exposure to pollution of any kind, proximity to noxious gas fumes such as chlorine bleach). Irritants in the environment decrease the client’s effectiveness in accessing oxygen during breathing.
• Refer to GOLD guidelines for management of home care and indications of hospital admission criteria (GOLD, 2011).
• Instruct the client to keep the home temperature above 68° F (20° C) and to avoid cold weather. Cold air temperatures cause constriction of the blood vessels, which impairs the client’s ability to absorb oxygen.
• Instruct the client to limit exposure to persons with respiratory infections. Viruses, bacteria, and environmental pollutants are the main causes of exacerbations of COPD (Barnett, 2008).
• Instruct the family in the complications of the disease and the importance of maintaining the medical regimen, including when to call a physician.
• When respiratory procedures are being implemented, explain equipment and procedures to family members, and provide needed emotional support. Family members assuming responsibility for respiratory monitoring often find this stressful.
• When electrically based equipment for respiratory support is being implemented, evaluate home environment for electrical safety, proper grounding, and so on. Ensure that notification is sent to the local utility company, the emergency medical team, and police and fire departments. Notification is important to provide for priority service.
• Support the family of the client with chronic illness. Severely compromised respiratory functioning causes fear and anxiety in clients and their families. Reassurance from the nurse can be helpful.
Client/Family Teaching and Discharge Planning:
• Teach the client how to perform pursed-lip breathing and inspiratory muscle training, and how to use the tripod position. Have the client watch the pulse oximeter to note improvement in oxygenation with these breathing techniques. EB: Studies have demonstrated that pursed-lip breathing was effective in decreasing breathlessness and improving respiratory function (Faager, Ståhle, & Larsen, 2008). A systematic review found that inspiratory muscle training was effective in increasing endurance of the client and decreasing dyspnea (Langer et al, 2009).
• Teach the client energy conservation techniques and the importance of alternating rest periods with activity. See nursing interventions for Fatigue.
Teach the importance of not smoking. Refer to smoking cessation programs, and encourage clients who relapse to keep trying to quit. Ensure that client receives appropriate medications to support smoking cessation from the primary health care provider. EB: A systematic review of research demonstrated that the combination of medications and an intensive, prolonged counseling program supporting smoking cessation were effective in promoting long-term abstinence from smoking (Fiore et al, 2008). A Cochrane review found that use of the medication varenicline (Chantix) increased the rate of smoking withdrawal two to three times more than smoking withdrawal without use of medications (Cahill, Stead, & Lancaster, 2008; GOLD, 2011).
Instruct the family regarding home oxygen therapy if ordered (e.g., delivery system, liter flow, safety precautions, number of tanks needed). Long-term oxygen therapy can improve survival, exercise ability, sleep and ability to think in hypoxemic clients (GOLD, 2011). Client education improves compliance with prescribed use of oxygen.
Teach the client the need to receive a yearly influenza vaccine. Receiving a yearly influenza vaccine is helpful to prevent exacerbations of COPD (Black & McDonald, 2009; Corbridge et al, 2012).
• Teach the client relaxation techniques to help reduce stress responses and panic attacks resulting from dyspnea. EB: Relaxation therapy can help reduce dyspnea and anxiety (Langer et al, 2009); teach the client to use music, along with a rest period, to decrease dyspnea and anxiety. CEB & EB: A study demonstrated that use of music along with a resting period was effective in relieving anxiety and exercise-induced dyspnea in clients with COPD (Sidani et al, 2004). Another study demonstrated that music could be more effective than progressive muscle relaxation tapes in decreasing dyspnea and anxiety (Singh & Rao, 2009).
References
Barnett, M. Nursing management of chronic obstructive pulmonary disease. Br J Nurs. 2008;17(21):1314–1318.
Berger, B., Kapella, M., Larson, J. The experience of stigma in chronic obstructive pulmonary disease. West J Nurs Res. 2011;33(7):916–932.
Bickley, L.S., Szilagyi, P. Guide to physical examination, ed 10. Philadelphia: Lippincott Williams & Wilkins; 2009.
Black, P.N., McDonald, C.F. Interventions to reduce the frequency of exacerbations of chronic obstructive pulmonary disease. Postgrad Med J. 2009;85(1001):141–147.
Brennan, C., Mazanec, P. Dyspnea management across the palliative care continuum. J Hosp Palliat Nurs. 2011;13(3):130–139.
Burns, S. Indices of oxygenation. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Cahill, K., Stead, L.F., Lancaster, T., Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev 2008;(3):CD006103.
Corbridge, S., et al. An evidence-based approach to COPD: part 1. AJN. 2012;112(3):46–59.
Faager, G., Ståhle, A., Larsen, F.F. Influence of spontaneous pursed lips breathing on walking endurance and oxygen saturation in patients with moderate to severe chronic obstructive pulmonary disease. Clin Rehabil. 2008;22(8):675–683.
Fiore, M.C., et al. Treating tobacco use and dependence clinical practice guideline, 2008 update, Rockville, MD. U.S.: Department of Health and Human Services, Public Health Service; 2008.
GOLD, Global strategy for the diagnosis, management, and prevention of COPD revised 2011. [Global Initiative for Chronic Obstructive Lung Disease].
Grap, M. Not-so-trivial pursuit: mechanical ventilation risk reduction. Am J Crit Care. 2009;18(4):299–309.
Hagle, M., et al. Vital signs monitoring. An EBP guideline. In: Ackley B., Ladwig G., Swann B.A., eds. Evidence-based nursing care guidelines: medical-surgical interventions. Philadelphia: Mosby, 2008.
Headley, J., Giuliano, K. Continuous venous oxygen saturation monitoring. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Jarvis, C. Physical examination and health, ed 6. St Louis: Elsevier Saunders; 2012.
Kaptein, A.A., et al. 50 years of psychological research on patients with COPD—road to ruin or highway to heaven? Respir Med. 2008;103:3–11.
Langer, D., et al. A clinical practice guideline for physiotherapists treating patients with chronic obstructive pulmonary disease based on a systematic review of available evidence. Clin Rehabil. 2009;23(5):445–462.
Marklew, A. Body positioning and its effect on oxygenation- a literature review. Br Assoc Crit Care Nurs. 2006;11(1):16–22.
Nici, L., et al. Pulmonary rehabilitation: what we know and what we need to know. J Cardiopulm Rehabil Prev. 2009;29(3):141–151.
Odencrants, S., Ehnfors, M., Ehrenbert, A. Nutritional status and patient characteristics for hospitalized older patients with chronic obstructive pulmonary disease. J Clin Nurs. 2008;17(13):1771–1778.
Schultz, S. Oxygen saturation monitoring with pulse oximetry. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Sidani, S., et al. Evaluating the effects of music on dyspnea and anxiety in patients with COPD: a process-outcome analysis. Int Nurs Perspect. 2004;4(1):5–14.
Siela, D. Evaluation standards for management of artificial airways. Crit Care Nurse. 2010;30(4):76–78.
Singh, V.P., Rao, V. Comparison of the effectiveness of music and progressive muscle relaxation for anxiety in COPD—a randomized controlled pilot study. Chronic Respir Dis. 2009;6(4):209–216.
Sud, S., et al. Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis. Intensive Care Med. 2010;36:585–599.
Thomas, L. Effective dyspnea management strategies identified by elders with end-stage chronic obstructive pulmonary disease. Appl Nurs Res. 2009;22(2):79–85.
Vas Fragoso, C.A., et al. Frailty and respiratory impairment in older persons. Am J Med. 2012;125(1):79–86.
Vollman, K., Powers, J. Pronation therapy. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Vollman, K., Sole, M. Endotracheal tube and oral care. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Wong, M., Elliott, M. The use of medical orders in acute care oxygen therapy. Br J Nurs. 2009;18(8):462–464.
Dysfunctional Gastrointestinal Motility
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Monitor for abdominal distention, and presence of abdominal pain. The acute onset of abdominal distention in conjunction with symptoms of cramping pain, weight loss, nausea, vomiting, obstipation, or diarrhea warrants further evaluation for disorders that cause intestinal obstruction (Camilleri, 2011).
• Auscultate for bowel sounds noting characteristics and frequency, also palpate, and percuss the abdomen. Hypoactive bowel sounds are found with decreased motility as with peritonitis, from paralytic ileus, or from late bowel obstruction. Hyperactive bowel sounds are associated with increased motility (Jarvis, 2012).
• Review history noting any anorexia, dyspepsia, nausea/vomiting, abnormal characteristics of bowel movements, including frequency, consistency, and the presence of gas. Other symptoms may include relation of symptoms to meals, especially if aggravated by food, early satiety, postprandial fullness/bloating, and weight loss (more with severe gastroparesis). These are signs of abnormal gastric motility (Khoo et al, 2009).
• Have client keep a diary of time food and fluid was consumed as it compares to pattern of defecation, including, but not limited to, consistency, amount, and frequency of stool (Holman, Roberts, & Nicol, 2008).
• Monitor for fluid deficits by checking skin turgor, and moisture of tongue. Refer to care plan Deficient Fluid Volume if relevant.
Slowed Gastrointestinal Motility
• Monitor the client for signs and symptoms of decreased gastric motility, which may include delayed emptying, nausea after meals, vomiting, heartburn, diarrhea, feeling full quickly while eating, abdominal bloating and/or pain, anorexia, and reflux (Shakil, Church, & Rao, 2008).
Monitor daily laboratory studies, ensuring ordered glucose levels are done and evaluated. Elevated blood glucose levels can cause delayed gastric emptying; therefore, it is important to normalize blood glucose levels (Shakil, Church, & Rao, 2008).
Evaluate medications the client is taking. Recognize that opioids and anticholinergics can cause gastric slowing, along with aluminum hydroxide antacids, beta-adrenergic receptor agonists; calcium channel blockers, diphenhydramine, histamine H2 antagonists, levodopa, proton pump inhibitors, sucralfate, and tricyclic antidepressants (Shakil, Church, & Rao, 2008).
• Obtain a thorough gastrointestinal history if the client has diabetes, as they are at high risk for gastroparesis and gastric reflux. Gastroparesis with delayed emptying of the stomach is a complication of diabetes associated with neuropathy of nerves supplying the stomach (Gregg, 2010).
Review laboratory and other diagnostic tools, including complete blood count (CBC), amylase, thyroid-stimulating hormone level, glucose with other metabolic studies, upper endoscopy, and gastric-emptying scintigraphy. The diagnosis of diabetic gastroparesis is made when other causes are excluded and postprandial gastric stasis is confirmed by gastric emptying scintigraphy, which is considered the gold standard for diagnosing gastroparesis (Shakil, Church, & Rao, 2008).
Obtain nutritional consult, considering diets lower or higher in liquids or solids, especially fats, depending on gastric motility. The person with diminished gastric emptying may be advised to avoid fatty meals while more liquid intake of nutrients may be advised (Shakil, Church, & Rao, 2008).
If client is receiving gastric enteral nutrition (EN), evaluate gastric residual volume (GRV) per hospital protocol. See the care plan Risk for Aspiration.
Administer prokinetic medications as ordered (Chang et al, 2011; Shakil, Church, & Rao, 2008).
For the client with nausea and vomiting associated with gastroparesis, review use of tricyclics, in addition to the traditional antiemetics and other prokinetic drugs. Tricyclic antidepressants are used in the treatment of many functional gastrointestinal disorders (Stapleton & Wo, 2009).
Recognize that acupuncture may be an option for both slowed and increased gastric motility. EB: Acupuncture stimulation, either mechanical or electrical, placed on abdominal locations of skin or muscle may induce a decrease in gastric motility, while application to a limb caused an increase via supraspinal reflex that activated vagal nerve fibers (Noguchi, 2010).
Postoperative Ileus
• Observe for complications of delayed intestinal motility. Symptoms include abdominal pain and distention, nausea, cramping, anorexia, and sometimes bloating. Other signs include tympany to percussion, with absence of flatus, bowel sounds or bowel movements (Hocevar, Robinson, & Gray, 2010; Woodard, Rastinehad, & Richstone, 2008).
Recommend chewing gum for the routine postoperative patient who is experiencing an ileus, is not at risk for aspiration, and has normal dentition. EBN: Gum chewing may decrease postoperative ileus because it “acts as a sham feeding, potentially stimulating gastric and bowel motility through repetitive stimulation of the cephalic-vagal complex.” It shortens time to passage of flatus and stool (Hocevar, Robinson, & Gray, 2010).
• Determine if the client is a smoker. Smoking increases intestinal motility. Constipation is common, but usually transient, when people stop smoking (Wilcox et al, 2010). CEB: In a survey about perceived effects of various foods and beverages on constipation, cigarette was the item that was most often perceived to have a laxative effect among smokers (Müller-Lissner et al, 2005).
• Help the client out of bed to walk at least two times per day. Exercise may increase gastrointestinal motility (Shakil, Church, & Rao, 2008).
If postoperative ileus is associated with opioid pain medication, request an order for a peripherally acting opioid antagonist. This medication has minimal penetration of the CNS so pain can continue to be relieved, while blocking peripheral sites so that an ileus can be relieved (Rathmell & Fields, 2012).
Note serum electrolyte levels, especially potassium and magnesium. A low potassium level decreases the function of intestinal smooth muscle and can result in an ileus. A low magnesium level makes the body refractory to potassium replacement (Mount, 2012).
Increased Gastrointestinal Motility
Observe for complications of gastric surgeries such as dumping syndrome. This syndrome is the effect of changes in size and function of the stomach, with rapid dumping of hyperosmolar food into the intestines (Alan et al, 2010).
• Watch for nausea, vomiting, bloating, cramping, diarrhea, dizziness, and fatigue. These are common signs and symptoms of early rapid gastric emptying (Alan et al, 2010).
• Monitor for low blood sugar, weakness, sweating, and dizziness 1 to 3 hours after eating as this is when late rapid gastric emptying may occur. Experiencing both early and late forms of gastric emptying is not uncommon (Alan et al, 2010).
Order a nutritional consult to discuss diet changes. Encourage several small meals per day that are low in carbohydrates, and higher in fiber supplements and fat. Space fluids around meal times, not with them (Alan et al, 2010).
Review the client’s medication profile, including current medication list, noting those that may increase gastric motility. Medications such as beta-adrenergic receptor antagonists and prokinetic agents can cause increased gastrointestinal motility (Shakil, Church, & Rao, 2008).
• Offer bathroom, commode, or bedpan assistance, depending on frequency, amount of diarrhea, and condition of client.
• Refer to the care plans for the nursing diagnoses of Deficient Fluid Volume, Nausea, and Diarrhea as relevant.
Pediatric:• Assess infants and children with suspected delayed gastric for fullness and vomiting. Babies and children with delayed gastric emptying take longer to get hungry again and throw up undigested or partially digested food several hours after feeding (Waseem, 2012).
• Continue to encourage the mother of a baby diagnosed with delayed gastric emptying to breastfeed, reinforcing the benefits of breastfeeding. Breast milk moves through the digestive system almost twice as fast as formula (MacLean, 2007).
If the infant is already on a bottle, encourage parents to discuss with the pediatrician a switch to a hypoallergenic formula. Hypoallergenic formula is already partially digested, making the transit time out of the stomach potentially faster (Skillman & Wischmeyer, 2008).
Observe for nutritional and fluid deficits with assessment of skin turgor, mucous membranes, fontanels, furrows of the tongue, electrolyte panel, fluid status, and cardiopulmonary function (Skillman & Wischmeyer, 2008).
Recommend gentle massage for preterm infants as appropriate. EB: With massage, there was increased vagal activity. This was then associated with increased gastric motility and greater weight gain (Field, Diego, & Hernandez-Reif, 2011).
Geriatric:• Closely monitor diet and medication use/side effects as they affect the gastrointestinal system. Watch for constipation. Many gastrointestinal functions are slowed in the elderly (Grassi et al, 2011).
Watch for symptoms of dysphagia, gastroesophageal reflux disease, dyspepsia, irritable bowel syndrome, maldigestion, and reduced absorption of nutrients. These are common gastrointestinal disorders in the elderly (Grassi et al, 2011).
If client takes metoclopramide for gastroesophageal reflux disease or slowed gastric motility, assess indication and side effects. Recognize that metoclopramide can cause drug-induced Parkinson’s disease in the elderly, in addition to other neurotoxic side effects. This medication should be used with great caution in the elderly client because of the increased side effect profile (Esper & Factor, 2008).
Client/Family Teaching and Discharge Planning:
• Teach the client and caregivers about their medications, reinforcing the side effects as they relate to gastrointestinal function.
Recommend possible exercise programs if appropriate. Exercise may increase gastric motility (Shakil, Church, & Rao, 2008).
• Teach client and caregivers to report signs and symptoms that may indicate further complications including increased abdominal girth, projectile vomiting, and unrelieved acute cramping pain (bowel obstruction).
• Review signs and symptoms of dehydration with client and caregivers.
References
Alan, B.R., et al. Dumping syndrome. Medscape reference. Retrieved May 21, 2011, from http://emedicine.medscape.com/article/173594-overview.
Camilleri, M., et al. Disorders of Gastrointestinal motility. In Goldman, ed.: Goldman’s Cecil medicine, ed 24, New York: McGraw Hill, 2011.
Chang, J., et al. Diabetic gastroparesis—backwards and forwards. J Gastroenterol Hepatol. 2011;26:46–57.
Dugdale, D.C. Gastroparesis, Medline Plus. U.S. National Library of Medicine. http://www.nlm.nih.gov/medlineplus/ency/article/000297.htm. [Accessed August 7, 2012].
Esper, C.D., Factor, S.A. Failure of recognition of drug-induced parkinsonism in the elderly. Mov Disord. 2008;23(3):401–404.
Field, T., Diego, M., Hernandez-Reif, M. Potential underlying mechanisms for greater weight gain in massaged preterm infants. Infant Behav Dev. 2011;34(3):383–389.
Grassi, M., et al. Changes, functional disorders, and diseases in the gastrointestinal tract of elderly. Nutr Hosp. 2011;26(4):659–668.
Gregg, K.H. Gastroparesis. MedSurg Nurs. 2010;19(6):345–346.
Hocevar, B.J., Robinson, B., Gray, M. Does chewing gum shorten the duration of postoperative ileus in patients undergoing abdominal surgery and creation of a stoma? J Wound Ostomy Continence Nurs. 2010;37(2):140–146.
Holman, C., Roberts, S., Nicol, M. Preventing and treating constipation in later life. Nurs Older People. 2008;20(5):22–24.
Jarvis, C. Physical examination and health assessment, ed 6. St Louis: Saunders Elsevier; 2012.
Khoo, J., et al. Pathophysiology and management of gastroparesis. Expert Rev Gastroenterol Hepatol. 2009;3(2):167–181.
MacLean, R., Gastroparesis, modified 2007 Retrieved July 23, 2009, from http://infantrefluxdisease.com/gastroparesis.php
Mount, D., et al. Fluid and electrolyte disturbances. In Longo D., ed.: Harrison’s textbook of internal medicine, ed 18, New York: McGraw-Hill, 2012.
Müller-Lissner, S.A., et al. The perceived effect of various foods and beverages on stool consistency. Eur J Gastroenterol Hepatol. 2005;17:109–112.
Noguchi, E. Acupuncture regulates gut motility and secretion via nerve reflexes. Auton Neurosci. 2010;156:15–18.
Rathmell, J., Fields, H., et al. Pain: pathophysiology and management. In Longo D., ed.: Harrison’s textbook of internal medicine, ed 18, New York: McGraw-Hill, 2012.
Shakil, A., Church, R., Rao, S.S. Gastrointestinal complications of diabetes. Am Fam Physician. 2008;77(12):1697–1703.
Skillman, H.E., Wischmeyer, P.E. Nutrition therapy in critically ill infants and children. J Parenter Enteral Nutr. 2008;32(5):520–534.
Stapleton, J., Wo, J.M. Current treatment of nausea and vomiting associated with gastroparesis: antiemetics, prokinetics, tricyclics. J Alt Complement Med. 2009;14(7):833–839.
Waseem, S., et al. Spectrum of gastroparesis in children. J Pediatr Gastroenterol Nutr. 2012;55(2):166–172.
Wilcox, C.S., Oskooilar, N., Erickson, J.S. An open-label study of naltrexone and bupropion combination therapy for smoking cessation in overweight and obese subjects. Addict Behav. 2010;35(3):229–234.
Woodard, E., Rastinehad, A.R., Richstone, L. Management of postoperative ileus. Urol Times. 2008;36(Suppl):S8–S14.
Risk for ineffective Gastrointestinal perfusion
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Maintain blood pressure within normal limits
• Remain free from abdominal distention
• Tolerate feedings without nausea, vomiting, or abdominal discomfort
• Pass stools of normal color, consistency, frequency, and amount
• Describe prescribed diet regimen
• Describe prescribed medication regimen including medication actions and possible side effects
• Verbalize understanding of treatment regimen including monitoring for signs and symptoms that may indicate problems with gastrointestinal tissue perfusion, the importance of diet and exercise to gastrointestinal health
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
Complete pain assessment. Assess and document the onset, intensity, character, location, duration, aggravating factors, and relieving factors. Determine whether the pain is exacerbated by eating. Notify the provider for any increase in pain or discomfort or if comfort measures are not effective. A significant symptom of mesenteric ischemia is pain that is disproportionate to the physical examination findings. Acute arterial mesenteric ischemia often has the most abrupt onset of pain. Clients presenting with acute mesenteric ischemia may have a history of abdominal angina, which is a syndrome of pain starting soon after eating and lasting for several hours (Stamatakos et al, 2008). Acute mesenteric ischemia should be considered with any acute onset of intense abdominal pain. It is an emergent condition and positive outcomes are only possible in the early stages, within 12 hours of onset (Debus et al, 2011; Hauser, 2011).
• Monitor vital signs frequently as needed watching for hypotension and tachycardia. Ischemia or infarction of the gastrointestinal blood supply is a serious situation and can result in death of the client, especially in the elderly (Cangemi, 2009; Hauser, 2011).
• Encourage the client to eat small, frequent meals rather than three larger meals. Encourage the client to rest after eating to maximize blood flow to the stomach and improve digestion. Smaller meals will reduce pressure on the lower esophageal sphincter (O’Malley, 2008).
• Perform a physical abdominal examination including inspection, auscultation, percussion, and palpation. Complete the assessment in the described order. Initially with decreased perfusion there may be increased bowel sounds, and then absence of bowel sounds (Hauser, 2011).
• Monitor frequency, consistency, color, and amount of stools. Clients presenting with sudden cramping, left lower abdominal pain, a strong urge to pass stool and bright red or maroon blood mixed with the stool should be evaluated for colon ischemia (Frishman et al, 2008). Obvious bleeding from the gastrointestinal tract is an ominous sign and often suggests bowel infarction (Hauser, 2011).
• Assess for abdominal distention. Measure abdominal girth and compare to client’s accustomed waist or belt size. Ischemia of the gastrointestinal system can result in decreased motility, and a paralytic ileus with abdominal distention (Urden, Stacey, & Lough, 2010).
Monitor for gastrointestinal side effects from medication administrations, particularly NSAIDs. Discuss the possibility of prescribing a gastroprotective agent such as a proton pump inhibitor with the provider for clients requiring long-term administration of NSAIDs. NSAIDs have significant gastrointestinal toxicity. The mechanisms of damage include disruption of the mucus layer, inhibition of bicarbonate secretion, local tissue hypoxia caused by vasoconstriction, and others. Up to 60%, taking these types of medications have some injury and serious adverse events including gastric and duodenal ulcers, perforation and hemorrhage can occur. The damage may be asymptomatic, especially in the elderly. The relative risk of injury increases with age (Jones et al, 2008).
• Review the client’s medical and surgical history. Certain conditions place clients at higher risk for ineffective tissue perfusion (e.g., diabetes mellitus, abdominal surgery, cardiothoracic surgery, trauma, mechanical ventilation). In addition to medical or surgical conditions, lifestyle choices such as smoking or cocaine and amphetamine use affect tissue perfusion (Hauser, 2011). EB: Gastrointestinal complications following cardiac surgery are rare, but substantially increase morbidity and mortality. Risk factors include age, intraoperative hypoperfusion, and need for high dose vasopressors (Abboud et al, 2008).
• Recognize that any client who has been in a shock state is vulnerable to decreased gastrointestinal perfusion, and watch for symptoms as just identified. In shock the blood flow is preferentially shunted away from the gut to the brain and heart to preserve life. Ischemia of the gut is part of the multiple organ dysfunction syndrome that follows a shock state, especially septic shock (Urden, Stacy, & Lough, 2010).
• Encourage the client to ambulate or perform activity as tolerated, but vigorous activity or heavy lifting should be avoided for several hours after meals. Upper mesenteric ischemia is often associated with upper abdominal pain, which can be elicited by a meal or by physical activity. These symptoms may cause clients to decrease their food intake, leading to weight loss (Hauser, 2011).
Prepare client for diagnostic or surgical procedures. Diagnostic studies may include abdominal x-ray to rapidly rule out intestinal obstruction, CT, angiography, and abdominal ultrasound. Surgical procedures include exploratory laparotomy, thrombectomy, surgical revascularization, and/or stent placement (Stamatakos et al, 2008). EB: Elderly clients with serum ferritin concentration in the low normal range should be considered for GI investigation using endoscopy. Anemic clients without evidence of iron deficiency have a low incidence of bleeding GI lesions and should not undergo GI investigation (Powell & McNair, 2008).
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