Nursing Care of Clients with Upper Gastrointestinal Disorders

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Care of Clients with Disorder of the Mouth A. Disorder includes inflammation, infection, neoplastic lesions B. Pathophysiology 1. Causes include mechanical trauma, irritants such as tobacco, chemotherapeutic agents 2. Oral mucosa is relatively thin, has rich blood supply, exposed to environment C. Manifestations 1. Visible lesions or erosions on lips or oral mucosa 2. Pain

Nursing Care of Clients with Upper Gastrointestinal Disorders 
D. Collaborative Care 1.Direct observation to investigate any problems; determine underlying cause and any coexisting diseases 2.Any undiagnosed oral lesion present for > 1 week and not responding to treatment should be evaluated for malignancy 3.General treatment includes mouthwashes or treatments to cleanse and relieve irritation a.Alcohol bases mouthwashes cause pain and burning b.Sodium bicarbonate mouthwashes are effective without pain 4. Specific treatments according to type of infection a.Fungal (candidiasis): nystatin ³swish and swallow´ or clotrimazole lozenges  b.Herpetic lesions: topical or oral acyclovir

Nursing Care of Clients with Upper Gastrointestinal Disorders
E. Nursing Care 1. Goal: to relieve pain and symptoms, so client can continue food and fluid intake in health care facility and at home 2. Impaired oral mucous membrane  a. Assess clients at high risk  b. Assist with oral hygiene post eating, bedtime  c. Teach to limit irritants: tobacco, alcohol, spicy foods 3. Imbalanced nutrition: less than body requirements  a. Assess nutritional intake; use of straws  b. High calorie and protein diet according to client preferences

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occupational exposure to chemicals.Client with Oral Cancer 1. Risk factors include smoking and using oral tobacco. marijuana use. viruses (human papilloma virus) . mortality  b. drinking alcohol. Highest among males over age 40  c.Background  a. Uncommon (5% of all cancers) but has high rate of morbidity.

ill-defined borders  c. Squamous cell carcinomas  b.Client with Oral Cancer 2. mandible. Begin as painless oral ulceration or lesion with irregular. Non-healing lesions should be evaluated for malignancy after one week of treatment . Lesions start in mucosa and may advance to involve tongue. maxilla  d. oropharynx. Pathophysiology  a.

Advanced carcinomas may necessitate radical neck dissection with temporary or permanent tracheostomy. Determination of malignancy with biopsy  c. chemotherapy. teaching family and client care involved post surgery. Collaborative Care  a. Determine staging with CT scans and MRI  d. support groups . general health and client¶s preference. Based on age. Surgeries may be disfiguring  f. refer to American Cancer Society. treatment may include surgery. tumor stage. Elimination of causative agents  b. and/or radiation therapy  e. Plan early for home care post hospitalization.Client with Oral Cancer 3.

Nursing Care a. Nursing Diagnoses  1. Imbalanced Nutrition: Less than body requirements  3. Risk for ineffective airway clearance  2. Need to seek medical attention for all nonhealing oral lesions (may be discovered by dentists). Disturbed Body Image . Impaired Verbal Communication: establishment of specific communication plan and method should be done prior to any surgery  4. early precancerous oral lesions are very treatable b. Health promotion:  1. Teach risk of oral cancer associated with all tobacco use and excessive alcohol use  2.Client with Oral Cancer 4.

.Gastroesophageal Reflux Disease (GERD) 1. affecting 15 ± 20% of adults  c. Definition  b. 10% persons experience daily heartburn and indigestion  d. Because of location near other organs symptoms may mimic other illnesses including heart problems  a. GERD common. Gastroesophageal reflux is the backward flow of gastric content into the esophagus.

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

Sore throat with hoarseness  e. Heartburn after meals. prolonged exposure causes ulceration. friable mucosa. Manifestations  a. during sleep and with gastroesophageal reflux esophageal mucosa is damaged and inflamed.Gastroesophageal Reflux Disease (GERD)  c. May have regurgitation of sour materials in mouth. while bending over.Normally the peristalsis in esophagus and bicarbonate in salivary secretions neutralize any gastric juices (acidic) that contact the esophagus. Atypical chest pain  d. and bleeding. pain with swallowing  c. untreated there is scarring and stricture 3. or recumbent  b. Bronchospasm and laryngospasm .

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Gastroesophageal Reflux Disease (GERD)
4. Complications  a. Esophageal strictures, which can progress to dysphagia  b. Barrett¶s esophagus: changes in cells lining esophagus with increased risk for esophageal cancer 5. Collaborative Care  a. Diagnosis may be made from history of symptoms and risks  b. Treatment includes 1.Life style changes 2.Diet modifications 3.Medications

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  d. Esophageal manometry, which measure pressures of esophageal sphincter and peristalsis  e. Esophageal motility studies

g. metoclopramide (reglan) . Promotility agent: enhances esophageal clearance and gastric emptying.Gastroesophageal Reflux Disease (GERD) 7. lansoprazole (Prevacid) initially for 8 weeks. given BID or more often.g. Proton-pump inhibitors: reduce gastric secretions. ranitidine. Antacids for mild to moderate symptoms.g. Mylanta. cimetidine. H2-receptor blockers: decrease acid production.g. e. omeprazole (prilosec). promote healing of esophageal erosion and relieve symptoms. e. e. nizatidine  c. Maalox. famotidine. Gaviscon  b. or 3 to 6 months  d.Medications  a. e.

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

Open surgical procedure: Nissen fundoplication 10. Assist client to institute home plan . Pain usually controlled by treatment  b. Nursing Care  a. Laparoscopic procedures to tighten lower esophageal sphincter  b.Surgery indicated for persons not improved by diet and life style changes  a.Gastroesophageal Reflux Disease (GERD) 9.

Part of stomach protrudes through the esophageal hiatus of the diaphragm into thoracic cavity  b. Predisposing factors include: Increased intra-abdominal pressure Increased age Trauma Congenital weakness Forced recumbent position .Definition  a.Hiatal Hernia 1.

Most cases are asymptomatic. client may develop gastritis with bleeding .Hiatal Hernia  c. Paraesophageal hiatal hernia: the gastroesophageal junction is in normal place but part of stomach herniates through esophageal hiatus. incidence increases with age  d. Sliding hiatal hernia: gastroesophageal junction and fundus of stomach slide through the esophageal hiatus  e. hernia can become strangulated.

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then surgery. Similar to GERD: diet and lifestyle changes. usually Nissen fundoplication by thoracic or abdominal approach  Anchoring the lower esophageal sphincter by wrapping a portion of the stomach around it to anchor it in place . medications  b. Diagnostic Tests  a. Barium swallow  b. Manifestations: Similar to GERD 3. Treatment  a.Hiatal Hernia 2. Upper endoscopy 4. If medical treatment is not effective or hernia becomes incarcerated.

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Types  a. Achalasia: characterized by impaired peristalsis of smooth muscle of esophagus and impaired relaxation of lower esophageal sphincter  b. Endoscopically guided injection of botulinum toxin  Denervates cholinergic nerves in the distal esophagus to stop spams  b. Treatment  a. Manifestations: Dysphagia and/or chest pain 3. Diffuse esophageal spasm: nonperistaltic contraction of esophageal smooth muscle 2. Balloon dilation of lower esophageal sphincter  May place stents to keep esophagus open .Impaired Esophageal Motility 1.

Adenocarcinoma 1. Definition: Relatively uncommon malignancy with high mortality rate.More common in African Americans than Caucasians 3.Esophageal Cancer 1.More common in Caucasians 3. complication of chronic GERD and achalasia .Most common affecting middle or distal portion of esophagus 2. Squamous cell carcinoma 1.Nearly as common as squamous cell affecting distal portion of esophagus 2.Associated with Barrett¶s esophagus.Risk factors cigarette smoking and chronic alcohol use  b. usually diagnosed late 2. Pathophysiology  a.

radiation therapy. hoarseness. Progressive dysphagia with pain while swallowing  b. cough  c. Choking. Manifestations  a. Controlling dysphagia  b. Collaborative Care: Treatment goals  a. weight loss 4.Esophageal Cancer 3. Anorexia. Maintaining nutritional status while treating carcinoma (surgery. and/or chemotherapy .

Chest xray. Esophagoscopy: allow direct visualization of tumor and biopsy  c. Liver function tests: elevated with liver metastasis . Diagnostic Tests  a. CT scans. Complete Blood Count: identify anemia  e.Esophageal Cancer 5. Barium swallow: identify irregular mucosal patterns or narrowing of lumen  b. Serum albumin: low levels indicate malnutrition  f. MRI: determine tumor metastases  d.

client¶s condition and preference  a. More advanced carcinoma: treatment is palliative and may include surgery. Treatments: dependent on stage of disease. Complications of radiation therapy include perforation. Early (curable) stage: surgical resection of affected portion with anastomosis of stomach to remaining esophagus.Esophageal Cancer 6. radiation and chemotherapy to control dysphagia and pain  c. may also include radiation therapy and chemotherapy prior to surgery  b. stricture . hemorrhage.

Nursing Care: Health promotion. education regarding risks associated with smoking and excessive alcohol intake 8. Nursing Diagnoses  a. Risk for Ineffective Airway Clearance (especially during postoperative period if surgery was done) .Esophageal Cancer 7. Anticipatory Grieving (dealing with cancer diagnosis)  c. Imbalanced Nutrition: Less than body requirements (may include enteral tube feeding or parenteral nutrition in hospital and home)  b.

self-limiting disorder . Acute Gastritis 1. Definition: Inflammation of stomach lining from irritation of gastric mucosa (normally protected from gastric acid and enzymes by mucosal barrier) 2. inflammation. Types  a.Gastric mucosa rapidly regenerates. superficial erosions 2.Gastritis 1.Disruption of mucosal barrier allowing hydrochloric acid and pepsin to have contact with gastric tissue: leads to irritation.

certain chemotherapeutic agents 4. hematemesis. Irritants include aspirin and other NSAIDS. corticosteroids. Mild: anorexia. complication of life-threatening condition (Curling¶s ulcer with burns). nausea. signs of peritonitis . Erosive: not associated with pain. More severe: abdominal pain. If perforation occurs. mild epigastric discomfort. caffeine  b. Causes of acute gastritis  a. alcohol. vomiting. Manifestations  a. Ingestion of corrosive substances: alkali or acid  c.Gastritis 3. belching  b. Erosive Gastritis: form of acute which is stress-induced. Effects from radiation therapy. gastric mucosa becomes ischemic and tissue is then injured by acid of stomach 5. bleeding occurs 2 or more days post stress event  d. melena  c.

Medications: proton-pump inhibitor or H2-receptor blocker. sucralfate (carafate) acts locally. If gastritis from corrosive substance: immediate dilution and removal of substance by gastric lavage (washing out stomach contents via nasogastric tube). NPO status to rest GI tract for 6 ± 12 hours. no vomiting .Gastritis 6. Treatment  a. intravenous fluid and electrolytes if indicated  b. reintroduce clear liquids gradually and progress. coats and protects gastric mucosa  c.

Chronic Gastritis  1. develops pernicious anemia Parietal cells normally secrete intrinsic factor needed for absorption of B12. Type A: autoimmune component and affecting persons of northern European descent. Progressive disorder beginning with superficial inflammation and leads to atrophy of gastric tissues  2. when they are destroyed by gastritis pts develop pernicious anemia . loss of hydrochloric acid and pepsin secretion.

caused by chronic infection of mucosa by Helicobacter pylori.Chronic Gastritis  3. associated with risk of peptic ulcer disease and gastric cancer . Type B: more common and occurs with aging.

epigastric heaviness not relieved by antacids  b. Treatment: Type B: eradicate H. Vague gastric distress. pylori infection with combination therapy of two antibiotics (metronidazole (Flagyl) and clarithomycin or tetracycline) and proton± pump inhibitor (Prevacid or Prilosec) . symptoms associated with pernicious anemia: paresthesias Lack of B12 affects nerve transmission 5. Fatigue associated with anemia.Chronic Gastritis 4. Manifestations  a.

Chronic Gastritis Collaborative Care  a. Management of acute gastritis with NPO state and then gradual reintroduction of fluids with electrolytes and glucose and advance to solid foods  d. treatment of alcohol abuse . Teach food safety measures to prevent acute gastritis from food contaminated with bacteria  c. Usually managed in community  b. Teaching regarding use of prescribed medications. smoking cessation.

red blood cell indices: anemia including pernicious or iron deficiency  c. Nursing Diagnoses:  a. Serum vitamin B12 levels: determine pernicious anemia  d. hematocrit. Deficient Fluid Volume  b. Upper endoscopy: visualize mucosa. Imbalanced Nutrition: Less than body requirements . Gastric analysis: assess hydrochloric acid secretion (less with chronic gastritis)  b. may treat areas of bleeding with electro or laser coagulation or sclerosing agent  5. obtain biopsies. Hemoglobin.Chronic Gastritis Diagnostic Tests  a. identify areas of bleeding.

affects 10% of US population  b. Common in smokers. Duodenal ulcers: most common. affect mostly males ages 30 ± 55. Gastric ulcers: affect older persons (ages 55 ± 70). users of NSAIDS. ulcers found near pyloris  c. found on lesser curvature and associated with increased incidence of gastric cancer  d.Peptic Ulcer Disease (PUD) Definition and Risk factors  a. alcohol. Break in mucous lining of GI tract comes into contact with gastric juice. familial pattern. ASA. cigarettes .

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

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Pylori Upper GI barium contrast studies EGD-esophagogastroduodenoscopy Serum and stool studies .Peptic Ulcer Disease  Diagnosis Endoscopy with cultures Looking for H.

aching hungerlike in epigastric region possibly radiating to back.Peptic Ulcer Disease (PUD) 3. dysphagia. Pain is classic symptom: gnawing. weight loss. burning. may have poorly localized discomfort. Symptoms less clear in older adult. Manifestations  a. occurs when stomach is empty and relieved by food (pain: food: relief pattern)  b. presenting symptom may be complication: GI hemorrhage or perforation of stomach or duodenum .

Peptic Ulcer Disease 
Treatment 
Rest and stress reduction Nutritional management Pharmacological management 
Antacids (Mylanta)
‡ Neutralizes acids 

Proton pump inhibitors (Prilosec, Prevacid)
‡ Block gastric acid secretion

Peptic Ulcer Disease 
Pharmacological management 
Histamine blockers (Tagamet, Zantac, Axid) 
Blocks gastric acid secretion 

Carafate 
Forms protective layer over the site 

Mucosal barrier enhancers (colloidal bismuth, prostoglandins) 
Protect mucosa from injury 

Antibiotics (PCN, Amoxicillin, Ampicillin) 
Treat H. Pylori infection

Peptic Ulcer Disease 
NG suction  Surgical intervention 
Minimally invasive gastrectomy 
Partial gastric removal with laproscopic surgery 

Bilroth I and II 
Removal of portions of the stomach 

Vagotomy 
Cutting of the vagus nerve to decrease acid secretion 

Pyloroplasty 
Widens the pyloric sphincter

Billroth I

Billroth II .

Complications  a. worsened ulcer symptoms . hematochezia (blood in stool).Hemorrhage: frequent in older adult: hematemesis. with significant bleed loss may develop hypovolemic shock  b.Peptic Ulcer Disease (PUD) 4. fatigue. melena.Gradual process 2. weakness.Obstruction: gastric outlet (pyloric sphincter) obstruction: edema surrounding ulcer blocks GI tract from muscle spasm or scar tissue 1. orthostatic hypotension and anemia. dizziness. nausea.Symptoms: feelings of epigastric fullness.

symptoms of shock 3.Perforation: ulcer erodes through mucosal wall and gastric or duodenal contents enter peritoneum leading to peritonitis.Time of ulceration: severe upper abdominal pain radiating throughout abdomen and possibly to shoulder 2. boardlike with absent bowel sounds.Peptic Ulcer Disease  c.Older adults may present with mental confusion and non-specific symptoms . chemical at first (inflammatory) and then bacterial in 6 to 12 hours 1.Abdomen becomes rigid.

gastritis and carcinoma .Upper GI Bleed  Mortality approx 10%  Predisposing factors include: drugs. esophageal varacies. esophagitis. PUD.

Upper GI Bleed  Signs and Symptoms Coffee ground vomitus Black. tarry stools Melena Decreased B/P Vertigo Drop in Hct. Hgb Confusion syncope .

vomitus studies Endoscopy . stool.Upper GI Bleed  Diagnosis History Blood.

Upper GI Bleed  Treatments Volume replacement Crystalloids.normal saline Blood transfusions NG lavage EGD Endoscopic treatment of bleeding ulcer Sclerotheraphy-injecting bleeding ulcer with necrotizing agent to stop bleeding .

Upper GI Bleed  Treatments Sengstaken-Blakemore tube Used with bleeding esophageal varacies Surgical intervention Removal of part of the stomach .

Sengstaken-Blakemore Tube .

Cancer of Stomach 1. but less common in US  b. African Americans. Incidence  a. Older adults of lower socioeconomic groups higher risk 2. spreads to lymph nodes and metastasizes early in disease to liver. peritoneum . males twice as often as females  c. Worldwide common cancer. lungs. Asian Americans. Incidence highest among Hispanics. Adenocarcinoma most common form involving mucus-producing cells of stomach in distal portion  b. Begins as localized lesion (in situ) progresses to mucosa. Pathophysiology  a. ovaries.

Colon Cancer .

H. abdominal mass. gastric polyps d. indigestion.    Risk Factors a. Chronic gastritis.      4. anorexia. Diet high in smoked foods and nitrates Manifestations a. pain after meals not responding to antacids c. stool positive for occult blood . cachexia (wasted away appearance). Disease often advanced with metastasis when diagnosed b. Later symptoms weight loss. pylori infection b. pernicious anemia. Early symptoms are vague: early satiety. Achlorhydria (lack of hydrochloric acid) e. Genetic predisposition c.Cancer of Stomach 3. vomiting.

Cancer of Stomach 5. Support client through testing b.Upper endoscopy: visualization and tissue biopsy of lesion . ultrasound identifies a mass c.CBC indicates anemia b. Diagnostic Tests a.Upper GI series. Collaborative Care a. Assist client to maintain adequate nutrition 6.

if diagnosis made prior to metastasis 1.Total gastrectomy (if cancer diffuse but limited to stomach) with esophagojejunostomy .Partial gastrectomy with anastomosis to jejunum: Bilroth II or gastrojejunostomy 3. Surgery.Partial gastrectomy with anastomosis to duodenum: Bilroth I or gastroduodenostomy 2.Cancer of Stomach 7. Treatment  a.

Occurs with partial gastrectomy. borborygmi. diaphoretic c.Manifestations 5 ± 30 minutes after meal: nausea with possible vomiting. client becomes tachycardic.Cancer of Stomach b.Manifestations 2 ± 3 hours after meal: symptoms of hypoglycemia in response to excessive release of insulin that occurred from rise in blood glucose when chyme entered intestine . and diarrhea. hypotensive. dizzy. Dumping Syndrome a. epigastric pain and cramping. flushed. undigested chyme bolus rapidly enters small intestine and pulls fluid into intestine causing decrease in circulating blood volume and increased intestinal peristalsis and motility b. hypertonic. Complications associated with gastric surgery  1.

antispasmodic medications may be added  6. Limit amount of food taken at one time .Cancer of Stomach d. Treatment: dietary pattern to delay gastric emptying and allow smaller amounts of chyme to enter intestine  1. Liquids and solids taken separately  2. reduced  4. Increased amounts of fat and protein  3. Client to rest recumbent or semi-recumbent 30 ± 60 minutes after eating  5. especially simple sugars. Carbohydrates. sedatives. Anticholinergics.

Cancer of the Stomach 
Common post-op complications 
Pneumonia Anastomotic leak Hemorrhage Relux aspiration Sepsis Reflux gastritis Paralytic ileus Bowel obstruction Wound infection Dumping syndrome

Cancer of Stomach 
Nutritional problems related to rapid entry of food into the bowel and the shortage of intrinsic factor  1 Anemia: iron deficiency and/or pernicious  2 Folic acid deficiency  3. Poor absorption of calcium, vitamin D c. Radiation and/or chemotherapy to control metastasic spread d. Palliative treatment including surgery, chemotherapy; client may have gastrostomy or jejunostomy tube inserted 7. Nursing Diagnoses  a. Imbalanced Nutrition: Less than body requirement: consult dietician since client at risk for protein-calorie malnutrition  b. Anticipatory Grieving

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

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

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

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

possible hyperemia without lesions d. intraluminal pressures.Visualize bowel mucosa. Erythrocyte Sedimentation Rate (ESR): to determine if anemia. obtain biopsies if indicated 2. ova and parasites. bacterial infection.     changes in feces elimination a. Diagnostic Tests: to find a cause for client¶s abdominal pain. functional colitis) 5. marked spasms. culture b.Stool examination for occult blood.Irritable Bowel Syndrome (IBS) (spastic bowel.Findings with IBS: normal appearance increased mucus.CBC with differential.Sigmoidoscopy or colonoscopy 1.Small bowel series (Upper GI series with small bowel-follow through) and barium enema: examination of entire GI tract. measure intraluminal pressures. IBS: increased motility . or inflammatory process c.

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

Some benefit from elimination of lactose. Often benefit from additional dietary fiber: adds bulk and water content to stool reducing diarrhea and constipation  b. Limiting intake of gas-forming foods. functional colitis) Dietary Management  a. stress management. Contact in health environments outside acute care  b. Home care focus on improving symptoms with changes of diet. caffeinated beverages 8. fructose.Irritable Bowel Syndrome (IBS) (spastic bowel. medications. Nursing Care  a. sorbitol  c. seek medical attention if serious changes occur .

Enteric bacteria enter the peritoneal cavity through a break of intact GI tract (e. lining that covers wall (parietal peritoneum) and organs (visceral peritoneum) of abdominal cavity  b. Inflammation of peritoneum. perforated ulcer. ruptured appendix) .Peritonitis Definition  a.g.

Peritonitis  Causes include: Ruptured appendix Perforated bowel secondary to PUD Diverticulitis Gangrenous gall bladder Ulcerative colitis Trauma Peritoneal dialysis .

Release of bile or gastric juices initially causes chemical peritonitis. Inflammatory process causes fluid shift into peritoneal space (third spacing). Proteus. infection occurs when bacteria enter the space  c. Klebsiella. leading to hypovolemia.Peritonitis Pathophysiology  a. Peritonitis results from contamination of normal sterile peritoneal cavity with infections or chemical irritant  b. then septicemia . Bacterial peritonitis usually caused by these bacteria (normal bowel flora): Escherichia coli. Pseudomonas  d.

Peritonitis 3. Depends on severity and extent of infection. age and health of client  b. severe abdominal pain 2. Manifestations  a.Pain may localize near site of infection (may have rebound tenderness) 3. Presents with ³acute abdomen´ 1.Abrupt onset of diffuse. Entire abdomen is tender with boardlike guarding or rigidity of abdominal muscle .Intensifies with movement  c.

Decreased urinary output 4.Few of classic signs 2.At risk for delayed diagnosis and higher mortality rates . tachycardia and tachypnea. Decreased peristalsis leading to paralytic ileus. Older or immunosuppressed client may have 1. oliguria with dehydration and shock  f. pooling of GI secretions lead to nausea and vomiting  e. malaise. restlessness.Vague abdominal complaints 5. bowel sounds are diminished or absent with progressive abdominal distention. disorientation.Peritonitis  d. Systemically: fever.Increased confusion and restlessness 3.

Septicemia. Diagnosis and identifying and treating cause  b.Peritonitis 4. Collaborative Care  a. Fibrous adhesions  d. fluid loss into abdominal cavity leads to hypovolemic shock 5. Complications  a. Abscess  c. mortality rate overall 40%  b. septic shock. Prevention of complications . May be life-threatening.

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

Often have drain in place and/or incision left unsutured to continue drainage . removed inflamed tissue)  b. Laparotomy to treat cause (close perforation.Peritonitis 8. Surgery  a. Peritoneal Lavage: washing out peritoneal cavity with copious amounts of warm isotonic fluid during surgery to dilute residual bacterial and remove gross contaminants  c.

Relieves abdominal distension secondary to paralytic ileus  2. Intestinal decompression with nasogastric tube or intestinal tube connected to suction  1. Bed rest in Fowler¶s position to localize infection and promote lung ventilation  c.Peritonitis 9. Treatment  a. NPO with intravenous fluids while having nasogastric suction . Intravenous fluids and electrolytes to maintain vascular volume and electrolyte balance  b.

Anxiety 11. Pain  b. Client may have prolonged hospitalization  b. Deficient Fluid Volume: often on hourly output. Ineffective Protection  d. Wound care  2. Nursing Diagnoses  a.Peritonitis 10. Home health referral  3. Home care often includes  1. Home intravenous antibiotics . nasogastric drainage is considered when ordering intravenous fluids  c. Home Care  a.

both have similar geographic distribution and genetic component  b. Includes 2 separate but closely related conditions: ulcerative colitis and Crohn¶s disease. may be related to infectious agent and altered immune responses  c.Client with Inflammatory Bowel Disease Definition  a. Peak incidence occurs between the ages of 15 ± 35. Etiology is unknown but runs in families. second peak 60 ± 80  d. Chronic disease with recurrent exacerbations .

Inflammatory Bowel Disease .

bleeding is common  4. Inflammatory process usually confined to rectum and sigmoid colon  2. friable. and shortening of colon . which leads to necrosis and sloughing of bowel mucosa  3. Chronic inflammation leads to atrophy. narrowing. Inflammation leads to mucosal hemorrhages and abscess formation.Ulcerative Colitis Pathophysiology  1. Mucosa becomes red. and ulcerated.

LLQ cramping  3. 10 ± 20 bloody stools per day leading to anemia. weakness . anorexia. Fecal urgency. Diarrhea with stool containing blood and mucus. malnutrition  2. tenesmus. Fatigue.Ulcerative Colitis Manifestations  1. hypovolemia.

Abcess. hypotension. tachycardia. need yearly colonoscopies  5. fistula formation  6. Toxic megacolon: usually involves transverse colon which dilates and lacks peristalsis (manifestations: fever. Hemorrhage: can be massive with severe attacks  2. change in stools. Increased risk for colorectal cancer (20 ± 30 times). Bowel obstruction  7. dehydration. Extraintestinal complications  Arthritis  Ocular disorders  Cholelithiasis .Ulcerative Colitis Complications  1. Colon perforation: rare but leads to peritonitis and 15% mortality rate  4. abdominal cramping)  3.

Ulcerative Colitis  Diet therapy Goal to prevent hyperactive bowel activity Severe symptoms NPO TPN Less severe Vivonex ‡ Elemental formula absorbed in the upper bowel ‡ Decreases bowel stimulation .

pepper.Ulcerative Colitis  Diet therapy Significant symptoms Low fiber diet Reduce or eliminate lactose containing foods Avoid caffeinated beverages. smoking . alcohol.

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

Ulcerative Colitis  Surgical Management 25% of patients require a colectomy Total proctocolectomy with a permanent ileostomy  Colon. rectum. anus removed  Closure of anus  Stoma in right lower quadrant In selected patients an ileoanal anastamosis or ileal reservoir to preserve the anal sphincter  J-shaped pouch is created internally from the end of the ileum to collect fecal material  Pouch is then connected to the distal rectum .

Ulcerative Colitis  Surgical management Total colectomy with a continent ileostomy Kock¶s ileostomy Intra-abdominal pouch where stool is stored untile client drains it with a catheter .

Ulcerative Colitis  Surgical management Total colectomy with ileoanal anastamosis Ileoanal reservoir or J pouch Removes colon and rectum and sutrues ileum into the anal canal .

Ulcerative Colitis Home Care  a. if client has ostomy: care and resources for supplies. Teaching to control symptoms. Inflammatory bowel disease is chronic and day-to-day care lies with client  b. adequate nutrition. support group and home care referral .

Ulcerative Colitis  Treatment Medications similar to treatment for Crohn¶s disease .

Risk for sexual dysfunction.Ulcerative Colitis Nursing Care: Focus is effective management of disease with avoidance of complications Nursing Diagnoses  a. client has surgery with ostomy  c. Disturbed Body Image. Risk for Impaired Tissue Integrity: Malnutrition and healing post surgery  e. Diarrhea  b. Imbalanced Nutrition: Less than body requirement  d. related to diarrhea or ostomy . diarrhea may control all aspects of life.

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

Crohn¶s disease .

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

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

Serum albumin. tissue biopsies. small risk of perforation  b. Many clients need surgery Diagnostic Tests  a. Supportive treatment  c.Crohn¶s Disease (regional enteritis) Collaborative Care  a. sigmoidoscopy: determine area and pattern of involvement. folic acid: lower due to malabsorption . CBC: shows anemia. barium enema  c. Stool examination and stool cultures to rule out infections  d. leukocytosis from inflammation and abscess formation  e. Establish diagnosis  b. Colonoscopy. Upper GI series with small bowel follow-through.

Sulfasalazine (Azulfidine): salicylate compound that inhibits prostaglandin production to reduce inflammation  b. Corticosteroids: reduce inflammation and induce remission. Immunosuppressive agents (azathioprine (Imuran). cyclosporine) for clients who do not respond to steroid therapy alone  Used in combination with steroid treatment and may help decrease the amount of steroid use . with ulcerative colitis may be given as enema.Crohn¶s Disease (regional enteritis) Medications: goal is to stop acute attacks quickly and reduce incidence of relapse  a. intravenous steroids are given with severe exacerbations  c.

New therapies including immune response modifiers. Metronidazole (Flagyl) or Ciprofloxacin (Cipro) For the fistulas that develop  f. Anti-diarrheal medications .Crohn¶s Disease  d. anti-inflammatory cyctokines  e.

Crohn¶s Disease (regional enteritis) Dietary Management  a. eliminate irritating foods  b. Individualized according to client. 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 removal of diseased portion of the bowel .

perforation. Disease process tends to recur in area remaining after resection . abscess  2. may have bowel resection and repair for obstruction. fistula. Bowel obstruction leading cause.Crohn¶s Disease a.Crohn¶s disease  1.

Polyp is mass of tissue arising from bowel wall and protruding into lumen  b.S.Neoplastic Disorders Background  1. B. 30% of people over 50 have polyps . Definition  a. Most often occur in sigmoid and rectum  c. Colon cancer is second leading cause of death from cancer in U. Large intestine and rectum most common GI site affected by cancer  2. Client with Polyps 1.

Polyp types include tubular.Neoplastic Disorders Pathophysiology  a. near 100% malignancy by age 40 . Most polyps are adenomas. villous. or tubularvillous  c. < 1% become malignant but all colorectal cancers arise from these polyps  b. Familial polyposis is uncommon autosomal dominant genetic disorder with hundreds of adenomatous polyps throughout large intestine. untreated. benign but considered premalignant.

Most asymptomatic  b. Repeat every 3 years since polyps recur .Client with Polyps Manifestations  a. Most reliable since allows inspection of entire colon with biopsy or polypectomy if indicated  c. Diagnosis is based on colonoscopy  b. Intermittent painless rectal bleeding is most common presenting symptom Collaborative Care  a.

Client with Polyps Nursing Care  a. Bowel preparation ordered prior to colonoscopy with cathartics and/or enemas . All clients advised to have screening colonoscopy at age 50 and every 5 years thereafter (polyps need 5 years of growth for significant malignancy)  b.

Polyps .

Inflammatory bowel disease  c. Family history  b. Five-year survival rate is 90%. protein . with early diagnosis and treatment Risk Factors  a. Third most common cancer diagnosed  b.Client with Colorectal Cancer Definition  a. calories. Diet high in fat. Affects sexes equally  c.

Client with Colorectal Cancer Pathophysiology  a. anemia . Most malignancies begin as adenomatous polyps and arise in rectum and sigmoid  b. anorexia. also change in bowel habits (diarrhea or constipation). lungs. bones. Spread by direct extension to involve entire bowel circumference and adjacent organs  c. weight loss. Presenting manifestation is bleeding. brain. pain. Often produces no symptoms until it is advanced  b. Metastasize to regional lymph nodes via lymphatic and circulatory systems to liver. palpable abdominal or rectal mass. and kidneys Manifestations  a.

Colon Cancer .

Client with Colorectal Cancer Complications  a. Fecal occult blood testing beginning at age 50. Direct extension of cancer to adjacent organs. annually  c. Digital exam beginning at age 40. every 3 ± 5 years . annually  b. Bowel obstruction  b. Perforation of bowel by tumor. peritonitis  c. reoccurrences within 4 years Collaborative Care: Focus is on early detection and intervention Screening  a. Colonoscopies or sigmoidoscopies beginning at age 50.

Carcinoembryonic antigen (CEA): not used as screening test. ultrasounds: to determine tumor depth. tumor growth  b. Fecal occult blood (guiac or Hemoccult testing): all colorectal cancers bleed intermittently  c. CTscans. detect reoccurrence may be elevated in 70% of people with CRC  d. Colonoscopy or sigmoidoscopy. Chest xray. organ involvement.Client with Colorectal Cancer Diagnostic Tests  a. metastasis . but is a tumor marker and used to estimate prognosis. polyps  e. monitor treatment. CBC: anemia from blood loss. tissue biopsy of suspicious lesions. MRI.

Client with Colorectal Cancer  Pre-op care Consult with ET nurse if ostomy is planned Bowel prep with GoLytely NPO NG .

and anus are removed through abdominal and perineal incisions and permanent colostomy created .Client with Colorectal Cancer Surgery  a. and regional lymph nodes is treatment of choice  b. rectum. Whenever possible anal sphincter is preserved and colostomy avoided. adjacent colon. Tumors of rectum are treated with abdominoperineal resection (A-P resection) in which sigmoid colon. anastomosis of remaining bowel is performed  c. Surgical resection of tumor.

loop suspended over a bridge. colon reconnected at later time when client ready for surgical repair . temporary  d. Named for area of colon is which formed  a. Sigmoid colostomy: used with A-P resection formed on LLQ  b. distal is mucous fistula  c. Transverse loop colostomy: emergency procedure.Client with Colorectal Cancer Colostomy 1. Double-barrel colostomy: 2 stomas: proximal for feces diversion. only proximal colostomy is brought to abdomen as stoma. Temporary measure to promote healing of anastomoses  b. Permanent means for fecal evacuation if distal colon and rectum removed 2. Hartman procedure: Distal portion is left in place and oversewn. Ostomy made in colon if obstruction from tumor  a. temporary.

Client with Colorectal Cancer  Post-op care Pain NG tube Wound management Stoma ‡ ‡ ‡ ‡ Should be pink and moist Drk red or black indicates ischemic necrosis Look for excessive bleeding Observe for possible separation of suture securing stoma to abdominal wall .

solid stool .Client with Colorectal Cancer  Post-op care Evaluate stool after 2-4 days postop Ascending stoma (right side) ‡ Liquid stool Transverse stoma ‡ Pasty Descending stoma ‡ Normal.

Provides local control of disease. Used preoperatively to shrink tumor  C. rectal cancer has high rate of regional recurrence if tumor outside bowel wall or in regional lymph nodes  b. Used as adjunct with surgery. does not improve survival rates Chemotherapy: Used postoperatively with radiation therapy to reduce rate of rectal tumor recurrence and prolong survival .Client with Colorectal Cancer Radiation Therapy  a.

red meat. Screening recommendations  3. Seek medical attention for bleeding and warning signs of cancer  4. Prevention is primary issue  b.Client with Colorectal Cancer Nursing Care  a. Client teaching  1. diet high in fruits and vegetables. Diet: decrease amount of fat. legumes  2. refined sugar. Anticipatory Grieving  d. Risk for Sexual Dysfunction . Pain  b. whole grains. Alteration in Body Image  e. Risk may be lowered by aspirin or NSAID use Nursing Diagnoses for post-operative colorectal client  a. Imbalanced Nutrition: Less than body requirements  c. increase amount of fiber.

Referral to support groups for cancer or ostomy  c. Referral to hospice as needed for advanced disease . Referral for home care  b.Client with Colorectal Cancer Home Care  a.

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

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

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

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

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

Manifestations: deep. Causes include cancer of bowel. severe. volvulus. cramping pain.Client with Intestinal Obstruction Large Bowel Obstruction  a. localized tenderness or palpable mass may be noted . continuous pain signals bowel ischemia and possible perforation. diverticular disease. fecal impaction  c. Only accounts for 15% of obstructions  b. inflammatory disorders.

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

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

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

less than a third of persons with diverticulosis develop symptoms Risk Factors  a. Incidence increases with age. Cultural changes in western world with diet of highly refined and fiber-deficient foods  b. Decreased activity levels  c.Client with Diverticular Disease Definition  a. Diverticula are saclike projections of mucosa through muscular layer of colon mainly in sigmoid colon  b. Postponement of defecation .

causing outpouchings  b. Diverticulosis is the presence of diverticula which form due to increased pressure within bowel lumen causing bowel mucosa to herniate through defects in colon wall. Muscle in bowel wall thickens narrowing bowel lumen and increasing intraluminal pressure  c. the inflammation of the diverticular sac . Complications of diverticulosis include hemorrhage and diverticulitis.Client with Diverticular Disease Pathophysiology  a.

Diverticulitis: diverticulum in sigmoid colon irritated with undigested food and bacteria forming a hard mass (fecalith) that impairs blood supply leading to perforation  e. more extensive perforation may lead to peritonitis or abscess formation . With microscopic perforation.Clients with Diverticular Disease  d. inflammation is localized.

Diverticulits .

Diverticulitis .

Peritonitis  b. Older adult may have vague abdominal pain Complications  a. vomiting. Pain. low-grade fever. tenderness and palpable LLQ mass  d. Fistula formation  e. Abscess formation  c. abdominal distention.Client with Diverticular Disease Manifestations  a. Bowel obstruction  d. left-sided. Constipation or frequency of defecation  c. May also have nausea. Hemorrhage . mild to moderate and cramping or steady  b.

Barium enema contraindicated in early diverticulitis due to risk of barium leakage into peritoneal cavity. fistula  b. WBC count with differential: leukocytosis with shift to left in diverticulitis  e. Abdominal CT scan. location of abscess. Hemocult or guiac testing: determine presence of occult blood . sigmoidoscopy or colonscopy used in diagnosis of diverticulosis  d. Abdominal Xray: detection of free air with perforation. but will confirm diverticulosis  c.Client with Diverticular Disease Collaborative Care: Focus is on management of symptoms and complications Diagnostic Tests  a.

Stool softener but not cathartic may be prescribed (nothing to increase pressure within bowel)  e. Fluids to correct dehydration  d. Analgesics for pain (non-narcotic)  c.Client with Diverticular Disease Medications  a. Anticholinergics to decrease intestinal hypermotility . oral or intravenous route depending on severity of symptoms  Flagyl plus Bactrim or Cipro  b. Broad spectrum antibiotics against gram negative and anaerobic bacteria to treat acute diverticulitis.

Diet modification may decrease risk of complications  b.Clients with Diverticular Disease Dietary Management  a. Some clients advised against foods with small seeds which could obstruct diverticula . High-fiber diet (bran. commercial bulk-forming products such as psyllium seed (Metamucil) or methycelluose)  c.

Surgical intervention indicated for clients with generalized peritonitis or abscess that does not respond to treatment  b. re-anastomosis performed 2 ± 3 months later . low-roughage diet psyillium seed products to soften stool and increase bulk  c. 2 stage Hartman procedure done with temporary colostomy. Client initially NPO with intravenous fluids (possibly TPN)  b. As symptoms subside reintroduce food: clear liquid diet. With acute infection. to soft. High fiber diet is resumed after full recovery Surgery  a.Client with Diverticular Disease Treatment for acute episode of diverticulitis  a.

related to unknown outcome of treatment. Referral for home health care agency.Client with Diverticular Disease Nursing Care: Health promotion includes teaching high-fiber foods in diet generally. Pain  c. Teaching regarding prescribed diet. Anxiety. possible surgery Home Care  a. may be contraindicated for persons with known conditions Nursing Diagnoses  a. if new colostomy client . fluid intake. medications  b. gastrointestinal  b. Impaired Tissue Integrity.

central nervous system disorders. . kidney or liver disorders. Nausea and vomiting are not diseases. Nausea and vomiting can sometimes be symptoms of more serious diseases such as heart attacks. brain tumors. and some forms of cancer. but rather are symptoms of many different conditions.

 Table 42-2 page 993 .

Nursing Diagnosis  Nausea  Deficient fluid volume  Imbalanced Nutrition Less than body requirements  Risk for injury (aspiration) .

Goals  Decrease in nausea and vomiting  Normal Fluid and Electrolyte balance  Maintain body weight  Maintain airway .

Interventions  Position the patient: To prevent aspiration Conscious: semi fowler¶s Unconscious: lateral  Provide good oral care measures .

 Relieve sensation of nausea by providing any of the following: Ice chips Hot tea with lemon Hot ginger ale Dry toast or crackers Cold cola beverage . Suction mouth as needed if the client is unable to expel vomitus.

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tachycardia. serum creatinine Elevated hematocrit . low BP Weight loss Sunken eyeballs Oliguria Dark. concentrated urine High specific gravity of urine Poor skin turgor Altered LOC (level of consciousness) Elevated BUN. flushed dry skin Fever. Replace fluid-electrolyte loss (oral or intravenous fluid infusion)  Observe for potential complications as follows:  Dehydration              Thirst (first sign) Dry mouth and mucus membrane Warm.

.

raw carrot.  Administer antiemetic as ordered by the physician Plasil (Metochlopramide) Tigan (Trimethobenzamide) Phenergan (Promethazine) Compazine (Prochlorperazine maleate) . raw tomato.Hypokalemia  Initial manifestation in muscle weakness in the legs or leg cramps  Provide postssium-rich foods such as banana. citrus fruits and dried fruits. baked potatoes.

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