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

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

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

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

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

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

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

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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

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

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

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

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.

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

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

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

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. usually diagnosed late 2.More common in African Americans than Caucasians 3. Squamous cell carcinoma 1.Associated with Barrett¶s esophagus. Adenocarcinoma 1.Nearly as common as squamous cell affecting distal portion of esophagus 2.Esophageal Cancer 1. complication of chronic GERD and achalasia . Pathophysiology  a.More common in Caucasians 3.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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 .

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

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 .

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

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

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

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

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

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 Volume replacement Crystalloids.

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

Sengstaken-Blakemore Tube .

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

Colon Cancer .

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

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

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

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

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

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

Irritable Bowel Syndrome (IBS) (spastic bowel. more common in females . diarrhea. or both  b. 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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Inflammatory Bowel Disease .

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

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

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

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 .

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

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

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 25% of patients require a colectomy Total proctocolectomy with a permanent ileostomy  Colon. 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 .

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

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

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

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

Crohn¶s disease .

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

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

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

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

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

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

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

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

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

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

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 .Client with Polyps Nursing Care  a.

Polyps .

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

bones. Often produces no symptoms until it is advanced  b. palpable abdominal or rectal mass. and kidneys Manifestations  a. anorexia. Metastasize to regional lymph nodes via lymphatic and circulatory systems to liver. also change in bowel habits (diarrhea or constipation). weight loss. pain. anemia . brain. 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. lungs. Presenting manifestation is bleeding.Client with Colorectal Cancer Pathophysiology  a.

Colon Cancer .

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

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

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

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

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

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

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. solid stool .

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

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

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

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

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

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

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

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

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

Restore fluid and electrolyte balance. Preoperative care  1. Insertion of nasogastric tube to relieve vomiting. correct acid and alkaline imbalances  3. gangrenous portion of intestines and anastomosis or creation of colostomy depending on individual case . persistent incomplete mechanical obstructions  b. Treatment for complete mechanical obstructions. Removal of cause of obstruction: adhesions. abdominal distention. tumors. 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. strangulated or incarcerated obstructions of small bowel. foreign bodies.

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

Cultural changes in western world with diet of highly refined and fiber-deficient foods  b.Client with Diverticular Disease Definition  a. less than a third of persons with diverticulosis develop symptoms Risk Factors  a. Diverticula are saclike projections of mucosa through muscular layer of colon mainly in sigmoid colon  b. Postponement of defecation . Incidence increases with age. Decreased activity levels  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.Client with Diverticular Disease Pathophysiology  a. Complications of diverticulosis include hemorrhage and diverticulitis. Muscle in bowel wall thickens narrowing bowel lumen and increasing intraluminal pressure  c. causing outpouchings  b. the inflammation of the diverticular sac .

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

Diverticulits .

Diverticulitis .

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

WBC count with differential: leukocytosis with shift to left in diverticulitis  e. location of abscess. Abdominal CT scan. 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. Hemocult or guiac testing: determine presence of occult blood . Barium enema contraindicated in early diverticulitis due to risk of barium leakage into peritoneal cavity. but will confirm diverticulosis  c. Abdominal Xray: detection of free air with perforation.

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

High-fiber diet (bran. commercial bulk-forming products such as psyllium seed (Metamucil) or methycelluose)  c.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.

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

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

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

 Table 42-2 page 993 .

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

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

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

 Suction mouth as needed if the client is unable to expel vomitus.  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 .

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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. concentrated urine High specific gravity of urine Poor skin turgor Altered LOC (level of consciousness) Elevated BUN. tachycardia. low BP Weight loss Sunken eyeballs Oliguria Dark. serum creatinine Elevated hematocrit .

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

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