NCM 116 Alterations in Nutri and GI Rev5

NCM 116 1st Examination Coverage
NCM 116 – Alterations in GI and Nutrition
Review of Anatomy and Physiology

The main function of the GI
system is to supply nutrients to
body cells. This is accomplished
through the processes of (1)
ingestion (taking in food), (2)
digestion (breaking down food),
and (3) absorption (transferring
food products into circulation).
Elimination is the process of
excreting the waste products of
digestion.
Table 1.0 Estimating Daily Energy Requirements. Retrieved from: Mifflin-St Jeor Equation
Nutrition
• CHO – main source of energy.
4cal/g
• CHON – needed for tissue growth,
repair and maintenance, body
regulatory functions, energy
production. 4cal/g
• Fats – another major source of
energy for the body. Carriers of
essential fatty acids and fat –
soluble vitamins. 9cal/g
• Vitamins
• Minerals
Malnutrition
• Malnutrition is a deficit, excess,
or imbalance of essential
nutrients.
• It may occur with or without
inflammation.
• Malnutrition affects body
composition and functional
status. Other terms used to
describe malnutrition include
undernutrition and overnutrition.
NCM 116 – Alterations in GI and Nutrition | Assessment
Subjective Data Objective Data

• Important Health Information • Mouth (Inspection and Palpation
• Past Health History • Abdomen (Inspection, Auscultation,
• Patient’s Bowel Habits Percussion, Palpation)
• History or Presence of Dse. • Rectum and Anus
• Weight History
• Medications
• Functional Health Patterns
• Health Perception – Health Management
• Nutritional - Metabolic Pattern
• Elimination Pattern
• Activity – Exercise Pattern
• Sleep – Rest Pattern
• Cognitive – Perceptual Pattern
• Role – Relationship Pattern
• Sexual – Reproductive Pattern
• Value – Belief Pattern
NCM 116 – Alterations in GI and Nutrition | Diagnostics
• For most diagnostic studies, make sure a signed

consent form for the procedure has been completed
and is in the medical record.
• The HCP doing the procedure is responsible for
explaining the procedure and obtaining written
consent.
• You have a key role in teaching patients about the
procedures.
• When preparing the patient, it is important to ask about
any known allergies to drugs, iodine, shellfish, Many GI
system diagnostic procedures require (1) measures to
cleanse the GI tract and (2) ingestion or injection of a
contrast medium or a radiopaque tracer.
Stool Specimens
1. Testing of stool specimens includes
inspecting the specimen for consistency
and color and testing for occult blood.
2. Tests for fecal urobilinogen, fat, nitrogen,
parasites, pathogens, food substances,
and other substances may be performed;
these tests require that the specimen be
sent to the laboratory.
Stool Specimens
3. Random specimens are sent promptly
to the laboratory.
4. Quantitative 24- to 72-hour collections
must be kept refrigerated until they are
taken to the laboratory.
5. Some specimens require that a certain
diet be followed or that certain
medications be withheld; check agency
guidelines regarding specific procedures.
Barium Swallow
A barium swallow is a special type of X-ray test
that helps your doctor take a close look at the
back of your mouth and throat, known as the
pharynx, and the tube that extends from the
back of the tongue down to the stomach, known
as the esophagus. To do a barium swallow, you
swallow a chalky white substance known as
barium. It’s often mixed with water to make a
thick drink that looks like a milkshake. When it’s
swallowed, this liquid coats the inside of your
upper GI.
Radiologic Studies | Upper Gastrointestinal

Series
An upper GI series with small bowel follow-through
provides visualization of the oropharyngeal area,
esophagus, stomach, and small intestine. The procedure
consists of the patient swallowing contrast medium (a
thick barium solution or gastrograffin) and then assuming
different positions on the x-ray table. The movement of
the contrast medium is observed with fluoroscopy, and a
series of x-rays are taken. An upper GI series is useful
in identifying esophageal strictures, polyps, tumors,
hiatal hernias, foreign bodies, and ulcers.
Radiologic Studies | Lower Gastrointestinal

Series
The purpose of a lower GI series, or a barium enema, is
to observe (using fluoroscopy) the colon filling with
contrast medium and to observe (by x-ray) the filled colon.
The patient receives an enema of contrast medium. This
procedure identifies polyps, tumors, and other
lesions in the colon.
Virtual Colonoscopy
Virtual colonoscopy combines CT scanning or MRI to
produce images of the colon and rectum less
invasively. It requires radiation and prior cleansing of
the colon but no sedation. Compared to conventional
colonoscopy, virtual colonoscopy provides a better
view inside the colon that is narrow from inflammation
or a growth. If a polyp is found, it will have to be
removed by conventional colonoscopy. Virtual
colonoscopy may be less sensitive in obtaining
information on the details and color of the mucosa
and in detecting small (less than 10 mm) or flat
polyps.
Endoscopy
Endoscopy refers to the direct visualization of a body
structure through an endoscope. An endoscope is a
fiberoptic instrument with a light and camera
attached, allowing the ability to take video and still
pictures (Figure 8.0). Some endoscopes have a
channel through which to pass instruments, such as
biopsy forceps and cytology brushes. Endoscopy can
examine the esophagus, stomach, duodenum, and
colon. Endoscopic retrograde
cholangiopancreatography (ERCP) visualizes the
pancreatic, hepatic, and common bile ducts.
Endoscopy is often combined with diagnostic
procedures, including biopsy, cytologic
Liver Function Studies

Liver function tests (LFTs) are
laboratory (blood) studies that
reflect hepatic disease.
Liver Biopsy
The purpose of a liver biopsy is to obtain
hepatic tissue to use to establish a diagnosis
of cancer or assess and stage fibrosis. It may
be done to follow the progress of liver
disease, such as chronic hepatitis. The 2
types of liver biopsy are open and closed. The
open method involves making an incision and
removing a wedge of tissue. It is done in the
operating room with the patient under general
anesthesia, often with another surgical
procedure.
Alterations / Problems in GI and
Nutrition, Acute and Chronic
NCM 116 – Alterations in GI and Nutrition | GERD
GASTROESOPHAGEAL REFLUX DSE.

• Gastric contents flow back into the
esophagus due to incompetent lower
esophageal sphincter.
• May result from impaired gastric emptying
from gastroparesis or partial gastric outlet
obstruction; or motility disorders such as
achalasia, scleroderma, or esophageal
spasm.
• Complications include stricture; ulceration
and possible fistula; aspiration pneumonia;
Barrett’s esophagus, which increases the risk
of adenocarcinoma

Assessment
1. Signs and Symptoms of GERD
• Heartburn
• Complaints of spontaneous regurgitation
of sour or bitter gastric contents into the
mouth
• Generalized dysphagia may occur
• May present with substernal chest pain,
hoarseness, sore throat, or chronic
cough

Diagnostic Evaluation
1. Endoscopy
2. Barium Swallow
3. Esophageal Manometry
4. Acid Perfusion Test
5. Ambulatory 24 hour pH Monitoring

Possible Nursing Diagnosis
1. Acute Pain
2. Deficient Knowledge

Therapeutic Interventions
1. Have patient follow a bland antireflux diet
2. Raise head of bed 6 to 8 inches (15 to
20cm)
3. Remain upright for 3 hours after eating
4. Avoid overeating
5. Cease smoking to help increase LES
pressure.
6. Reduce or eliminate alcohol intake
7. Avoid tight - fitting clothes, which increase
intra abdominal pressure.

Pharmacologic Interventions
1. Antacids as needed to treat heartburn;
provides symptomatic relief but does not
heal esophageal lesions
2. Histamine 2 receptor antagonists, such as
ranitidine and famotidine to decrease gastric
acid secretions
3. Proton pump inhibitor (PPI) such as
omeprazole or lansoprazole to suppress
gastric acids

Surgical Interventions
1. Surgery is indicated for patients who do not
respond to other approaches. Consists of
Nissen fundoplication; upper portion of the
stomach is wrapped around the distal
esophagus and sutured, creating a tight LES
2. There are several endoscopic procedures
that reduces reflux symptoms by tightening
the LES
3. For strictures, mechanical dilatation may be
necessary several times.
NCM 116 – Alterations in GI and Nutrition | HIATAL HERNIA
HIATAL HERNIA
• A protrusion of part of the stomach thru the
hiatus of the diaphragm and into the
thoracic cavity
• Two types of hiatal hernias: (1) SLIDING
HERNIA and (2) PARAESOPHAGEAL
HERNIA
• Results from muscle weakening caused by
aging or other conditions such as
esophageal carcinoma, trauma, or as
complication after certain surgical
procedures.
HIATAL HERNIA
Assessment
1. May be asymptomatic
2. Patient may report feeling of fullness or chest
pain resembling angina
3. Sliding hernia may cause dysphagia, heartburn
(with or without episodes of regurgitation of
gastric contents into the mouth), or retrosternal
or substernal chest pain from gastric reflux.
4. Severe pain or shock may result from
incarceration of stomach in thoracic cavity with
paraesophageal hernia.
HIATAL HERNIA
1. Upper GI series with barium contrast shows
outline of hernia in the esophagus
2. Endoscopy visualizes defect and rules out
other disorders, such as tumors or esophagitis
HIATAL HERNIA
Possible Nursing Diagnoses
1. Chronic Pain
2. Deficient Knowledge
3. Nausea
HIATAL HERNIA
Therapeutic Intervention
1. Elevate head of the bed 6 to 8 inches (15 to
20cm) to reduce nightime reflux
Pharmacologic Intervention
1. Antacids to neutralize gastric acid and reduce
pain
2. If patient has esophagitis, give histamine 2
receptor antagonist (cimetidine or ranitidine) or
PPIs (omeprazole) to decrease gastric
secretions
HIATAL HERNIA
Surgical Intervention
1. Gastropexy to fix the
stomach in position is
indicated if symptoms are
severe.
2. Nissen Fundoplication
NCM 116 – Alterations in GI and Nutrition | ACHALASIA
ACHALASIA
• primary esophageal motility disorder
characterized by the absence of
esophageal peristalsis and impaired
relaxation of the lower esophageal
sphincter (LES) in response to swallowing.
• occurs when nerves in the esophagus
become damaged. As a result, the
esophagus becomes paralyzed and dilated
over time and eventually loses the ability to
squeeze food down into the stomach
ACHALASIA
Assessment
• Inability to swallow (dysphagia), which may
feel like food or drink is stuck in your throat
• Regurgitating food or saliva
• Heartburn
• Belching
• Chest pain that comes and goes
• Coughing at night
• Pneumonia (from aspiration of food into the
lungs)
• Weight loss
• Vomiting
ACHALASIA
Diagnostics
• Esophageal Manometry
• Upper GI Series
• Upper Endoscopy
ACHALASIA
• Imbalanced Nutrition: Less Than Body
Requirements
• Acute Pain
• Risk for Aspiration
• Deficient Knowledge
ACHALASIA
• Pneumatic dilation
• Some patients with achalasia benefit from
eating slowly, taking small bites, and
avoiding swallowing large volumes of food
or liquid. Patient education centers on
adaptations the patient may make to avoid
esophageal pain, regurgitation, and weight
loss.
ACHALASIA
• Botox (botulinum toxin type A). This muscle
relaxant can be injected directly into the
esophageal sphincter with an endoscopic needle.
The injections may need to be repeated, and
repeat injections may make it more difficult to
perform surgery later if needed.
• Your doctor might suggest muscle relaxants
such as nitroglycerin (Nitrostat) or nifedipine
(Procardia) before eating. These medications
have limited treatment effect and severe side
effects.
ACHALASIA
• Heller myotomy. The surgeon cuts the muscle at the
lower end of the esophageal sphincter to allow food to
pass more easily into the stomach. The procedure can be
done noninvasively (laparoscopic Heller myotomy). Some
people who have a Heller myotomy may later develop
gastroesophageal reflux disease (GERD).
• Peroral endoscopic myotomy (POEM). In
the POEM procedure, the surgeon uses an endoscope
inserted through your mouth and down your throat to
create an incision in the inside lining of your esophagus.
Then, as in a Heller myotomy, the surgeon cuts the
muscle at the lower end of the esophageal sphincter.
NCM 116 – Disturbances in GI and Nutrition | Nausea
NAUSEA and VOMITING

• Nausea is an uneasiness of the stomach
that often accompanies the urge to
vomit, but doesn't always lead to
vomiting.
• Vomiting is the forcible voluntary or
involuntary emptying ("throwing up") of
stomach contents through the mouth.
NAUSEA and VOMITING

Possible Causes:
• Seasickness and other motion sicknesses
• Early pregnancy
• Intense pain
• Exposure to chemical toxins
• Emotional stress (fear)
• Gallbladder disease Another concern with vomiting is DEHYDRATION.
Adults have a lower risk of becoming
• Food poisoning
dehydrated because they can usually detect the
• Indigestion symptoms of dehydration (such as increased thirst
• Various viruses and dry lips or mouth). Children have a greater
• Certain smells or odors risk of becoming dehydrated, especially if the
vomiting occurs with diarrhea, because young
children may often be unable to tell an adult about
symptoms of dehydration.
NAUSEA and VOMITING

Nursing Diagnoses:
• Risk for deficient fluid volume related to
vomiting
• Acute Pain related to vomiting secondary
to vascular dilatation and hyperperistalsis
• Nausea related to effects of drug therapy
NAUSEA and VOMITING

Therapeutic Interventions:
For Nausea For Vomiting
• When trying to control nausea: • Drinking gradually larger amounts of clear
• Drink clear or ice-cold drinks. liquids
• Eat light, bland foods (such as saltine crackers or • Avoiding solid food until the vomiting episode
plain bread). has passed
• Avoid fried, greasy, or sweet foods. • Resting
• Eat slowly and eat smaller, more frequent meals. • Temporarily discontinuing all oral medications,
• Do not mix hot and cold foods. which can irritate the stomach and make
• Drink beverages slowly. vomiting worse
• Avoid activity after eating.
• Avoid brushing your teeth after eating.
• Choose foods from all the food groups as you can
tolerate them to get adequate nutrition.
NCM 116 – Disturbances in GI and Nutrition | GI Bleeding
GASTROINTESTINAL BLEEDING
• Symptom of many upper or lower GI
disorders
• May be obvious (in emesis or stool) or
occult (hidden)
• May result from trauma anywhere along
the GI tract; erosions or ulcers; esophageal
or gastric varices; etc.
Assessment
• Changes in bowel patterns or in stool color
(dark black, red, or streaked with blood)
• Hematemesis
• Nausea, abdominal pain or tenderness, or
rectal pain
• Intermittent melena or “coffee - ground”
emesis to large amount of melena with
clots or bright red hematemesis
• Rapid pulse, drop in BP, and signs of
shock may occur in significant blood loss
Assessment
• Pallor, weakness, dizziness, and shortness of breath
may occur as anemia develops
• Stool or emesis will test positive for occult blood
• Characteristics of blood to help determine the site of
origin
a) Bright red hematemesis – vomited from high in
esophagus
b) Bright red flow or coating stool – from rectum or distal
colon and small intestine
c) Dark red blood mixed with stool - higher up in colon
and small intestine
d) Shades of black (“coffee – ground”) emesis – vomited
from esophagus, stomach and duodenum
e) Tarry stool (melena) – occurs when excessive blood
accumulates in the stomach
• Complete Blood Count – decreased Hct
and Hgb; coagulation studies evaluate
prothrombin time.
• Endoscopy visualizes the GI mucosa and
source of bleeding and also determines
the risk of rebleeding
• Imaging studies may be necessary to
detect source of bleeding
• Stool test for occult blood.
• Bowel Incontinence
• Deficient fluid volume
• Imbalanced nutrition: less than body
requirements
Therapeutic Interventions:
• Same interventions for Shock
o Oxygen therapy
o Intubation and assisted ventilation if
necessary
o Fluid resuscitation for hypovolemic shock,
preferably thru two large-bore or central
lines, initially with LR solution
o Blood product replacement as indicated
o Hemodynamic monitoring with Swan-Ganz
catheter, especially for cardiogenic shock
o Hypothermia blanket in septic shock to cool
patient
Monitoring:
• Monitor intake and output, VS, and CVP to
evaluate fluid status
• Observe for changes indicating shock,
such as tachycardia, tachypnea,
hypotension, decreased urine output, and
changes in mental status
• Monitor stools and NG drainage for blood.
• Maintain patient on NG tube and NPO
status to rest GI tract and evaluate
bleeding.
Pharmacologic Interventions:
• For upper GI bleeding, histamine-2
blockers may used to block the acid-
secreting action of histamine.
• Antacids or cytoprotective agents such as
sucralfate may be also used.
• If peptic ulcer disease is the cause, an
antiulcer drug is prescribed, along with
lifestyle change and dietary modifications
• Discontinue any medications such as
NSAIDs that may be causing bleeding.
NCM 116 – Disturbances in GI and Nutrition | Gastritis
GASTRITIS
• a general term for a group of conditions
with one thing in common: inflammation
of the lining of the stomach.
• most often the result of infection with the
same bacterium that causes most
stomach ulcers.
• Gastritis may occur suddenly (acute Common Causes:
• Helicobacter pylori
gastritis), or appear slowly over time • Long term use of NSAIDs
• Aspirin
(chronic gastritis). • Alcohol
• Excessive amounts of
caffeine
• High stress levels
• Smoking
• Intolerance to spicy/citric
food
GASTRITIS
Assessment
• Gnawing or burning ache or pain
(indigestion) in your upper abdomen that
may become either worse or better with
eating
• Nausea
• Vomiting
• A feeling of fullness in your upper
abdomen after eating
GASTRITIS
• H. pylori Test - H. pylori may be detected
in a blood test, in a stool test or by a breath
test.
• Endoscopy - If a suspicious area is found,
your doctor may remove small tissue
samples (biopsy) for laboratory
examination. A biopsy can also identify the
presence of H. pylori in your stomach
lining.
• Upper GI series
GASTRITIS
• Imbalanced Nutrition: Less Than Body
Requirements
• Acute Pain
• Risk for Deficient Fluid Volume
• Knowledge Deficit
GASTRITIS
• If the patient is vomiting, give antiemetics.
• Administer I.V. fluids as ordered to maintain
fluid and electrolyte imbalance.
• When the patient can tolerate oral feedings,
provide a bland diet that takes into account his
food preference. Restart feedings slowly.
• Offer smaller, more frequent servings to reduce
the amount of irritating gastric secretions.
GASTRITIS
• Help patient identify specific foods that cause
gastric upset and eliminate them from his diet.
• Administer antacids and other prescribed
medications as ordered.
• If pain or nausea interferes with the patient’s
appetite, administer pain medications or
antiemetics about 1 hour before meals.
• Monitor the patient’s fluid intake and output
and electrolyte levels.
GASTRITIS
• Assess the patient for presence of bowel
sounds.
• Monitor the patient’s response to antacids and
other prescribed medications.
• Monitor the patient’s compliance to treatment
and elimination of risk factors in his lifestyle.
• Teach the patient about the disorder.
• Urge the patient to seek immediate attention for
recurring signs and symptoms, such as
hematemesis, nausea, or vomiting.
GASTRITIS
• Antibiotics to kill H. pylori (clarithromycin,
amoxicillin, metronidazole)
• Proton pump inhibitors to reduce acid
secretions.
• Histamine – 2 blockers to reduce the
amount of acid released into the digestive
tract
• Antacids to neutralize stomach acid
NCM 116 – Disturbances in GI and Nutrition | PUD
PEPTIC ULCER DISEASE

• A lesion in the mucosa of the lower
esophagus, stomach, pylorus, or
deudenum
• Causative factors:
a. H. pylori
b. NSAIDs use
c. Zollinger – Ellison Syndrome
d. Genetic factors
e. Cigarette smoking, stress,
socioeconomic factors

Assessment
• Abdominal pain
a. Occurs in the epigastric area radiating to the back; described as
dull, aching, and gnawing
b. Pain may increase when the stomach is empty, at night, or approx.
1 to 3 hours after eating. Pain is relieved by taking antacids
(common in duodenal ulcers
• Nausea, anorexia, early satiety (common with gastric ulcers),
belching
• Dizziness, syncope, hematemesis, melena with GI hemorrhage
a. Positive fecal occult blood
Emergency Alert!
b. Decreased Hgb and Hct, indicating anemia
Sudden, intense, midepigastric
c. Orthostatic blood pressure and pulse changes
pain radiating to the right
shoulder may indicate ulcer
perforation

• Upper GI Series – outlines ulcer or area of
inflammation.
• Endoscopy –esophagogastroduodenoscopy) –
visualizes duodenal mucosa and helps identify
imflamm. changes, lesions, bleeding sites, and
malignancy
• Gastric Secretory Studies – elevated in Zollinger –
Ellison syndrome
• H. pylori antibody titer – may be positive, esp. in
recurrent ulcers; however, there is a high rate of
false – positive results; C – urea breath test or biopsy
testing is more definitive than H. pylori

• Acute Pain
• Deficient Fluid Volume
• Deficient Knowledge
• Diarrhea
• Imbalanced nutrition: Less than body
requirements

• Diet therapy includes well – balanced
meals at regular intervals; avoid dietary
irritants
• Eliminate cigarette smoking, which
decreases rate of healing and increases
rate of recurrence
• Eliminate NSAIDs from diet and reduce
alcohol intake.
• Monitor the patient for signs of bleeding
through fecal occult blood, vomiting,
persistent diarrhea, and change in VS

• Diet therapy includes well – balanced
meals at regular intervals; avoid dietary
irritants
• Eliminate cigarette smoking, which
decreases rate of healing and increases
rate of recurrence
• Eliminate NSAIDs from diet and reduce
alcohol intake.
• Monitor the patient for signs of bleeding
through fecal occult blood, vomiting,
persistent diarrhea, and change in VS

• Histamine - 2 (H2) receptor antagonists to
reduce gastric acid secretion
• Proton-pump inhibitor to help ulcer heal
quickly in 4 to 8 weeks
• Cytoprotective drug sucralfate, which
protects ulcer surface against acid, bile,
pepsin
• Antacids to reduce acid concentration and
help reduce symptoms
• Antibiotics

• Gastroduodenostomy (Bilroth I)
• Gastrojejunostomy (Bilroth II)
• Antrectomy
• Total gastrectomy
• Pyloroplasty
• Vagotomy
NCM 116 – Disturbances in Absorption | Inflamm. Bowel Dse.
INFLAMMATORY BOWEL DISEASE

• Inflammatory bowel disease (IBD) is a
group of disorders that cause chronic
inflammation (pain and swelling) in the
intestines.
• IBD includes Crohn’s disease and
ulcerative colitis.

Types of IBD
• Crohn’s disease causes pain and swelling in
the digestive tract. It can affect any part from
the mouth to the anus. It most commonly
affects the small intestine and upper part of
the large intestine.
• Ulcerative colitis causes swelling and sores
(ulcers) in the large intestine (colon and
rectum).
• Microscopic colitis causes intestinal
inflammation that’s only detectable with a
microscope.

Causes of IBD
• Genetics: As many as 1 in 4 people with IBD have
a family history of the disease.
• Immune system response: The immune
system typically fights off infections. In people with
IBD, the immune system mistakes foods as foreign
substances. It releases antibodies (proteins) to fight
off this threat, causing IBD symptoms.
• Environmental triggers: People with a family
history of IBD may develop the disease after
exposure to an environmental trigger. These
triggers include smoking, stress, medication use
and depression.
INFLAMMATORY BOWEL DISEASE |

CROHN’S DISEASE
• A chronic transmural inflammation of the
GI tract that usually affects the small and
large intestines, tho can occur in any
part of the alimentary canal

CROHN’S DISEASE
Assessment
1. Signs and symptoms are characterized by exacerbations
and remissions; onset may be abrupt or insidious
2. Crammpy intermittent pain
a. Inflammatory pattern results in milder abdominal pain, but
with malnutrition due to malabsorption and weight loss, and
possible anemia (hypochromic or macrocytic)
b. Fibrostenotic pattern may present with partial small bowel
obstruction: diffuse abdominal pain, nausea, vomiting, and
bloating
c. Perforating pattern is characterized by sudden profuse
diarrhea, fever, localized tenderness, (due to abscess), and
symptoms of fistulae, such as pneumaturia and recurrent
urinary tract infections

CROHN’S DISEASE
Assessment
3. Abdominal tenderness occurs, especially in
the right lower quadrant; right lower quadrant
fullness or mass is palpable
4. Chronic diarrhea caused by irritating
discharge; usual consistency is soft or semiliquid.
Bloody stools or steatorrhea may occur. Fecal
urgency and tenesmus occur.
5. Low – grade fever occurs if abscesses are
present
6. Arthralgia may also occur.

CROHN’S DISEASE
• Increased WBC count and sedimentation rate;
decreased Hgb; decreased albumin; and
possibly decreased K, Mg, and Ca due to
diarrhea
• Stool Analysis – (+) leukocytes but no
pathogen
• Barium Enema
• Upper GI Barium – shows classic “string sign”
• Colonoscopy

CROHN’S DISEASE
• Acute pain
• Anxiety
• Diarrhea
• Imbalanced nutrition: less than body
requirements
• Risk for fluid volume deficit

CROHN’S DISEASE
• Diet low in residue fiber, and fat, and high in calories, protein,
and carbohydrates, with vitamin supplements (esp. vitamin K)
• During exacerbation, hyperalimentation to maintain nutrition
while allowing the bowel to rest
• During remission, regular balanced diet to maintain ideal
body weight.
• Monitor frequency and consistency of stools to evaluate
volume losses and effectiveness of therapy
• Monitor electrolytes, esp. K. monitor I&O, acid-base balance
• Monitor for distention, increased temp., hypotension, and
rectal bleeding; all signs of obstruction caused by
inflammation.

CROHN’S DISEASE
• 5 – aminosalicylic acid PO or by enema or suppository
• Sulfasalazine PO to inhibit inflammatory processes (effective only
for colonic disease)
• Corticosteriods to reduce inflammation
• Antibiotics such as metronidazole to treat infection and try to
induce remission
• Immunomodulators
• Infliximab (a new monoclonal antibody) blocks action of tumor
necrosis factor
• Antispasmodics (dicyclomine) and bulking agents (psyllium) to help
reduce abdominal pain
• Antidiarrheal agents to control diarrhea related to malabsorption of
bile salts

CROHN’S DISEASE
• Indicated only for complications. Roughly 70% of
Crohn’s disease patients eventually require one or
more operations for obstruction, fistulae, fissures,
abscesses, toxic megacolon or perforation
• Surgical options include:
1. Segmental bowel resection with anastomosis
2. Subtotal colectomy with ileorectal anastomosis
(spares the rectum)
3. Total proctocolectomy with end ileostomy for
severe disease in the colon and rectum

| ULCERATIVE COLITIS
• A chronic inflammatory disease of the mucosa, and
less frequently, the submucosa of the colon and
the rectum
• Usually begins in the rectum and sigmoid and
spreads upward, eventually involving the entire
colon
• Multiple crypt abscesses develop in the mucosa,
which may become necrotic and lead to ulceration.
• Complications may include perforation,
hemorrhage, toxic megacolon, abscess formation,
stricture and obstruction, anal fistula, malnutrition,
anemia, and secondary colon cancer.

Assessment
1. Diarrhea is the prominent symptom; it may be bloody or
contain pus or mucus. Tenesmus (painful straining),
urgency, and cramping may be associated with bowel
movements
2. Crampy abdominal pain may be prominent and brought on
by certain foods or diary products
3. May be increased bowel sounds, and left lower abdomen
may be tender on palpation
4. As the disease progresses, there may be anorexia, nausea
and vomiting, weight loss, fever, dehydration, hypokalemia,
and cachexia
5. There may be associated systemic manifestations such as
arthritis, iritis, and skin lesions.

1. Stool evaluation for culture and ova and parasite
rules out other causes of diarrhea. Test for blood
are positive during active disease
2. Blood tests may show low hemoglobin and
hematocrit caused by bleeding; increased WBC,
erythrocyte sedimentation rate; decreased K, Mg,
and albumin levels
3. Proctosigmoidoscopy or colonoscopy with biopsy
is necessary to confirm diagnosis
4. Barium enema determines the extent of disease
and detects pseudopolyps, carcinoma, and
strictures

1. Acute pain
2. Chronic pain
3. Deficient fluid volume
4. Imbalanced nutrition: less than body requirements
5. Ineffective coping
6. Risk for infection

ULCERATIVE COLITIS
• During acute exacerbations, bed rest, IV fluids containing
potassium and vitamins, and clear liquid diet are indicated
• For severe dehydration and excessive diarrhea, total
parenteral nutrition may be necessary to rest the intestinal
tract and restore nitrogen balance.
• Monitor I&O, including liquid stools
• Monitor serum or fingerstick glucose of the patient on
corticosteroids or hyperalimentation, and report elevations.
• Weigh patient daily; rapid increase or decrease may relate
to fluid imbalance, slower change related to nutritional
status.

ULCERATIVE COLITIS
• Iron supplements to treat anemia from chronic bleeding; blood
replacement for massive bleeding
• Sulfasalazine is the mainstay drug for acute and maintenance
therapy
• If sulfasalazine is not tolerated, oral salicylates such as
mesalamine appear to be as effective as sulfasalazine
• Mesalamine enema is available for proctosigmoiditis;
suppository for proctitis
• Corticosteroids may be used IV orally or by enema to manage
inflammatory disease and induce remission.
• Antidiarrheal medications may be prescribed to control
diarrhea, rectal urgency and cramping, and abdominal pain;
however, their use is not routine

ULCERATIVE COLITIS
• Surgery is recommended when patient fails to respond to
medical therapy, if clinical status is worsening, for severe
hemorrhage, or for signs of toxic megacolon. Noncurative
procedures (possible curative procedure and reconstruction
later include:
a. Temporary loop colostomy for decompression of toxic
megacolon
b. Colectomy with ileorectal anastomosis
• Curative surgery aims to remove entire colon and rectum to
cure patient of ulcerative colitis. Procedures include:
a. Total proctocolectomy with end-ileostomy
b. Total proctocolectomy with continent ileostomy
c. Total colectomy with ileal reservoir – anal anastomosis
NCM 116 – Disturbances in Absorption | Malabsorption Syn
MALABSORPTION SYNDROME
• A group of symptoms and physical signs
resulting from poor nutrient absorption in the
small intestine, especially of fats and fat
soluble vitamins A, D, E, and K.
• Poor absorption of other nutrients, including
CHO, CHON, Minerals may also occur.
• Multiple causes including gallbladder or
pancreatic disease, lymphatic obstruction,
vascular impairment, or bowel resection
• Also known/associated with Celiac Disease
MALABSORPTION SYNDROME | Celiac

Disease
Assessment
Ages 3 to 9 months Older Child and Adult
1. Acutely ill; severe diarrhea and vomiting 1. Signs and symptoms are commonly related
2. Irritability to nutritional or secondary deficiencies
3. Possible failure to thrive resulting from disease
a. Anemia, vitamin deficiency (A, D, E, K)
Ages 9 to 18 months b. Hypoproteinemia with edema
1. Slackening of weigh followed by weight loss c. Hypocalcemia, hypokalemia,
2. Abnormal stools hypomagnesemia
• Pale, soft, bulky d. Hypoprothrombinemia from vitamin K
• Offensive color deficiency
• Greasy (steatorrhea) e. Disaccharide (sugar intolerance)
• May increase in number
f. Osteoporosis due to calcium deficiency
3. Abdominal distention
2. Anorexia, fatigue, weight loss
4. Anorexia, discoloration of teeth 3. May have colicky abdominal pain, distention,
5. Muscle wasting: most obvious in buttocks and proximal parts of extremities flatulence, constipation, and steatorrhea
6. Hypotonia, seizure (bulky, greasy, pale stools)
7. Mood changes: ill humor, irritability, temper tantrums, shyness
8. Mild clubbing of fingers
9. Vomiting: usually occurs in evening
10. Aphthous ulcers, dermatitis
MALABSORPTION SYDROMES
Reduced Digestion
Pancreatic Exocrine Deficiency Cystic fibrosis, pancreatitis,
Schwachman sydrome
Bile salt deficiency Cholestasis, biliary atresia,
hepatitis, cirrhosis, bacterial
deconjugation
Enzyme Defects Lactase, sucrase,
enterokinase, lipase
deficiencies
Reduced Absorption
Primary absorption defects Glucose – galactose malabsorption,
abetalipoproteinemia, cystinuria,
Hartnup disease
Decreased mucosal surface area Crohn’s disease, malnutrition, short
bowel syndrome, antimetabolite
chemotherapy, familial villous
atrophy
Small intestinal disease Celiac disease, tropical sprue,
giardiasis, immune or allergic
enteritis, Crohn’s disease,
Lymphoma, AIDS
Lymphatic Obstruction Lymphangiectasia, Whipple
Disease, Lymphoma, Chylous
ascites
Others
Drugs Antibiotics, antimetabolites,
neomycin, laxatives
Collagen Vascular Scleroderma
Infestations Hookworms, tapeworm,
giardiasis, immune defects
MALABSORPTION SYNDROME |
Celiac Disease
1. Small – bowel biopsy, which demonstrates characteristic
abnormal mucosa
a. Severely damaged or flat, villous lesions
b. Histologic recovery after gluten elimination
c. Histologic recurrence of villous injury within 2 years
of gluten reintroduction
2. Hemoglobin, folic acid, and vit K levels may be reduced
3. Prothrombin time may be prolonged
4. Elevated IgA endomysium antibodies and IgA anti-tissue
transglutaminase antibodies
5. Total protein and albumin may be decreased
6. 72 hour stool collection for fecal fat is increased
7. D-xylose absorption test – decreased blood and urine
levels
8. Sweat test and pancreatic function studies may be done
to rule out cystic fibrosis
MALABSORPTION SYNDROME |
Celiac Disease
1. Acute pain
3. Imbalanced nutrition: less than body
requirements
4. Readiness for enhanced knowledge
5. Risk for impaired skin integrity
MALABSORPTION SYNDROME | Celiac

Disease
1. Dietary modifications include a lifelong gluten – free
diet, avoiding all foods containing wheat, rye,
barley, and possibly oats
a. Biopsy reverts to normal when with appropriate
diet
b. Clinical signs of improvement should be seen 1 to
4 weeks after proper diet is initiated
2. In some cases, fats may be reduced
3. Lactose and sucrose may be eliminated from diet
for 6 to 8 weeks, based on reduced
disaccharidase activity
MALABSORPTION SYNDROME
1. Supplemental vitamins and minerals
a. Folic acid for 1 to 2 months
b. Vitamins A and D because of decreased absorption
c. Iron as needed for anemia
d. Vitamin K if there is evidence of
hypoprothrombinemia and bleeding
e. Calcium if milk is restricted
2. Pancreatic enzymes are given for pancreatic
insufficiency (cystic fibrosis, pancreatitis)
NCM 116 – Disturbances in Elimination | Intestinal Obstruction
INTESTINAL OBSTRUCTION
Mechanical Obstruction
• A physical blockage to the passage
of intestinal contents.
• May result from postsurgical
adhesions, hernia, volvulus,
hematoma, tumor, intussusception,
stricture, stenosis, foreign body,
fecal or barium impaction, or polyp
Functional Obstruction
• Also known as Paralytic ileus
• Involves no physical obstruction
• Peristalsis is ineffective, blood supply is
not interrupted, and the condition
usually disappears spontaneously after
2 to 3 days
• Causes: spinal cord injuries, vertebral
fractures, peritonitis, pneumonia, GI or
abdominal surgeries, wound
dehiscence
INTESTINAL OBSTRUCTION Pediatric alert:

Episodes of severe abdominal pain
Assessment combined with vomiting in the infant
suggest intussusception.
1. Crampy abdominal pain that may occur in waves
(colic)
2. No bowel movements; however, blood or mucus
Gerontologic alert:
may be passed Watch for air – fluid lock syndrome
3. Vomiting, first of stomach contents, then bilious, in elderly patients, who often remain
finally containing fecal matter (if obstruction of in the recumbent position for
ileum or distal) extended periods. In this syndrome,
4. Abdominal distention fluid collects in dependent bowel
5. Signs of dehydration – malaise, thirst, dry mucus loops, and peristalsis is too weak to
push fluid “uphill”. The obstruction
membrane primarily occurs in the large bowel.
6. Signs and symptoms of large bowel obstruction Turn the patient every 10 minutes
develop more slowly with constipation being until enough flatus is passed to
prominent decompress the abdomen. A rectal
7. Signs of shock – pallor, hypertension, tachycardia, tube may help.
reduced level of consciousness
1. Abdominal Xrays show intestinal gas or fluid
2. Barium enema shows a distended, air filled colon or
a closed sigmoid loop
3. Decreased serum sodium, potassium, and chloride
levels because of vomiting; elevated white blood
cell counts with necrosis, strangulation, or
peritonitis; and increased serum amylase levels
from irritation of the pancreas by the bowel loop.
4. Arterial blood gas analysis may indicate metabolic
acidosis or alkalosis
5. Flexible sigmoidoscopy or colonoscopy may be
done to identify cause.
1. Acute pain
2. Anxiety
3. Constipation
5. Ineffective breathing pattern
7. Risk for injury
1. Correct fluid and electrolyte imbalances:
a. Na, K, blood component therapy
b. Normal saline or Ringer’s lactose to correct
interstitial fluid deficit
2. Nasogastric decompression of GI tract to reduce
gastric secretions; nasointestinal tubes such as
Cantor or Miller Abbott may also be used
3. Treatment for shoch and peritonitis with IV fluids,
vasopressors, or antibiotics
4. Hyperalimentation to correct protein deficiency from
chronic obstruction, paralytic ileus, or infection
5. Ambulation to try to induce peristalsis in a patient
with paralytic ileus.
1. Bowel resection with end to end
anastomosis
2. Closed bowel procedure such as lysis of
adhesions or reduction of volvulus
3. Double – barrel ostomy if end to end
anastomosis too risky
4. Loop colostomy to divert fecal stream and
decompress bowel, with bowel resection to
be done as second procedure.

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NCM 116 1st Examination Coverage

NCM 116 – Alterations in GI and Nutrition

Review of Anatomy and Physiology

Subjective Data Objective Data

• For most diagnostic studies, make sure a signed

Radiologic Studies | Upper Gastrointestinal

Radiologic Studies | Lower Gastrointestinal

Liver Function Studies

GASTROESOPHAGEAL REFLUX DSE.

GASTROESOPHAGEAL REFLUX DSE.

GASTROESOPHAGEAL REFLUX DSE.

GASTROESOPHAGEAL REFLUX DSE.

GASTROESOPHAGEAL REFLUX DSE.

GASTROESOPHAGEAL REFLUX DSE.

GASTROESOPHAGEAL REFLUX DSE.

NAUSEA and VOMITING

NAUSEA and VOMITING

NAUSEA and VOMITING

NAUSEA and VOMITING

PEPTIC ULCER DISEASE

PEPTIC ULCER DISEASE

PEPTIC ULCER DISEASE

PEPTIC ULCER DISEASE

PEPTIC ULCER DISEASE

PEPTIC ULCER DISEASE

PEPTIC ULCER DISEASE

PEPTIC ULCER DISEASE

INFLAMMATORY BOWEL DISEASE

INFLAMMATORY BOWEL DISEASE

INFLAMMATORY BOWEL DISEASE

INFLAMMATORY BOWEL DISEASE |

INFLAMMATORY BOWEL DISEASE |

INFLAMMATORY BOWEL DISEASE |

INFLAMMATORY BOWEL DISEASE |

INFLAMMATORY BOWEL DISEASE |

INFLAMMATORY BOWEL DISEASE |

INFLAMMATORY BOWEL DISEASE |

INFLAMMATORY BOWEL DISEASE |

INFLAMMATORY BOWEL DISEASE

INFLAMMATORY BOWEL DISEASE

INFLAMMATORY BOWEL DISEASE

INFLAMMATORY BOWEL DISEASE

INFLAMMATORY BOWEL DISEASE |

INFLAMMATORY BOWEL DISEASE |

INFLAMMATORY BOWEL DISEASE |

MALABSORPTION SYNDROME | Celiac

MALABSORPTION SYNDROME | Celiac

INTESTINAL OBSTRUCTION Pediatric alert:

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