Gastrointestinal Nursing

Gastrointestinal Nursing

Gastrointestinal (GI) disorders represent a significant portion of NCLEX questions under the Physiological Integrity category. Nurses must understand the anatomy and physiology of the GI tract, recognize acute and chronic conditions, and implement evidence-based interventions. This guide covers the most commonly tested GI topics, from bleeding emergencies to ostomy management. For a comprehensive overview of this category, visit the Physiological Integrity study guide.

Upper vs. Lower GI Bleeding

GI bleeding is classified by location relative to the ligament of Treitz. Accurate identification of the source guides nursing assessment and intervention.

Feature	Upper GI Bleeding	Lower GI Bleeding
Location	Esophagus, stomach, duodenum	Jejunum, ileum, colon, rectum
Common causes	Peptic ulcer disease, esophageal varices, Mallory-Weiss tear, gastritis	Diverticulosis, colorectal cancer, hemorrhoids, inflammatory bowel disease
Stool appearance	Melena (black, tarry stools)	Hematochezia (bright red blood per rectum)
Other signs	Hematemesis (bloody or coffee-ground emesis), epigastric pain	Lower abdominal cramping, urgency
Diagnosis	Esophagogastroduodenoscopy (EGD)	Colonoscopy, angiography

Nursing management for GI bleeding:

• Assess hemodynamic status: monitor vital signs for tachycardia, hypotension, and signs of hypovolemic shock
• Establish two large-bore IV lines for fluid resuscitation and potential blood transfusion
• Monitor hemoglobin, hematocrit, and coagulation studies
• Maintain NPO status in preparation for endoscopy
• Insert a nasogastric tube if ordered for lavage in upper GI bleeding
• Administer proton pump inhibitors (PPIs) as prescribed for upper GI bleeding
• Document the color, amount, and frequency of emesis and stools

GERD and Peptic Ulcer Disease

Gastroesophageal reflux disease (GERD) occurs when the lower esophageal sphincter relaxes inappropriately, allowing gastric acid to reflux into the esophagus. Patients report heartburn, regurgitation, and dysphagia. Nursing education includes elevating the head of the bed 30 degrees, avoiding eating 2-3 hours before bedtime, reducing trigger foods (caffeine, alcohol, spicy and fatty foods), and weight management. PPIs (omeprazole, pantoprazole) and H2 receptor antagonists (famotidine) are commonly prescribed.

Peptic ulcer disease (PUD) involves erosion of the gastric or duodenal mucosa. Gastric ulcers cause pain with eating, while duodenal ulcers cause pain 2-3 hours after meals and at night, often relieved by food. Helicobacter pylori infection is a leading cause treated with triple therapy (PPI, clarithromycin, amoxicillin). NSAIDs are another major cause. Complications include hemorrhage, perforation (sudden severe abdominal pain with rigid abdomen), and gastric outlet obstruction.

Liver Disease

Cirrhosis is irreversible scarring of the liver resulting from chronic damage (alcohol use, chronic hepatitis B/C, nonalcoholic fatty liver disease). Complications include:

• Portal hypertension: Increased pressure in the portal venous system leads to ascites, splenomegaly, and development of collateral circulation
• Esophageal varices: Dilated veins in the esophagus prone to life-threatening hemorrhage. Avoid hard or rough foods. Beta-blockers (propranolol) reduce portal pressure. Bleeding varices require emergent endoscopic band ligation or sclerotherapy. A Sengstaken-Blakemore tube may be used temporarily
• Ascites: Fluid accumulation in the peritoneal cavity. Management includes sodium restriction, diuretics (spironolactone, furosemide), paracentesis, and daily weight monitoring. Measure abdominal girth at the same level each day
• Hepatic encephalopathy: Accumulation of ammonia causes confusion, asterixis (liver flap), and can progress to coma. Lactulose is the primary treatment; it promotes excretion of ammonia through the stool. The goal is 2-3 soft stools per day. Rifaximin may be added. Restrict dietary protein only in acute episodes. Monitor ammonia levels and neurological status

Hepatitis is inflammation of the liver. Hepatitis A is transmitted fecal-orally, Hepatitis B through blood and body fluids, and Hepatitis C primarily through blood. Nursing care includes monitoring liver function tests (AST, ALT, bilirubin), providing rest, maintaining nutrition, and implementing appropriate isolation precautions.

Pancreatitis

Pancreatitis is inflammation of the pancreas, most commonly caused by gallstones and alcohol use. It presents with severe epigastric pain radiating to the back, nausea, and vomiting.

Feature	Acute Pancreatitis	Chronic Pancreatitis
Onset	Sudden	Progressive, recurrent episodes
Key labs	Elevated amylase and lipase (lipase more specific)	May be normal or mildly elevated
Complications	Hemorrhagic necrosis, pseudocyst, ARDS, shock	Pancreatic insufficiency, malabsorption, diabetes, calcifications
Management	NPO, IV fluids, pain management, NG suction if vomiting	Pancreatic enzyme replacement, pain management, alcohol cessation, small frequent low-fat meals

Key assessment findings in severe pancreatitis:

• Cullen's sign: Bluish discoloration around the umbilicus, indicating intraperitoneal hemorrhage
• Grey Turner's sign: Bluish discoloration of the flanks, indicating retroperitoneal hemorrhage

Position the patient in a side-lying position with knees flexed to reduce pain. Avoid morphine if possible (may cause spasm of the sphincter of Oddi); hydromorphone is often preferred.

Bowel Obstruction

Bowel obstruction is a blockage that prevents normal passage of intestinal contents. It may be mechanical (physical blockage) or functional (paralytic ileus).

Feature	Small Bowel Obstruction	Large Bowel Obstruction
Common causes	Adhesions (most common), hernias, tumors	Colorectal cancer (most common), volvulus, diverticulitis
Vomiting	Early, frequent, possibly feculent	Late or absent
Distension	Moderate	Significant
Pain pattern	Colicky, intermittent	Gradual, continuous
Bowel sounds	High-pitched, hyperactive early; absent later	Low-pitched, hypoactive

Nursing management: Maintain NPO status, insert nasogastric tube for decompression, administer IV fluids, monitor strict intake and output, assess for signs of strangulation (fever, rebound tenderness, increasing pain), and prepare for surgery if conservative management fails.

Ostomy Care

An ostomy is a surgically created opening on the abdomen for diversion of fecal or urinary output.

• Ileostomy: Created from the ileum; output is liquid to semi-liquid and continuous. Higher risk for fluid and electrolyte imbalances, especially dehydration and hypokalemia
• Colostomy: Created from the colon; output consistency depends on location. Ascending colostomy produces liquid stool, transverse produces semi-formed, and descending/sigmoid produces formed stool

Stoma assessment: A healthy stoma should be pink to red, moist, and slightly raised above the skin surface. Report a dusky, pale, or cyanotic stoma immediately as it may indicate compromised blood supply.

Patient education for ostomy care:

• Empty the pouch when it is one-third to one-half full to prevent leakage
• Cut the wafer opening to fit 1/8 inch larger than the stoma
• Clean peristomal skin with warm water only (no soap with oils or moisturizers)
• Change the appliance every 3-7 days or when leaking
• Monitor for peristomal skin breakdown
• Ileostomy patients should increase fluid intake and be aware of foods that cause blockage (popcorn, nuts, raw vegetables)

NCLEX GI Focus Points

• Lactulose therapy: assess for 2-3 soft stools per day; hold if diarrhea develops
• Esophageal varices: avoid Valsalva maneuver, straining, and hard foods
• Post-liver biopsy: position patient on the right side to apply pressure to the biopsy site
• Pancreatitis positioning: side-lying with knees flexed reduces pain
• Ostomy teaching is a priority nursing diagnosis

Review the GI Nursing Cheat Sheet for a quick-reference summary, and test your knowledge with Physiological Integrity flashcards.