Function of G I system

The Primary Digestive Functions are 1. Break down food particles molecular
forms 2. Absorb into the bloodstream the small molecules 3. Eliminate waste products & undigested food

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Function of G I system
Chewing & Swallowing
1. 1.5 L of saliva are secreted daily 2. Ptyalin salivary amylase starch digestion 3. Saliva lubricate food as it chewed & swallowed

Gastric function
1. Hydrochloric acid to destruct most ingest bacteria ,& break down food 2. Pepsin for initiation of protein digestion 3. Intrinsic factors 4. The food mixed with gastric secretions is called chyme
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Function of G I system
Small Intestine function 1. Pancreas : -Trypsin aids in digestion of proteins -Amylase aids in digestion starch -Lipase aids in digestion of fats 2. Liver : bile aids in emulsifying ingested fats 3. Intestinal Glands :secrete mucus ,hormones ,electrolytes ,and enzymes 4. Two types of contractions Segmentation contraction Intestinal peristalsis
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Function of G I system
Colonic Function 1. Two types of colonic secretion -Mucus: protect colonic mucosa -Electrolytes: mainly HCo3 neutralize the end products 2. Slow peristaltic to allow absorption of water & electrolytes

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Assessment
Health history ( diet history ,appetite , weight gain & loss , stool ch.ch.,& eating pattern Clinical Manifestations :1. Pain 2. Indigestion 3. Intestinal Gas 4. Nausea & Vomiting 5. Change in Bowel Habits &Stool ch.ch.
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Assessment
1. 2. 3. 4. Physical Assessment Inspection Auscultation Palpation Percussion

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Assessment
1. 2. 3. 4. 5. 6. 7. 8. Diagnostic Evaluation Upper GI tract study Lower GI tract study Gastric Analysis Endoscopy Laparoscopy (Peritoneoscopy ) Anoscopy ,proctoscopy ,&Sigmoidscopy Colonoscopy Abdominal U/S , Abd CT scan ,&Abd MRI
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Assessment
Stool Tests -Analysis & culture -occult blood test Hydrogen Breath Test Urea Breath Test Tagged Red Blood Cells & Leukocytes

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Disorders of the Jaw

Abnormal conditions affecting the mandible (Jaw)& the tempomandibular joint include congenital malformation, fractures , chronic dislocation , cancer , & syndrome ch.ch pain & limited motion Tempomandibular Disorders Are a group of conditions that cause pain &\or dysfunction of the tempomandibular joint &/or the muscle of mastication, as well as contiguous tissue components
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Disorders of the Jaw

Clinical Manifestations 1. Pain (from dull to throbbing ) 2. Debilitating pain radiated to the ears, teeth, neck muscle & facial sinuses 3. Restricted jaw motion & clicking 4. Difficulty chewing & swallowing 5. Depression may accompany
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Disorders of the Jaw

1. 2. 3. 4. Management Patient education in stress Management Range of motion exercises Pain Management (NSAID) Muscle relaxant &/or mild antidepressant

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Parotitis
Inflammation of the parotid gland is the most common inflammatory condition of the salivary gland Mumps (epidemic Parotitis) viral seen in children

Clinical Manifestations
1. 2. 3. 4. Fever & red shiny skin The gland swells ,tense ,&tender Pain felt in ear Swollen gland interfere with swallowing
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Parotitis
Medical Management
1. Preventive Measures (dental care, oral hygiene, adequate fluid& nutrition ,& D/C of medication that may diminished salivary secretion) 2. Antibiotics for infection 3. Analgesic for pain 4. Drainage of gland 5. Parotidectomy
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Impaired Esophageal Motility Achalasia

Achalasia: characterized by impaired
peristalsis of smooth muscle of esophagus and impaired relaxation of lower esophageal sphincter

Manifestations:
1. 2. 3. 4. Dysphagia chest pain (pyrosis) Sensation of food stick in lower esophagus Food regurgitation
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Achalasia

Treatment
1. Eat slowly &drink fluids with meals 2. Calcium channel blockers 3. Endoscopically guided injection of botulinum toxin 4. Balloon dilation of lower esophageal sphincter or pneumatic dilation 5. Esophageal myotomy (abdominal or thoracic approach
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Gastroesophageal Reflux Disease (GERD)

1. Definition 1. GERD common, affecting 15 20% of adults 2. Because of location near other organs symptoms may mimic other illnesses including heart problems 3. Gastroesophageal reflux is the backward flow of gastric content into the esophagus.
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Gastroesophageal Reflux Disease (GERD)

2. Pathophysiology a. Gastroesophageal reflux results from transient relaxation or incompetence of lower esophageal sphincter, sphincter, or increased pressure within stomach b. Factors contributing to Gastroesophageal reflux 1.Increased gastric volume (post meals) 2.Position pushing gastric contents close to Gastroesophageal juncture (such as bending or lying down) 3.Increased gastric pressure (obesity or tight clothing) 4.Hiatal hernia Husni Rousan 17

Gastroesophageal Reflux Disease (GERD)

1.
2. 3. 4. 5. Manifestations Heartburn after meals, while bending over, or recumbent Dyspepsia or indigestion May have regurgitation of sour materials in mouth, pain with swallowing Atypical chest pain Sore throat with hoarseness
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Gastroesophageal Reflux Disease (GERD)

6.Diagnostic Tests a. Barium swallow (evaluation of esophagus, stomach, small intestine) b. Upper endoscopy: direct visualization; biopsies may be done c. 24-hour ambulatory pH monitoring

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Gastroesophageal Reflux Disease (GERD)

7.Medications
a. Antacids for mild to moderate symptoms, e.g. Maalox, Mylanta, Gaviscon b. H2-receptor blockers: decrease acid production; given BID or more often, e.g. cimetidine, ranitidine, famotidine, nizatidine c. Proton-pump inhibitors: reduce gastric secretions, promote healing of esophageal erosion and relieve symptoms, e.g. omeprazole (prilosec); lansoprazole d. Promotility agent: enhances esophageal clearance and gastric emptying
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Gastroesophageal Reflux Disease (GERD)

Dietary and Lifestyle Management
a. Elimination of acid foods (tomatoes, spicy, citrus foods, coffee) b. Avoiding food which relax esophageal sphincter or delay gastric emptying (fatty foods, chocolate, alcohol) c. Maintain ideal body weight d. Eat small meals and stay upright 2 hours post eating; no eating 3 hours prior to going to bed e. Elevate head of bed on 6 8 blocks to decrease reflux f. No smoking g. Avoiding bending and wear loose fitting clothing
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Gastroesophageal Reflux Disease (GERD)

9.Surgery indicated for persons not improved by diet and life style changes a. Laparoscopic procedures to tighten lower esophageal sphincter b. Open surgical procedure: fundoplication 10. Nursing Care a. Pain usually controlled by treatment b. Assist client to institute home plan
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Hiatal Hernia
1. Definition
Part of stomach protrudes through the esophageal hiatus of the diaphragm into thoracic cavity Types 1. Sliding hiatal herni 2. Paraesophageal hiatal hernia: ( hernia can become strangulated; client may develop gastritis with bleeding)
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Hiatal Hernia
1. 2. Manifestations: Similar to GERD Diagnostic Tests a. Barium swallow b. Upper endoscopy

Treatment

1. Similar to GERD: diet and lifestyle changes, medications 2. If medical treatment is not effective or hernia becomes incarcerated, then surgery; usually 3. Fundoplication by thoracic or abdominal approach
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Diverticulum
It is an outpouching of mucosa& submucosa that protrudes through a weak portion of the musculature

Clinical Manifestations
Difficulty of swallowing & neck fullness Belching Regurgitation of undigested food Gargling noise after eating Halitosis & sour taste in the mouth May dysphagia & chest pain
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1. 2. 3. 4. 5. 6.

Diverticulum
Management 1. Diverticulectomy &myoectomy for muscle 2. NPO until x-ray show no leakage at surgical site 3. During O.P. avoid trauma to carotid artery and jugular vein

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Perforation
May result from stab or bullet wounds of the neck & the chest as well as from accidental puncture by surgical instrument

Clinical Manifestations
1. Persistent pain followed by dysphagia 2. Infection ,fever ,& leukocytosis 3. May sign of Pnuemothorax
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Perforation
1. 2. 3. Management Broad spectrum antibiotics Nasogastric tube & suctioning NPO total parenteral nutrition gastrostomy 4. Closed the wound &post op management
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Gastritis
1. Definition: Inflammation of stomach lining from irritation of gastric mucosa (normally protected from gastric acid and enzymes by mucosal barrier) 2. Types a. Acute Gastritis 1.Disruption of mucosal barrier allowing hydrochloric acid and pepsin to have contact with gastric tissue: leads to irritation, inflammation, superficial erosions 2.Gastric mucosa rapidly regenerates; self-limiting disorder
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Gastritis
Causes of acute gastritis
a. Irritants

include aspirin and other NSAIDS, corticosteroids, alcohol, caffeine

b.Ingestion of corrosive substances: alkali or acid

c.food contamination (microorganisms)

Manifestations
headache, mild epigastric discomfort, abdominal pain, nausea anorexia, vomiting Belching, heart burn , &sour taste in mouth If perforation occurs, signs of peritonitis
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Gastritis
Treatment As a rule the patient recover in a day NPO status to rest GI tract for 6 12 hours, reintroduce clear liquids gradually and progress; intravenous fluid and electrolytes if indicated b. antacids If gastritis from corrosive substance: immediate dilution and removal of substance by gastric lavage (washing out stomach contents via nasogastric tube), If extreme condition Gastrojejunostomy or gastric resection
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Gastritis
1. 2. 3. 4. Nursing Management Reducing anxiety Promoting optimal nutrition Promoting fluid balance Relieving pain Chronic Gastritis Progressive disorder beginning with superficial inflammation and leads to atrophy of gastric tissues (prolong Gastritis)
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Peptic Ulcer Disease (PUD)

Definition and Risk factors

Break in mucous lining of GI tract comes into contact with gastric juice , referred to as gastric ,duodenal , or esophageal ulcer Duodenal ulcers: most common; affect mostly males ages 30 55 ulcers found near pyloris Gastric ulcers:affect older persons(ages 55 70)
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Peptic Ulcer Disease (PUD)

2. Pathophysiology a. Ulcers or breaks in mucosa of GI tract occur with 1.H. pylori infection (spread by oral to oral, fecaloral routes) damages gastric epithelial cells reducing effectiveness of gastric mucus 2.Use of NSAIDS: interrupts prostaglandin synthesis which maintains mucous barrier of gastric mucosa b. Chronic with spontaneous remissions and exacerbations associated with trauma, infection, physical or psychological stress
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Peptic Ulcer Disease (PUD)

Manifestations Pain is classic symptom: burning, aching hunger like in epigastric region possibly radiating to back; occurs when stomach is empty and relieved by food (pain: food: relief pattern) Vomiting , nausea , constipation &diarrhea Symptoms less clear in older adult; may have poorly localized discomfort, dysphagia, weight loss; presenting symptom may be complication: GI hemorrhage or perforation of stomach or duodenum
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Peptic Ulcer Disease (PUD)

Treatment
1. 2. 3. 4. Pharmacologic therapy H2 receptor antagonist Proton pump inhibitors Cytoprotective agents Antacid Stress Reduction & Rest Smoking Cessation Dietary Modification
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Peptic Ulcer Disease (PUD)

1. 2. 1. 2. 3. Surgical Management Vagotomy Truncal Selective Pyloroplasty Antrectomy Gastroduodenostomy Gastrojejunostomy Subtotal gastroectomy with anastomosis
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Gastric Surgery
Gastric surgery : may be performed on patient with peptic ulcers who have life threatening hemorrhage , obstruction , perforation ,or whose condition dose not respond to medical treatment

Nursing Care
1. 2. 3. 4. 5. Reducing Anxiety Increasing Knowledge Resuming enteral Intake Relieving pain &prevent complications Teaching Dietary self Management
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Intestinal and rectal disorders Constipation

Abnormal hardening of stool that makes difficult & some time painfull,decrease in stool volume , or retention of stool on rectum for prolonged period of time

Clinical Manifestations
1. 2. 3. 4. Abdominal distention & intestinal rumbling Pain & pressure Anorexia fatigue & headache Incomplete emptying & strain defecation
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Intestinal and rectal disorders Constipation

1. 2. 3. 4. 5. Medical Management Treatment of the underlying cause High Fiber Diet & increase fluid intake Maintain regular pattern of exercises Laxatives & bulk forming Agents Bran 6-12 tsp Complications: -hypertension - hemorrhoid & fissure - fecal impaction & megacolon
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Intestinal and rectal disorders Diarrhea

It is an increase frequency of bowel movement more than three times /day

Causes : 1. 2. 3. 4. 5. Certain medications Tube feeding formula Certain metabolic disease Viral & bacterial infectious disease Ulcerative colitis .enteritis & chrons disease
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Intestinal and rectal disorders Diarrhea

Clinical Manifestations
1. Abdominal cramps, distention, intestinal rumbling 2. Increase frequency & fluid content of stool 3. Anorexia , thirst , & dehydration
4. Fluid electrolytes imbalance

Complications:-cardiac arrhythmia due to fluid & K loss -drowsiness & hypotension

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Intestinal and rectal disorders Diarrhea

1. 2. 3. 4. 1. 2. 3. 4. Medical Management Treatment of underlying cause Controlling symptoms & preventing complications Antibiotics & antinflammatory agents Antidiarrheal & antispasmoic agents Nursing Managements Assessment the ch.ch. & pattern of diarrhea Bed rest & monitoring of fluid status Serum electrolytes (K) Perenial care
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Fecal Incontinence
The involuntary passage of stool from the rectum Clinical Manifestations 1. Minor soiling 2. Occasional Urgency & loss of control 3. Poor Control of flatus 4. Diarrhea ,or constipation may be present
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Fecal Incontinence
Medical Management
1. 2. 3. 4.
1. 2. 3. 4.

Bowel training program Surgical reconstruction Sphincter repair Fecal diversion

Assessment & Health History Bowel Training program Maintain skin integrity Assist patient & family to cope with illness
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Nursing Management

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Irritable Bowel Syndrome

Functional disorder of intestinal motility ,the change may be related to neurologic regulatory system, infection or irritation or a vascular or metabolic disturbances The peristaltic waves are affected at specific segment

Clinical Manifestations
1. Alteration in bowel pattern 2. Pain , bloating , & abd distention 3. Pain precipitated by eating & relieved by defecation
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Irritable Bowel Syndrome

1. 2. 3. 1. 2. 3. 4. Medical Management Controlling symptoms & reducing stress Anticholonergic & antidepressant agents Well balanced diet Nursing Management teaching &reinforcing good dietary habits Encourage eat regular time & chew slowly Fluids should not taken with meal Discourage smoking & alcohol
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Acute Inflammatory Intestinal Disorders (Appendicitis)

1. 2. 3. 4. 5. Acute inflammation of appendix Clinical Manifestations Rt Lower Quadrant pain Low Grade Fever, nausea , vomiting anorexia Rebound & Revosing signs Local tenderness when pressure applied Increase W.B.C.s count Complications: perforation peritonitis or abdominal abscess ,occurs after 24 hrs after onset of symptoms (pain Tenderness ,fever,& toxic appearance)
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Acute Inflammatory Intestinal Disorders (Appendicitis)

Medical Management 1. Surgery is indicated if surgery diagnosed (laprascopic or open appendectomy) 2. NPO ,IVF , antibiotics 3. Analgesic after diagnosis is made Nursing Management 1. Relieving pain &preventing FVD 2. Elimination of potential infection 3. Maintaining skin integrity 4. Reducing anxiety 5. Pre&post care
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Acute Inflammatory Intestinal Disorders Ulcerative Colitis

Recurrent ulcerative & inflammatory disease of the mucosal layer Clinical Manifestations 1. Diarrhea & abdominal pain 2. Intermittent tenesmus 3. Rectal bleeding 4. Anorexia , weight loss , fever 5. Vomiting & dehydration
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Acute Inflammatory Intestinal Disorders Ulcerative Colitis

Medical Management
1. Nutritional therapy : - oral fluid - low residue caloric protein diet with supplementary vit & Iron 2. Pharmacological therapy : - antibiotics& corticosteroids (enema) -sedatives , antidiarrheal ,& antiperstaltic agents -Immunosuppressive agents 3. Surgical Managements: -colectomy segmental ,subtotal - total colectomy with ilioanal anastomosis -fecal diversion
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Ulcerative Colitis
Nursing Management
1. 2. 3. 4. 5. 6. 7. 8. Maintaining normal elimination pattern Relieving pain Maintaining fluid Intake Maintaining optimal nutrition Promoting rest Reducing anxiety Preventing skin breakdown Monitoring complications
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INTESTINAL OBSTRUCTION
Blockage prevents the normal flow of intestinal contents through the intestinal tract
A- mechanical: obstruction from pressure on the intestinal walls occurs due to adhesion, tumor & hernias B- functional: obstruction when intestinal musculature cant propel the contents

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Small Bowel Obstruction

Clinical manifestation
Crampy pain wave like & colicky Pass of blood & mucus without feces Vomiting ( reverse peristalsis ) Thirst & generalized malaise

Management
Decompression of bowel through N/G tube IVF to replace H2O, electrolytes deplession Surgical treatment of the cause Resection & end to end anastomosis
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Large Bowel Obstruction

Clinical manifestations
Abdominal distension, Crampy lower abdomen Fecal vomiting Symptoms of shock may occur

Medical management
Colonoscopy, to untwist or decompress bowel Cecostomy to relief pressure Rectal tube to decompress the lower part Surgical resection Temporary or permanent colostomy Ilio-anal anastomosis
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Nursing management
Administer IV fluids & electrolytes as prescribed Emotional support Pre & post operative care for abdominal surgery

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ANO-RECTAL DISORDERS
1- Anal Fistula Definition: tubular tract extends into anal canal from an opening beside the anus, from infection, abscess, trauma & fissure S & S
Pus or stool leakage Passage of flatus or feces from vagina or bladder depends on site of fistula

Treatment
Fistulectomy ( excision of fistulous tract ) Untreated fistula causes systematic infections
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2- Anal Fissure Definition: tear or ulceration in the lining of anal canal results from constipation, child birth & trauma S & S
Painful defecation Burning & bleeding

Treatment
Conservative treatment ( stool softener, sitz bath, analgesics ) Anal dilatation & fissure excision
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3- Hemorrhoids ( piles ) Definition: dilated portion of veins in the anal canal Types
Internal: above the internal sphincter External: out side the external sphincter

S & S
Itching & pain Bright red bleeding with defecation Piles come out side anus

Complications
Massive bleeding results in anemia Thrombosis & infection
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Treatment
Conservative treatment (sitz bath, laxative, high residual diet, anesthetic ointments & rest) Injection of sclerosing solutions Rubber band ligation procedure Hemorrhoidectomy

Nursing management
Pre-operative: cleansing enema, shaving & cross match, Hb + IV fluids Post-operative: analgesia hour before defecation, sitz bath in warm saline & remove the back
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4- Pilonidal Sinus / cyst Definition: found on the posterior surface of the lower sacrum results from the penetration of hair into the epithelium & subcutaneous tissue lead to recurrent abscess formation Treatment
Excision & drainage, antibiotic & analgesia

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 Nursing management (Ano -Rectal condition )

Relieving constipation Reducing anxiety Relieving pain Promoting urinary elimination Monitoring & managing complications

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Nursing Care of Clients with Bowel Disorders

Factors affecting bodily function of elimination A. GI tract 1. Food intake 2. Bacterial flora in bowel B. Indirect 1. Psychologic stress 2. Voluntary postponement of defecation

C. Normal bowel elimination pattern

1. 2. Varies with the individual 2 3 times daily to 3 stools per week
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Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)

Definition a. Functional GI tract disorder without identifiable cause characterized by abdominal pain and constipation, diarrhea, or both b. Affects up to 20% of persons in Western civilization; more common in females
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Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)

Pathophysiology a. Appears there is altered CNS regulation of motor and sensory functions of bowel 1.Increased bowel activity in response to food intake, hormones, stress 2.Increased sensations of chyme movement through gut 3.Hypersecretion of colonic mucus b. Lower visceral pain threshold causing abdominal pain and bloating with normal levels of gas c. Some linkage of depression and anxiety
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Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)

Manifestations a. Abdominal pain relieved by defecation; may be colicky, occurring in spasms, dull or continuous b. Altered bowel habits including frequency, hard or watery stool, straining or urgency with stooling, incomplete evacuation, passage of mucus; abdominal bloating, excess gas c. Nausea, vomiting, anorexia, fatigue, headache, anxiety d. Tenderness over sigmoid colon upon palpation 4. Collaborative Care a. Management of distressing symptoms b. Elimination of precipitating factors, stress reduction
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Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)

5. Diagnostic Tests: to find a cause for clients abdominal pain,

changes in feces elimination a.Stool examination for occult blood, ova and parasites, culture b.CBC with differential, Erythrocyte Sedimentation Rate (ESR): to determine if anemia, bacterial infection, or inflammatory process c.Sigmoidoscopy or colonoscopy 1.Visualize bowel mucosa, measure intraluminal pressures, obtain biopsies if indicated 2.Findings with IBS: normal appearance increased mucus, intraluminal pressures, marked spasms, possible hyperemia without lesions d.Small bowel series (Upper GI series with small bowel-follow through) and barium enema: examination of entire GI tract; IBS: increased motility

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Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)

Medications a. Purpose: to manage symptoms b. Bulk-forming laxatives: reduce bowel spasm, normalize bowel movement in number and form c. Anticholinergic drugs (dicyclomine (Bentyl), hyoscyamine) to inhibit bowel motility; given before meals d. Antidiarrheal medications (loperamide (Imodium), diphenoxylate (Lomotil): prevent diarrhea prophylactically e. Antidepressant medications f. Research: medications altering serotonin receptors in GI tract
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Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)

Dietary Management a. Often benefit from additional dietary fiber: adds bulk and water content to stool reducing diarrhea and constipation b. Some benefit from elimination of lactose, fructose, sorbitol c. Limiting intake of gas-forming foods, caffeinated beverages 8. Nursing Care a. Contact in health environments outside acute care b. Home care focus on improving symptoms with changes of diet, stress management, medications; seek medical attention if serious changes occur
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Peritonitis
Definition a. Inflammation of peritoneum, lining that covers wall (parietal peritoneum) and organs (visceral peritoneum) of abdominal cavity b. Enteric bacteria enter the peritoneal cavity through a break of intact GI tract (e.g. perforated ulcer, ruptured appendix)
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Peritonitis
Pathophysiology a. Peritonitis results from contamination of normal sterile peritoneal cavity with infections or chemical irritant b. Release of bile or gastric juices initially causes chemical peritonitis; infection occurs when bacteria enter the space c. Bacterial peritonitis usually caused by these bacteria (normal bowel flora): Escherichia coli, Klebsiella, Proteus, Pseudomonas d. Inflammatory process causes fluid shift into peritoneal space (third spacing); leading to hypovolemia, then septicemia
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Peritonitis
3. Manifestations a. Depends on severity and extent of infection, age and health of client b. Presents with acute abdomen 1.Abrupt onset of diffuse, severe abdominal pain 2.Pain may localize near site of infection (may have rebound tenderness) 3.Intensifies with movement c. Entire abdomen is tender with boardlike guarding or rigidity of abdominal muscle
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Peritonitis
d. Decreased peristalsis leading to paralytic ileus; bowel sounds are diminished or absent with progressive abdominal distention; pooling of GI secretions lead to nausea and vomiting e. Systemically: fever, malaise, tachycardia and tachypnea, restlessness, disorientation, oliguria with dehydration and shock f. Older or immunosuppressed client may have 1.Few of classic signs 2.Increased confusion and restlessness 3.Decreased urinary output 4.Vague abdominal complaints 5.At risk for delayed diagnosis and higher mortality rates
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Peritonitis
4. Complications a. May be life-threatening; mortality rate overall 40% b. Abscess c. Fibrous adhesions d. Septicemia, septic shock; fluid loss into abdominal cavity leads to hypovolemic shock 5. Collaborative Care a. Diagnosis and identifying and treating cause b. Prevention of complications

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Peritonitis
6. Diagnostic Tests a. WBC with differential: elevated WBC to 20,000; shift to left b. Blood cultures: identify bacteria in blood c. Liver and renal function studies, serum electrolytes: evaluate effects of peritonitis d. Abdominal xrays: detect intestinal distension, airfluid levels, free air under diaphragm (sign of GI perforation) e. Diagnostic paracentesis 7. Medications a. Antibiotics 1.Broad-spectrum before definitive culture results identifying specific organism(s) causing infection 2.Specific antibiotic(s) treating causative pathogens Husni Rousan 81 b. Analgesics

Peritonitis
8. Surgery a. Laparotomy to treat cause (close perforation, removed inflamed tissue) b. Peritoneal Lavage: washing out peritoneal cavity with copious amounts of warm isotonic fluid during surgery to dilute residual bacterial and remove gross contaminants c. Often have drain in place and/or incision left unsutured to continue drainage
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Peritonitis
9. Treatment a. Intravenous fluids and electrolytes to maintain vascular volume and electrolyte balance b. Bed rest in Fowlers position to localize infection and promote lung ventilation c. Intestinal decompression with nasogastric tube or intestinal tube connected to suction 1. Relieves abdominal distension secondary to paralytic ileus 2. NPO with intravenous fluids while having nasogastric suction
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Peritonitis
10. Nursing Diagnoses a. Pain b. Deficient Fluid Volume: often on hourly output; nasogastric drainage is considered when ordering intravenous fluids c. Ineffective Protection d. Anxiety 11. Home Care a. Client may have prolonged hospitalization b. Home care often includes 1. Wound care 2. Home health referral 3. Home intravenous antibiotics
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Client with Inflammatory Bowel Disease

Definition a. Includes 2 separate but closely related conditions: ulcerative colitis and Crohns disease; both have similar geographic distribution and genetic component b. Etiology is unknown but runs in families; may be related to infectious agent and altered immune responses c. Peak incidence occurs between the ages of 15 35; second peak 60 80 d. Chronic disease with recurrent exacerbations
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Ulcerative Colitis
Pathophysiology 1. Inflammatory process usually confined to rectum and sigmoid colon 2. Inflammation leads to mucosal hemorrhages and abscess formation, which leads to necrosis and sloughing of bowel mucosa 3. Mucosa becomes red, friable, and ulcerated; bleeding is common 4. Chronic inflammation leads to atrophy, narrowing, and shortening of colon
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Ulcerative Colitis
Manifestations 1. Diarrhea with stool containing blood and mucus; 5 10 stools per day leading to anemia, hypovolemia, malnutrition 2. Fecal urgency, tenesmus, LLQ cramping 3. Fatigue, anorexia, weakness 4. Severe cases: arthritis, uveitis
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Ulcerative Colitis
Complications 1. Hemorrhage: can be massive with severe attacks 2. Toxic megacolon: usually involves transverse colon which dilates and lacks peristalsis (manifestations: fever, tachycardia, hypotension, dehydration, change in stools, abdominal cramping) 3. Colon perforation: rare but leads to peritonitis and 15% mortality rate 4. Increased risk for colorectal cancer (20 30 times); need yearly colonoscopies 5. Sclerosing cholangitis
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Crohns Disease (regional enteritis)

Pathophysiology 1. Can affect any portion of GI tract, but terminal ileum and ascending colon are more commonly involved 2. Inflammatory aphthoid lesion (shallow ulceration) of mucosa and submuscosa develops into ulcers and fissures that involve entire bowel wall 3. Fibrotic changes occur leading to local obstruction, abscess formation and fistula formation 4. Fistulas develop between loops of bowel (enteroenteric fistulas); bowel and bladder (enterovesical fistulas); bowel and skin (enterocutaneous fistulas) 5. Absorption problem develops leading to protein 89 Husni Rousan loss and anemia

Crohns Disease (regional enteritis)

Manifestations 1. Often continuous or episodic diarrhea; liquid or semi-formed; abdominal pain and tenderness in RLQ relieved by defecation 2. Fever, fatigue, malaise, weight loss, anemia 3. Fissures, fistulas, abscesses
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Crohns Disease (regional enteritis)

Complications 1. Intestinal obstruction: caused by repeated inflammation and scarring causing fibrosis and stricture 2. Fistulas lead to abscess formation; recurrent urinary tract infection if bladder involved 3. Perforation of bowel may occur with peritonitis 4. Massive hemorrhage 5. Increased risk of bowel cancer (5 6 times)
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Crohns Disease (regional enteritis)

Collaborative Care a. Establish diagnosis b. Supportive treatment c. Many clients need surgery Diagnostic Tests a. Colonoscopy, sigmoidoscopy: determine area and pattern of involvement, tissue biopsies; small risk of perforation b. Upper GI series with small bowel follow-through, barium enema c. Stool examination and stool cultures to rule out infections d. CBC: shows anemia, leukocytosis from inflammation and abscess formation e. Serum albumin, folic acid: lower due to malabsorption Husni Rousan 92 f. Liver function tests may show enzyme elevations

Crohns Disease (regional enteritis)

Medications: goal is to stop acute attacks quickly and reduce incidence of relapse a. Sulfasalazine (Azulfidine): sulfonamide antibiotic with topical effect in colon; used with ulcerative colitis b. Corticosteroids: reduce inflammation and induce remission; with ulcerative colitis may be given as enema; intravenous steroids are given with severe exacerbations c. Immunosuppressive agents (azathioprine (Imuran), cyclosporine) for clients who do not respond to steroid therapy d. New therapies including immune response modifiers, anti-inflammatory cyctokines e. Metronidazole (Flagyl) or Ciprofloxacin (Cipro) 93 Husni Rousan f. Anti-diarrheal medications

Crohns Disease (regional enteritis)

Dietary Management a. Individualized according to client; eliminate irritating foods b. Dietary fiber contraindicated if client has strictures c. With acute exacerbations, client may be made NPO and given enteral or total parenteral nutrition (TPN) Surgery: performed when necessitated by complications or failure of other measures a. Crohns disease 1. Bowel obstruction leading cause; may have bowel resection and repair for obstruction, perforation, fistula, abscess Husni Rousan 94 2. Disease process tends to recur in area remaining after resection

Ulcerative Colitis
1. Total colectomy to treat disease, repair complications (toxic megacolon, perforation, hemorrhage, prophylactic for cancer risk) 2. Total colectomy with an ileal pouchanal anastomosis (initially has temporary ileostomy)

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Ulcerative Colitis
Ostomy 1. Surgically created opening between intestine and abdominal wall that allows passage of fecal material 2. Stoma is the surface opening which has an appliance applied to retain stool and is emptied at intervals 3. Name of ostomy depends on location of stoma 4. Ileostomy: opening in ileum; may be permanent with total proctocolectomy or temporary (loop ileostomy) 5. Ileostomies: always have liquid stool which can be corrosive to skin since contains digestive enzymes 6. Continent (or Kocks) ileostomy: has intraabdominal reservoir with Rousan Husni nipple valve formation to 96 allow catheter insertion to drain out stool

Ulcerative Colitis
Nursing Care: Focus is effective management of disease with avoidance of complications Nursing Diagnoses a. Diarrhea b. Disturbed Body Image; diarrhea may control all aspects of life; client has surgery with ostomy c. Imbalanced Nutrition: Less than body requirement d. Risk for Impaired Tissue Integrity: Malnutrition and healing post surgery e. Risk for sexual dysfunction, related to diarrhea or ostomy
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Ulcerative Colitis
Home Care a. Inflammatory bowel disease is chronic and day-to-day care lies with client b. Teaching to control symptoms, adequate nutrition, if client has ostomy: care and resources for supplies, support group and home care referral

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Client with Intestinal Obstruction

Definition a. May be partial or complete obstruction b. Failure of intestinal contents to move through the bowel lumen; most common site is small intestine c. With obstruction, gas and fluid accumulate proximal to and within obstructed segment causing bowel distention d. Bowel distention, vomiting, third-spacing leads to hypovolemia, hypokalemia, renal insufficiency, shock
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Client with Intestinal Obstruction

Pathophysiology a. Mechanical 1. Problems outside intestines: adhesions (bands of scar tissue), hernias 2. Problems within intestines: tumors, IBD 3. Obstruction of intestinal lumen (partial or complete) a. Intussusception: telescoping bowel b. Volvulus: twisted bowel c. Foreign bodies d. Strictures
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Client with Intestinal Obstruction

Functional 1. Failure of peristalsis to move intestinal contents: adynamic ileus (paralytic ileus, ileus) due to neurologic or muscular impairment 2. Accounts for most bowel obstructions 3. Causes include a. Post gastrointestinal surgery b. Tissue anoxia or peritoneal irritation from hemorrhage, peritonitis, or perforation c. Hypokalemia d. Medications: narcotics, anticholinergic drugs, antidiarrheal medications e. Renal colic, spinal cord injuries, uremia
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Client with Intestinal Obstruction

a.
b. c. d. e. Manifestations Small Bowel Obstruction Vary depend on level of obstruction and speed of development Cramping or colicky abdominal pain, intermittent, intensifying Vomiting 1. Proximal intestinal distention stimulates vomiting center 2. Distal obstruction vomiting may become feculent Bowel sounds 1. Early in course of mechanical obstruction: borborygmi and high-pitched tinkling, may have visible peristaltic waves 2. Later silent; with paralytic ileus, diminished or absent bowel sounds throughout Husni Rousan Signs of dehydration

102

Client with Intestinal Obstruction

Complications a. Hypovolemia and hypovolemic shock can result in multiple organ dysfunction (acute renal failure, impaired ventilation, death) b. Strangulated bowel can result in gangrene, perforation, peritonitis, possible septic shock c. Delay in surgical intervention leads to higher mortality rate
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Client with Intestinal Obstruction

Large Bowel Obstruction a. Only accounts for 15% of obstructions b. Causes include cancer of bowel, volvulus, diverticular disease, inflammatory disorders, fecal impaction c. Closed-loop obstruction: competent ileocecal valve causes massive colon dilation d. Manifestations: deep, cramping pain; severe, continuous pain signals bowel ischemia and possible perforation; localized tenderness or palpable mass may be noted
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Client with Intestinal Obstruction

Collaborative Care a. Relieving pressure and obstruction b. Supportive care Diagnostic Tests a. Abdominal Xrays and CT scans with contrast media 1. Show distended loops of intestine with fluid and /or gas in small intestine, confirm mechanical obstruction; indicates free air under diaphragm 2. If CT with contrast media meglumine diatrizoate (Gastrografin), check for allergy to iodine, need BUN and Creatinine to determine renal function b. Laboratory testing to evaluate for presence of infection and electrolyte imbalance: WBC, Serum amylase, osmolality, electrolytes, arterial blood gases c. Barium enema or colonoscopy/sigmoidoscopy to identify large bowel obstruction Gastrointestinal Decompression a. Treatment with nasogastric or long intestinal tube provides bowel rest and removal of air and fluid b. Successfully relieves many partial small bowel obstructions
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Client with Intestinal Obstruction

Surgery a. Treatment for complete mechanical obstructions, strangulated or incarcerated obstructions of small bowel, persistent incomplete mechanical obstructions b. Preoperative care 1. Insertion of nasogastric tube to relieve vomiting, abdominal distention, and to prevent aspiration of intestinal contents 2. Restore fluid and electrolyte balance; correct acid and alkaline imbalances 3. Laparotomy: inspection of intestine and removal of infarcted or gangrenous tissue 4. Removal of cause of obstruction: adhesions, tumors, foreign bodies, gangrenous portion of intestines and anastomosis or creation of colostomy depending on individual case
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Client with Intestinal Obstruction

Nursing Care a. Prevention includes healthy diet, fluid intake b. Exercise, especially in clients with recurrent small bowel obstructions Nursing Diagnoses a. Deficient Fluid Volume b. Ineffective Tissue Perfusion, gastrointestinal c. Ineffective Breathing Pattern Home Care a. Home care referral as indicated b. Teaching about signs of recurrent obstruction and seeking medical attention
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Gastrointestinal Intubation

It is the insertion of a rubber or plastic tube into the stomach ,duodenum ,or intestine . The tube may inserted through the mouth , nose , or the abdomen

Intubation may be performed to:1. 2.

3. 4. 5. 6.

Decompress the stomach & remove gas &fluid Lavage the stomach & remove toxic ingested substances Diagnose GI motility & other disorders Administer medication & feedings Treat an obstruction Compress a bleeding site
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Gastrointestinal Intubation
Types
1. Short tubes 2. Medium : 3. Long (nasoenteric)

Nursing care includes

Providing instructions Inserting the tube
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Gastrointestinal Intubation
Confirming placement Securing the tube Advancing the nasoenteric decompression tube Providing oral & nasal Hygiene Monitoring the patient & maintaining tube function Monitoring & managing potential complications Removing the tube
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Gastrointestinal Intubation
Gastrostomy Is surgical procedure to create an opening into the stomach for the purpose of administer food & fluids Elderly & debilitated patients Comatose patients Percutaneous endoscopic gastrostomy
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TPN
Is a method of supplying nutrients to the body by an IV rout Clinical Indications 1. Insufficient intake to maintain anabolic 2. Impaired ability to ingest food 3. Ingestion unwilling 4. prolonged pre & post op. nutritional needs
Husni Rousan 112

TPN
Types of nutritional solutions 1. TPN (aminoacids + dextrose formula ) 2. Total nutrient admixture (aminoacids +dextrose formula + intralipids ) Methods of Administration 1. Peripheral Partial Method 2. Central line Method D/C gradually
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