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

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

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

Health promotion:  1.Client with Oral Cancer 4. Nursing Diagnoses  1. Risk for ineffective airway clearance  2. Imbalanced Nutrition: Less than body requirements  3. 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. Need to seek medical attention for all nonhealing oral lesions (may be discovered by dentists). Nursing Care a. Disturbed Body Image . Teach risk of oral cancer associated with all tobacco use and excessive alcohol use  2.

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

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

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

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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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 .

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

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

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

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

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

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 .

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

Colon Cancer .

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

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

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

diaphoretic c. flushed.Occurs with partial gastrectomy. and diarrhea. hypotensive. Complications associated with gastric surgery  1. Dumping Syndrome a. epigastric pain and cramping. client becomes tachycardic. dizzy. hypertonic. borborygmi.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 . 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.Cancer of Stomach b.

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

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

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

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

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

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

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

perforated ulcer.Peritonitis Definition  a. Enteric bacteria enter the peritoneal cavity through a break of intact GI tract (e.g. Inflammation of peritoneum. ruptured appendix) . 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 .

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

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

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

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

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

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

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

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

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

Inflammatory Bowel Disease .

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

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

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

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 .

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

Ileostomies: always have liquid stool which can be corrosive to skin since contains digestive enzymes  6. Surgically created opening between intestine and abdominal wall that allows passage of fecal material  2. 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. Ileostomy: opening in ileum.Ulcerative Colitis Ostomy  1. Name of ostomy depends on location of stoma  4. Continent (or Kock¶s) ileostomy: has intraabdominal reservoir with nipple valve formation to allow catheter insertion to drain out stool .

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

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

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

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

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

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

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

Crohn¶s disease .

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

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

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

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

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

Crohn¶s Disease (regional enteritis) Dietary Management  a. With acute exacerbations. Individualized according to client. eliminate irritating foods  b. Dietary fiber contraindicated if client has strictures  c. client may be made NPO and given enteral or total parenteral nutrition (TPN) Surgery: performed when necessitated by complications or failure of other measures removal of diseased portion of the bowel .

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

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

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

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

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

Polyps .

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

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

Colon Cancer .

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

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

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

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

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 .

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

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

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

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

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

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

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

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

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

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

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

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

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

Diverticulosis is the presence of diverticula which form due to increased pressure within bowel lumen causing bowel mucosa to herniate through defects in colon wall. causing outpouchings  b. Muscle in bowel wall thickens narrowing bowel lumen and increasing intraluminal pressure  c.Client with Diverticular Disease Pathophysiology  a. the inflammation of the diverticular sac . 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. inflammation is localized. With microscopic perforation.Clients with Diverticular Disease  d. more extensive perforation may lead to peritonitis or abscess formation .

Diverticulits .

Diverticulitis .

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

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

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

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

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

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

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

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

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

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