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

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

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

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

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

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

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

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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

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

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

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

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

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

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Barium swallow  b. Diagnostic Tests  a. Manifestations: Similar to GERD 3. If medical treatment is not effective or hernia becomes incarcerated. Treatment  a. medications  b.Hiatal Hernia 2. then surgery. Upper endoscopy 4. 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 .

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

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

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

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

Treatments: dependent on stage of disease. More advanced carcinoma: treatment is palliative and may include surgery. Complications of radiation therapy include perforation. Early (curable) stage: surgical resection of affected portion with anastomosis of stomach to remaining esophagus. stricture .Esophageal Cancer 6. may also include radiation therapy and chemotherapy prior to surgery  b. radiation and chemotherapy to control dysphagia and pain  c. hemorrhage. client¶s condition and preference  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. Risk for Ineffective Airway Clearance (especially during postoperative period if surgery was done) . Anticipatory Grieving (dealing with cancer diagnosis)  c. Nursing Diagnoses  a.Esophageal Cancer 7.

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

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

no vomiting . coats and protects gastric mucosa  c. NPO status to rest GI tract for 6 ± 12 hours. intravenous fluid and electrolytes if indicated  b. sucralfate (carafate) acts locally.Gastritis 6. reintroduce clear liquids gradually and progress. Treatment  a. 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.

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.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.

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

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

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

hematocrit. Nursing Diagnoses:  a. 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. Upper endoscopy: visualize mucosa. red blood cell indices: anemia including pernicious or iron deficiency  c. Serum vitamin B12 levels: determine pernicious anemia  d. Deficient Fluid Volume  b. obtain biopsies.Chronic Gastritis Diagnostic Tests  a. identify areas of bleeding. Hemoglobin. Imbalanced Nutrition: Less than body requirements .

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

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

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

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

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 .

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

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

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

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

stool. vomitus studies Endoscopy .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 .

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

Colon Cancer .

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

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

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

Dumping Syndrome a. 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.Occurs with partial gastrectomy. Complications associated with gastric surgery  1. and diarrhea. hypertonic. epigastric pain and cramping. dizzy.Manifestations 5 ± 30 minutes after meal: nausea with possible vomiting. diaphoretic c. hypotensive.Cancer of Stomach b. borborygmi. client becomes tachycardic.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 .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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. Treatment  a. Intravenous fluids and electrolytes to maintain vascular volume and electrolyte balance  b. Relieves abdominal distension secondary to paralytic ileus  2.Peritonitis 9. NPO with intravenous fluids while having nasogastric suction .

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

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

Inflammatory Bowel Disease .

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

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

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

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.

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

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 .

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

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

Crohn¶s disease .

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

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

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

Immunosuppressive agents (azathioprine (Imuran).Crohn¶s Disease (regional enteritis) Medications: goal is to stop acute attacks quickly and reduce incidence of relapse  a. 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 . Corticosteroids: reduce inflammation and induce remission. with ulcerative colitis may be given as enema. intravenous steroids are given with severe exacerbations  c.

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

With acute exacerbations. Individualized according to client. eliminate irritating foods  b. Dietary fiber contraindicated if client has strictures  c. 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 .Crohn¶s Disease (regional enteritis) Dietary Management  a.

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

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

untreated. near 100% malignancy by age 40 . < 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.Neoplastic Disorders Pathophysiology  a. villous. Most polyps are adenomas. Polyp types include tubular. or tubularvillous  c. benign but considered premalignant.

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

Client with Polyps Nursing Care  a. 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. Bowel preparation ordered prior to colonoscopy with cathartics and/or enemas .

Polyps .

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

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

Colon Cancer .

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

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

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

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

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.

Used as adjunct with surgery.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. does not improve survival rates Chemotherapy: Used postoperatively with radiation therapy to reduce rate of rectal tumor recurrence and prolong survival .

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

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

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

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

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

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

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

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

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

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

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

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

Complications of diverticulosis include hemorrhage and diverticulitis.Client with Diverticular Disease Pathophysiology  a. 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. causing outpouchings  b. the inflammation of the diverticular sac . Muscle in bowel wall thickens narrowing bowel lumen and increasing intraluminal pressure  c.

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. more extensive perforation may lead to peritonitis or abscess formation . inflammation is localized. With microscopic perforation.

Diverticulits .

Diverticulitis .

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

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

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. Analgesics for pain (non-narcotic)  c. Fluids to correct dehydration  d. Anticholinergics to decrease intestinal hypermotility .Client with Diverticular Disease Medications  a. Stool softener but not cathartic may be prescribed (nothing to increase pressure within bowel)  e.

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

Client initially NPO with intravenous fluids (possibly TPN)  b. With acute infection. High fiber diet is resumed after full recovery Surgery  a. re-anastomosis performed 2 ± 3 months later . low-roughage diet psyillium seed products to soften stool and increase bulk  c.Client with Diverticular Disease Treatment for acute episode of diverticulitis  a. 2 stage Hartman procedure done with temporary colostomy. 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.

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

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

 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. 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. serum creatinine Elevated hematocrit . low BP Weight loss Sunken eyeballs Oliguria Dark.

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

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