Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Patients With Gastrointestinal

Alterations III


Continuation of Alteration in Digestion Dumping Syndrome

rapid gastric emptying happens when the lower end of the small intestine, the jejunum, fills too quickly with undigested food from the stomach “Early Dumping” begins during / right after 30 minutes after a meal o Clinical Manifestations: Nausea / Vomiting Bloating Cramping Diarrhea Dizziness Fatigue Abdominal failure “Late Dumping” happens 1 – 3 hours after eating o Clinical Manifestations: Weakness Sweating (Perspiration) Dizziness Hypoglycemia Pallor Drowsiness Causes

Topics Discussed Here Are: 1. Continuation of Alteration in Digestion a. Dumping Syndrome 2. Disturbance in Absorption a. Diarrhea b. Constipation c. Irritable Bowel Syndrome (IBS) 3. Structural and Obstructive Bowel Disorders a. Intestinal Obstruction b. Crohn’s Disease (CD) c. Ulcerative Colitis (UC)

Gastrectomy / gastric bypass surgery / Billroth I and II Esophagectomy from esophageal cancer clients Pathophysiology wala XD Management - Limit fluid intake o No fluid with meals o No salt - No ↑CHO

Nursing Interventions
1. 2. 3. 4. Advice client to eat ↓ CHO, ↑ FAT and ↑ CHON diet (↑ Fiber) Instruct to eat small frequent meals, include more dry items Instruct to avoid consuming fluid with meals Instruct to LIE DOWN AFTER MEALS (OPPOSITE sa mga DATING DISORDERS) Administer antispasmodic medications to delay gastric emptying (Metoclopramide)



fluid. secretion of fluid and electrolytes due to secretions of bacterial endotoxin Some examples: o Cholera.Painless. Osmotic Secretory Motility Osmotic Diarrhea Presence of unabsorbable substance in the intestine causes it to be drawn into the lumen by OSMOSIS Pathophysiology Lactase deficiency is the most common cause of osmotic diarrhea!! Non-absorbable substance – Milk. 2. 3. Crohn’s disease (Entire mucosa SI and LI) o Inflammation of the intestine / colon o Cramping pain o Urgency and frequency o Fecal impaction (liquid pushes impacted feces) o Secretions produced by the colon to lubricate the impacted feces o Move towards the anal canal flowing around the impaction THREE MAJOR MECHANISMS OF DIARRHEA 1. E.Painful! .Infants and elderly = 2 – 3 weeks SEVERE Adults and children = 4 weeks SEVERE . without mucous . coli o Neoplasms like gastinoma/thyroid carcinoma which both can produce hormones that stimulate intestinal secretions jcmendiola_Achievers2013 .Disturbance in Absorption Diarrhea ↑ frequency of defecation and the fluidity and volume loss more than 3 times a day LARGE VOLUME DIARRHEA .Caused by excessive amounts of water / secretions in the intestine . and large colon).Volume of feces is not increased and is usually a result from excessive intestinal motility . sugar and lactose Intestine does not produce enough lactase Lactose remains in the intestinal lumen (Because it is not digested and absorbed) Secretory Diarrhea Form of large volume diarrhea caused by excessive mucosa.Diabetic neuropathy has lesions / blockage of the nerve and it impairs autonomic control of motility SMALL VOLUME DIARRHEA .Diarrhea in which VOLUME OF FECES is called LARGE VOLUME DIARRHEA .Causes: o Ulcerative colitis (Mucosa and submucosa.

Exercise to strengthen abdominal Opiates. Treatment ٪ Restoration of fluid and electrolyte imbalance – IVF ٪ Management of distressing symptom ٪ Correction of nutritional deficiencies ٪ Administration of substances that solidify stool (Metamucil) ٪ Opium alkaloids like Lomotil which suppress motility. anticholinergics. complication of Crohn’s Disease) jcmendiola_Achievers2013 . 2. relieves cramping and reduce stool volume and frequency Clinical Manifestations MORE :o Constipation Difficulty or infrequent defecation Clinical Manifestations: 1. hemorrhage/neoplastic lesions of the colon Auscultate Bowel Sounds – Usually hypoactive.Excessive motility ↓ transit timing ↓ mucosal surface contact ↓ fluid absorption Large volume of stool reaches rectum producing urgency and frequency of elimination Motility Diarrhea Caused by resection of small intestine Surgical bypass of an area of intestine Fistula formation between loops of intestine Causes: o Food is not mixed properly o Impaired drying o ↑ motility o Diarrhea Frequency – It is important to discover whether evacuation was stimulated by enemas / laxative Stool Constituents / Presence of Blood – Blood may present as a result of bleeding. antacids muscles Systemic Diseases (Hypothyroidism. Smaller stool volume Causes: 1. History and Physical Assessment ẅ History to document onset and frequency of diarrhea ẅ Physical examination – To identify the underlying systemic disease ẅ Fecalysis / Stool Culture ẅ Abdominal X-ray ẅ Intestinal Biopsy B.Draw habit training ↓ Residue diet ↑ Fiber and fluid intake Neurologic (Hirschsprung’s Disease) Depression .Discontinue laxative abuse Sedentary lifestyle . 5. 8. 4. absent Systemic Effects of Prolonged Diarrhea • • • Dehydration Electrolyte Imbalance Weight loss A. Feeling of bowel fullness and discomfort 4. - - Abdominal distention Borborygmus – Gurgling sound caused by passage of gas in the intestine Pain and pressure Indigestion Sense of vomiting emptying Straining Hard dry stool Abdominal muscle weakness Medical Management: Painful anal lesions (hemorrhoids) . Diabetic Neuropathy) Megacolon (Enlarged dilated colon. Less frequent defecation 2. 3. 7. Difficulty of evacuating rectum 3. 6.

Involves passage of stool from the rectum . masses.Rectal motility Clinical Manifestations: • Soiling • Occasional urge and loss of control • Complete incontinence • Poor control of flatus Medical Management • Biofeedback therapy • Bowel training program • Surgery: Reconstruction of the sphincter Irritable Bowel Syndrome (IBS) Functional disorder of motility in the intestines.Ability of the rectum to sense and accommodate stool . Bowel retraining 2. Avoidance of high-caloric irrigations with large volume of fluid to prevent rupture of bowel D. because it accompanies the development of organic lesions that require careful education B. Engage in moderate exercise.A. Complications 1. excessive motility Causes ↑ In FAT! FRESH FRUITS! Gas forming foods Carbonated beverages Alcohol Cause is unknown Hereditary Stress. Proctosigmoidoscopy: Visualizing the lumen of the rectum 2. drink more fluid (↑ Fiber intake) 3.Integrity of the anal sphincter . tenderness $ Digital Rectal Examination (DRE) Assess sphincter and detect anal lesion $ Functional Constipation Resulting from lifestyle / bowel habits. Valsalva maneuver may result to rupture of a major artery in the brain / elsewhere 2. Assessment $ Due to different personal bowel habits. Megacolon / dilated and atomic colon – Cause by fecal mass that obstructs the passage of colon 4. Cathartic Colon – Mucosa atrophy of the colon with muscle thickening subsequent to chronic use of laxatives Fecal Incontinence . depression Smoking jcmendiola_Achievers2013 . Fecal impaction 3. Enemas 5. Diagnostic Test 1. Treatment ¥ Dysfunctional: Manage underlying disease / lesion ¥ Functional 1. Barium Enema: May be required if no lesions is directly visualized and symptoms persisted often simple treatment C. it must be individually defined $ Normal bowel habits 2 – 3 evacuations /day $ Cramping Symptom of bowel obstruction Palpation discloses colonic distention.Amount and consistency of the stool . Stool softeners and laxative agents 4. usually has a long history $ Dysfunctional Constipation More likely to be sudden.

8 hour sleep 6. It may or may not compromise the blood supply TYPES and CAUSES Mechanical Obstruction Non-Mechanical Obstruction jcmendiola_Achievers2013 . Encourage to ↓ stress 3. whole wheat and grains) ↓ FAT. Limit / stop smoking and alcohol consumption 4. bloating and abdominal distention • Pain is precipitated by eating • Frequently relieved by defecation Other Signs and Symptoms • Nausea • Distention • Dyspepsia • Eructation • Borborygmi • ↓ Gas motility Diagnostic Tests It will usually take 3 months before it is diagnosed Sigmoidoscopy / colonoscopy Barium enema CBC / Stool examination ** No confirmatory test / histologic feature (NOTE: Explore technique that could eliminate the possibility that the patient…) Health Promotion 1. Regular exercise 5.Pathophysiology Clinical Manifestations • Diarrhea (Can be alternative) • Constipation • Lower left quadrant pain (morning after eating) • Tenderness in the SIGMOID area • Alteration in bowel pattern • Pain. may be complete / incomplete. ↑ Oral fluid intake (8 glasses/day) 7. Metamucil (↓ Bulk in diet) Structural and Obstructive Bowel Disorders Intestinal Obstruction • Is an interruption of the normal flow of intestinal contents along the intestinal contents along the intestinal tract. Sedatives 2. ↑ Fiber diet (Miller’s bran. avoidance of carbonated drinks 2. The block may occur in the small or large intestine. Antispasmodics 3. Limit milk / milk products Medications 1. bran cereals. maybe mechanical or paralytic.

hernia (out pouching which may lead to necrosis). volvulus (twisted loop of intestine) 2. Major traumas (Spinal cord injuries. rectum is the most common tumural obstruction. intussusception. Peritonitis / Sepsis 4. ischemic bowel. Post-operatively after abdominal / GI surgery particularly if the bowel has been extensively manipulated 3. assocated with abdominal surgery. hypokalemia.Mechanical Obstruction A physical block at the passage of intestinal contents without disturbing the blood supply of bowel Types: 1. Mesenteric Vascular Occlusion / Infarction and Strangulation Compromised blood flow Mesenteric Vascular Occlusion Infarction Result from extensive atherosclerosis of the mesenteric arteries or mesenteric thrombosis creates ischemia in the bowel 15 – 30 minutes after eating (usually pain occurs) CANNOT BE RELIEVED BY REST! Strangulation: Prolonged mechanical obstruction 3. congenital Atresia (telescopic appearance which occurs with mucosal inflammation and cancer). obstructing the intestinal lumen both proximally and distally Commonly occurs in the SIGMOID COLON 4. peritonitis. more common in infants than adults (muscular structure is not yet developed) 10 – 15 months Twisting of the intestine with occlusion of blood supply most frequently in middle aged and elderly men Inflamed saccular herniation (diverticuli) of the mucosa most common in obese individuals older than 60 years old Growth into the intestinal lumen. masses (colorectal cancer which can obstruct colon). inflammatory disease (Crohn’s Disease) Non-Mechanical Obstruction Types: 1. adenocarcinoma of the colon. Extrinsic Adhesions from surgery. vertebrae fractures) 2. Electrolyte imbalance – Particularly hypovolemia 2. Volvulus A twisting of the bowel upon itself usually at least a full 180°. Paralytic Ileus (Adynamic Neurogenic) Absence of peristalsis Peristalsis is ineffective (diminished motor activity perhaps because of toxic or traumatic disturbance of the ANS) There is no physical obstruction and no interrupted blood supply Disappears spontaneously after 2 – 3 days Causes: 1. spinal trauma jcmendiola_Achievers2013 . common in individuals older than 60 years of age Loss of peristaltic motor activities in the intestine. tumor. Intrinsic Fecal impaction. Intussusception The bowel segments containing the mass is propelled by peristalsis on to the adjacent bowel segment There is obstruction due to change in movement Pathophysiology Hernia Intussusceptions Volvulus Diverticulosis Tumor Paralytic Ileum Protrusion of the intrinsic through a weak abdominal muscle or through an inguinal ring Telescoping of warm part of the intestine into another usually causes strangulation of the blood supply. stricture / stasis.

Signs and Symptoms • • • • • • • • • • Abdominal Pain (Colicky: Minimal diffuse tenderness) Abdominal distention Nausea / Vomiting – Vomiting may be persistent Bowel Sounds – Increase / Hyperactive .*HUSH* Sounds Tachycardia ↓ BP Body weakness ↑ WBC Fever Difficulty of breathing – Tachypnea – Dilated intestine compressing the thorax jcmendiola_Achievers2013 .

Na and Cl Peritonitis Shock Death due to shock Nursing Management Achieving pain relief 1. Monitor serum electrolyte levels. May show presence and location of small or large intestinal obstruction 2. 4. Provide supportive care during NG insertion to assist with discomfort Maintaining Fluid and Electrolyte Balance 1. Bird beak lesion in colonic volvulus 3. Record amount. drop in BP may indicate blood loss 2.Some signs and symptoms may vary depending on the location of the intestinal obstruction Diagnostic Evaluation Abdominal and Chest X-Rays 1. Ileus may be identified by oral barium: Laboratory Tests a. Maintain adequate fluid balance 3. consistency of stools jcmendiola_Achievers2013 . strangulation / peritonitis ENDOSCOPIC Studies / Proctosigmoidoscopy Direct visualization on a narrowed intestinal lumen Management • Non-Surgical Correction of fluid and electrolyte imbalance with NS/LR with KCl solution is required NG Suction to decompress bowel Treatment of SHOCK and PERITONITIS TPN may be necessary to correct protein deficiency from chronic obstruction. intussusceptions and incarcerated hernia Enterostomy (Opening) for removal of foreign bodies Resection of bowel obstruction lesions or strangulated bowel with end to end anastomosis (Removal of affected area and connection of good layers) Temporary ostomy • Complications 1. Foreign body visualization Contrast Studies (Barium) 1. Dehydration due to loss of water. Elevated WBC count with necrosis. Provision of Diversional activities 3. VS. Administer prescribed analgesics as prescribed LOL (redundant naman XD) 2. 3. K and Cl levels due to vomiting b. blood cell counts and refer abdominal results 3. reduction of volvulus. avoiding opiates (Morphine) due to GI motility inhibition Antibiotics for peritonitis Surgical Management: Consists of relieving obstruction Closed Bowel Procedure – Lysis of adhesion. paralytic ileus Analgesics and sedatives. Monitor I&O. 2. Barium enema may diagnose colon obstruction or intussusceptions 2. May show ↑ NA. Collect stool samples to test for occult blood if ordered 2. Administer IV fluid and parenteral nutrition as ordered Maintaining Normal Bowel Elimination 1.

and IV fluids. blocking the passage of the intestinal contents ‫ ח‬Fistulae – Can develop between two loops of bowel. between the bowel and bladder. and bloating ٨ Nausea / vomiting ٨ Abdominal distention Systemic ٨ Growth failure – Weight loss (Due to ↓ oral) ٨ Fever Complications GI Symptoms ‫ ח‬Obstruction – Typically occurs from strictures or adhesions which narrow the lumen. Transmural Inflammation (Affecting the entire wall of the involved bowel) and. NPO status. 2. inflammatory condition of the GI tract Characterized by bowel movement: 1. fatty or refined foods Smoking Oral contraceptives Bacteria found in the colon such as mycobacterium avium sub species paratuberculosis Signs and Symptoms GI Symptoms ٨ Abdominal pain Crampy and may be relieved by defecation Often accompanied by diarrhea which may be bloody ٨ More than 20 BM/day in SEVERE CASES ٨ Bloody BM are typically intermittent and my be bright and dark red in color ٨ (+) flatus. Encourage client to follow up as directed and to notify the surgeon for: Abdominal pain Vomiting Fever Crohn’s Disease (CD) Also known as REGIONAL ENTERITIS Chronic. episodic.4. Teach wound care if indicated 4. Explain the rationale for NG suctioning. Maintain NGT to decompress as ordered Maintain Proper Lung Ventilation 1. Keep client in fowler’s position to promote ventilation 2. Monitor ABG for oxygenation levels if ordered Patient Education 1. advise client to progress diet slowly as tolerated once home 2. Advise plenty of rest and slow progression of activity as directed by the surgeon 3. Skip Lesions (Areas of inflammation with areas of normal lining in between) Cause: • Unknown • Genetic and environmental factors have been invoked in the pathogenesis of the disease • Environmental factors such as: Diets high in sweet. between the bowel and vagina and bowel and skin ‫ ח‬Abscess – Are walled off collections of infection and can occur in the abdomen or in the perianal area in Crohn’s disease sufferers ‫ ח‬Malnutrition and Cancer ‫ ח‬Bone Complications – Prolonged steroid use and menopausal women are at risk ‫ ח‬Liver and Gallbladder – Effect of medications (Nephrotoxicity and hepatotoxicity) jcmendiola_Achievers2013 .

severity and onset of abdominal cramping of pain Ask the client about weight losses and anorexia. Hmg. ESR ‫ ק‬Fluid and electrolyte imbalance (Due to Na. 5. Cl. K dehydration) Treatment • To treat acute disease and maintain remission Involves the use of medications to treat any infection and to reduce inflammation Usually involves the use of aminosalicylate anti-inflammatory drugs and corticosteroids and may induce antibiotics • Surgery Resection and anastomosis May be required for complications such as obstruction or abscesses or if the disease does not respond to drugs within a reasonable time • Diet and Lifestyle Stress management techniques (Exercise) ↓ Residue diet may reduce volume of stool per day Lactose Intolerance – Avoid lactose containing foods Smoking and NSAIDS drugs should be avoided • Lifestyle changes • Physical rest • ↓ Residue diet (To slow motility / stool) • Elimination of dairy products for lactose intolerance • Treatment in children: If the disease is not treated before 18.Barium study of the upper GI o Is confirmatory which shows classic string on X-ray film indicating constriction of the segments involved o Nursing Interventions 1. 4. including duration and amount Ask about family history of GI diseases Diagnostic Tests Upper GI series (Location) Flexible Sigmoidoscopy Barium enema Biopsy Lab findings ‫ ↑ ק‬WBC ‫ ↓ ק‬Hct. Assess frequency and characteristics of stool to evaluate losses and effectiveness of therapy Have the client describe the location. 6. 2. 3.Proctosigmoidoscopy initially .Stool examination – May be (+) for occult blood and steatorrhea . Wight daily to monitor changes Have the client describe the food eaten to elicit dietary exacerbation Determine if the client smokes.Assessment and Diagnostic Findings . ½ of the children have short stature or delayed growth • Intervention: Aggressive nutrition therapy Ulcerative Colitis (UC) Spans the entire length of the colon Involves mucosa and submucosal layer More COMMON than Crohn’s disease jcmendiola_Achievers2013 .

↑ CHON diet Administer drugs – Anti-inflammatory. TPN if prescribed (Monitor complications of diarrhea) Instruct the client to avoid gas forming foods. nausea .Fluid volume deficit related to diarrhea . 7. alcohol and Diet Progressive = Clear liquid ↓ Residue. 6. 3. milk products such as wheat grains. Altered immune status Recurrent ulcer and inflammatory condition of the mucosa and submucosal layers of the rectum The colon becomes edematous and develop bleeding ulcerations Scarring develops over time with impaired water absorption and loss of elasticity Clinical Manifestations 1. fever 5. Severe diarrhea (10 – 20 liquid stools/day) with rectal bleeding 2. bulk forming agents (Metamucil) vitamins / iron supplements jcmendiola_Achievers2013 . dehydration. LLQ Abdominal pain and cramping ↓ Hct and hmg and albumin 8. steroids. Allergic reaction 3. colonoscopy Barium Enema MRI and CT Scan Complication Toxic megacolon Perforation Bleeding Osteoporotic fracture Nursing Intervention for CD and UC 1. Fever Assessment and Diagnostic Findings 4. Dehydration Stool exam (+) for blood 7. level of hydration and nutritional status 6.Altered nutrition: less than body requirements related to pain. antibiotics. stool and blood studies Restrict activity = Rest and comfort Administer IVF. electrolyte imbalance Monitor bowel sounds. nuts. Anorexia Assess for tachycardia. hypotension. 2. 8. electrolytes.Causes 1. History of exposure to bacteria 2. 4. Tenesmus – Straining on defecation ↑ WBC Nursing Diagnoses . Maintain NPO during acute Monitor for complications like severe bleeding. pepper. Weight loss 3. especially spinach. Tachypnea.Pain related to inflammatory disease of the small intestine Sigmoidoscopy. RAW fruits and vegetables. 5. Anemia and hypocalcemia and pallor.

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