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

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

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

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

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

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

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

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

Gastroesophageal Reflux Disease (GERD)
6. Diagnostic Tests  a. Barium swallow (evaluation of esophagus, stomach, small intestine)  b. Upper endoscopy: direct visualization; biopsies may be done  c. 24-hour ambulatory pH monitoring  d. Esophageal manometry, which measure pressures of esophageal sphincter and peristalsis  e. Esophageal motility studies

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

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

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

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

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

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

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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. Types  a. Achalasia: characterized by impaired peristalsis of smooth muscle of esophagus and impaired relaxation of lower esophageal sphincter  b. Manifestations: Dysphagia and/or chest pain 3. Endoscopically guided injection of botulinum toxin  Denervates cholinergic nerves in the distal esophagus to stop spams  b.

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

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

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

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

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

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

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

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

develops pernicious anemia Parietal cells normally secrete intrinsic factor needed for absorption of B12. when they are destroyed by gastritis pts develop pernicious anemia . Type A: autoimmune component and affecting persons of northern European descent.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 B: more common and occurs with aging. associated with risk of peptic ulcer disease and gastric cancer .Chronic Gastritis  3. caused by chronic infection of mucosa by Helicobacter pylori.

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

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

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

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

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

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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 .

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

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

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

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

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

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

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

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

Sengstaken-Blakemore Tube .

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

Colon Cancer .

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

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

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

flushed. dizzy. Dumping Syndrome a.Occurs with partial gastrectomy. and diarrhea. borborygmi. diaphoretic c.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 .Cancer of Stomach b. undigested chyme bolus rapidly enters small intestine and pulls fluid into intestine causing decrease in circulating blood volume and increased intestinal peristalsis and motility b.Manifestations 5 ± 30 minutes after meal: nausea with possible vomiting. hypotensive. Complications associated with gastric surgery  1. epigastric pain and cramping. client becomes tachycardic. hypertonic.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Analgesics . shift to left  b. WBC with differential: elevated WBC to 20. Diagnostic Tests  a. Liver and renal function studies. free air under diaphragm (sign of GI perforation)  e. Diagnostic paracentesis 7. Abdominal xrays: detect intestinal distension. Medications  a. serum electrolytes: evaluate effects of peritonitis  d. airfluid levels. Antibiotics 1.000.Specific antibiotic(s) treating causative pathogens  b.Peritonitis 6. Blood cultures: identify bacteria in blood  c.Broad-spectrum before definitive culture results identifying specific organism(s) causing infection 2.

Laparotomy to treat cause (close perforation. Surgery  a.Peritonitis 8. 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.

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

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

may be related to infectious agent and altered immune responses  c. second peak 60 ± 80  d. Includes 2 separate but closely related conditions: ulcerative colitis and Crohn¶s disease.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. Etiology is unknown but runs in families. Chronic disease with recurrent exacerbations .

Inflammatory Bowel Disease .

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

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

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

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

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

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

rectum.Ulcerative Colitis  Surgical Management 25% of patients require a colectomy Total proctocolectomy with a permanent ileostomy  Colon. 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 .

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

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

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

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

Crohn¶s disease .

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

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

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

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

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

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

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

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

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

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

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

Polyps .

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

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

Colon Cancer .

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

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

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

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

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 .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diverticulits .

Diverticulitis .

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

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

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

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

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

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

and some forms of cancer. kidney or liver disorders. central nervous system disorders. Nausea and vomiting are not diseases. brain tumors. . Nausea and vomiting can sometimes be symptoms of more serious diseases such as heart attacks. 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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concentrated urine High specific gravity of urine Poor skin turgor Altered LOC (level of consciousness) Elevated BUN. 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. tachycardia. flushed dry skin Fever. low BP Weight loss Sunken eyeballs Oliguria Dark. serum creatinine Elevated hematocrit .

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citrus fruits and dried fruits. raw carrot.  Administer antiemetic as ordered by the physician Plasil (Metochlopramide) Tigan (Trimethobenzamide) Phenergan (Promethazine) Compazine (Prochlorperazine maleate) . baked potatoes.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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