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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
viruses (human papilloma virus) .Client with Oral Cancer 1.Background a. mortality b. Uncommon (5% of all cancers) but has high rate of morbidity. marijuana use. drinking alcohol. occupational exposure to chemicals. Highest among males over age 40 c. Risk factors include smoking and using oral tobacco.
maxilla d. oropharynx. mandible. Squamous cell carcinomas b. Lesions start in mucosa and may advance to involve tongue. ill-defined borders c. Begin as painless oral ulceration or lesion with irregular. Non-healing lesions should be evaluated for malignancy after one week of treatment . Pathophysiology a.Client with Oral Cancer 2.
Client with Oral Cancer 3. Advanced carcinomas may necessitate radical neck dissection with temporary or permanent tracheostomy. refer to American Cancer Society. Plan early for home care post hospitalization. chemotherapy. Determine staging with CT scans and MRI d. Determination of malignancy with biopsy c. and/or radiation therapy e. support groups . general health and client¶s preference. tumor stage. treatment may include surgery. Based on age. teaching family and client care involved post surgery. Elimination of causative agents b. Collaborative Care a. Surgeries may be disfiguring f.
Need to seek medical attention for all nonhealing oral lesions (may be discovered by dentists). Nursing Care a. Imbalanced Nutrition: Less than body requirements 3. Risk for ineffective airway clearance 2. Health promotion: 1. Impaired Verbal Communication: establishment of specific communication plan and method should be done prior to any surgery 4. Nursing Diagnoses 1. Teach risk of oral cancer associated with all tobacco use and excessive alcohol use 2.Client with Oral Cancer 4. early precancerous oral lesions are very treatable b. Disturbed Body Image .
Gastroesophageal Reflux Disease (GERD) 1. Because of location near other organs symptoms may mimic other illnesses including heart problems a. 10% persons experience daily heartburn and indigestion d. affecting 15 ± 20% of adults c. GERD common. Gastroesophageal reflux is the backward flow of gastric content into the esophagus. . Definition b.
Increased gastric volume (post meals) 2.Position pushing gastric contents close to gastroesophageal juncture (such as bending or lying down) 3.Gastroesophageal Reflux Disease (GERD) 2. Gastroesophageal reflux results from transient relaxation or incompetence of lower esophageal sphincter.Increased gastric pressure (obesity or tight clothing) 4. Pathophysiology a. or increased pressure within stomach b. Factors contributing to gastroesophageal reflux 1. sphincter.Hiatal hernia .
while bending over. Heartburn after meals. prolonged exposure causes ulceration. or recumbent b.Gastroesophageal Reflux Disease (GERD) c. Bronchospasm and laryngospasm . friable mucosa. Atypical chest pain d. untreated there is scarring and stricture 3. Sore throat with hoarseness e. during sleep and with gastroesophageal reflux esophageal mucosa is damaged and inflamed. Manifestations a. May have regurgitation of sour materials in mouth.Normally the peristalsis in esophagus and bicarbonate in salivary secretions neutralize any gastric juices (acidic) that contact the esophagus. and bleeding. pain with swallowing c.
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
e. promote healing of esophageal erosion and relieve symptoms.Gastroesophageal Reflux Disease (GERD) 7. nizatidine c. or 3 to 6 months d. metoclopramide (reglan) . lansoprazole (Prevacid) initially for 8 weeks. Proton-pump inhibitors: reduce gastric secretions. Antacids for mild to moderate symptoms.g.g. e. cimetidine. omeprazole (prilosec). Promotility agent: enhances esophageal clearance and gastric emptying. H2-receptor blockers: decrease acid production. ranitidine. e. Mylanta. given BID or more often. famotidine.Medications a.g. e. Gaviscon b. Maalox.g.
chocolate. Eat small meals and stay upright 2 hours post eating. citrus foods. No smoking g. Avoiding bending and wear loose fitting clothing . coffee) b. no eating 3 hours prior to going to bed e. peppermint. Maintain ideal body weight d.Gastroesophageal Reflux Disease 8. Elevate head of bed on 6 ± 8t blocks to decrease reflux f. Avoiding food which relax esophageal sphincter or delay gastric emptying (fatty foods. spicy. Elimination of acid foods (tomatoes. alcohol) c. Dietary and Lifestyle Management a.
Pain usually controlled by treatment b. Nursing Care a.Surgery indicated for persons not improved by diet and life style changes a. Assist client to institute home plan . Open surgical procedure: Nissen fundoplication 10. Laparoscopic procedures to tighten lower esophageal sphincter b.Gastroesophageal Reflux Disease (GERD) 9.
Part of stomach protrudes through the esophageal hiatus of the diaphragm into thoracic cavity b.Definition a. Predisposing factors include: Increased intra-abdominal pressure Increased age Trauma Congenital weakness Forced recumbent position .Hiatal Hernia 1.
client may develop gastritis with bleeding . hernia can become strangulated. Paraesophageal hiatal hernia: the gastroesophageal junction is in normal place but part of stomach herniates through esophageal hiatus. incidence increases with age d. Most cases are asymptomatic. Sliding hiatal hernia: gastroesophageal junction and fundus of stomach slide through the esophageal hiatus e.Hiatal Hernia c.
Upper endoscopy 4. Similar to GERD: diet and lifestyle changes. Barium swallow b. 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 . Diagnostic Tests a. Treatment a. If medical treatment is not effective or hernia becomes incarcerated. medications b.Hiatal Hernia 2. Manifestations: Similar to GERD 3. then surgery.
Manifestations: Dysphagia and/or chest pain 3.Impaired Esophageal Motility 1. Types a. Diffuse esophageal spasm: nonperistaltic contraction of esophageal smooth muscle 2. Endoscopically guided injection of botulinum toxin Denervates cholinergic nerves in the distal esophagus to stop spams b. Treatment a. Achalasia: characterized by impaired peristalsis of smooth muscle of esophagus and impaired relaxation of lower esophageal sphincter b. Balloon dilation of lower esophageal sphincter May place stents to keep esophagus open .
Squamous cell carcinoma 1.More common in African Americans than Caucasians 3.Associated with Barrett¶s esophagus. usually diagnosed late 2.More common in Caucasians 3. complication of chronic GERD and achalasia .Most common affecting middle or distal portion of esophagus 2. Definition: Relatively uncommon malignancy with high mortality rate.Risk factors cigarette smoking and chronic alcohol use b.Nearly as common as squamous cell affecting distal portion of esophagus 2.Esophageal Cancer 1. Adenocarcinoma 1. Pathophysiology a.
Controlling dysphagia b. Manifestations a. Collaborative Care: Treatment goals a. cough c. Progressive dysphagia with pain while swallowing b. Maintaining nutritional status while treating carcinoma (surgery. Choking. hoarseness. weight loss 4. Anorexia. and/or chemotherapy . radiation therapy.Esophageal Cancer 3.
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. Complete Blood Count: identify anemia e. CT scans. Chest xray. Diagnostic Tests a. Esophagoscopy: allow direct visualization of tumor and biopsy c. Liver function tests: elevated with liver metastasis .
radiation and chemotherapy to control dysphagia and pain c. Early (curable) stage: surgical resection of affected portion with anastomosis of stomach to remaining esophagus. hemorrhage. Treatments: dependent on stage of disease. stricture .Esophageal Cancer 6. client¶s condition and preference a. Complications of radiation therapy include perforation. More advanced carcinoma: treatment is palliative and may include surgery. may also include radiation therapy and chemotherapy prior to surgery b.
Nursing Diagnoses a. Nursing Care: Health promotion. Imbalanced Nutrition: Less than body requirements (may include enteral tube feeding or parenteral nutrition in hospital and home) b. education regarding risks associated with smoking and excessive alcohol intake 8.Esophageal Cancer 7. Anticipatory Grieving (dealing with cancer diagnosis) c. Risk for Ineffective Airway Clearance (especially during postoperative period if surgery was done) .
Gastric mucosa rapidly regenerates.Gastritis 1. Types a. inflammation. Acute Gastritis 1. Definition: Inflammation of stomach lining from irritation of gastric mucosa (normally protected from gastric acid and enzymes by mucosal barrier) 2. self-limiting disorder . superficial erosions 2.Disruption of mucosal barrier allowing hydrochloric acid and pepsin to have contact with gastric tissue: leads to irritation.
nausea. hematemesis.Gastritis 3. Effects from radiation therapy. vomiting. Irritants include aspirin and other NSAIDS. More severe: abdominal pain. melena c. bleeding occurs 2 or more days post stress event d. caffeine b. Erosive: not associated with pain. gastric mucosa becomes ischemic and tissue is then injured by acid of stomach 5. Mild: anorexia. Causes of acute gastritis a. Ingestion of corrosive substances: alkali or acid c. mild epigastric discomfort. Manifestations a. If perforation occurs. belching b. corticosteroids. signs of peritonitis . Erosive Gastritis: form of acute which is stress-induced. certain chemotherapeutic agents 4. complication of life-threatening condition (Curling¶s ulcer with burns). alcohol.
coats and protects gastric mucosa c.Gastritis 6. reintroduce clear liquids gradually and progress. Treatment a. 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). Medications: proton-pump inhibitor or H2-receptor blocker. no vomiting . NPO status to rest GI tract for 6 ± 12 hours. intravenous fluid and electrolytes if indicated b.
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.Chronic Gastritis 1. develops pernicious anemia Parietal cells normally secrete intrinsic factor needed for absorption of B12. loss of hydrochloric acid and pepsin secretion. when they are destroyed by gastritis pts develop pernicious anemia .
associated with risk of peptic ulcer disease and gastric cancer .Chronic Gastritis 3. caused by chronic infection of mucosa by Helicobacter pylori. Type B: more common and occurs with aging.
pylori infection with combination therapy of two antibiotics (metronidazole (Flagyl) and clarithomycin or tetracycline) and proton± pump inhibitor (Prevacid or Prilosec) . Fatigue associated with anemia. epigastric heaviness not relieved by antacids b. Treatment: Type B: eradicate H. symptoms associated with pernicious anemia: paresthesias Lack of B12 affects nerve transmission 5.Chronic Gastritis 4. Manifestations a. Vague gastric distress.
Teaching regarding use of prescribed medications. treatment of alcohol abuse . smoking cessation. Management of acute gastritis with NPO state and then gradual reintroduction of fluids with electrolytes and glucose and advance to solid foods d. Usually managed in community b.Chronic Gastritis Collaborative Care a. Teach food safety measures to prevent acute gastritis from food contaminated with bacteria c.
hematocrit. red blood cell indices: anemia including pernicious or iron deficiency c. Upper endoscopy: visualize mucosa. Deficient Fluid Volume b. Hemoglobin. identify areas of bleeding. Imbalanced Nutrition: Less than body requirements . Gastric analysis: assess hydrochloric acid secretion (less with chronic gastritis) b. Nursing Diagnoses: a.Chronic Gastritis Diagnostic Tests a. Serum vitamin B12 levels: determine pernicious anemia d. obtain biopsies. may treat areas of bleeding with electro or laser coagulation or sclerosing agent 5.
Common in smokers. familial pattern. ulcers found near pyloris c. users of NSAIDS. affect mostly males ages 30 ± 55. affects 10% of US population b.Peptic Ulcer Disease (PUD) Definition and Risk factors a. ASA. Duodenal ulcers: most common. alcohol. cigarettes . found on lesser curvature and associated with increased incidence of gastric cancer d. Break in mucous lining of GI tract comes into contact with gastric juice. Gastric ulcers: affect older persons (ages 55 ± 70).
physical or psychological stress . Ulcers or breaks in mucosa of GI tract occur with 1. fecaloral routes) damages gastric epithelial cells reducing effectiveness of gastric mucus 2. pylori infection (spread by oral to oral. Chronic with spontaneous remissions and exacerbations associated with trauma.H.Peptic Ulcer Disease (PUD) 2. Pathophysiology a. infection.Use of NSAIDS: interrupts prostaglandin synthesis which maintains mucous barrier of gastric mucosa b.
Pylori Upper GI barium contrast studies EGD-esophagogastroduodenoscopy Serum and stool studies .Peptic Ulcer Disease Diagnosis Endoscopy with cultures Looking for H.
dysphagia. burning. weight loss. Symptoms less clear in older adult. Pain is classic symptom: gnawing. 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 . Manifestations a. aching hungerlike in epigastric region possibly radiating to back. may have poorly localized discomfort.Peptic Ulcer Disease (PUD) 3.
Peptic Ulcer Disease
Rest and stress reduction Nutritional management Pharmacological management
Proton pump inhibitors (Prilosec, Prevacid)
Block gastric acid secretion
Peptic Ulcer Disease
Histamine blockers (Tagamet, Zantac, Axid)
Blocks gastric acid secretion
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
Cutting of the vagus nerve to decrease acid secretion
Widens the pyloric sphincter
Billroth II .
Hemorrhage: frequent in older adult: hematemesis. orthostatic hypotension and anemia.Obstruction: gastric outlet (pyloric sphincter) obstruction: edema surrounding ulcer blocks GI tract from muscle spasm or scar tissue 1.Peptic Ulcer Disease (PUD) 4.Symptoms: feelings of epigastric fullness. fatigue. Complications a. worsened ulcer symptoms . nausea. dizziness. hematochezia (blood in stool).Gradual process 2. weakness. with significant bleed loss may develop hypovolemic shock b. melena.
Time of ulceration: severe upper abdominal pain radiating throughout abdomen and possibly to shoulder 2.Abdomen becomes rigid. boardlike with absent bowel sounds. symptoms of shock 3.Older adults may present with mental confusion and non-specific symptoms . chemical at first (inflammatory) and then bacterial in 6 to 12 hours 1.Perforation: ulcer erodes through mucosal wall and gastric or duodenal contents enter peritoneum leading to peritonitis.Peptic Ulcer Disease c.
Upper GI Bleed Mortality approx 10% Predisposing factors include: drugs. gastritis and carcinoma . esophagitis. PUD. esophageal varacies.
Hgb Confusion syncope . tarry stools Melena Decreased B/P Vertigo Drop in Hct.Upper GI Bleed Signs and Symptoms Coffee ground vomitus Black.
Upper GI Bleed Diagnosis History Blood. vomitus studies Endoscopy . stool.
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 .
Incidence a. African Americans. Worldwide common cancer. Begins as localized lesion (in situ) progresses to mucosa. Asian Americans. Older adults of lower socioeconomic groups higher risk 2. Incidence highest among Hispanics.Cancer of Stomach 1. Adenocarcinoma most common form involving mucus-producing cells of stomach in distal portion b. but less common in US b. Pathophysiology a. lungs. ovaries. peritoneum . spreads to lymph nodes and metastasizes early in disease to liver. males twice as often as females c.
Colon Cancer .
Early symptoms are vague: early satiety.Cancer of Stomach 3. Later symptoms weight loss. anorexia. pain after meals not responding to antacids c. indigestion. Disease often advanced with metastasis when diagnosed b. Achlorhydria (lack of hydrochloric acid) e. abdominal mass. cachexia (wasted away appearance). Risk Factors a. stool positive for occult blood . 4. gastric polyps d. pernicious anemia. Diet high in smoked foods and nitrates Manifestations a. pylori infection b. vomiting. Genetic predisposition c. Chronic gastritis. H.
Diagnostic Tests a. ultrasound identifies a mass c.Cancer of Stomach 5. Assist client to maintain adequate nutrition 6. Collaborative Care a.CBC indicates anemia b. Support client through testing b.Upper GI series.Upper endoscopy: visualization and tissue biopsy of lesion .
Cancer of Stomach 7.Total gastrectomy (if cancer diffuse but limited to stomach) with esophagojejunostomy .Partial gastrectomy with anastomosis to duodenum: Bilroth I or gastroduodenostomy 2. if diagnosis made prior to metastasis 1.Partial gastrectomy with anastomosis to jejunum: Bilroth II or gastrojejunostomy 3. Treatment a. Surgery.
borborygmi. flushed. hypotensive. dizzy. 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.Manifestations 5 ± 30 minutes after meal: nausea with possible vomiting.Occurs with partial gastrectomy. Dumping Syndrome a.Cancer of Stomach b. hypertonic. client becomes tachycardic. diaphoretic c. epigastric pain and cramping. and diarrhea. Complications associated with gastric surgery 1.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 .
Carbohydrates. Anticholinergics. Client to rest recumbent or semi-recumbent 30 ± 60 minutes after eating 5. Treatment: dietary pattern to delay gastric emptying and allow smaller amounts of chyme to enter intestine 1. Increased amounts of fat and protein 3.Cancer of Stomach d. especially simple sugars. Limit amount of food taken at one time . sedatives. reduced 4. Liquids and solids taken separately 2. antispasmodic medications may be added 6.
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
Varies with the individual 2 ± 3 times daily to 3 stools per week
functional colitis) Definition a. diarrhea. or both b. Affects up to 20% of persons in Western civilization.Irritable Bowel Syndrome (IBS) (spastic bowel. Functional GI tract disorder without identifiable cause characterized by abdominal pain and constipation. more common in females .
Increased bowel activity in response to food intake.Increased sensations of chyme movement through gut 3.Irritable Bowel Syndrome (IBS) (spastic bowel. functional colitis) Pathophysiology a.Hypersecretion of colonic mucus b. Some linkage of depression and anxiety . Lower visceral pain threshold causing abdominal pain and bloating with normal levels of gas c. stress 2. hormones. Appears there is altered CNS regulation of motor and sensory functions of bowel 1.
Elimination of precipitating factors. excess gas c. Nausea. may be colicky. hard or watery stool. occurring in spasms. vomiting. headache. Altered bowel habits including frequency. Collaborative Care a. fatigue. dull or continuous b. anorexia. Abdominal pain relieved by defecation. anxiety d. functional colitis) Manifestations a. passage of mucus. straining or urgency with stooling. Management of distressing symptoms b. abdominal bloating. stress reduction .Irritable Bowel Syndrome (IBS) (spastic bowel. incomplete evacuation. Tenderness over sigmoid colon upon palpation 4.
Small bowel series (Upper GI series with small bowel-follow through) and barium enema: examination of entire GI tract.Sigmoidoscopy or colonoscopy 1. IBS: increased motility . measure intraluminal pressures.Findings with IBS: normal appearance increased mucus. marked spasms.Irritable Bowel Syndrome (IBS) (spastic bowel. culture b. ova and parasites. obtain biopsies if indicated 2. intraluminal pressures.Visualize bowel mucosa. functional colitis) 5. or inflammatory process c.Stool examination for occult blood. Diagnostic Tests: to find a cause for client¶s abdominal pain.CBC with differential. possible hyperemia without lesions d. bacterial infection. Erythrocyte Sedimentation Rate (ESR): to determine if anemia. changes in feces elimination a.
Anticholinergic drugs (dicyclomine (Bentyl). Antidiarrheal medications (loperamide (Imodium). Research: medications altering serotonin receptors in GI tract to stimulate peristalsis of the GI tract . Bulk-forming laxatives: reduce bowel spasm. normalize bowel movement in number and form c. hyoscyamine) to inhibit bowel motility and prevent spasms.Irritable Bowel Syndrome (IBS) (spastic bowel. Antidepressant medications f. diphenoxylate (Lomotil): prevent diarrhea prophylactically e. functional colitis) Medications a. given before meals d. Purpose: to manage symptoms b.
Nursing Care a. Some benefit from elimination of lactose. Contact in health environments outside acute care b. stress management. seek medical attention if serious changes occur . caffeinated beverages 8. fructose. functional colitis) Dietary Management a. Often benefit from additional dietary fiber: adds bulk and water content to stool reducing diarrhea and constipation b. sorbitol c. Limiting intake of gas-forming foods.Irritable Bowel Syndrome (IBS) (spastic bowel. medications. Home care focus on improving symptoms with changes of diet.
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.Peritonitis Definition a. Inflammation of peritoneum. ruptured appendix) . perforated ulcer.
Peritonitis Causes include: Ruptured appendix Perforated bowel secondary to PUD Diverticulitis Gangrenous gall bladder Ulcerative colitis Trauma Peritoneal dialysis .
then septicemia . Klebsiella. Bacterial peritonitis usually caused by these bacteria (normal bowel flora): Escherichia coli. leading to hypovolemia. Proteus. Inflammatory process causes fluid shift into peritoneal space (third spacing).Peritonitis Pathophysiology a. infection occurs when bacteria enter the space c. Release of bile or gastric juices initially causes chemical peritonitis. Pseudomonas d. Peritonitis results from contamination of normal sterile peritoneal cavity with infections or chemical irritant b.
severe abdominal pain 2.Peritonitis 3.Pain may localize near site of infection (may have rebound tenderness) 3.Intensifies with movement c. Presents with ³acute abdomen´ 1.Abrupt onset of diffuse. Entire abdomen is tender with boardlike guarding or rigidity of abdominal muscle . Depends on severity and extent of infection. age and health of client b. Manifestations a.
tachycardia and tachypnea. Systemically: fever.Decreased urinary output 4.Vague abdominal complaints 5. malaise. restlessness. disorientation.Peritonitis d.Increased confusion and restlessness 3.At risk for delayed diagnosis and higher mortality rates .Few of classic signs 2. bowel sounds are diminished or absent with progressive abdominal distention. pooling of GI secretions lead to nausea and vomiting e. Decreased peristalsis leading to paralytic ileus. Older or immunosuppressed client may have 1. oliguria with dehydration and shock f.
Fibrous adhesions d. Septicemia. fluid loss into abdominal cavity leads to hypovolemic shock 5. May be life-threatening. septic shock. Diagnosis and identifying and treating cause b. mortality rate overall 40% b. Complications a. Collaborative Care a. Prevention of complications . Abscess c.Peritonitis 4.
Abdominal xrays: detect intestinal distension. Diagnostic paracentesis 7.Specific antibiotic(s) treating causative pathogens b. airfluid levels.000. Liver and renal function studies. Analgesics . serum electrolytes: evaluate effects of peritonitis d. Diagnostic Tests a.Broad-spectrum before definitive culture results identifying specific organism(s) causing infection 2. Blood cultures: identify bacteria in blood c.Peritonitis 6. shift to left b. Medications a. free air under diaphragm (sign of GI perforation) e. Antibiotics 1. WBC with differential: elevated WBC to 20.
Often have drain in place and/or incision left unsutured to continue drainage . Peritoneal Lavage: washing out peritoneal cavity with copious amounts of warm isotonic fluid during surgery to dilute residual bacterial and remove gross contaminants c. Laparotomy to treat cause (close perforation. removed inflamed tissue) b. Surgery a.Peritonitis 8.
Peritonitis 9. Bed rest in Fowler¶s position to localize infection and promote lung ventilation c. Intestinal decompression with nasogastric tube or intestinal tube connected to suction 1. NPO with intravenous fluids while having nasogastric suction . Treatment a. Intravenous fluids and electrolytes to maintain vascular volume and electrolyte balance b. Relieves abdominal distension secondary to paralytic ileus 2.
Peritonitis 10. Home Care a. Deficient Fluid Volume: often on hourly output. nasogastric drainage is considered when ordering intravenous fluids c. Anxiety 11. Client may have prolonged hospitalization b. Home intravenous antibiotics . Wound care 2. Home health referral 3. Home care often includes 1. Pain b. Nursing Diagnoses a. Ineffective Protection d.
Etiology is unknown but runs in families. second peak 60 ± 80 d. Peak incidence occurs between the ages of 15 ± 35. both have similar geographic distribution and genetic component b. Includes 2 separate but closely related conditions: ulcerative colitis and Crohn¶s disease.Client with Inflammatory Bowel Disease Definition a. Chronic disease with recurrent exacerbations . may be related to infectious agent and altered immune responses c.
Inflammatory Bowel Disease .
Chronic inflammation leads to atrophy. and shortening of colon . and ulcerated. Inflammatory process usually confined to rectum and sigmoid colon 2. which leads to necrosis and sloughing of bowel mucosa 3. friable. Mucosa becomes red.Ulcerative Colitis Pathophysiology 1. bleeding is common 4. narrowing. Inflammation leads to mucosal hemorrhages and abscess formation.
weakness . LLQ cramping 3. hypovolemia. tenesmus. 10 ± 20 bloody stools per day leading to anemia. anorexia.Ulcerative Colitis Manifestations 1. Fatigue. Fecal urgency. malnutrition 2. Diarrhea with stool containing blood and mucus.
Abcess. need yearly colonoscopies 5. Bowel obstruction 7. dehydration. Hemorrhage: can be massive with severe attacks 2. hypotension.Ulcerative Colitis Complications 1. tachycardia. fistula formation 6. Toxic megacolon: usually involves transverse colon which dilates and lacks peristalsis (manifestations: fever. Colon perforation: rare but leads to peritonitis and 15% mortality rate 4. abdominal cramping) 3. Increased risk for colorectal cancer (20 ± 30 times). change in stools. Extraintestinal complications Arthritis Ocular disorders Cholelithiasis .
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 .
smoking . alcohol. pepper.Ulcerative Colitis Diet therapy Significant symptoms Low fiber diet Reduce or eliminate lactose containing foods Avoid caffeinated beverages.
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. may be permanent with total proctocolectomy or temporary (loop ileostomy) 5. Surgically created opening between intestine and abdominal wall that allows passage of fecal material 2. Name of ostomy depends on location of stoma 4. Ileostomy: opening in ileum. Continent (or Kock¶s) ileostomy: has intraabdominal reservoir with nipple valve formation to allow catheter insertion to drain out stool .Ulcerative Colitis Ostomy 1.
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 .
Teaching to control symptoms. adequate nutrition. support group and home care referral . Inflammatory bowel disease is chronic and day-to-day care lies with client b.Ulcerative Colitis Home Care a. if client has ostomy: care and resources for supplies.
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. Disturbed Body Image. diarrhea may control all aspects of life. related to diarrhea or ostomy . client has surgery with ostomy c. Risk for Impaired Tissue Integrity: Malnutrition and healing post surgery e. Imbalanced Nutrition: Less than body requirement d. Diarrhea b.
abscess formation and fistula formation 4. Can affect any portion of GI tract. Inflammatory aphthoid lesion (shallow ulceration) of mucosa and submuscosa develops into ulcers and fissures that involve entire bowel wall 3. but terminal ileum and ascending colon are more commonly involved 2. bowel and skin (enterocutaneous fistulas) 5. bowel and bladder (enterovesical fistulas). Absorption problem develops leading to protein loss and anemia . Fibrotic changes occur leading to local obstruction.Crohn¶s Disease (regional enteritis) Pathophysiology 1. Fistulas develop between loops of bowel (enteroenteric fistulas).
Crohn¶s disease .
weight loss. liquid or semi-formed. fistulas. malaise. Often continuous or episodic diarrhea. fatigue. Fever. abdominal pain and tenderness in RLQ relieved by defecation 2. abscesses . Fissures.Crohn¶s Disease (regional enteritis) Manifestations 1. anemia 3.
Fistulas lead to abscess formation. Massive hemorrhage 5. Perforation of bowel may occur with peritonitis 4.Crohn¶s Disease (regional enteritis) Complications 1. Increased risk of bowel cancer (5 ± 6 times) . Intestinal obstruction: caused by repeated inflammation and scarring causing fibrosis and stricture 2. recurrent urinary tract infection if bladder involved 3.
Upper GI series with small bowel follow-through. Supportive treatment c. Establish diagnosis b. barium enema c. sigmoidoscopy: determine area and pattern of involvement. CBC: shows anemia. Colonoscopy. folic acid: lower due to malabsorption . tissue biopsies. Serum albumin.Crohn¶s Disease (regional enteritis) Collaborative Care a. leukocytosis from inflammation and abscess formation e. Stool examination and stool cultures to rule out infections d. small risk of perforation b. Many clients need surgery Diagnostic Tests a.
with ulcerative colitis may be given as enema. Immunosuppressive agents (azathioprine (Imuran). intravenous steroids are given with severe exacerbations c.Crohn¶s Disease (regional enteritis) Medications: goal is to stop acute attacks quickly and reduce incidence of relapse a. Corticosteroids: reduce inflammation and induce remission. Sulfasalazine (Azulfidine): salicylate compound that inhibits prostaglandin production to reduce inflammation b. 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 .
New therapies including immune response modifiers. Anti-diarrheal medications . anti-inflammatory cyctokines e. Metronidazole (Flagyl) or Ciprofloxacin (Cipro) For the fistulas that develop f.Crohn¶s Disease d.
Individualized according to client. eliminate irritating foods b.Crohn¶s Disease (regional enteritis) Dietary Management a. 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 . Dietary fiber contraindicated if client has strictures c.
Disease process tends to recur in area remaining after resection . Bowel obstruction leading cause. fistula. abscess 2. perforation. may have bowel resection and repair for obstruction.Crohn¶s disease 1.Crohn¶s Disease a.
Large intestine and rectum most common GI site affected by cancer 2. Definition a.Neoplastic Disorders Background 1. 30% of people over 50 have polyps .S. Most often occur in sigmoid and rectum c. Client with Polyps 1. Colon cancer is second leading cause of death from cancer in U. B. Polyp is mass of tissue arising from bowel wall and protruding into lumen b.
villous. < 1% become malignant but all colorectal cancers arise from these polyps b.Neoplastic Disorders Pathophysiology a. Familial polyposis is uncommon autosomal dominant genetic disorder with hundreds of adenomatous polyps throughout large intestine. Polyp types include tubular. Most polyps are adenomas. near 100% malignancy by age 40 . or tubularvillous c. untreated. benign but considered premalignant.
Client with Polyps Manifestations a. Intermittent painless rectal bleeding is most common presenting symptom Collaborative Care a. Repeat every 3 years since polyps recur . Most reliable since allows inspection of entire colon with biopsy or polypectomy if indicated c. Most asymptomatic b. Diagnosis is based on colonoscopy b.
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.Client with Polyps Nursing Care a.
Family history b. with early diagnosis and treatment Risk Factors a. calories. Inflammatory bowel disease c. Affects sexes equally c. Five-year survival rate is 90%. Diet high in fat. protein .Client with Colorectal Cancer Definition a. Third most common cancer diagnosed b.
palpable abdominal or rectal mass. Metastasize to regional lymph nodes via lymphatic and circulatory systems to liver. also change in bowel habits (diarrhea or constipation). lungs. weight loss. Presenting manifestation is bleeding. anemia . pain. and kidneys Manifestations a. Spread by direct extension to involve entire bowel circumference and adjacent organs c. Often produces no symptoms until it is advanced b. anorexia.Client with Colorectal Cancer Pathophysiology a. Most malignancies begin as adenomatous polyps and arise in rectum and sigmoid b. brain. bones.
Colon Cancer .
Colonoscopies or sigmoidoscopies beginning at age 50. peritonitis c. Bowel obstruction b. annually b. Digital exam beginning at age 40. annually c. Direct extension of cancer to adjacent organs.Client with Colorectal Cancer Complications a. reoccurrences within 4 years Collaborative Care: Focus is on early detection and intervention Screening a. every 3 ± 5 years . Fecal occult blood testing beginning at age 50. Perforation of bowel by tumor.
Colonoscopy or sigmoidoscopy. but is a tumor marker and used to estimate prognosis. monitor treatment. polyps e. Carcinoembryonic antigen (CEA): not used as screening test. MRI. metastasis . ultrasounds: to determine tumor depth. CBC: anemia from blood loss.Client with Colorectal Cancer Diagnostic Tests a. tumor growth b. tissue biopsy of suspicious lesions. CTscans. Chest xray. organ involvement. Fecal occult blood (guiac or Hemoccult testing): all colorectal cancers bleed intermittently c. detect reoccurrence may be elevated in 70% of people with CRC d.
Client with Colorectal Cancer Pre-op care Consult with ET nurse if ostomy is planned Bowel prep with GoLytely NPO NG .
Surgical resection of tumor. Tumors of rectum are treated with abdominoperineal resection (A-P resection) in which sigmoid colon. and regional lymph nodes is treatment of choice b.Client with Colorectal Cancer Surgery a. adjacent colon. anastomosis of remaining bowel is performed c. Whenever possible anal sphincter is preserved and colostomy avoided. rectum. and anus are removed through abdominal and perineal incisions and permanent colostomy created .
Ostomy made in colon if obstruction from tumor a. colon reconnected at later time when client ready for surgical repair . loop suspended over a bridge. Named for area of colon is which formed a.Client with Colorectal Cancer Colostomy 1. distal is mucous fistula c. temporary d. Sigmoid colostomy: used with A-P resection formed on LLQ b. Hartman procedure: Distal portion is left in place and oversewn. Double-barrel colostomy: 2 stomas: proximal for feces diversion. temporary. Temporary measure to promote healing of anastomoses b. Transverse loop colostomy: emergency procedure. only proximal colostomy is brought to abdomen as stoma. Permanent means for fecal evacuation if distal colon and rectum removed 2.
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.
Client with Colorectal Cancer Radiation Therapy a. rectal cancer has high rate of regional recurrence if tumor outside bowel wall or in regional lymph nodes b. Used preoperatively to shrink tumor C. Provides local control of disease. 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 .
Anticipatory Grieving d. Diet: decrease amount of fat. whole grains. diet high in fruits and vegetables. Screening recommendations 3. Prevention is primary issue b. legumes 2. Seek medical attention for bleeding and warning signs of cancer 4. Client teaching 1. red meat. Imbalanced Nutrition: Less than body requirements c. Pain b. Risk for Sexual Dysfunction .Client with Colorectal Cancer Nursing Care a. increase amount of fiber. refined sugar. Risk may be lowered by aspirin or NSAID use Nursing Diagnoses for post-operative colorectal client a. Alteration in Body Image e.
Client with Colorectal Cancer Home Care a. Referral to hospice as needed for advanced disease . Referral for home care b. Referral to support groups for cancer or ostomy c.
third-spacing leads to hypovolemia. shock . vomiting.Client with Intestinal Obstruction Definition a. gas and fluid accumulate proximal to and within obstructed segment causing bowel distention d. hypokalemia. May be partial or complete obstruction b. With obstruction. Failure of intestinal contents to move through the bowel lumen. renal insufficiency. most common site is small intestine c. Bowel distention.
Problems within intestines: tumors. Mechanical 1. Obstruction of intestinal lumen (partial or complete) a. IBD 3.Client with Intestinal Obstruction Pathophysiology a. Foreign bodies d. Strictures . Problems outside intestines: adhesions (bands of scar tissue). Intussusception: telescoping bowel b. Volvulus: twisted bowel c. hernias 2.
anticholinergic drugs. Medications: narcotics. peritonitis. Failure of peristalsis to move intestinal contents: adynamic ileus (paralytic ileus. Hypokalemia d. ileus) due to neurologic or muscular impairment 2. antidiarrheal medications e.Client with Intestinal Obstruction Functional 1. Causes include a. Post gastrointestinal surgery b. Spinal cord injuries. uremia. alterations in electrolytes . Tissue anoxia or peritoneal irritation from hemorrhage. Accounts for most bowel obstructions 3. or perforation c.
Client with Intestinal Obstruction a. b. with paralytic ileus. c. Proximal intestinal distention stimulates vomiting center 2. may have visible peristaltic waves 2. Distal obstruction vomiting may become feculent Bowel sounds 1. Later silent. e. intensifying Vomiting 1. Early in course of mechanical obstruction: borborygmi and high-pitched tinkling. intermittent. Manifestations Small Bowel Obstruction Vary depend on level of obstruction and speed of development Cramping or colicky abdominal pain. diminished or absent bowel sounds throughout Signs of dehydration . d.
impaired ventilation. peritonitis. Delay in surgical intervention leads to higher mortality rate .Client with Intestinal Obstruction Complications a. perforation. possible septic shock c. Strangulated bowel can result in gangrene. death) b. Hypovolemia and hypovolemic shock can result in multiple organ dysfunction (acute renal failure.
inflammatory disorders. cramping pain. volvulus. localized tenderness or palpable mass may be noted . diverticular disease. Only accounts for 15% of obstructions b. severe. fecal impaction c.Client with Intestinal Obstruction Large Bowel Obstruction a. continuous pain signals bowel ischemia and possible perforation. Causes include cancer of bowel. Manifestations: deep.
Successfully relieves many partial small bowel obstructions . Supportive care Diagnostic Tests a. check for allergy to iodine. confirm mechanical obstruction. Serum amylase. osmolality. indicates free air under diaphragm 2. Show distended loops of intestine with fluid and /or gas in small intestine.Client with Intestinal Obstruction Collaborative Care a. Laboratory testing to evaluate for presence of infection and electrolyte imbalance: WBC. arterial blood gases c. Relieving pressure and obstruction b. electrolytes. need BUN and Creatinine to determine renal function b. Barium enema or colonoscopy/sigmoidoscopy to identify large bowel obstruction Gastrointestinal Decompression a. Abdominal Xrays and CT scans with contrast media 1. Treatment with nasogastric or long intestinal tube provides bowel rest and removal of air and fluid b. If CT with contrast media meglumine diatrizoate (Gastrografin).
Restore fluid and electrolyte balance. Insertion of nasogastric tube to relieve vomiting. abdominal distention. foreign bodies. tumors. strangulated or incarcerated obstructions of small bowel. gangrenous portion of intestines and anastomosis or creation of colostomy depending on individual case . and to prevent aspiration of intestinal contents 2. Laparotomy: inspection of intestine and removal of infarcted or gangrenous tissue 4.Client with Intestinal Obstruction Surgery a. persistent incomplete mechanical obstructions b. Preoperative care 1. Removal of cause of obstruction: adhesions. correct acid and alkaline imbalances 3. Treatment for complete mechanical obstructions.
gastrointestinal c. Prevention includes healthy diet. especially in clients with recurrent small bowel obstructions Nursing Diagnoses a. Ineffective Tissue Perfusion. Home care referral as indicated b. fluid intake b. Deficient Fluid Volume b. Exercise. Teaching about signs of recurrent obstruction and seeking medical attention . Ineffective Breathing Pattern Home Care a.Client with Intestinal Obstruction Nursing Care a.
Postponement of defecation . Decreased activity levels c. Incidence increases with age.Client with Diverticular Disease Definition a. Diverticula are saclike projections of mucosa through muscular layer of colon mainly in sigmoid colon b. Cultural changes in western world with diet of highly refined and fiber-deficient foods b. less than a third of persons with diverticulosis develop symptoms Risk Factors a.
causing outpouchings b.Client with Diverticular Disease Pathophysiology a. Muscle in bowel wall thickens narrowing bowel lumen and increasing intraluminal pressure c. 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. Complications of diverticulosis include hemorrhage and diverticulitis. the inflammation of the diverticular sac .
more extensive perforation may lead to peritonitis or abscess formation . With microscopic perforation. inflammation is localized. Diverticulitis: diverticulum in sigmoid colon irritated with undigested food and bacteria forming a hard mass (fecalith) that impairs blood supply leading to perforation e.Clients with Diverticular Disease d.
Fistula formation e. Hemorrhage . Abscess formation c. Constipation or frequency of defecation c.Client with Diverticular Disease Manifestations a. mild to moderate and cramping or steady b. Pain. tenderness and palpable LLQ mass d. May also have nausea. low-grade fever. Older adult may have vague abdominal pain Complications a. vomiting. left-sided. Peritonitis b. abdominal distention. Bowel obstruction d.
sigmoidoscopy or colonscopy used in diagnosis of diverticulosis d. fistula b. Barium enema contraindicated in early diverticulitis due to risk of barium leakage into peritoneal cavity. Abdominal CT scan. Abdominal Xray: detection of free air with perforation. WBC count with differential: leukocytosis with shift to left in diverticulitis e. Hemocult or guiac testing: determine presence of occult blood . location of abscess. 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.Client with Diverticular Disease Medications a. Fluids to correct dehydration d. Analgesics for pain (non-narcotic) c. Broad spectrum antibiotics against gram negative and anaerobic bacteria to treat acute diverticulitis. oral or intravenous route depending on severity of symptoms Flagyl plus Bactrim or Cipro b. Anticholinergics to decrease intestinal hypermotility .
Clients with Diverticular Disease Dietary Management a. Diet modification may decrease risk of complications b. 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. As symptoms subside reintroduce food: clear liquid diet. to soft. Client initially NPO with intravenous fluids (possibly TPN) b. low-roughage diet psyillium seed products to soften stool and increase bulk c. 2 stage Hartman procedure done with temporary colostomy. With acute infection. High fiber diet is resumed after full recovery Surgery a.Client with Diverticular Disease Treatment for acute episode of diverticulitis a. re-anastomosis performed 2 ± 3 months later .
Impaired Tissue Integrity. if new colostomy client . medications b. Pain c. gastrointestinal b. Referral for home health care agency. possible surgery Home Care a.Client with Diverticular Disease Nursing Care: Health promotion includes teaching high-fiber foods in diet generally. Teaching regarding prescribed diet. may be contraindicated for persons with known conditions Nursing Diagnoses a. fluid intake. related to unknown outcome of treatment. Anxiety.
kidney or liver disorders. but rather are symptoms of many different conditions. central nervous system disorders. . brain tumors. and some forms of cancer. Nausea and vomiting are not diseases. Nausea and vomiting can sometimes be symptoms of more serious diseases such as heart attacks.
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.
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. low BP Weight loss Sunken eyeballs Oliguria Dark. tachycardia. serum creatinine Elevated hematocrit .
Hypokalemia Initial manifestation in muscle weakness in the legs or leg cramps Provide postssium-rich foods such as banana. citrus fruits and dried fruits. Administer antiemetic as ordered by the physician Plasil (Metochlopramide) Tigan (Trimethobenzamide) Phenergan (Promethazine) Compazine (Prochlorperazine maleate) . baked potatoes. raw tomato. raw carrot.
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