Disorders of Gastrointestinal System | Peptic Ulcer | Vomiting

Disorders of Gastrointestinal System

Nausea and Vomiting
• Nausea is an unpleasant feeling that vomiting is imminent. • Vomiting is the involuntary act in which stomach contracts and forcefully expels gastric contents

• Loss of fluid and electrolytes is the primary consequence of repeated vomiting; • The very young and the elderly are more susceptible to the complications of fluid imbalances. • Prolonged vomiting will precipitate a metabolic problem
– Metabolic alkalosis is associated with prolonged vomiting and loss of hydrochloric acid – Metabolic acidosis occurs with severe prolonged vomiting of contents of the small intestine, resulting a loss of bicarbonate.

a. Precipitating causes
1. Pathogenic: related to a disease process -intestinal obstruction -peptic ulcer disease (PUD) -increased intracranial pressure -indigestion of toxic substances (food poisoning) -Vertigo

2. Iatrogenic: resulting from a disease treatment -chemotherapy/radiation -medications -Surgery (postoperative complications) 3. Psychogenic -Psychosis/neurosis -Reaction to Psychological Trauma 4. Pregnancy

• • Identify precipitating cause Assess frequency of vomiting, amount of vomiting, and contents of vomitus Hematemesis: presence of blood in the vomitus – Bright red blood is indicative of hemorrhage – Coffee ground material is indicative of blood retained in the stomach; the digestive process has broken down the hemoglobin – Projectile vomiting: vomiting not preceded by nausea in which vomiting is expelled with excessive force – Presence of fecal odor and bile in vomitus indicates a backflow of intestinal contents into stomach

1. Eliminate the precipitating cause 2. Antiemetics 3. Parenteral replacement of fluids

Nursing Interventions
Goal: To prevent recurrence of nausea and vomiting and ensuing complications • Prophylactic antiemetics for the client with tendency to vomit • Prompt removal of unpleasant odors, used emesis basin, used equipment, and soiled linens • Good oral hygiene • Place conscious client on side or in semi-fowlers position; place unconscious client on side with head of bed slightly elevated to promote drainage of oral cavity.

• Withhold food and beverages initially after vomiting; begin oral intake slowly with clear liquids • Assess client who has undergone surgery for bowel sounds; do not begin oral administration of fluids until bowel sounds are present • Support abdominal incisions during prolonged vomiting

Goal: To relieve nausea and vomiting
• Administer antiemetics, as indicated • Evaluate precipitating causes; relieve if possible

Goal: To assess client’s response to prolonged vomiting
• • • • • • Monitor and maintain fluid and electrolyte status Continued presence of gastric distention Overall vital sign changes Intake and output Assess for adequate hydration Evaluate weight loss

• Exists when the interval between bowel movements is longer than normal for the individual and the stool is dry and hard

• Precipitating Causes
– – – – – – – – – Decreased fiber intake Decreased fluid intake, dehydration Immobility, inadequate exercise Medications, narcotics, antidepressant, iron supplements, anticonvulsants Irritable bowel syndrome Advanced age Overuse of laxatives Ignoring the urge to defecate Diverticulosis, tumors, intestinal obstructions

Clinical manifestations
• • • • • Abdominal distention Decrease in an amount of stool Dry, hard stool Straining to pass stool Grunting, grimacing

• Change dietary intake: increase intake of bulk and fluids • Bulk laxatives or enemas for occasional constipation problem • Instruct client to maintain normal bowel schedule and not to ignore urge to defecate • Discourage long term use of laxatives and enemas • Encourage regular exercise

Nursing Interventions
Goal: To identify client at risk of developing problems and institute preventive measures • Increase intake of high fiber foods: raw vegetables, whole grain breads and cereals, fresh fruits • Increase fluid intake • Maintain regular activity, daily walking • Discourage use of laxatives and enemas; client may become dependent on them • Encourage use of bulk forming products to provide increased fiber (methylcellulose, psyllium) • Encourage bowel movement at same time each day • Try to position client on bedside commode rather than on bedpan • If client is experiencing diarrhea, check to see if stool is oozing around an impaction

Goal: to implement treatment measures for fecal impaction removal • Considered an impaction if client has had no bowel movement for 3 days or has passed only small of semisoft or liquid stool • Specific neurological and metabolic diseases associated with risk for constipation
– – – – Spinal cord injury Parkinson’s disease Thyroid irregularities Diabetes

• Very young and very old are most susceptible to problems with impaction • Steps in removing – Manually check for presence with nonsterile, lubricated gloved finger – Gently attempt to break up impaction – Follow with suppository, enema or laxative as ordered by physician – Emphasis is on prevention of impaction • Evaluate client’s use of home remedies and OTC drugs. Assess what the client is using to treat constipation; frequently, the geriatric client is using harsh laxatives

• Rapid movement of intestinal contents through the small bowel. • Significant increase in number of stools • Decrease in the consistency of the stool. With an increase in fluid content • Infants and elderly most susceptible to complications of diarrhea • Complications of severe diarrhea
– Dehydration, resulting in hypovolemia – Metabolic acidosis

• Precipitating causes
– Traveler’s diarrhea: bacteria (Escheria Coli, Salmonella spp.), viruses, and parasites (Giardia spp). – Food poisoning – Medications (antibiotics and antacids) – Food intolerance (Lactose intolerance) – Irritable bowel syndrome – Emotional factors – Acquired immunodeficiency syndrome (AIDS) – Colon cancer – Malabsorption problems – Rotavirus: most common pathogen in young children

Clinical Manifestation
• Frequent, watery bowel movements • Stools may contain undigested food, mucus, pus or blood • Frequently foul smelling • Abdominal cramping, distention, and vomiting frequently occur with diarrhea • Weight loss • Hyperactive bowel sounds • May precipitate dehydration, hypovolemia, hypokalemia, and shock

• Treat the underlying problem • Decrease activity and irritation of the GI tract by decreasing intake • Parenteral replacement of fluids and electrolytes, if diarrhea is severe • Administer antidiarrheal medications

Nursing Intervention
Goal: To decrease diarrhea and prevent complications • Identify precipitating causes and eliminate, if possible • Decrease food intake: offer more soft, non irritating food • Administer oral rehydrating solutions (Pedialytic, Rehydrate, Infalyte) and progress fluids and diet as tolerated • Administer medication as indicated • Maintain good hygiene in the rectal area to prevent skin excoriation • Decrease activity

Goal: to evaluate client’s response diarrhea • Evaluate changes in vital signs correlating with fluid loss • Evaluate electrolyte changes and urine specific gravity • Record intake and output and daily weight if diarrhea is progressive • Assess changes in abdominal distention and cramping • Continue ongoing evaluation of characteristics of diarrhea

Goal: To prevent spread of diarrhea • Good hand washing techniques • Contact-based precautions
– Proper disposal of diapers and soiled linens close to bedside – Instruct family regarding hand washing technique – Keep bedpans, soiled linens, diapers away from clean areas

• Is the most common pathogen in young children hospitalized for treatment of diarrhea • Affects all age groups and is most common in cool weather • Incubation period is 1-3 days • Important source of nosocomial infections is hospitalized • Is frequently associated with an upper respiratory tract infection • Children 6-24 months old are most susceptible

• Clinical manifestation
– – – – Abrupt onset Nausea and vomiting Persistent foul smelling, explosive, diarrhea Fever lasts approximately 48 hours

• Diagnostics
– History regarding onset and duration – Laboratory determination of electrolyte levels to determine status of hydration

• Usually self limiting • Oral rehydration with glucose, electrolyte solution • Intravenous (IV) fluid replacement as needed • Antidiarrheal medications • Strict record of intake and output • Child may begin eating solid food as soon as tolerated. Soft diet as acceptable

Nursing Intervention
Goal: To maintain fluid and electrolytes balances (nursing intervention for client with diarrhea) • Fluid and electrolyte replacement, initially oral rehydration therapy with solutions to replace electrolyte (oral rehydration solutions) • Monitor IV fluids in cases of severe diarrhea • Administer antidiarrheal medications. Monitor stools child is at increased risk for developing paralytic ileus • Strict monitory of hydration status • May begin providing solid food as soon as child can tolerate; generally soft, easily digestible food, does no have to be clear liquids.

Gastroesophageal Reflux Disease
• Gastroesophageal reflux disease (GERD) is caused by the backward flow of GI contents into the esophageal (esophageal reflux). Reflux is often associated with a hiatal hernia, the herniation of the upper portion of the stomach through the diaphragm into the thoracic cavity. • Pathophysiology: Gastric volume or intraabdominal pressure elevated, or LES tone decreased—frequent episodes of acid reflux— breakdown of mucosal barrier—esophageal inflammation, hyperemia, and erosion—fibrotic tissue formation—esophageal stricture— impaired swallowing.

• Risk factors – Lifestyle factors: obesity; smoking, excess alcohol intake; consumption of high fat, spicy, or acidic foods; consumption of caffeine and carbonated beverages; stress – Pathological predisposing factors: PUD, asthma, cystic fibrosis, cancer – Medications: acetysalicylic acid and non steroidal antiinflammatory drugs (NSAIDS), bronchial inhalers, potassium, iron supplements, nitrates, anticholinergics – Anatomical factors: eating heavy meal before lying down, strenuous exercise after eating, scoliosis, poor esophangeal sphincter tone, consuming an excessive amount of food and beverage. – Clients with prolonged GERD are at increased risk for cancer

Clinical manifestations
• Reflux esophagitis: heartburn, dyspepsia • Increased pain after meals; may be relieved by antacids • Activities that increase intraabdominal pressure increase esophageal discomfort • Pain may radiate to back and neck • Regurgitation not associated with belching or nausea • Diagnostics: 24 hour pH monitoring, esophageal manometry, esophagoscopy

• Medical
– Diet therapy: decrease intake of fatty foods, small frequent feeding – Medications: histamine receptor antagonist, antacids, GI stimulants

• Surgical
– Surgical corrections of hernia

Nursing Intervention
Goal: Decrease esophageal reflux • Drink adequate fluids at meals to increase food passage • Avoid temperature extremes in foods • Avoid drinking fluids 3 hours before bedtime • Elevate the head of the bed on 6-to 8- inch blocks • Lose weight to decrease abdominal pressure gradient • Avoid tobacco, alcohol, NSAIDS, and salicylates. • Decrease intake of highly seasoned foods • Eat frequent small meals to prevent gastric dilation • Avoid any food that precipitates discomfort (fats, caffeine, chocolate, nicotine will decrease esophageal sphincter tone) • Do not lie down after eating

Goal: To perform preoperative nursing interventions Goal: to provide postoperative nursing care
– If surgical thoracic approach is used, the client will have a chest tube after surgery – Client should continue preoperative dietary restrictions after surgery.

• Gastritis is an inflammation of the gastric mucosa • Acute Gastritis is generally self limiting with no residual damage • Chronic gastritis is due to repeated irritation of the gastric mucosa caused by a breakdown of the normal protective mucosal barrier • Gastritis is also classified as erosive or non erosive, depending on the severity of mucosal injury

• Risk factors/etiology
– Often caused by dietary indiscretion (gastric irritants: coffee, aspirin, alcohol etc) – Alcohol intake (especially alcoholism) – Contaminated foods (Staphylococcus or Salmonella organism) – Medications causing gastric irritation (aspirin, corticosteroids, chemotherapy) – Acute Gastritis is a common problem in intensive care units because of significant amount of stress. – Clients with burns, sepsis, shock, mechanical ventilation, or multiorgan dysfunction who are not receiving some enteral feeding are at significantly increased risk.

Clinical Manifestations
• • • • Epigastric tenderness Nausea and vomiting Anorexia Chronic gastritis is frequently caused by the presence of Helicobacter pylori
– May precipitated pernicious anemia – May be caused by uremia – May be associated with PUD

Smoking exacerbates condition

– Endoscopic examination of the gastric mucosa with biopsy – Stool examination for occult blood – Gastric analysis

• Medical management
– Eliminate cause – Antiemetics, antacids, acid blockers, proton pump inhibitor – Treatment for H.pylori with antibiotics plus H2 receptor antagonists, a proton pump inhibitor, and antacids

• Surgical intervention, if medical treatment fails or hemorrhage occurs.

Nursing Interventions
Goal: To decrease gastric irritation • Nothing by mouth (NPO status) initially, with IV fluid and electrolyte replacement • Administer medication as prescribed • Bed rest • Begin clear liquids when symptoms subside Goal: To assist client to identify and avoid precipitating causes

• Gastroenteritis is the irritation and inflammation of the mucosa of the stomach and small bowel • This can rapidly progress to dehydration, hypovolemic shock and severe electrolyte disturbances.

• Risk Factors/Etiology
– Equal incidence in men and women but more severe in infants and elderly – Salmonella: fecal oral transmission by direct contact or via contaminated food – Staphylococcal: transmission via foods that were handled by contaminated carrier – Dysentery: E. coli and Shigella spp.

Clinical Manifestations
• • • • Abdominal cramping Nausea, vomiting, and diarrhea Fever and chills Loss of appetite

Diagnostic: identify causative agents Treatment: appropriate medication for causative agents

Nursing interventions
Goal: To maintain hydration and electrolyte balance and to prevent spread of disease • Maintain NPO status until vomiting cease • Examine anal area for irritation, apply moisture barrier • IV fluid replacement if severe dehydration occurs • Begin clear liquids gradually after vomiting cease • Contact based precautions • Avoid aspirin and ibuprofen because these worsen condition Goal: to provide symptomatic nursing care for diarrhea, nausea, and vomiting

Peptic ulcer Disease
• PUD refers to an erosion of the GI mucosa by hydrochloric acid and pepsin • Locations of ulcers include the lower esophagus, stomach, pyloric channel, and duodenum (accounts for 80% of all ulcers), as well as postoperative ulcers near sites of surgical anastomosis. When the ulcer is located in the duodenum, it is also known as a duodenal ulcer. • Types of peptic ulcers – Duodenal (most common) – Gastric – Stress-induced ulcers, drug induced ulcers.

• Histamine release occurs with the erosion of the gastric mucosa in both duodenal and gastric ulcers. This stimulates further secretion of gastric acid and formation of mucosal edema. The continued erosion will eventually damage the blood vessels, leading to hemorrhage or erosion through gastric mucosa.

• • • Failure of the body to regenerate mucous epithelium at a sufficient rate to counter balance the damage to tissue during the breakdown of protein; Decrease in the quantity and quality of the mucus; poor local mucosal blood flow, along with individual susceptibility to the ulceration. A peptic ulcer is a hole in the lining of the stomach, duodenum, or esophagus. This hole occurs when the lining of these organs is corroded by the acidic digestive juices secreted by the stomach cells. Excess acid is still considered to be significant in ulcer formation. The leading cause of ulcer disease is currently believed to be infection of the stomach by Helicobacter pylori (H.pylori). Another major cause of ulcers is chronic use of nonsteriodal anti inflammatory drugs (NSAIDS). Cigarette smoking is also an important cause of ulcers.

• •

• Risk factors – H. pylori (causes two thirds of ulcers) – NSAIDS – Medications that alter gastric mucosa and secretions – Increased physical stress (trauma, surgery) – Psychosocial stress (duodenal ulcers) – Smoking, Alcohol • Aggravating factors – Stress: emotional or physical stress (e.g., surgery) – Smoking – Alcohol – Increased incidence if family member has ulcers

• Clinical manifestations – Pain: the pain associated with ulcers may be confusing, and symptoms may overlap from one type of ulcer to another. Be careful to avoid confusing ulcer pain with angina • Peptic (gastric) ulcers: dull, aching; often aggravated by eating; may awaken patient at night • Duodenal ulcers: gnawing pain in epigastric (upper central region of abdomen), worsening several hours after a meal. Eating may lessen the discomfort – Significant weight loss – Nausea and vomiting – Bleeding when ulcers erodes through vessels

• All types • X-ray film of upper GI system • Esophagogastroduodenoscopy

• Medications
– – – – – Antacids Histamine receptor antagonist Anticholinergic medications for duodenal ulcers Prostaglandin analogs and acid pump inhibitors Medications to eliminate H.pylori bacteria • Metronidazole (Flagyl) • Omeprazole (Prilosec) • Clarithromycin (Biaxin) or Tetracycline

Lifestyle modifications

Surgical interventions for intractable ulcers

– Avoid foods that cause discomfort – Decrease or stop smoking – Decrease activity and psychological stress

– Partial gastrectomy: removal of majority of stomach (antrum and pylorus) with anastomosis to either the duodenum or the jejunum (preferred)

• Vagotomy: denervation of a portion of the stomach to decrease acid secreting stimulus to gastric cells • Pyloroplasty: (pyloric stenosis repair) method for relieving a narrowed pyloric sphincter to allow the stomach contents to pass more easily into the duodenum; may be done in combination with vagotomy • Complications – Hemorrhage • Hematemesis, melena or both • Hypovolemic shock – Perforation of ulcer into the peritoneal cavity • Sudden, severe, diffuse upper abdominal pain • Abdominal muscles contract as abdomen becomes more rigid • Bowel sounds are absent • Respirations become shallow and rapid • Severity of peritonitis is proportional to size of perforation and amount of gastric spillage

• Dumping syndrome – Affects up to half of clients who have undergone gastrectomy

Nursing Interventions
Goal: To promote health in clients with PUD
– Identify factors in lifestyle contributing to development of ulcer – Identify factors that precipitate pain and discomfort – Do not take OTC medications, especially aspirin compounds and NSAIDS – Identify stress factors in lifestyle. Counseling may be indicated to help client improve ability to cope with stress.

Goal: to assess for complications of gastric obstruction Goal: to assess for complications of hemorrhage
– Assess for symptoms indicating hemorrhage • Evaluate hemoglobin and hematocrit levels • Assess for distention, increase in pain, and tenderness • Correlate vital signs with changes in client’s overall condition • Assess stools and nasogastric drainage for present of blood.

• If hemorrhage occurs:
– Establish peripheral infusion line, preferably with large-gauge needle for blood infusion – Insert indwelling urinary catheter to monitor urinary output – Insert nasogastric tube for removal of gastric contents and maintain gastric suction – May implement iced saline solution lavage – Prepare to administer whole blood transfusion

• Position client supine with legs slightly elevated • Begin oxygen administration • Initiate preoperative preparation

Goal: To assist client to return to homeostasis after gastric resection • Provide general postoperative care as indicated • Maintain nasogastric suction until peristalsis returns • After removal of nasogastric tube, assess for
– Increasing abdominal distention – Nausea, vomiting – Changes in bowel sounds

• • • •

No oral fluids until client is able to tolerate removal of nasogastric tube Begin oral fluids slowly; clear liquids, then progress to bland, soft diet Based on client’s condition, total parenteral nutrition may be necessary to maintain adequate nutrition Encourage ambulation to promote peristalsis

Goal: to prevent the development of pernicious anemia after total gastric resection

Goal: to identify dumping syndrome • Dumping syndrome – Condition occurs when a large bolus of gastric chyme and hypertonic fluid enter the intestine Goal: to assess for symptoms of condition – Weakness, dizziness, tachycardia – Epigastric fullness and abdominal cramping – Diaphoresis – Generally occurs within 30 minutes of eating – Condition is usually self limiting and resolves in about 6-12 months

Goal: to prevent dumping syndrome – Decrease amount of food eaten at one meal – Decrease carbohydrates, decrease salt intake and roughage, increase proteins and fats as tolerated – No added fluid with meal or for 1 hour after meal – No milk, sweets or sugars – Position client in semi-recumbent position during meals; client should lie down on the left side for 20-30 minutes after meals to delay stomach emptying – Hypoglycemia may occur 2-3 hours after eating, caused by rapid entry of carbohydrates into jejunum. – Alert: implement measures to improve client’s nutritional intake. Prevent dumping syndrome and/or care client experience dumping syndrome

• Appendicitis is an obstruction and inflammation of the appendix, leading to bacterial infection. If appendicitis is not treated, the appendix can become gangrenous and burst, causing peritonitis, septicemia, and potential death. It is the most common reason for emergency abdominal surgery in children. • Obstruction of the blind sac of the appendix precipitates inflammation, ulceration, and necrosis. • Problems arise when the necrotic area ruptures, spilling intestinal contents into the peritoneal cavity, causing peritonitis


– – – – – – –

Risk factors/etiology
Age: peak at 20-30 years old; rare in children younger than 2 years Diet: low-fiber and refined carbohydrate diets Viruses: coxsakievirus B, adenovirus Amebiasis Bacterial gastroenteritis Mumps Barium ingestion

Clinical manifestations
– – – – – – Abdominal cramping and pain, beginning near navel then migrating toward McBurney’s point (Right Lower quadrant). Pain worsens with time Anorexia, nausea, vomiting and constipation Elevated temperature and heart rate Side lying, fetal position for comfort Client complains of pain when asked to cough: asking client to cough is better assessment method than palpating for rebound tenderness Sudden relief from pain may indicate rupture of appendix

Diagnostics • Clinical manifestations • Urinalysis to rule out urinary tract infection • Ultrasonography to identify inflamed appendix • White blood cell count revealing leukocytosis Complication
– peritonitis

• Laparoscopic appendectomy is the only effective treatment • Abdominal laparotomy and peritoneal lavage if appendix ruptured (less desirable) • Broad spectrum antibiotic therapy • Early ambulation after surgery

Nursing Intervention
Goal: to assess clinical manifestation and to prepare for surgery, as indicated • Careful nursing assessment for clinical manifestation • Maintain NPO status until otherwise indicated • Maintain bed rest in position of comfort • Do not apply heat to the abdomen; cold applications may provide some relief or comfort • Do not administer enemas • Avoid unnecessary palpation of abdomen Goal: to maintain homeostasis and healing after appendectomy Goal: to prevent abdominal distention and to assess bowel function after abdominal laparatomy
– Maintain NPO status – Gastric decompression by nasogastric tube; maintain patency and suction – Monitor abdomen for distention – Assess peristaltic activity – Evaluate and record character of bowel movements

Goal: to decrease infection and promote healing after abdominal laparatomy
– Place client in semi fowlers position to localize infection and prevent spread of infection or development of subdiaphragmatic abscess – Antibiotics are usually administered via IV infusion; monitor response to antibiotics and status of IV infusion site. – Monitor Vital signs frequently (2-4hours) and evaluate for infection process – Provide appropriate wound care; evaluate drainage from abdominal Penrose Drains and incisional area – Maintain adequate hydration via IV infusion – Evaluate tolerance of oral liquids when nasogastric tube is removed – Begin oral administration of clear liquids when peristalsis returns – Progress diet tolerated – Administer analgesics as indicated.

Goal; to maintain adequate hydration and nutrition and to promote comfort after abdominal laparatomy

Alerts: – Determine need for administration of pain medications. Do not give narcotics for pain control before a diagnosis of appendicitis is confirmed, because they mask signs if the appendix ruptures – Determine whether client is prepared for surgery or procedures. appendicitis is a very common problems; know how to care for client during diagnostic phase – Identify infection: peritonitis is common after surgery for a ruptured appendix. Undiagnosed Abdominal Pain – Do Not • Give anything by mouth • Put any heat on the abdomen • Give an enema • Give Strong Narcotics • Give a Laxative – Do • Maintain bed rest • Place in a position of comfort • Assess hydration • Assess abdominal Status; distention, bowel sounds, passage of stool or flatus, generalized or local pains

• Peritonitis is the generalized inflammation of the peritoneal cavity, leading to intraabdominal infection • Intestinal motility is decreased, and fluid accumulates as a result of the inability of the intestine to reabsorb fluid • Fluid will leak into the peritoneal cavity, precipitating fluid, electrolyte and protein losses, as well as fluid depletion

• Risk factors/etiology – Chemical peritonitis may result from gastric ulcer perforation or a ruptured ectopic pregnancy – Bacterial peritonitis results from traumatic injury (abdominal trauma, ruptured appendix) – Chemical peritonitis is rapidly followed by bacterial peritonitis – Postoperative dehiscence – Pancreatic necrosis Clinical manifestations – Presence of precipitating cause – Pain over involved area; rebound tenderness – Abdominal mass or distention – Abdominal muscle rigidity (board like abdomen) – Unexplained persistent or labile fever – Anorexia, nausea or vomiting – Increased pulse, decreased blood pressure, shallow respiration – Decreased or absent bowel sounds – Hypovolemia, dehydration – Shallow respiration in attempt to avoid pain

– Complete blood count for elevated white blood cell count – Contrast- enhanced computed tomography – Ultrasonography may identify mass – X-ray film of abdomen – Paracentesis to evaluate abdominal fluid

• Identify and treat precipitating cause ( may require surgical intervention) • Antibiotics • IV fluids • Decrease Abdominal Distention

Nursing Intervention
Goal: To maintain Fluid and Electrolyte Balance and Reduce gastric Distention • Maintain nasogastric suction • Maintain IV fluid replacement usually normal saline or lactated Ringer’s Solution • Administer potassium supplements with caution because of the possible complication of poor renal function • Evaluate peristalsis and return of bowel function • Maintain intake and output records • Assess for problems of dehydration and hypovolemia • Encourage activities to facilitate return of bowel function
– – – – – – Encourage ambulation Attempt to decrease analgesics and maintain adequate pain control Maintain adequate hydration

Goal: To reduce infection process

Administer antibiotics via IV infusion; assess client’s tolerance of antibiotics and status of infusion site Evaluate vital signs and correlate with progress of infection Maintain in semi-fowlers position to enhance respiration, as well as to localize drainage and prevent formation of subdiaphragmatic abcess.

Diverticular Disease
• When a diverticulum ( a pouch like herniation of superficial layers of the colon through weakened bowel wall) becomes inflamed, it is known as diverticulitis. In diverticulosis, there are asymptomatic diverticula. • Meckel’s diverticulum is diverticular disease of the ileum in children. It is the most common congenital anomaly of the GI tract in children • Diverticulum: dilatation or outpouching of a weakened area in the intestinal wall. • Diverticulitis: inflammation of the diverticulum

• Risk factors/etiology – Low fiber diet: high intake of processed foods – Age • May be due to constipation and low fiber diet • Indigestible fibers (corn, seeds, etc.,) will precipitate diverticulitis • The edema that accompanies the inflammation results in increased swelling and bowel irritation Clinical manifestations – Diverticulum, including Meckel’s diverticulum, is usually asymptomatic; symptoms vary with degree of inflammation – Intermittent left lower quadrant tenderness, abdominal cramping – Inflammatory changes may precipitate perforation or abscess formation – Diverticulitis • Fever • Left lower quadrant pain, usually accompanied by nausea and vomiting • Abdominal distention • Frequently constipated • May progress to intestinal obstruction

Diagnostics (diverticulosis)
– Barium enema to visualize colon – Sigmoidoscopy or colonoscopy – Ultrasonography and/ or computed tomography scan – Stool examination – Barium enema and colonoscopy are done after the acute phase

• Management of uncomplicated diverticulum – High residue diet and fiber supplements – Avoid laxatives and enemas • Diverticulosis with pain – Liquid or bland diet – Stool softeners or mineral oil • Diverticulitis without perforation – Oral antibiotics when symptoms are mild – Antispasmodic medications – Liquid or low fiber foods for acute diverticulitis • Severe diverticulitis – Hospitalized with IV antibiotic management – NPO status – Surgery for obstruction, abscess, hemorrhage or perforation

Nursing Interventions
Goal: to assist client to understand dietary implications and maintain prescribed therapy to prevent exacerbations
– Understand high fiber diet – Avoid indigestible roughage such as nuts, popcorn, raw celery corn and seeds – Maintain high fluid intake – Avoid large meals – Avoid alcohol – Weight reduction, if indicated – Avoid activities that increase intraabdominal pressure (e.g., straining at stool, bending and lifting); avoid wearing tight restrictive clothing

Goal: to decrease colon activity in client with diverticulitis
– – – – Maintain clear liquids or NPO status Bed rest Adequate hydration via parenteral fluids As attack subsides, introduce oral fluids gradually

• Self care
– High fiber that is low in indigestible fibers – If client has any abdominal distress, then all fiber should be avoided until tenderness resolves – Report fevers, consistent abdominal pain, and dark tarry stools.

Crohn’s Disease (Ileitis or Enteritis)
• Crohn’s disease is a chronic inflammatory disease of the intestines that causes ulcerations primarily in the intestines • The inflammation may extend through every layer of the affected bowel tissue. Patches of inflammatory occur next to health bowel tissue • Most commonly affects the small bowel, especially to the area of the terminal ileum. Lesions may also arise in the cecum and ascending colon • Edema, inflammation, and fibrosis occur—involving all layers of the bowel wall • Inflammatory process occurs in patchy segment, separated by normal tissue • Client may experience periods of complete remission that alternate with exacerbations

• Risk factors/etiology – May begin in adolescence; peak incidence occurs between ages 2040 years – Familial tendencies – Food allergies – Smoking – Immune disorders Clinical manifestations – Acute symptoms • Chronic diarrhea and abdominal pain • Nausea, cramping, fever, flatulence – Chronic Symptoms • Multiple diarrhea stools each day • Weight loss • Anemia Diagnostic – Stool analysis to rule out bacterial or parasitic infection – Barium enema (pretest procedures may be modified for this client, check with the physician) – Colonoscopy

• Perirectal and intraabdominal fistulas and abscesses • Inflammation of the intestine, leading to perforation and generalized peritonitis • Nutritional deficiencies, especially of fatsoluble vitamins.

• Dietary modifications; increased calories and protein and decreased fats and residue. Encourage client to eat small servings several times a day • Medications – Corticosteroids to reduce the inflammation – Sulfasalazine (an antimicrobial agent) to control inflammation – Immunosuppressive in long term management of chronic problems – Antidiarrheal medications – Anticholinergics – Metronidazole (Flagyl) – Infliximab ( Remicade) • Surgical intervention, if fistulas, perforation, bleeding, or intestinal obstruction occur

Nursing Intervention
• Goal (immediate): to decrease inflammatory response and to promote healing • Evaluate and maintain adequate hydration status • NPO status to decrease bowel activity, fluids are introduced gradually • IV fluids; may require parenteral hyperalimentation • Evaluate electrolyte status • Good skin hygiene around anal area to prevent excoriation caused by diarrhea • Antidiarrheal agents • If fistulas form, the client is most often malnourished, may require total parenteral nutrition • Assess characteristics in patterns of stool

Self Care
• Dietary modifications: teach client to eat small, frequent meals that are high in protein and calories • Medication regimen: precautions regarding steroids or immunosuppressive medication • Symptoms of reoccurrence of the problem; when to call the physician • Dressing and wound care if fistula is present • Identify appropriate measures to decrease stress in lifestyle
– Continued diarrhea and weight loss – Chills, fever, malaise

Ulcerative Colitis
• Ulcerative colitis is an inflammation and ulceration of the colon and rectum; it is more common than Crohn’s disease • Area of inflammation is diffuse, involving mucosa and submucosa of the intestinal wall. Inflammatory process progresses to scar formation • Problem frequently begins in the rectum and spreads in a continuous manner up to the colon; seldom is the small intestine involved • Mucosa develops ulcerated areas that can precipitate hemorrhage • Condition has periods of exacerbations and remissions: is frequently associated with psychological factors and stress • Acute symptoms may be exacerbated or, as disease progresses, may become chronic

• Risk factors/etiology – May occur at any age; peaks at ages 15 to 25 years and 55-65 years. – Increased incidence in Jewish population – Familial tendencies – Increased incidence in females – Pyschophysiological characteristics Clinical Manifestations – Diarrhea, frequently bloody; client may have 20 or more stools per day – Abdominal pain, rebound tenderness – Fever – Rapid depletion of fluid and electrolytes occurs during exacerbation – Anorexia, weight loss – Anemia Diagnostic – Colonoscopy – Barium enema – Stool studies

• Obstruction, perforation, abscess, fistulas • Increased incidence for development of colon cancer

• Mild to moderate disease – Sulfasalazine to help control inflammation – Corticosteriods – Medicaton for pain, antidiarrheal agents, and immunosuppressive agents • Acute or active disease – Corticosteroids: administered intravenously, if oral administration is ineffective – NPO status to rest bowel – Retention enemas and rectal foams to ease inflammation – Immunosuppresive drugs in combination with steroids • Surgical interventions – Resection of the diseased portion of the bowel – Ileostomy – Ileoanal anastomosis

Nursing interventions
• Nursing goals and activities are essentially the same as for the client with regional enteritis (Crohn’s disease)

• • A hernia is a protrusion of the intestine through an abnormal opening or weakened area of the abdominal wall Types – Inguinal: a weakness in which the spermatic cord in men and the round ligament in women passes through the abdominal wall in the groin area; more common in men – Femoral: protrusion of the intestine through the femoral ring; more common in women – Umbilical: occurs most often in children when the umbilical opening fails to close adequately; occurs in adults in an area where the rectus muscle is weak – Incisional: weakness in the abdominal wall caused by a previous incision Classification – Reducible: hernia may be replaced into the abdominal cavity by manual manipulation. – Incarcerated, irreducible or imprisoned: hernia cannot be pushed back into place – Strangulated: blood supply and intestinal flow in the herniated area are obstructed; strangulated hernia leads to intestinal obstruction

Risk Factors
• Chronic cough, such as smoker’s cough or cough associated with cystic fibrosis • Obesity or weakened abdominal musculature • Straining during bowel movement or lifting heavy objects • Pregnancy

• Clinical manifestation • hernia protrudes over the involved are when the client stands or strains • Severe pain occurs if hernia becomes strangulated • Strangulated hernia occurs with symptoms of intestinal obstruction • Diagnostics
– History – Clinical manifestations

• General elective surgery to prevent complications of strangulation (herniorrhaphy • Strangulated hernia involves resection of the involved bowel

Nursing Intervention
• Goal: to prepare client for surgery, if indicated • Goal: to maintain homeostasis and promote healing after herniorrhaphy • General postoperative nursing care • Repair of an indirect hernia: assess male clients for development of scrotal edema • Encourage deep breathing and turning • If coughing occurs, teach client how to splint the incision • Refrain from heavy lifting for approximately 68 weeks after surgery

• Intussusception is the telescoping of one portion of the intestine into another, which may result in an intestinal obstruction. The common site is the ileocecal valve

• Risk factors/etiology
– Incidence of problem increases in client with cystic fibrosis or celiac disease. – Most common cause of intestinal obstruction in children from ages 3 months to 3 years – More common in males – Child is healthy with sudden occurrence of acute abdominal pain – Pain may be episodic, characterized by periods of absence of pain – Vomiting occurs initially – Child may pass one normal stool, then as condition deteriorates, he or she may pass a stool described as “currant jelly” ( a mixture of blood and mucus) – Abdominal tenderness and distention – A “sausage-shaped mass may be palpated in the abdomen

Clinical manifestations

• Diagnostics: radiographic studies to assess for free air in the abdomen before a barium enema • Treatment
– Initial treatment may consist of administration of a water-soluble contrast medium and air pressure to reduce intussusception – Barium enema may be used for reduction of intussusception, as well as for the confirmation of the problem. – Barium enema is associated with an increased risk of peritonitis if there is a perforation

Nursing intervention
• Goal: assist in diagnostic evaluation and maintain ongoing nursing assessment for pertinent data • Careful assessment of client’s physical and behavioral symptoms • Maintain NPO status and assess for electrolyte imbalance • Nasogastric suctioning may be necessary • Monitor all stools; passage of normal stool may indicate reduction of the intussusception • A barium enema is contraindicated if there is air the abdomen, high fever, vomiting and/or signs of peritonitis. • Prepare the child for barium enema as though surgery will follow: NPO status, nasogastric tube, IV fluids • Goal: to provide preoperative preparation of client or child and parents if surgery is indicated • Goal: to maintain homeostasis and promote healing after surgery

Pyloric Stenosis
• Pyloric stenosis is the obstruction of the pyloric sphincter by hypertrophy and hyperplasia of the circular muscle of the pylorus • Assessment
– Risk factors/etiology • Occurs most often in firstborn, term infants (infantile hypertrophic pyloric stenosis) • More common in male infants • Seen more frequently in white infants

Clinical Manifestations
• Onset of vomiting may be gradual, occurring in first few weeks; or forceful, projectile vomiting may develop at 4-6 weeks of age • Emesis is not bile stained by may be curdled from length of time in stomach • Vomiting occurs shortly after feeding • Infant is hungry and nurses well • Infant does not appear to be in pain or acute distress • Weight loss occurs, if untreated • Stools decrease in number and in size • Dehydration occurs as condition progresses; hypochloremia and hypokalemia occur as vomiting continues • Upper abdomen is distended, and an “olive-shaped” mass may be palpated in the right epigastric area

• Diagnostics
– – – – Palpation of abdominal mass Prolonged vomiting X-ray film and ultrasound examination of abdomen Treatment: surgical release of the pyloric muscle (pyloromyotomy)

Nursing Intervention
• • Goal: To restore and maintain hydration and electrolyte balance; initiate appropraite preoperative nursing activities If infant is being fed orally
– – – – Feed slowly with infant in upright position Frequent burping during feeding to prevent gastric distention After feeding, place infant slightly on the right side is high fowler’s position or in an infant seat Minimal handling after feeding

• • • • • • •

Monitor vital signs and check for signs of peritonitis Assess hydration status and electrolyte balance If child is dehydrated, NPO status with continuous IV infusion (most often saline solutions) may be required Accurate intake and output records: complete description of all vomitus and stools Monitor electrolyte balance closely; especially serum calcium, sodium, and potassium level Gastric decompression and suction may be used before surgery; maintain patency of tube and record type and amount of drainage Preoperative teaching for parents

• Goal: To maintain adequate hydration and promote healing after pyloromyotomy • Postoperative vomiting in the first 24-48 hours is not uncommon • Assess infant’s response to surgery • Continue to monitor infant in the same manner as in the preoperative period • Feedings are initiated early; bottle fed infant may begin with clear liquids, then diluted formula; gradually increase length of time nursing for breast fed infants • Continue feedings in the same manner as before surgery • Monitor infant’s response to feedings • Encourage parents to visit and be involve in child’s care • Goal: To assist parents to provide appropriate home care after pyloromyotomy • No residual problems are anticipated after surgery • Instruct parents regarding care of the incisional area

Oral cancer
• Oral cancer is an uncontrollable growth of abnormal cells that invade and cause damage to areas around the mouth including lips, cheek, tongue, soft and hard palate, the floor of the mouth, tonsils, sinuses, and even the pharynx. If detected early, it is frequently curable • May occur in any area of the mouth; frequently curable if discovered early • Sites of oral cancer – Lips – Tongue – Salivary glands – Floor of the mouth • Types of oral cancer – Basal cell carcinoma: occurs primarily on the lips results from excessive exposure to sunlight – Squamous cell carcinoma: occurs on the lower lip and the tongue; associated with alcohol intake and tobacco use

• Risk factors/etiology
– Smoking – Continuous oral irritation caused by poor dental hygiene – Chewing tobacco – Leukoplakia: whitish patch on oral mucosa or tongue (premalignant lesion) – Oral lesions tend to be fixed and hard; may ulcerate – Pain and dysphagia are late symptoms – Biopsy of the lesion

• Clinical manifestations

• Diagnostic

• Surgery
– Surgical resection – Reconstructive surgery – Radial Neck dissection is common

• Radiation
– Radioactive seeds may be implanted in the affected area

• Chemotherapy

Nursing Intervention
• Goal: To prevent oral cancer – Avoid chemical, physical or thermal trauma to the mouth – Good oral hygiene, brushing and flossing – Prevent constant irritation in the mouth; repair dentures or other dental problems – See doctor for any oral lesion that does not heal in 2 to 3 weeks • Goal: To prepare client for surgery – General preoperative care – Discuss with physician the anticipated extent of surgery reinforce information with client – Emphasize good oral hygiene – If reconstructive surgery is anticipated, encourage ventilation of feelings regarding anticipated changes in body image.

Goal: To maintain patent airway after surgery

Goal: to maintain oral hygiene and prevent injury and infection after surgery
– Type of oral hygiene is indicated by the extent of the procedure • Mouth irrigations • Soothing mouth rinses (cool normal saline or nonirritating antiseptic solutions) • If dentures are present, clean mouth well before replacing • Oral hygiene before and after oral intake – Avoid using stiff toothbrushes and metal tipped suction catheters

– Elevate head of bed slightly to promote venous and lymphatic drainage and to promote patent airway – Evaluate swelling around suture areas – Evaluate ability of client to handle oral secretions – Perform respiratory assessment to identify problems of hypoxia – Client may have a tracheostomy (depends on the extent of surgery)

• Goal: To maintain nutrition after surgery
– Monitor return of bowel sounds before beginning tube feedings or oral intake – May be necessary to maintain nutrition by total parenteral nutrition or tube feedings – Oral intake • Liquid, soft, nonirritating foods • No extremes in temperature of food • Small, frequent feedings • Provide privacy and do not rush during meals

Self Care
• Assist client to identify community resources for individual problems in rehabilitation
– – – – Speech therapist Dietician Counseling Home health care agency, if appropriate

• Assist client to decrease or stop smoking • Assist client to maintain good oral hygiene and dressing care and to take medications • Teach client to identify symptoms of complications and to notify physician

Celiac Disease
• Celiac disease is also known as sprue, gluten enteropathy, and malabsorption syndrome. This disease is an inborn error in metabolism of rye, wheat, barley, and oat products. • Symptoms generally begin between the ages of 1 year and 5 years, but they may also occur in those 50-60 years. • Severe malnutrition results from a loss of nutrients via the stool

• Cause: congenital defect in metabolism • Clinical manifestations
– Symptoms begin when child has increased intake of gluten type foods: cereals, breads, pastas etc – Watery, pale diarrhea, steatorrhea – Vomiting, anorexia – Poor weight gain, failure to thrive – Constipation, vomiting, and abdominal pain may be the initial presenting signs/symptoms – Abdominal distention – Secondary illness such as atopic dermatitis, alopecia, or oral ulcers may be initial signs/symptoms

• Diagnostic
– Stool analysis – Jejunal biopsy

• Treatment
– Primarily dietary management, gluten free diet

Nursing Intervention
• Goal: To assist parents and client to understand diet therapy and promote optimal nutrition intake • Written information regarding a gluten free diet; corn and rice may be substituted for grains in diet • Diet should be high calorie, high protein and low fat • Teach parents how to read food labels for grain contents • Important to discuss with parents and older children necessity of maintaining a lifelong gluten restricted diet, problems may occur in teenagers who relax their diet and experience an exacerbation of disease state • Lack of adherence to dietary restrictions may precipitate growth retardation, anemia and bone deformities • Alert: adapt the diet to meet client’s specific needs

Hirschsprung’s disease
• Hirschsprung’s disease (congenital aganglionic megacolon) is characterized by a congenital absence of innervation in a segment of the colon wall • May precipitate a neurogenic bowel obstruction; cause of 25% of neonatal intestinal obstructions • Most common site is the rectosigmoid colon; colon proximal to the area dilates (i.e., megacolon)

• Risk factors/etiology – Congenital, may be associated with Down syndrome • Clinical Manifestations – Varies according to age and amount of colon involved – Inadequate or absent peristalsis – Newborn • Failure to pass meconium within 24 hours to 48 hours after birth • Vomiting • Abdominal distention • Reluctance to take fluids • Older infant – Passage of watery stools and diarrhea – Failure to thrive – Lack of appetite – Persistent constipation, impaction

• Diagnostics
– Rectal biopsy – Barium enema

• Treatment
– Surgical correction usually involves creation of a temporary colostomy, then a pull-through of the colon to a point near the rectum. After the reanastomosis has healed, the temporary colostomy is closed.

Nursing intervention
• Goal: To promote normal attachment and prepare infant and parents for surgery • Allow parents to ventilate feelings regarding congenital defect of infant • Foster infant parent attachment • General preoperative preparation of the infant; neonate does not require any bowel preparation • Careful explanation of colostomy to parents • Goal: To assist parents to understand and provide appropriate home care for the child after colostomy • Colostomy is most often temporary • Parents should be actively involved in colostomy care before discharge

Intestinal obstruction
• • Interference with normal peristalsis and impairment to forward flow of intestinal contents is known as intestinal obstruction Types of obstruction – Mechanical obstruction • Strangulated hernia • Intussusception of the bowel ( common in infants and small children) • Volvulus: twisting of the bowel • Tumors: cancer (most frequent cause of obstruction in the elderly) • Adhesions – Neurogenic: interference with nerve supply in the intestine • Paralytic ileus or adynamic ileus occuring as a result of abdominal surgery or inflammatory process • Potential sequelae from spinal cord injury – Vascular obstruction: interference with the blood supply to the bowel • Infarction of superior mesenteric artery • Bowel obstruction related to intestinal ischemia may occur very rapidly and may be life threatening

• • • • • • •

Regardless of the precipitating cause, the ensuing problems are a result of the obstructive process The higher the obstruction in the intestine, the more rapidly symptoms will occur Fluid, gas, and intestinal contents accumulate proximal to the obstruction. This causes distention proximal to the obstruction and bowel collapse distal to the obstruction As fluid accumulation increases, so does pressure against the bowel. This precipitates extravasation of fluids and electrolytes into the peritoneal cavity. Increased pressure may cause the bowel to rupture The location of the obstruction determines the extent of fluid and electrolyte imbalance and acid base imbalance
– – – Dehydration and electrolyte imbalance do not occur rapidly if obstruction is in the large intestine If obstruction is located high in the intestine, dehydration occurs rapidly because of the inability of the intestine to reabsorb fluids If persistent vomiting is a problem, the client will have metabolic alkalosis; if contents of the small intestine are lost through vomiting, metabolic acidosis will occur.

• • Risk factors/etiology Clinical manifestations
– Identify type of obstruction and precipitating cause – Vomiting occurs early and is more severe if obstruction is high; may not occur if obstruction is below the ileum – Abdominal distention – Bowel sounds initially may be hyperactive proximal to the obstruction and decreased or absent distal to the obstruction; eventually, all bowel sounds will be absent – Colicky type abdominal pain – – – – – X-ray film of the abdomen Evaluation of history of abdominal problems Leukocytosis Barium enema Computed tomographic scan for clients with abdominal malignancy and symptoms of obstruction


• • • • Infection/ septicemia Gangrene of the bowel Perforation of the bowel Fluid imbalances

• Mechanical and vascular intestinal obstruction are generally treated surgically; ileostomy or colostomy may be necessary • Treatment of neurogenic obstruction may consist of intestinal intubation and decompression • Maintain fluid and electrolytes balances and adequate nutrition

Nursing Intervention
• • • • • • • • • • •

• • • •

Goal: To prepare client for diagnostic evaluation and to maintain ongoing nursing assessment for pertinent data Goal: To decrease gastric distention and to maintain hydration and electrolyte balance Maintain NPO status Maintain nasogastric suction or intestinal suction Maintain IV fluid replacement; most often normal saline or lactated Ringer’s solution Administer potassium supplements with caution because of complications of decreased renal function Evaluate peristalsis and return of bowel function Maintain accurate intake and output records Assess dehydration, hypovolemia, and eletrolyte disturbance Measure abdominal girth to determine whether distention is increasing Encourage activities to facilitate return of bowel function – Encourage physical activity, as tolerated – Attempt to decrease amount of medication required for effective pain control – Maintain hydration Goal : to decrease infection and promote healing after surgery Antibiotics are administered via IV infusion. Monitor client’s response to antibiotics, as well as status of IV infusion site. Monitor vital signs frequently and evaluate for presence or escalation of infection process Provide wound care. Evaluate drainage and healing from abdominal Penrose or JacksonPratt drains, as well as from abdominal incisional area

• Goal: To reestablish normal nutrition and promote comfort after abdominal laparotomy
– Evaluate tolerance of liquids when nasogastric tube is removed – Begin administration of clear liquids initially and continue to evaluate presence of peristalsis – Progress diet as tolerated – Administer analgesics as indicated – Promote psychological comfort • Respond promptly to requests • Carefully explain procedures • Encourage questions and ventilation of feelings regarding status of illness.

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