4F-D: Fluid Electrolytes Gastrointestinal Tract

(Indigestion) ○ Upper abdominal

discomfort associated
Gastrointestinal Tract with eating upper
- 100-200 ml loss of fluid from the GI tract abdominal or
- 8L fluid circulates through the GI system epigastric pain,
every 24 hours discomfort, fullness,
- Small intestine is the most of the fluid is bloating, early satiety,
belching, heartburn or
reabsorbed into the bloodstream regurgitation
- Fecal matter is compose of 75% fluid and ○ Causes: fatty food,
25% solid material salads and coarse
veges, highly
Regulating Body Fluids seasoned foods

Average Daily Fluid Average Daily Fluid Flatulence/int ● Farting; feeling “full of gas”
Intake for an Adult Output for an Adult estinal gas

Amount Belching ● Burping

Source Source Amount (mL)
(mL) ● ! food intolerance or
gallbladder disease
Oral fluids 1200-1500 Urine 1400-1500
Nausea and Nausea
Insensibl Vomiting ● Uncomfortable sensation of
Water in e losses sickness or “queasiness”
1000
foods Lungs 350-400 ● Can be triggered by odors,
Skin 350-400 activity, medications or food
intake
Water as
by-product Vomitus/Emesis
200 Sweat 100
of food ● May vary in color and content
metabolism ● Contain undigested food
particles, blood
Feces 100-200 (hematemesis), bilious
material mixed with gastric
Total 2400-2700 Total 2300-2600
juices

Common Symptoms
Pain ● Major symptom of GI disease Changes in Bowel Habits and Stool
● Use OLDCART or PQRST characteristics
○ Onset ● may signal colonic dysfunction or disease
○ Location
● Diarrhea- abnormal increase in the
○ Duration
○ Characteristics frequency and liquidity of the stool
○ Aggravating factors ● Constipation- decrease in the frequency of
○ Relieving factor the stool or stools that are hard, dry, and
○ Treatment smaller volume than
○ Black Tarry Stool: MELENA
● PQRST ○ Brown: due to BILE
○ Provocation/palliation
○ Fresh blood: HEMATOCHEZIA
○ Quality/Quantity
○ Region/radiation
○ Severity scale Vomiting
○ Timing ● the forceful expulsion of gastric contents
through the mouth preceded by nausea
Dyspepsia ● Most common symptom
 ● results from a coordinated sequence of
abdominal muscle contractions and reverse
esophageal peristalsis common sign of Gl
disorders
● occurs with fluid and electrolvte imbalances:
infections: and metabolic, endocrine,
labyrinthine, central nervous system (CNS),
and cardiac disorders.
● can also result from drug therapy, surgery,
or radiation that occurs normally during the
first trimester of pregnancy, but its
subsequent development may signal
complications.
● can also result from stress, anxiety, pain,
alcohol intoxication, overeating, or ingestion
of distasteful foods or liquids.
Major concern in children who are vomiting
➔ Risk for dehydration
➔ Loss of fluid and electrolyte
➔ Development of metabolic alkalosis
Additional concerns:
➔ Aspiration
➔ Development of atelectasis or pneumonia
Pathophysiology
Intestinal contents accumulating in the duodenum
and stomach stimulate the vomiting center in the
medulla oblongata.
1) contractions of the stomach begin to push
the gastric contents into the esophagus as
the lower esophageal sphincter relaxes;
2) a deep breath is taken and the vestibular
and vocal folds close the opening of the
larynx;
3) the hyoid bone and larynx are elevated,
opening the upper esophageal sphincter;
4) the soft palate elevates, closing the
connection between the oropharynx and
nasopharynx;
5) the diaphragm and abdominal muscles are
forcefully contracted, strongly compressing
the stomach and increasing the intragastric
pressure;
6) the lower esophageal sphincter relaxes
completely; and
7) the gastric contents are forced out of the
stomach, through the esophagus and oral
cavity, to the outside.
History and Physical examination
● Ask your patient to describe the onset,
duration, and intensity of his vomiting.
● Explore any associated complaints,
particularly nausea, abdominal pain,
anorexia and weight loss, changes in bowel
habits or stools, excessive belching or
flatus, and bloating or fullness.
● Obtain a medical history, noting Gl,
endocrine, and metabolic disorders, recent
infections, and cancer, including
chemotherapy or radiation therapy.
● Ask about current medication use and
alcohol consumption.
● If the patient is a female of childbearing age,
ask if she is or could be pregnant. Ask
which contraceptive method she's using
Vomitus: Characteristics and Causes
When you collect a sample of the patient's vomitus,
observe it carefully for clues to the under ving
disorder. Here's what vomitus may indicate:
BILE-STAINED (GREENISH) VOMITUS
● Obstruction below the pylorus, as from a
duodenal lesion
BLOODY VOMITUS
● Upper GI bleeding (if bright red, may result
from gastritis or a peptic ulcer; if dark red,
from esophageal or gastric varices)
BROWN VOMITUS WITH A FECAL ODOR
● Intestinal obstruction or infarction
BURNING, BITTER-TASTING VOMITUS
● Excessive hydrochloric acid in gastric
contents
COFFEE-GROUND VOMITUS
● Digested blood from slowly bleeding gastric
or duodenal lesion
UNDIGESTED FOOD

History and Physical Examination
● Inspect the abdomen for distention, and
auscultate for bowel sounds and bruits
● Palpate for rigidity and tenderness, and test
for rebound tenderness.
● Palpate and percuss the liver for
enlargement. Assess other body systems as
appropriate.
*projectile vomiting unaccompanied by nausea may
indicate increased intracranial pressure
Management:
If this occurs in a patient with CNS injury, you
should quickly check his vital signs. Be alert for
widened pulse pressure or bradycardia.
Page 20-30
Vomiting interventions
1. Maintain a patent airway
2. Position the child on the side to prevent
aspiration.
3. Monitor the character, amount, and
frequency of vomiting
4. Assess the force of the vomiting: projectile
vomiting may indicate pyloric stenosis
or increased intracranial pressure
5. Monitor strict intake and output
6. Monitor for signs and symptoms of
dehydration, such as sunken fontanel
(age-appropriate), non elastic skin turgor,
dry mucous membranes, decreased tear
production, changes in vital signs, and
oliguria
Gastric/ Intestinal Decompression/ Lavage
● A procedure meant to empty stomach of
toxic substances
● Gastric or intestinal tubes attached to some
clients after surgery and ordered to be
connected to a suction
● Suctioning can be intermittent or continuous
● Mostly used to clients who ingested poison
Purpose
● To relieve abdominal distention
● To maintain gastric decompression after
surgery
● To remove blood and secretions from GI
tract
● To relieve discomfort (bowel obstruction)
● Maintain patency of the nasogastric tube
Interventions:
● Fluids and electrolytes must be replaced
intravenously when gastric suction or
continuous drainage is ordered
● Irrigate before and after feedings or the
instillation of medication
● Offer mouth care every 2 hours
● Avoid tension and pulling on the tube
● Maintain suction ordered by the physician
● Report increasing amount of bloody
drainage
Imbalance associated with gastric juice loss
(vomiting or suction)
- Fluid volume deficit
- Metabolic alkalosis
- Potassium deficit
- Sodium deficit
Diarrhea
- Increased frequency of bowel movements
(>3x a day)
- Increased amount of stools (>200 mg a day)
- Altered consistency of stool (increased
liquidity)
- Contents move rapidly through intestine →
inadequate time for GI secretions to be
absorbed
Causes:
Any condition that causes
- Increased intestinal secretions
- Decreased mucosal absorption
- Altered motility
- Medications
- Tube-feeding formulas
- Metabolic and endocrine disorders
- Viral or bacterial infection
 Classification of Diarrhea - Caused by lactase deficiency,
pancreatic dysfunction or intestinal
hemorrhage
Acute Persistent Chronic Diarrhea
Diarrhea Diarrhea
3. Malabsorptive
● usually ● Lasts ● Persists for - Combines mechanical and
self between more than 4 biochemical actions, inhibiting
limiting 2 and 4 weeks and effective absorption of the nutrients
● lasts weeks may return
- Lows serum albumin levels leads to
betwee ● Frequent sporadically
n 1 to 2 ly ● Caused by: intestinal mucosa swelling and liquid
days caused adverse stool
● Freque by viral effects of
ntly infection chemothera 4. Infectious
caused s py, - Results from infectious agents
by viral ● Medicati antiarrythma
invading the intestinal mucosa
infectio ons: tic,
ns antibiotic antihyperten - C. difficile- moste identified agent in
● Medica s and sive, antibiotic-associated diarrhea
tions: magnesi metabolic
antibiot um and 5. Exudative
ics and containin endocrine - Caused by changes in mucosal
magne g disorders, integrity, epithelial loss or tissue
sium antacids malabsorptiv
destruction by radiation and
contain e disorder,
ing anal chemotherapy
antacid spinchter Page 31-39
s defect, Clinical Manifestation
Zollinger-Elli ● Intestinal malabsorption- voluminous,
son greasy stools
syndrome, ● Inflammatory enteritis or colitis - there is
AIDS and by
presence of blood, mucus and pus in the
parasitic
infection or stool
clostridium ● Pancreatic insufficiency - oil droplets on
infection the toilet water
● Diabetic neuropathy - nocturnal diarrhea
Types of Chronic Diarrhea ● Clostridium difficile infection -
1. Secretory unexplained diarrhea who are taking
- High volume antibiotics.
- Associated with bacterial toxins and Diagnostic Findings
chemotherapeutic agents used to ● complete blood cell count
treat neoplasm ● serum chemistries
- Caused by increased production and ● urinalysis
secretion of water and electrolytes ● routine stool examination
by the intestinal mucosa into the ● stool examinations for infectious or parasitic
intestinal lumen organisms,bacterial
● toxins, blood, fat, electrolytes, and white
2. Osmotic blood cells.
- When water is pulled into the ● Endoscopy or barium enema
intestine by the osmotic pressure of Complications
unabsorbed particles, slowing the ● Dehydration
absorption of the water
 - most common complication of
diarrhea
- cardiac dysrhythmia-dehydration
with potassium loss
● Metabolic acidosis - loss of bicarbonate
Must be reported!
- Urinary output < 0.5ml/kg/h for 2-3
consecutive hours
- Muscle weakness
- Paresthesia
- Hypotension
- Anorexia
- Drowsiness with Potassium level < 3.5
mEq/L
- (diarrhea),
Medical Management
● Control symptoms
● Prevent complications
● Eliminate or treat the underlying disease
Medications
● Antibiotics and anti-inflammatory agents
● Antidiarrheal agents - loperamide
(Imodium),
● diphenoxylate with atropine (Lomotil)
Loperamide- medication of choice
Nursing Management
● Assess and monitor the characteristics and
pattern of diarrhea
● Acquire a health history should address the
patient's medication therapy, medical and
surgical history, and dietary patterns and
intake
● Ask for any reports of recent acute illness or
recent travel to another geographic area
● Assess the abdomen (Inspection,
Auscultation, Palpation, Percussion)
● Obtain stool exam
● Assess for skin excoriation at the perianal
area
● Encourage bed rest and intake of liquids
and foods low in bulk until the acute attack
subsides. recommends a bland diet of
semisolid and solid foods
● Avoid caffeine, alcoholic beverages, and
very hot and very cold foods, fatty
food-stimulate intestinal motility
● Restrict milk products, fat, whole-grain
products, fresh fruits, and vegetables for
several days
● Administer antidiarrheal medications as
prescribed
● Administer Intravenous (IV) fluid therapy-
rapid rehydration
● Monitor serum electrolyte levels closely
● Report evidence of dysrhythmias or a
change in a patient's level of consciousness
● Encourage to do perianal skin care
Imbalances associated with gastric juice loss
1. Fluid volume deficit
2. Metabolic acidosis
3. Potassium deficit
4. Sodium deficit
39
Page 40-52
DRAINING FISTULA
- Fistula is an abnormal connection between
2 body parts, such as an organ or blood
vessel and another structure.
- Fistulas are usually the result of an injury or
surgery. Infection or inflammation can also
cause fistula to form
- Draining fistula - leakage of the cutaneous
opening of the fistula
- Tract between 2 epithelialized surfaces such
as the bowel stomach and the skin
- Causes:
1. Surgical operation complication
2. History of radiation to the abdomen
3. Infection
4. Inflammatory bowel disease
5. Cancer
● Major complication: fluid and electrolyte
disturbances, sepsis and malnutrition.
● A gastrointestinal fistula is an abnormal
opening in the stomach or intestines that
allows the contents to leak.
 ● Leaks that go through to a part of the
intestines are called entero-enteral Laxatives
fistulas. a. Bulk-forming
● Leaks that go through to the skin are called i. Description
enterocutaneous fistulas. 1. Absorb water into the feces
● Other organs can be involved, such as the and increase bulk to produce
bladder, vagina, anus, and colon. large and soft stools
● The more proximal the fistula, the greater 2. Contraindicated in bowel
the fluid loss obstruction
● High-output fistula - drains 500ml or more in 3. Dependency can occur with
24 hours long-term use.
● Can lead to: ii. Side and adverse effects include
○ Fluid volume deficit gastrointestinal
○ Hypoperfusion 1. Disturbances, dehydration,
○ Multi-organ failure and electrolyte imbalances.

● Electrolytes lost depend on the exact site of b. Stimulants: stimulate motility of large
the fistula intestine
● Ex: pancreatic fistula - high sodium content
c. Emollients
● TREATMENT i. Inhibit water absorption so fecal
○ Antibiotic mass remains large and soft
○ Immune suppressing medicines -
Crohn's disease d. Osmotics: attract water into the large
○ Surgery to remove fistula intestine to produce bulk and stimulate
○ Nutrition through a vein peristalsis

● Complication Antidiarrheals
○ Malnutrition ● Identify and treat the underlying cause, treat
○ Dehydration dehydration, replace fluids and electrolytes,
○ Skin problems relieve abdominal discomfort and cramping,
and reduce the passage of stool
● Medications
○ Antiemetics ● Opioids
○ Laxatives ○ Are effective antidiarrheals
○ Antidiarrheals medications that decrease intestinal
motility and peristalsis.
Antiemetics ○ When poisons, infections, or
- Medications used to control vomiting and bacterial toxins are the cause of the
motion sickness diarrhea, opioids worsen the
- The choice of the antiemetics is determined condition by delaying the elimination
by the cause of the nausea and vomiting. of toxins.
- Monitor vital signs and intake and output
and for signs of dehydration and fluid and
Commonly Administered Antiemetics
electrolyte imbalances.
- Limit odors in the client’s room when the Serotonin Antagonists
client is nauseated or vomiting. ● Dolasetron
- Limit oral intake to clear liquids when the ● Granisetron
client is nauseated or vomiting. ● Ondansetron
 ● Magnesium hydroxide
Glucocorticoids ● Magnesium citrate
● Dexamethasone ● Sodium phosphates
● Methylprednisolone ● Polyethylene glycol and electrolytes
● Lactulose
Substance P/Neurokinin-1 Antagonists
● Aprepitant
● Fosaprepitant Medications to Control Diarrhea
● Rolapitant
Opioids and Related Medications
Benzodiazepine ● Diphenoxylate with atropine sulfate
● Lorazepam ● Loperamide

Dopamine antagonists Other Antidiarrheals

● Phenothiazines ● Bismuth subsalicylate
○ Chlorpromazine ● Bulk-forming medications
○ Perphenazine ● Anticholinergic antispasmodics:
○ Prochlorperazine dicyclomine, glycopyrrolate
○ Promethazine
● Butyrophenones
○ Haloperidol
○ Droperidol
● Others
○ Metoclopramide
○ Trimethobenzamide

Cannabinoids
● Dronabinol
● Nabilone

Anticholinergics
● Scopolamine transdermal

Antihistamines
● Cyclizine
● Dimenhydrinate
● Diphenhydramine
● Hydroxyzine
● Meclizine hydrochloride

Laxatives

Bulk-forming
● Methylcellulose
● Polycarbophil
● Psyllium
Stimulants
● Bisacodyl
● Senna

Emollient
● Docusate sodium

Osmotics