CARE OF

CLIENTS WITH
GASTRO-
INTESTINAL
AND
NUTRITION
PROBLEMS
 Malabsorption Syndrome
ETIOLOGY AND PATHOPHYSIOLOGY
1. Failure to absorb one or more of necessary ingested nutrients; can
occur anywhere in the digestive tract.
2. May be primary disorder (CELIAC OR LACTASE DEFICIENCY), or
secondary to gastric or intestinal surgery (e.g. short bowel
syndrome), inflammatory disease, infection, radiation or drug side
effects.
 Malabsorption Syndrome
CLINICAL FINDINGS:
1. SUBJECTIVE : weakness, fatigue, anorexia and decreased feeling of
well-being.
2. OBJECTIVE: weight loss, flatulence, borborygmus (loud bowel
sounds), abdominal distention, diarrhea or bulky stool, steatorrhea,
CLINICAL FINDINGS of deficient protein, fat soluble vitamin intake;
dehydration, low serum values ( e.g. albumin, transferrin, total
lymphocyte count etc) Lactose intolerance, deficiency in absorption
tests
 Malabsorption Syndrome
THERAPEUTIC INTERVENTIONS
1. RESOLVE PRECIPITATING EVENT
2. DIETARY THERAPY:
Avoid aggravating substances, supplementation of nutrients,
reduction of flatuence (celiac – wheat, rye, oats, barley; restriction
of milk for lactose intolerance)
Tube feedings, PPN, TPN during exaccerbations
3. ADMINISTRATION OF DRUGS: antidiarrheals, antispasmodics,
antibiotics and vitamins.
• Chronic GI disorder, with chronic or
recurrent diarrhea, constipation,
abdominal pain and bloating
• Spastic colon, impairment
of the motor/sensory
function→ diarrhea
alternating with
constipation
• Usually begin as a
young adult
• Stress, anxiety
and familial
factors may
predispose
patient
• Assessment:
– History of bowel pattern
– Manning criteria‐
abdominal pain relieved
by defection, abdominal
distention, sensation of
incomplete evacuation of
stool, presence of
mucus with the stool
• Assessment:
– Pain in LLQ and cramps, may be tenderness and air in bowels
– Dx‐ flexible sigmoidoscopy or colonoscopy if >40
– Barium enema
• Interventions
– Diet therapy‐ limit caffeine, alcohol, beverages with
sorbitol, take in fiber and bulk, 30‐40 gm/day
– Drug therapy:
• Bulk forming laxatives (Metamucil)
• antidiarrheals (loperamide)
• anticholinergics (bentyl)
• antidepressants (elavil) – reduce visceral
hypersenstivity
– Stress management‐ relaxation techniques
• Instruct client to:
– eliminate irritating and gas producing substances
–Initially NPO then gradual reintroduction of foods to
high fiber in diet
–Schedule meals regularly
–Chew thoroughly and eat slowly
–Minimize beverages with meals to avoid distention
–Avoid smoking and alcohol
–Maintain an adequate fluid intake
–Perform meticulous perianal skin care
• Ulcerative Colitis:
– Remissions and exacerbations
– Loose stools with blood and mucous
10‐20/day
– Poor absorption of nutrients and thickening of
the colon wall
– Abdominal distention and cramping
– Complications are: hemorrhage,
perforation, fistulas and nutritional
deficiencies
– May be familial tendency, inflammation
r/t response to normal flora
ULCERATIVE COLITIS
• Manifestations:
– Abdominal pain, bloody diarrhea,
tenesmus‐ uncontrolled straining
– Dx‐ COLONOSCOPY, ABDOMINAL CT SCAN,
BLOOD STUDIES, STOOL TESTS, barium enema
• Nursing Diagnoses:
– Diarrhea r/t inflammation of the bowel
– Acute and chronic pain
– Imbalance nutrition: less than body
requirements
– Disturbed body image
• Diarrhea management‐
– Drugs‐ salicylate compounds‐ Sulfasalazine
(Azulfidine) inhibits prostaglandins to
reduce inflammation, also use Asacol,
Pentasa
– Corticosteroids‐ Prednisone to decrease
edema
– Immunosuppressive‐ cyclosporine
– Antidiarrheals
– Monoclonal antibody‐ Remicade neutralizes
the activity of tumor necrosis factor and
prevents toxic megacolon
• Diet therapy:
– NPO at first, then TPN, may have low fiber
or low residue
• Surgical management:
– Total Proctocolectomy with permanent
Ileostomy
– Total colectomy with a continent ileostomy
– Total colectomy with ileoanal
anastomosis and ileoanal reservoir or
pouch
• Postop‐ teaching for ostomy, pain
control and monitoring for GI bleeding
and fluid volume deficit
• INSTRUCT CLIENT TO:
– Eat small frequent meals high in protein, high-calorie foods; low
fat diet to decrease steatorrhea, vitamins A and E may be
supplemental if steatorrhea is present.
– Avoid irritating foods and spices.
– Take prescribed supplements (e.g. iron, calcium, zinc)
– Self-administer prescribed monthly vitamin B12 injections to
treat anemia associated with ileal involvement.
– AVOID! All food allergens, especially milk products and dairy
products.
• PROVIDE PRE-OP/POST OP CARE
– Teach about stoma site assessment and
care (preop)
– Maintain nasogastric suction during
immediate postoperative period
(decompression)
– Provide colostomy care
– Monitor I & O (fecal drainage and fluid
balance)
– Teach ileostomy care
• Crohn’s disease
– Terminal ileum, patching
involvement through all layers of
the bowel
– Deep fissures and ulcers occur
– 5‐8 loose stools/day, rarely bloody
– Complications are:
• Fistulas, nutritional deficiencies
– Cause is thought to be
mycobacterium
paratuberculosis, genetic
predisposition
• Aggravated by bacterial infection,
inflammation and smoking
• History of fever, abdominal pain and
loose stools, weight loss
• Steatorrhea is common‐ fatty stools
• Fistulas may occur between bladder
and vagina
• Fistulas may occur between bladder
and vagina
• Drug therapy‐ same as UC,
except may take
metronidazole if fistulas
and imuran as an
immunosuppressant
• Diet therapy‐ may be on TPN,
supplements like ensure, vivonex
• Monitor for fistulas‐ infections,
skin problems, malnutrition, fluid
and electrolyte imbalances
• Fluid and electrolyte therapy
• Surgical management:
– Bowel resections
– Fistula repairs
– Ileostomies may also be required to
rest the bowel or repair damaged
areas.
• Encourage verbalization of feelings
• Monitor Fluid and electrolyte imbalances and I
&O
• Monitor for complications (fever, nausea and
vomiting etc)
• Assist with TPN if prescribed
• Adhere to dietary restrictions
• Avoid taking laxatives and salicylates that
irritate intestinal mucosa
• Provide skin care if perianal area is irritated
• Partial or complete
• Mechanical‐ bowel is physically obstructed
by adhesions, tumors
• Nonmechanical‐ paralytic ileus or
adynamic ileus, neuromuscular
distrubance‐ slow movement or backup
• Contents accumulate at or above the
obstruction→ distention, peristalsis
increases to aid movement, stimulates
more secretions→ more distention→
edema of the bowel, increased capillary
permeability
• Plasma leaks into the peritoneal cavity and
trapped fluid decreases the absorption of
fluid and electrolytes into the vascular
space→ reduced blood volume and
electrolyte imbalances, can → hypovolemic
shock
• Can also lead to metabolic alkalosis if high
and there is a loss of gastric acid, if low,
metabolic acidosis occurs with the loss of
alkaline fluids
• Bacterial peritonitis and septic shock can also
occur from the release of endotoxins
• Adhesions account for 45‐60%, r/t scar
tissue
• Intussusception‐ telescoping bowel
and volvulus‐ twisting of the bowel
• Paralytic ileus‐ decreased peristalsis
from trauma, toxin or autonomic, can
result from surgery, MI’s, rib fracture,
pneumonia, peritonitis and vascular
insufficiency from heart failure or
shock
• Assessment:
– History of symptoms and occurrence
– Abdominal pain and cramping
– constipation, vomiting with brown
and foul smelling
– Borborygni above the obstruction, then
absent
– Abdominal distention and tympanic
abdomen
– Abdominal films and CT of abdomen
– WBC elevated in some cases
• Nonsurgical management:
– NGT to decompress to LCS
– Nasointestinal tubes‐ Miller‐Abbott,
mercury balloons and migrate down the
intestine by peristalsis, don’t irrigate with
fluid‐ it will increase edema at the
obstruction
– Fluid and electrolyte replacement‐ NPO, give
NSS or LR, replace K
– Pain control‐ not normally given
opioids, mask pain and peritonitis
– Antibiotics if suspect perforation
• Surgical management:
– Exploratory laparotomy
• NURSING INTERVENTIONS
Provide special care associated with an intestinal tube
a. After tube reaches stomach, position on right side to facilitate passage
of tube through pylorus; then in semi-Fowler position to permit gradual
advance into intestines
b. Coil and loosely attach extra tubing to client’s gown to avoid tension
against peristaltic action
c. Instill or irrigate with sterile saline every 6 to 8 hours or as ordered to
maintain patency
d. Assess advancement of tube by identifying markings on tube; record
level of advancement; advance (usually 2 to 3 inches every hour) as ordered
e. When tube is discontinued, remove gradually because it is being pulled
against peristalsis
5. Encourage fluids and foods high in fiber if constipated
END