Nursing Lecture on Gastrointestinal Tract GIT system

GASTRO INTESTINAL TRACT DISORDERS http://nursinglectures.blogspot.com

Backflow of gastric contents into the esophagus

Usually due to incompetent lower esophageal sphincter, pyloric stenosis or motility disorder

Symptoms may mimic ANGINA or MI

Fatty foods

Caffeinated beverages, such as coffee, tea, and cola

Chocolate

Citrus fruits

Tomatoes and tomato products

Nicotine in cigarette smoke

Calcium channel blockers

Nitrates

Peppermint

Alcohol

Anticholinergic drugs

NGT placement

Heartburn

Dyspepsia

Regurgitation

Epigastric pain

Difficulty swallowing

Ptyalism

Diagnostic test

Endoscopy or barium swallow

Gastric pH analysis

1. Instruct the patient to AVOID stimulus that increases stomach pressure and decreases GES pressure 2. Instruct to avoid spices, coffee, tobacco and carbonated drinks 3. Instruct to eat LOW-FAT, HIGH-FIBER diet 4. Avoid foods and drinks TWO hours before bedtime

5. Elevate the head of the bed with an approximately 8-inch block 6. Administer prescribed H2-blockers, PPI and prokinetic meds like cisapride and metochlopromide 7. Advise proper weight reduction

Result from long standing untreated GERD

Identified as a precancerous condition and if untreated can result in adenocarcinoma of the esophagus

Common among middle aged white men, woman, and African Americans

GERD Untreated GERD Barret’s esophagus Adenocarcinoma of the esophagus

Clinical Manifestation

Frequent heart burn

Complain symptom same as GERD, peptic ulcer or esophageal stricture

Diagnostic finding

Esophagogastroduodenoscopy (EGD) is performed

Biopsy are taken

Assessment

It reveals an esophageal lining that is red rather than pink

Management

EGD in six to twelve months

Medical management is similar that of GERD

Inflammation of the gastric or stomach mucosa.

 Common GI problem

Signs & Symptoms

A. Acute Gastritis

Abdominal discomfort

Headache

Lassitude

Nausea

Anorexia

Vomiting

B. Chronic Gastritis

Anorexia

Heartburn after eating

Belching

A sour taste in the mouth

Nausea and vomiting

Gastritis

ACUTE GASTRITIS

CHRONIC GASTRITIS

Rapid onset of epigastric pain or discomfort

Nausea and vomiting

Hematemesis (vomiting blood)

Gastric hemorrhage

Dyspepsia (heart burn)

Anorexia

Vague complaint of epigastric pain that is relieved by food

Anorexia

Nausea or vomiting

Intolerance to fatty and spicy foods

Pernicious anemia

Treatment 1.Naso gastric intubation 2.Sedatives 3.Antacids 4.Intravenous fluids 5.Fiberoptic endoscopy 6.Gastrojejunostomy or gastric resection (Pyloric obstruction) 7.Antibiotics 8.Proton Pump Inhibitors 9.Bismuth salt

Nursing Intervention 1.Reducing anxiety 2.Promoting optimal nutrition 3.Promoting fluid balance 4.Relieving pain 5.Teaching patient self-care

Avoid drinking excessive amounts of alcoholic beverages

Use caution in taking large doses of aspirin, NSAIDS

Avoid excessive intake of caffeine-containing beverages

Stop smoking

Protect yourself against exposure to toxic substances in the work place, such as lead and nickle

Seek medical treatment if you are experiencing symptoms of esophageal reflux

These are circumscribed lesions in the mucosal membranes of the stomach and duodenum

Commonly referred with respect to the location  if in the stomach , gastric ulcer and if in the duodenum , duodenal ulcer

The precise cause is not known, but there are implicated factors that can lead to its development:

PEPTIC ULCER DISEASE Pathophysiology Imbalance between Acid secretion and mucosal barrier Ulceration Bleeding Erosion Autodigestion Emotional Psychogenic Drugs Pain Alcohol Caffeine N/V Genetic Factors Cigarette Smoking

Ulceration of the mucosal lining of the stomach; most commonly found in the antrum

Gastric secretions and stomach emptying rate are usually normal

Also characterized by reflux into the stomach of bile containing duodenal contents

Occurs more often in men, in unskilled laborers, and in lower socioeconomic groups; peak age 40 – 55 years (older age group)

Caused by smoking, alcohol abuse, emotional tension, and drugs (salicylates, steroids)

1. Pain located in the upper left epigastrium, with possible radiation to the back; usually occurs 1 – 2 hours after meals, rarely at night. The pain is described as burning, aching, gnawing discomfort. The pain is NOT relived by eating. 2. Weight loss, vomiting, bleeding episodes, epigastric tenderness, and pyrosis. 3. Complications associate with peptic ulcer: Bleeding, Perforation, Pyloric obstruction and intractable pain. A chronic complication seen in gastric ulcer is gastric cancer.

Hgb and Hct decreased (if anemic)

Endoscopy reveals ulceration; BIOPSY is usually done to detect H. pylori infection and to rule out MALIGNANCY!

Gastric analysis: normal gastric acidity in gastric ulcer (increased in duodenal ulcer)

Upper GI series: presence of ulcer confirmed

1. Administer medications as ordered. Watch out for side – effects of cimetidine like dizziness, rash, mild diarrhea, muscle pain and gynecomastia in males. 2. Provide nursing care for the client with ulcer surgery. 3. Prepare the client for diagnostic procedure for barium swallow and EGD 4. Provide client teaching and discharge planning concerning

A. Medication regimen 1) Take medications at prescribed times. Antacids are taken ONE hour AFTER meals. 2) Have antacids available at all times. 3) Recognize situations that would increase the need for antacids. 4) Avoid ulcerogenic drugs (salicylates, steroids). 5) Know proper dosage, action, and side effects.

B. Proper diet 1) Bland diet consisting of six small meals/ day. 2) Eat meals slowly. 3) Avoid acid-producing substances (caffeine, alcohol, highly seasoned foods, milk and creams). 4) Avoid stressful situations at mealtime. 5) Plan for rest periods after meals. 6) Avoid late bedtime snacks.

C. Avoidance of stress-producing situations and development of stress-reduction methods (relaxation techniques, exercises, biofeedback).

Most commonly found in the first 2 cm of the duodenum

Occur more frequently than gastric ulcers

Characterized by gastric hyperacidity and a significant increased rate of gastric emptying

Occur more often in younger men; more women affected after menopause; peak age: 35 – 45 years (younger than gastric ulcer group)

Caused by smoking, alcohol abuse, psychologic stress

An acute duodenal ulcer is seen in two views on upper endoscopy in the panels below.

Pain located in mid – epigastrium and described as burning, cramping; usually occurs 2 – 4 hours after meals and is relieved by food.

Usually not accompanied by nausea and vomiting

Diagnostic tests: same as for gastric ulcer.

Nursing interventions: same as for gastric ulcers.

Medical management: same as for gastric ulcers

Types

Vagotomy: severing of part of the vagus nerve innervating the stomach to decrease gastric acid secretion

Antrectomy: removal of the antrum of the stomach to eliminate the gastric phase of digestion (contains the cells that secrete gastrin)

Pyloroplasly: enlargement of the pyloric sphincter with acceleration of gastric emptying

Gastroduodenostomy (Billroth I): removal of the lower portion of the stomach with anastomosis of the remaining portion of the duodenum

Gastrojejunostomy (Billroth II): removal of the antrum and distal portion of the stomach and duodenum with anastomosis of the remaining portion of the stomach to the jejunum

Gastrectomy: removal of 60% - 80% of the stomach

Esophagojejunostomy (total gastrectomy): removal of the entire stomach with a loop of jejunum anastomosed to the esophagus

Pre – op Care

Teach deep breathing exercises (high abdominal incision causes respiratory complications).

Provide nutritional support  TPN

Inform about post-op measures and tubes to anticipate

Nasogastric tube

TPN until peristalsis returns

Post-op Care

Promote patent airway and ventilation

Semi-Fowler ’ s position

Reinforce Deep Breathing and Coughing exercise, incentive spirometry

Administer analgesic before activities

Splint incision before patient coughs

Encourage early ambulation

Promote adequate nutrition

NPO until peristalsis returns

Measure NG drainage accurately ( reddish for the first 12 hrs.)

Monitor for sign of leakage of anastomosis, e.g. dyspnea, pain, fever, when oral fluids are initiated

Small, frequent feedings

Monitor for early satiety and regurgitation

Eat less food at a slower pace

Monitor weight regularly

Prevent potential complications

Bleeding – first 24 hours, 4th to 7th day post-op due to non-healing

Monitor NG drainage for blood

Avoid unnecessary irrigation or repositioning of the NGT

Monitor for signs of peritonitis:

Severe abdominal pain, rigidity fever

Dumping Syndrome

A group of unpleasant vasomotor and G.I. symptoms caused by rapid emptying of gastric content into the jejunum.

Abrupt emptying of stomach contents into the intestine

Common complication of some types of gastric surgery

Eat in a recumbent or semi  recumbent position

Lie down after a meal

Small, frequent feedings

Moderate fat, high protein diet.

 Fats slow down gastric motility, proteins increase colloidal osmotic pressure and prevents shifting of plasma

Limit carbohydrates, no simple sugars

Give fluids few hours after meals or in between meals

Avoid very hot and cold foods and beverages

The client is scheduled to have an upper gastrointestinal tract series. Which of the following treatments should the nurse anticipate after the examination?

Administering a laxative.

Placing the client on a clear liquid diet.

Giving the client a tapwater enema.

Starting an intravenous infusion.

The client is scheduled to have an upper gastrointestinal tract series. Which of the following treatments should the nurse anticipate after the examination?

Administering a laxative.

Placing the client on a clear liquid diet.

Giving the client a tapwater enema.

Starting an intravenous infusion.

A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet?

Lean beef.

Air-popped popcorn.

Hot chocolate.

Raw vegetables.

A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet?

Lean beef.

Air-popped popcorn.

Hot chocolate.

Raw vegetables.

The client with (GERD) complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions?

Development of laryngeal cancer.

Irritation of the esophagus.

Esophageal scar tissue formation.

Aspiration of gastric contents.

The client with (GERD) complains of a chronic cough. The nurse understands that in a client with GERD this symptom may be indicative of which of the following conditions?

Development of laryngeal cancer.

Irritation of the esophagus.

Esophageal scar tissue formation.

Aspiration of gastric contents.

The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client says that she will decrease her intake of which of the following food?

Fats.

High-sodium foods.

Carbohydrates.

High-calcium foods.

The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client says that she will decrease her intake of which of the following food?

Fats.

High-sodium foods.

Carbohydrates.

High-calcium foods.

Which of the following dietary measures would be useful in preventing esophageal reflux?

Eating small, frequent meals.

Increasing fluid intake.

Avoiding air swallowing with meals.

Adding a bedtime snack to the dietary plan.

Which of the following dietary measures would be useful in preventing esophageal reflux?

Eating small, frequent meals.

Increasing fluid intake.

Avoiding air swallowing with meals.

Adding a bedtime snack to the dietary plan.

A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?

Ineffective Coping related to fear of diagnosis of chronic illness.

Deficient Knowledge related to unfamiliarity with significant signs and symptoms.

Constipation related to decreased gastric motility.

Imbalanced Nutrition: Less Than Body Requirements related to gastric bleeding.

A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?

Ineffective Coping related to fear of diagnosis of chronic illness.

Deficient Knowledge related to unfamiliarity with significant signs and symptoms.

Constipation related to decreased gastric motility.

Imbalanced Nutrition: Less Than Body Requirements related to gastric bleeding.

The client asks the nurse what causes a peptic ulcer to develop. The nurse responds that recent research indicates that many peptic ulcers are the result of which of the following?

Work-related stress.

Helicobacter pylori infection.

Diets high in fat.

A genetic defect in the gastric mucosa.

The client asks the nurse what causes a peptic ulcer to develop. The nurse responds that recent research indicates that many peptic ulcers are the result of which of the following?

Work-related stress.

Helicobacter pylori infection.

Diets high in fat.

A genetic defect in the gastric mucosa.

A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate?

Imbalanced Nutrition: Less than Body Requirements related to anorexia.

Disturbed Sleep Pattern related to epigastric pain.

Ineffective Coping related to exacerbation of duodenal ulcer.

Activity Intolerance related to abdominal pain.

A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate?

Imbalanced Nutrition: Less than Body Requirements related to anorexia.

Disturbed Sleep Pattern related to epigastric pain.

Ineffective Coping related to exacerbation of duodenal ulcer.

Activity Intolerance related to abdominal pain.

The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following?

Bland foods.

High-protein foods.

Any foods that are tolerated.

Large amounts of milk.

The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following?

Bland foods.

High-protein foods.

Any foods that are tolerated.

Large amounts of milk.

The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from his briefcase and arguing on the telephone with a coworker. The nurse’s response to observing these actions should be based on knowledge that:

Involvement with his job will keep the client from becoming bored.

A relaxed environment will promote ulcer healing.

Not keeping up with his job will increase the client’s stress level.

Setting limits on the client’s behavior is an important nursing responsibility.

The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from his briefcase and arguing on the telephone with a coworker. The nurse’s response to observing these actions should be based on knowledge that:

Involvement with his job will keep the client from becoming bored.

A relaxed environment will promote ulcer healing.

Not keeping up with his job will increase the client’s stress level.

Setting limits on the client’s behavior is an important nursing responsibility.

A client with a peptic ulcer has been instructed to avoid intense physical activity and stress. Which activity should the client incorporate into the home care plan?

Conduct physical activity in the morning so that he can rest in the afternoon.

Have the family agree to perform the necessary yard work at home.

Give up jogging and substitute a less demanding hobby.

Incorporate periods of physical and mental rest in his daily schedule.

A client with a peptic ulcer has been instructed to avoid intense physical activity and stress. Which activity should the client incorporate into the home care plan?

Conduct physical activity in the morning so that he can rest in the afternoon.

Have the family agree to perform the necessary yard work at home.

Give up jogging and substitute a less demanding hobby.

Incorporate periods of physical and mental rest in his daily schedule.

A client is to take one daily dose of ranitidine, (Zantac) at home to treat her peptic ulcer. The nurse knows that the client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times?

Before meals.

With meals.

At bedtime.

When pain occurs.

A client is to take one daily dose of ranitidine, (Zantac) at home to treat her peptic ulcer. The nurse knows that the client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times?

Before meals.

With meals.

At bedtime.

When pain occurs.

A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client’s constipation?

The client has not been including enough fiber in his diet.

The client needs to increase his daily exercise.

The client is experiencing a side effect of the aluminum hydroxide.

The client has developed a gastrointestinal obstruction.

A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client’s constipation?

The client has not been including enough fiber in his diet.

The client needs to increase his daily exercise.

The client is experiencing a side effect of the aluminum hydroxide.

The client has developed a gastrointestinal obstruction.

Can be partial or complete

Classified as mechanical or non-mechanical

Mechanical

Bowel is physically obstructed by disorders outside the intestine (adhesions, hernia)

Or by blockages in the lumen of the intestines (tumors, inflammation, strictures, or fecal impactions)

Non-mechanical

Also known as paralytic ileus or adynamic ileus

A result of neuromuscular disturbance

Peristalsis is decreased or absent, resulting in a slowing of the movement or a backup of intestinal contents

Mechanical intestinal obstruction:

 physical blockage of the passage of intestinal contents with subsequent distention by fluid and gas caused by:

Adhesion

Hernias

Volvulus  twisting of the intestine

Intussusceptions  telescoping of a segment of the intestine within itself

Inflammatory bowel disease

Foreign bodies

Strictures  due to Crohn’s disease

Neoplasmas

Fecal impaction  especially in older adults

Paralytic ileus (neurogenic or adynamic ileus):

 interference with the nerve supply to the intestine resulting in decreased or absent peristalsis caused by:

abdominal surgery

peritonitis

pancreatic toxic conditions

shock

spinal cord injuries

electrolyte imbalances (especially hypokalemia)

Vascular obstructions:

 interference with the blood supply to the portion of the intestine, resulting in ischemia and gangrene of the bowel caused by:

an embolus

atherosclerosis

Small intestine : non- fecal vomiting; colicky intermittent abdominal pain

Large intestine : cramplike abdominal pain, occasional fecal vomitus; client will be unable to pass stools or flatus.

Abdominal distention

Abdominal rigidity

High- pitch bowel sounds above the level of the obstruction

Decreased or absent bowel sound distal to obstruction

Abdominal discomfort or pain possibly accompanied by visible peristaltic waves in upper and middle abdomen

Upper or epigastric abdominal distention

Nausea and early, profuse vomiting

Obstipation

Severe F and E imbalances

Metabolic alkalosis

Intermittent lower abdominal cramping

Lower abdominal cramping

Minimal or no vomiting (may contain fecal material)

Obstipation or ribbon like stool

No major F and E imbalance

Metabolic Acidosis

Large Bowel

Flat-plate (x-ray) of the abdomen reveals the presence of the gas and fluid (air – fluid levels)

Hct increased

Serum sodium, potassium, chloride decreased (from plasma leaking into the peritoneal cavity and fluid trapped in the intestinal lumen)

BUN increased (from dehydration and loss of plasma volume)

Monitor fluid and electrolyte balance, prevent further imbalance, keep client

NPO and administer IV fluids as ordered.

Accurately measure drainage from NG/ intestinal tube.

Place client in fowler’s position to alleviate pressure on diaphragm

Encourage nasal breathing to minimize swallowing of air and further abdominal distention .

Institute comfort measures associated with NG intubation and intestinal decompression.

Prevent complications.

Measure abdominal girth daily to assess for increasing abdominal distention.

Assess for signs and symptoms of peritonitis.

Monitor urinary output.

The physician orders intestinal decompression with a Cantor tube for the client. The primary purpose of a nasoenteric tube such as a Cantor tube is to accomplish which of the following?

Remove fluid and gas from the intestine.

Prevent fluid accumulation in the stomach.

Break up the obstruction.

Provide an alternative route for drug administration.

The physician orders intestinal decompression with a Cantor tube for the client. The primary purpose of a nasoenteric tube such as a Cantor tube is to accomplish which of the following?

Remove fluid and gas from the intestine.

Prevent fluid accumulation in the stomach.

Break up the obstruction.

Provide an alternative route for drug administration.

Which of the following nursing diagnoses would be most appropriate for a client with an intestinal obstruction?

Impaired Swallowing related to NPO status.

Urinary Retention related to deficient fluid volume.

Deficient Fluid Volume related to nausea and vomiting.

Chronic Pain related to abdominal distention.

Which of the following nursing diagnoses would be most appropriate for a client with an intestinal obstruction?

Impaired Swallowing related to NPO status.

Urinary Retention related to deficient fluid volume.

Deficient Fluid Volume related to nausea and vomiting.

Chronic Pain related to abdominal distention.

Break muna tayo!!!

ULCERATIVE COLITIS

Is a recurrent ulcerative and inflammatory disease of the mucosal and submucosal layer of the colon and rectum.

Is a serious disease, accompanied by systemic complications and a high mortality rate.

ULCERATIVE COLITIS

Signs and Symptoms:

Predominant Symptoms

 diarrhea, abdominal pain, rectal bleeding

Pallor; if bleeding is severe

Anorexia

Weight Loss

Dehydration

Cramping

Anemia

macky fbg06

The most intense inflammation begins at the lower right in the sigmoid colon and extends upward and around to the ascending colon.

At the lower left is the ileocecal valve with a portion of terminal ileum that is not involved.

Inflammation with ulcerative colitis tends to be continuous along the mucosal surface and tends to begin in the rectum .

Gross appearance – UC

TREATMENT

1. Diet and Fluid intake

Oral fluids, low-residue diets; supplemental vitamin therapy; and iron replacement

IV Therapy

Smoking Cessation

Avoiding foods that exacerbate symptoms, such as milk and cold foods

Parental Nutrition (PN) may be provided as indicated

TREATMENT

2. Pharmacologic therapy

Sedative, antidiarrheal, and antiperistaltic medications

Sulfasalazine (Azulfidine)

 Which are effective for mild or moderate inflammation.

 Given with a glass of water to prevent stone precipitation

Antibiotics for secondary infections

Adrenocortico tropic hormone (ACTH) and certicosteroids (↓ bleeding)

Aminosalicylates (Topical and oral)

Immunomodulator agent (eg. IMURAN)

Treatment

3. Surgical management

Total colectomy with ileostomy

An opening into the ileum or small intestine (usually by means of an ileal stoma on the abdominal wall) is commonly performed after a total colectomy (i.e. Excision of the entire colon).

Total Colectomy with continent ileostomy

Involves the removal of the entire colon and creation of the continent ileal reservoir (i.e. Cock pouch)

Total Colectomy with ileonal anastomosis

Surgical procedures that eliminates the need for a permanent ileostomy.

It establishes an ileal reservoir and anal sphincter control of elimination is retained.

The client with ILEOSTOMY

Provide explanation of pre-operative and post-operative procedures

Oral antibiotics  to ↓ intestinal bacteria thus ↓potential for peritonitis and wound infection post-op

Maintain fluid and electrolyte balance

Self – care activities; minimize odor formation

WOF: obstruction as evidenced by sudden decrease in drainage or onset of severe abdominal pain, vomiting

NURSING INTERVENTIONS 1. Maintaining Normal Elimination  Determine if there is a relationship between diarrhea and certain foods, activities, or emotional stress  Encourage bed rest to decrease peristalsis 2. Relieving Pain  Administer anticholinergic medications 30 mins. before a meal to decrease intestinal motility  Give Analgesic agents as prescribed

NURSING INTERVENTIONS 3. Maintaining Fluid balance  Record I and 0 including wound / fistula drainage  Monitor weight daily  Assess for signs of fluids volume deficit  Encourage oral intake

NURSING INTERVENTIONS 4. Promoting Nutritional measures  Use PN when symptoms are severe  Test for glucose daily  Give feeding high in protein and low in fat and reside after PN therapy  Provide small frequent, low residue feedings if oral foods are tolerated 5. Promoting rest  Recommend intermittent rest periods during the day  Encourage activity within limits

NURSING INTERVENTIONS 6. Reducing Anxiety  Establish report by being attentive and displaying a calm confidence manner  Tailor information about impending surgery to patients level of understanding and desire for detail 7. Promoting coping skills  Provide understanding and emotional support to patient who feels isolated helpless and out of control  Use stress-reduction measures: relaxation techniques breathing exercises and biofeedback

CROHN’S DISEASE

“ REGIONAL ENTERITIS”

Is an inflammatory disease of the GIT affecting usually the small intestine

Commonly occurs in adolescents and young adults

Signs and Symptoms:

- Anorexia, n/v

- Weight Loss

- Anemia

- Abdominal distention

- Diarrhea (rarely bloody)

- Colicky abdominal pain

macky Crohn’s Disease: Anatomic Distribution Small bowel alone (33%) Colon alone (20%) Ileocolic (45%) Least Most Freq of involvement

Though any portion of the GIT may be involved, the small intestine and the terminal ileum in particular -- is most likely to be involved.

The middle portion of bowel seen here has a thickened wall and the mucosa has lost the regular folds.

The areas of inflammation tend to be discontinuous throughout the bowel.

Gross appearance – CD

NURSING INTERVENTIONS

Maintain NPO during the active phase

Monitor for complications like severe bleeding , dehydration, electrolyte imbalance

Monitor bowel sounds, stool and blood studies

Restrict activities

Administer IVF, electrolytes and TPN if prescribed

Instruct the patient to AVOID gas-forming foods,milk products and foods such as whole grains, nuts, raw fruits and vegetables, pepper, alcohol and caffeine

Diet progression  clear fluid to low residue, high protein diet

Administer drugs  anti-inflammatory, antibiotics, steroids, bulk-forming agents and vitamin/iron supplements

CHRONIC INFLAMMATORY BOWEL DISORDERS A. Regional ENTERITIS (Crohn’s Disease) B. Ulcerative Colitis

Transmural

Mucous ulceration

Ileum/ascending colon

Rectum/ lower colon

Cause

Unknown

Unknown

Jewish

Familial

Environmental

Jewish

Emotional stress

Age

20-30 years

40-60 years

15-40 years

Bleeding

 ; stool with pus and mucus

Severe; stool with blood, pus and mucus

Perianal involvement

Severe

Mild

Fistulas

Common

Rare

Rectal involvement

20%

100%

Diarrhea

5-6 soft stool/ day

20-30 watery stool/ day

Abdominal pain

+

+

Weight loss

+

+

Intervention

TPN

Steriods

Azulfidine (Sulfasalazine)

Ileostomy

Colectomy

Diet

TPN

Steriods

Azulfidine (Sulafasalazine)

Ileostomy/

Proctocolectomy

A client who had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors was most likely of greatest significance in causing an exacerbation of ulcerative colitis?

A demanding and stressful job.

Changing to a modified vegetarian diet.

Beginning a weight-training program.

Walking 2 miles everyday.

A client who had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors was most likely of greatest significance in causing an exacerbation of ulcerative colitis?

A demanding and stressful job.

Changing to a modified vegetarian diet.

Beginning a weight-training program.

Walking 2 miles everyday.

Which goal for the client’s care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?

Promoting self-care and independence.

Managing diarrhea.

Maintaining adequate nutrition.

Promoting rest and comfort.

Which goal for the client’s care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis?

Promoting self-care and independence.

Managing diarrhea.

Maintaining adequate nutrition.

Promoting rest and comfort.

The client with ulcerative colitis is following orders for bed rest with bathroom privileges. Which would be the primary rationale for this activity restriction?

To conserve energy.

To reduce intestinal peristalsis.

To promote rest and comfort.

To prevent injury.

The client with ulcerative colitis is following orders for bed rest with bathroom privileges. Which would be the primary rationale for this activity restriction?

To conserve energy.

To reduce intestinal peristalsis.

To promote rest and comfort.

To prevent injury.

A client who has ulcerative colitis says to the nurse, “I can’t take this anymore! I’m constantly in pain, and I can’t leave my room because I need to stay by the toilet. I don’t know how to deal with this.” Based on these comments, an appropriate nursing diagnosis for this client would be

Impaired Physical Mobility related to fatigue.

Disturbed Thought Processes related to pain.

Social Isolation related to chronic fatigue.

Ineffective Coping related to chronic abdominal pain.

A client who has ulcerative colitis says to the nurse, “I can’t take this anymore! I’m constantly in pain, and I can’t leave my room because I need to stay by the toilet. I don’t know how to deal with this.” Based on these comments, an appropriate nursing diagnosis for this client would be

Impaired Physical Mobility related to fatigue.

Disturbed Thought Processes related to pain.

Social Isolation related to chronic fatigue.

Ineffective Coping related to chronic abdominal pain.

A client newly diagnosed with ulcerative colitis has been placed on steroids. He states that he has heard that taking steroids can be dangerous and asks the nurse why steroids are prescribed. Which of the following statements by the nurse provides the client with accurate information about the use of steroid therapy in the treatment of ulcerative colitis?

“ Ulcerative colitis can be cured by the use of steroids.”

“ Steroids are used in severe flare-ups because they can decrease the incidence of bleeding.”

“ Long-term use of steroids will prolong periods of remission.”

“ The side effects of steroids outweigh their benefit to clients with ulcerative colitis.”

A client newly diagnosed with ulcerative colitis has been placed on steroids. He states that he has heard that taking steroids can be dangerous and asks the nurse why steroids are prescribed. Which of the following statements by the nurse provides the client with accurate information about the use of steroid therapy in the treatment of ulcerative colitis?

“ Ulcerative colitis can be cured by the use of steroids.”

“ Steroids are used in severe flare-ups because they can decrease the incidence of bleeding.”

“ Long-term use of steroids will prolong periods of remission.”

“ The side effects of steroids outweigh their benefit to clients with ulcerative colitis.”

A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the physician will order which of the following treatment approaches to help the client meet his nutritional needs?

Initiate continuous enteral feedings.

Encourage a high-calorie, high-protein diet.

Implement total parenteral nutrition.

Provide six small meals a day.

A client who has ulcerative colitis has persistent diarrhea. He is thin and has lost 12 pounds since the exacerbation of his ulcerative colitis. The nurse should anticipate that the physician will order which of the following treatment approaches to help the client meet his nutritional needs?

Initiate continuous enteral feedings.

Encourage a high-calorie, high-protein diet.

Implement total parenteral nutrition.

Provide six small meals a day.

The physician prescribes sulfasalazine (Azulfidine) for the client with ulcerative colitis to continue taking at home. What instructions should the nurse give the client about taking this medication?

Avoid taking it with food.

Take the total dose at bedtime.

Take it with a full glass (240 mL) of water.

Stop taking it if urine turns orange yellow.

The physician prescribes sulfasalazine (Azulfidine) for the client with ulcerative colitis to continue taking at home. What instructions should the nurse give the client about taking this medication?

Avoid taking it with food.

Take the total dose at bedtime.

Take it with a full glass (240 mL) of water.

Stop taking it if urine turns orange yellow.

Which of the following diets would be most appropriate for the client with ulcerative colitis?

High calorie, low protein.

High protein, low residue.

Low fat, high fiber.

Low sodium, high carbohydrate.

Which of the following diets would be most appropriate for the client with ulcerative colitis?

High calorie, low protein.

High protein, low residue.

Low fat, high fiber.

Low sodium, high carbohydrate.

Which of the following would be a priority focus of care for a client experiencing an exacerbation of his Crohn’s disease?

Encouraging regular ambulation.

Promoting bowel rest.

Maintaining current weight.

Decreasing episodes of rectal bleeding.

Which of the following would be a priority focus of care for a client experiencing an exacerbation of his Crohn’s disease?

Encouraging regular ambulation.

Promoting bowel rest.

Maintaining current weight.

Decreasing episodes of rectal bleeding.

A client ulcerative colitis symptoms have been present for longer than 1 week. The nurse recognizes that the client should be assessed carefully for signs of which of the following complications?

Heart failure.

Deep vein thrombosis.

Hypokalemia.

Hypocalcemia.

A client ulcerative colitis symptoms have been present for longer than 1 week. The nurse recognizes that the client should be assessed carefully for signs of which of the following complications?

Heart failure.

Deep vein thrombosis.

Hypokalemia.

Hypocalcemia.

A client is scheduled for an ileostomy. Which of the following interventions would be most helpful in preparing the client psychologically for the surgery?

Include family members in preoperative teaching sessions.

Encourage the client to ask questions about managing an ileostomy.

Provide a brief, thorough explanation of all preoperative and postoperative procedures.

Invite a member of the ostomy association to visit the client.

A client is scheduled for an ileostomy. Which of the following interventions would be most helpful in preparing the client psychologically for the surgery?

Include family members in preoperative teaching sessions.

Encourage the client to ask questions about managing an ileostomy.

Provide a brief, thorough explanation of all preoperative and postoperative procedures.

Invite a member of the ostomy association to visit the client.

A client who is scheduled for an ileostomy has an order for oral neomycin to be administered before surgery. The nurse understands that the rationale for administering oral neomycin before surgery is to

Prevent postoperative bladder infection.

Reduce the number of intestinal bacteria.

Decrease the potential for postoperative hypostatic pneumonia.

Increase the body’s immunologic response to the stressors of surgery.

A client who is scheduled for an ileostomy has an order for oral neomycin to be administered before surgery. The nurse understands that the rationale for administering oral neomycin before surgery is to

Prevent postoperative bladder infection.

Reduce the number of intestinal bacteria.

Decrease the potential for postoperative hypostatic pneumonia.

Increase the body’s immunologic response to the stressors of surgery.

Of the following outcomes for client care after an ileostomy, which has the highest priority?

Providing relief from constipation.

Assisting the client with self-care activities.

Maintaining fluid and electrolyte balance.

Minimizing odor formation.

Of the following outcomes for client care after an ileostomy, which has the highest priority?

Providing relief from constipation.

Assisting the client with self-care activities.

Minimizing odor formation.

The client asks the nurse, “Is it really possible to lead a normal life with an ileostomy?” Which action by the nurse would be the most effective to address this question?

Have the client talk with a member of the clergy about these concerns.

Tell the client to worry about those concerns after surgery.

Arrange for a person with an ostomy to visit the client preoperatively.

Notify the surgeon of the client’s question.

The client asks the nurse, “Is it really possible to lead a normal life with an ileostomy?” Which action by the nurse would be the most effective to address this question?

Have the client talk with a member of the clergy about these concerns.

Tell the client to worry about those concerns after surgery.

Arrange for a person with an ostomy to visit the client preoperatively.

Notify the surgeon of the client’s question.

The nurse should instruct the client with an ileostomy to report which of the following symptoms immediately?

Passage of liquid stool from the stoma.

Occasional presence of undigested food in the effluent.

Absence of drainage from the ileostomy for 6 or more hours.

Temperature of 99.8F (37.7C).

The nurse should instruct the client with an ileostomy to report which of the following symptoms immediately?

Passage of liquid stool from the stoma.

Occasional presence of undigested food in the effluent.

Absence of drainage from the ileostomy for 6 or more hours.

Temperature of 99.8F (37.7C).

APPENDICITIS

Infectious and inflammatory process of the appendix creating acute abdominal pain and nausea.

Signs & Symptoms

Vague epigastric or peri-umbilical pain which progress to right lower quadrant pain

Low-grade fever

Nausea

Vomiting

Loss of appetite

Local tenderness when pressure is applied

This is the normal appearance of the appendix against the background of the cecum.

Seen here is acute appendicitis with yellow to tan exudate and hyperemia, including the periappendiceal fat superiorly , rather than a smooth, glistening pale tan serosal surface.

APPENDICITIS

Pain gradually becomes localized in RLQ / Mc Burney’s point

Pain is initially intermittent then become steady and severe over a short period.

Rebound tenderness (Blumberg sign)

Psoas sign (lateral position with right hip flexion)

Rovsing’s sign (right quadrant pain when the left is palpated)

Obturator sign (pain on external rotation of the right thigh)

McBurney's point is located one third of the distance along a line from the front of the right pelvic bone and the belly button.

APPENDICITIS Inflammation   Intraluminal pressure   Lymphoid Swelling   Venous drainage  Thrombosis  Bacterial invasion  Abscess  Gangrene  Perforation (24-36hrs)  Peritonitis Pathophysiology

APPENDICITIS

Treatment:

1. Antibiotics

2. Analgesics given post – op

3. Appendectomy

4. General or spinal anesthetic with a low abdominal

incision or by laparoscopy

Goals:

NPO

Bed rest

Relieve pain (cold application over the abdomen NEVER heat)

Avoid factors that increase peristalsis, thereby rupture:

 Heat application over the abdomen

 Laxative

 Enema

REVIEW QUESTIONS

4 items

In a client with acute appendicitis, the nurse should anticipate which of the following treatments?

Administration of enemas to clean bowel.

Insertion of a nasogastric tube.

Placement of client on NPO status.

Administration of heat to the abdomen.

In a client with acute appendicitis, the nurse should anticipate which of the following treatments?

Administration of enemas to clean bowel.

Insertion of a nasogastric tube.

Placement of client on NPO status.

Administration of heat to the abdomen.

A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse suspects which of the following complications?

Deficient fluid volume.

Intestinal obstruction.

Bowel ischemia.

Peritonitis.

A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse suspects which of the following complications?

Deficient fluid volume.

Intestinal obstruction.

Bowel ischemia.

Peritonitis.

Postoperative nursing care for a client after an appendectomy would include which of the following interventions?

Administering sitz baths four times a day.

Noting the first bowel movement after surgery.

Limiting the client’s activity to bathroom privileges.

Measuring abdominal girth every 2 hours.

Postoperative nursing care for a client after an appendectomy would include which of the following interventions?

Administering sitz baths four times a day.

Noting the first bowel movement after surgery.

Limiting the client’s activity to bathroom privileges.

Measuring abdominal girth every 2 hours.

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The nurse understands that the purpose of the drain is to accomplish which of the following?

Provide access for wound irrigation.

Promote drainage of wound exudates.

Minimize development of scar tissue.

Decrease postoperative discomfort.

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The nurse understands that the purpose of the drain is to accomplish which of the following?

Provide access for wound irrigation.

Promote drainage of wound exudates.

Minimize development of scar tissue.

Decrease postoperative discomfort.

Peritonitis

Local or generalized inflammation of part or all of the parietal and visceral surfaces of the abdominal cavity.

Initial response:

Edema

Vascular congestion

Hypermotility of the bowel

Outpouring of plasma-like fluid from the extracellular, vascular and interstitial compartments into the peritoneal space.

Peritonitis

Later response:

Abdominal distention leading to respiratory compromise,

Hypovolemia results in decreased urinary output.

Intestinal motility gradually decrease and progresses to paralytic ileus.

Causes

Ruptured appendix

Perforated peptic ulcer

Diverticulitis

Pelvic inflammatory disease

Urinary tract infection or trauma

Bowel obstruction

Bacteria invasion

Inflammation Adhesions Abscess Intestinal Obstruction Fluid shift into abdominal cavity (300-500 ml.)  Peristalsis Bowel distended with gas & fluid

Hypovolemia

Electrolyte imbalance

Dehydration

Shock

Pathophysiology

Medical Management

NPO with fluid replacement.

Drug therapy: antibiotics to combat infection

Surgery

Laparatomy: opening made through the abdominal wall into the peritoneal cavity to determine the cause of peritonitis.

Depending on cause, bowel resection may be necessary.

Assessment findings

Severe abdominal pain, rebound tenderness, muscle ridigity, absent bowel sounds, abdominal distention (particularly if large bowel obstruction).

Anorexia, nausea and vomiting

Swallow respirations; decreased urinary output; weak,rapid pulse; elevated temperature.

Signs of shock

Tachycardia

Tachypnea

Oliguria

Restlessness

Weakness pallor

Diaphoresis

Assessment findings

Diagnostic tests

WBC elevated WBC (20,000/cu. mm or higher)

Hct elevated (if hemoconcentration)

Nursing Interventions

Assess respiratory status for possible distress.

Assess characteristics of abdominal pain and changes overtime.

Administer medications as ordered.

Perform frequent abdominal assessment.

Monitor and maintain fluid and electrolyte balance; monitor for sings of septic shock.

Maintain patency of NG or intestinal tubes.

Provide routine pre-and post-op care if surgery ordered.

Collaborative Management

Monitor VS, I and O.

NGT is inserted to relieve abdominal distention

Bed rest in semi-fowler’s position

Encourage deep breathing exercises

Insertion of drainage tube

Fluid, electrolytes and colloids replacement

Antibiotics

TPN solutions

HEMORRHOIDS

Dilated blood vessels beneath the

lining of the anal canal

Dilated portions of veins in the anal canal

HEMORRHOIDS

Signs and Symptoms

Constipation in an effort to prevent pain or bleeding associated with defecation

Anal pain

Rectal bleeding

Anal itchiness

Mucous secretion from the anus

Sensation of incomplete evacuation of the rectum

Intestinal hemorrhoids may prolapsed

Bright red bleeding

Edema (caused by thrombus)

Ischemia of the area

Necrosis

Shearing of the mucosa during defecation ↓ ↑ P during pregnancy or straining , Sliding of the structures in the anal wall ↓ Inflammation & edema of the anus ↓ Thrombosis of the hemorrhoid ↓ Ischemia ↓ Necrosis Pathophysiology

HEMORRHOIDS

Treatment

Surgery

Hemorrhoidectomy

Sclerotherapy (5 % phenol oil)

Cryosurgery

Rubber band ligation

Preop care

Low residue diet to reduce the bulk of stool

Stool softeners

Postop care

Promotion of comfort

Analgesics as prescribed

Excision For the patient with small, external hemorrhoids , where there is severe pain, clot formation, and danger of infection, simple excision of the clot may be all that is necessary. This means that after the hemorrhoidal area has been anethesized, a small incisioin is made in the skin directly over the blood clot. The clot is then gently squeezed out with thumb and forefinger .

Injection This works best for small, internal hemorrhoids that are not prolapsed and where intermittent bleeding is the only symptom. A special solutions is injected into the tissue surrounding the hemorrhoid. This solution causes the blood in the swollen veins to clot ; the clot eventually dissolves and pain and bleeding soon disappear.

Banding If the hemorrhoids are too large to respond satisfactorily to injection, and if they are not permanently prolapsed, the banding technique offers a safe, effective, and painless alternative to surgery. In this procedure, rubber bands are placed around the base of the hemorrhoidal mass. In about seven days, the hemorrhoid dries up and sloughs off.

Hemorrhoidectomy The only method for complete cure of large, permanently protruding hemorrhoids is surgical removal. This is especially true if other measures have failed to relieve symptoms. In this operation, all of the hemorrhoidal tissue is removed from beneath the skin and mucous membrane. The incision is then closed with sutures. The patient can usually leave the hospital in six or seven days. Final healing takes three to four week

HEMORRHOIDS

Promotion of comfort

Analgesics as prescribed

Side lying position

Hot sitz bath 12-24 hrs. Postop

Promotion of elimination

Stool softener as prescribed

Encourage the client to defecate as soon as the urge occurs

Analgesic before initial defecation

Enema as prescribed, using a small-bore rectal tube

HEMORRHOIDS

Nursing Intervention

High fiber diet

Bulk laxatives

Provide good personal hygiene

Increase Fluid intake

Warm compress, sitz bath

Analgesic ointments

Suppositories

Patient teaching

REVIEW QUESTIONS

4 items

A 36-year-old female client has been diagnosed with hemorrhoids. Which of the following factors in the client’s history would most likely be a primary cause of her hemorrhoids?

Her age.

Three vaginal delivery pregnancies.

Her job as a schoolteacher.

Varicosities in her legs.

A 36-year-old female client has been diagnosed with hemorrhoids. Which of the following factors in the client’s history would most likely be a primary cause of her hemorrhoids?

Her age.

Three vaginal delivery pregnancies.

Her job as a schoolteacher.

Varicosities in her legs.

Which position would be ideal for the client in the early postoperative period after a hemorrhoidectomy?

High Fowler’s

Supine.

Side-lying.

Trendelenburg’s.

Which position would be ideal for the client in the early postoperative period after a hemorrhoidectomy?

High Fowler’s

Supine.

Side-lying.

Trendelenburg’s.

The nurse instructs the client who has had a hemorrhoidectomy not to use sitz baths until at least 12 hours postoperatively to avoid inducing which of the following complications?

Hemorrhage.

Rectal spasm.

Urinary retention.

Constipation.

The nurse instructs the client who has had a hemorrhoidectomy not to use sitz baths until at least 12 hours postoperatively to avoid inducing which of the following complications?

Hemorrhage.

Rectal spasm.

Urinary retention.

Constipation.

The nurse teaches the client who has had rectal surgery the proper timing for sitz baths. The nurse knows that the client has understood the teaching when the client states that it is most important to take a sitz bath

First thing each morning.

As needed for discomfort.

After a bowel movement.

At bedtime.

The nurse teaches the client who has had rectal surgery the proper timing for sitz baths. The nurse knows that the client has understood the teaching when the client states that it is most important to take a sitz bath

First thing each morning.

As needed for discomfort.

After a bowel movement.

At bedtime.

Conditions of the Accessory organs The Gallbladder macky

CONDITION OF THE GALLBLADDER

Cholecystitis

Inflammation of the gallbladder

Can be acute or chronic

macky

Cholecystitis

Acute cholecystitis usually is due to gallbladder stones

macky

Cholecystitis

Chronic cholecystitis is usually due to long standing gall bladder inflammation

macky

Cholelithiasis

Formation of GALLSTONES in the biliary apparatus

macky

Predisposing FACTORS

“ F”

Female

Fat

Forty

Fertile

macky

Obesity increases the risk for cholelithiasis. Note the mix gallstones with a prominent component of yellowish cholesterol seen here in an opened gallbladder removed at surgery.

macky

Pathophysiology

Supersaturated bile, Biliary stasis

Stone formation

Blockage of Gallbladder

Inflammation, Mucosal Damage and WBC infiltration

macky

PATHOPHYSIOLOGY ↓ bile acid synthesis, ↑ cholesterol synthesis Bile becomes supersaturated w/ cholesterol Cholesterol stones form Gall stone Inflammatory changes in gallbladder Obstruction of bile passage Congestion/distension of gall bladder ↓ bile transport to duodenum  clay-colored stool

↑ bile absorption by blood

Jaundice

dark colored urine

Gross appearance of gallbladder after sectioning longitudinally. Notice thickness of gallbladder wall, abundant stones

ASSESSMENT findings for cholecystitis

1. Indigestion, belching and flatulence

2. Fatty food intolerance

macky

3. Epigastric pain that radiates to the scapula or localized at the RUQ

4. Mass at the RUQ

macky

5. Murphy’s sign

6. Jaundice

7. CHARCOT TRIAD (fever, jaundice, RUQ pain)

macky

DIAGNOSTIC PROCEDURES

1. Ultrasonography- can detect the stones

2. Abdominal X-ray

3. Cholecystography

macky

DIAGNOSTIC PROCEDURES

4. WBC count increased

5. ERCP: reveals inflamed gallbladder with gallstone

macky

1. Maintain NPO in the active phase

2. Maintain NGT decompression

macky

3. Administer prescribed medications to relieve pain. Usually Demerol (MEPERIDINE)

Codeine and Morphine may cause spasm of the Sphincter  increased pain. Morphine cause MORE PAIN

macky

4. Instruct patient to AVOID HIGH- fat diet and GAS-forming foods

5. Assist in surgical and non-surgical measures

6. Surgical procedures- Cholecystectomy, Choledochotomy, laparoscopy

macky

PHARMACOLOGIC THERAPY

Analgesic- Meperidine

Chenodeoxycholic acid= to dissolve the gallstones

Antacids

Anti-emetics

macky

Surgical Management

Cholecystectomy  removal of the gall bladder

Laparoscopic Cholecystectomy

Choledocotomy  opening of the gallbladder to remove stones

Choledocostomy  CBD exploration

macky

macky T-tube

CHOLEDOCHOSTOMY

If with CBD exploration: T – tube

Purpose: to drain the bile

Drainage:

Brownish red for the first 24 hours (combination of bile and blood)

300 – 500 mL of bile drainage for the first 24 hours

Drainage bottle should be placed in bed at the level of incision; this is to drain the excess bile, not all the bile

Post-operative nursing interventions

1. Monitor for surgical complications

2. Post-operative position after recovery from anesthesia- LOW / SEMI FOWLER’s

macky

3. Encourage early ambulation

4. Administer medication before coughing and deep breathing exercises

5. Advise client to splint the abdomen to prevent discomfort during coughing

macky

6. Administer analgesics, antiemetics, antacids

7. Care of the biliary drainageor T-tube drainage

8. Fat restriction is only limited to 4-6 weeks. Normal diet is resumed

macky

REVIEW QUESTIONS

5 items

A client is admitted to the hospital with a diagnosis of cholecystitis. The client is complaining of severe abdominal pain and extreme nausea and has vomited several times. Based on this data, which nursing diagnosis would have the highest priority for intervention at this time?

Anxiety related to severe abdominal discomfort.

Deficient Fluid Volume related to vomiting.

Pain related to gallbladder inflammation.

Imbalanced Nutrition: Less Than Body Requirements related to vomiting.

A client is admitted to the hospital with a diagnosis of cholecystitis. The client is complaining of severe abdominal pain and extreme nausea and has vomited several times. Based on this data, which nursing diagnosis would have the highest priority for intervention at this time?

Anxiety related to severe abdominal discomfort.

Deficient Fluid Volume related to vomiting.

Pain related to gallbladder inflammation.

Imbalanced Nutrition: Less Than Body Requirements related to vomiting.

A client with cholecystitis is complaining of severe right upper quadrant pain. Which of the following medications would the nurse anticipate administering to relieve the client’s pain?

Meperidine (Demerol).

Acetaminophen with codeine.

Promethazine (Phenergan).

Morphine sulfate.

A client with cholecystitis is complaining of severe right upper quadrant pain. Which of the following medications would the nurse anticipate administering to relieve the client’s pain?

Meperidine (Demerol).

Acetaminophen with codeine.

Promethazine (Phenergan).

Morphine sulfate.

If a gallstone becomes lodged in the common bile duct, the nurse should anticipate that the client’s stools would most likely become what color?

Green.

Gray.

Black.

Brown.

If a gallstone becomes lodged in the common bile duct, the nurse should anticipate that the client’s stools would most likely become what color?

Green.

Gray.

Black.

Brown.

Which of the following discharge instructions would be appropriate for a client who has had a laparoscopic cholecystectomy?

Avoid showering for 48 hours after surgery.

Return to work within 1 week.

Change the dressing daily until the incision heals.

Use acetaminophen (Tylenol) to control any fever.

Which of the following discharge instructions would be appropriate for a client who has had a laparoscopic cholecystectomy?

Avoid showering for 48 hours after surgery.

Return to work within 1 week.

Change the dressing daily until the incision heals.

Use acetaminophen (Tylenol) to control any fever.

How much bile would the nurse expect the T-tube to drain during the first 24 hours after a choledocholithotomy?

50 to 100 mL.

150 to 250mL.

300 to 500 mL.

550 to 700 mL.

How much bile would the nurse expect the T-tube to drain during the first 24 hours after a choledocholithotomy?

50 to 100 mL.

150 to 250mL.

300 to 500 mL.

550 to 700 mL.

DIVERCULAR DISEASE

Sac like outpouching or herniation of the lining of the bowel that protrudes through a weak portion of the muscle layer.

Commonly in the colon

diverticula

Signs and Symptoms

Diverticulosis

Exist when multiple diverticula are present without inflammation or symptoms

Common in 60 years old and above

Diverticulitis (+ inflammation)

Narrowing of large bowel with fibrotic structure

Chronic constipation with episodes of diarrhea

Occult bleeding

Weakness, fatigue and anorexia

Tenderness, palpable mass, fever

Abdominal pain, rigid board like abdomen (due to development of abscess or perforation)

Low fecal volume in the colon Increased intraluminal pressure Decreased muscle strength in the colon wall Herniation/Outpoutching of mucous membrane Entrapment of fecal material and bacteria Inflammation and infection Scarring Abscess Bleeding Perforation Peritonitis Decreased muscle strength in the colon wall

Treatment

high fiber diet to prevent constipation

clear liquids until inflammation subsides

low fat diet

antibiotics for 7-10 days

laxatives

antispasmodics for spastic pain, taken before

meals an at bed time

stool softeners, warm oil enemas

surgery is necessary if perforation, peritonitis,

abscess formation, hemorrhage or obstruction

occurs, recurrence of diverticula is common.

maintain normal elimination pattern

increase fluid intake to 2L/day

soft food but high fiber content

exercise program to improve abdominal muscle tone

encourage daily intake of laxatives

relieve pain

analgesics as ordered

monitor and record pain (location and duration)

monitor and manage potential complications

REVIEW QUESTIONS

5 items

Which of the following laboratory findings would the nurse expect to find in a client with diverticulitis?

Elevated red blood cell count.

Decreased platelet count.

Elevated white blood cell count.

Elevated serum blood urea nitrogen concentration.

Which of the following laboratory findings would the nurse expect to find in a client with diverticulitis?

Elevated red blood cell count.

Decreased platelet count.

Elevated white blood cell count.

Elevated serum blood urea nitrogen concentration.

The nurse is aware that the diagnostic test typically ordered for acute diverticulitis do not include a barium enema

Can perforate an intestinal abscess.

Would greatly increase the client’s pain.

Is of minimal diagnostic value in diverticulitis.

Is too lengthly a procedure for the client to tolerate.

The nurse is aware that the diagnostic test typically ordered for acute diverticulitis do not include a barium enema

Can perforate an intestinal abscess.

Would greatly increase the client’s pain.

Is of minimal diagnostic value in diverticulitis.

Is too lengthly a procedure for the client to tolerate.

Which of the following measures should the client with diverticulitis be taught to integrate into his daily routine at home?

Using enemas to relieve constipation.

Decreasing fluid intake to increase the formed consistency of the stool.

Eating a high-fiber diet when symptomatic with diverticulitis.

Refraining from straining and lifting activities.

Which of the following measures should the client with diverticulitis be taught to integrate into his daily routine at home?

Using enemas to relieve constipation.

Decreasing fluid intake to increase the formed consistency of the stool.

Eating a high-fiber diet when symptomatic with diverticulitis.

Refraining from straining and lifting activities.

Which of the following signs would be indicative of peritonitis in a client with diverticulitis?

a. Hyperactive bowel sounds.

b. Rigid abdominal wall.

c. Explosive diarrhea.

d. Excessive flatulence.

Which of the following signs would be indicative of peritonitis in a client with diverticulitis?

a. Hyperactive bowel sounds.

b. Rigid abdominal wall.

c. Explosive diarrhea.

d. Excessive flatulence.

Which of the following medications would the nurse anticipate administering to a client with diverticular disease?

Psyllium hydrophilic mucilloid (Metamucil).

Diphenoxylate with atropine sulfate (Lomotil).

Diazepam (Valium).

Aluminum hydroxide (Amphojel).

Which of the following medications would the nurse anticipate administering to a client with diverticular disease?

Psyllium hydrophilic mucilloid (Metamucil).

Diphenoxylate with atropine sulfate (Lomotil).

Diazepam (Valium).

Aluminum hydroxide (Amphojel).

Acute Pancreatitis Characterized by edema and inflammation confined to the pancreas.

Signs and Symptoms

Abdominal pain LUQ; may start at the epigastrium, radiate to the back, flanks

Jaundice

Fever

Nausea & vomiting

Dehydration

Mental confusion

Dyspnea

Tachypnea

Hypotension

Absent or decrease bowel sounds

Criteria on admission to hospital

Age > 55 years old

WBC . 16,000 mm 3

Serum glucose > 200mg/dL (> 11.1 mmol/L)

Serum LDH > 350 u/mL

AST > 200 u/mL

Pathophysiology Damage to pancreatic cells Inflammation Edema of the pancreas and pancreatic duct Obstruction to the flow of pancreatic enzyme Activation of pancreatic enzymes inside the pancreas Auto digestion of the pancreas Ulceration Hemorrhage Fatty necrosis Infection

DIAGNOSTIC TEST

Serum AMYLASE and Lipase are increased

Serum Calcium is decreased

Calicium combine with fatty acid released by lipolysis  soaps

CT Scan

Shows enlargement of the pancreas

Serum Glucose

Is increased, due to damage to Islet of Langerhans causing inadequate insulin secretion

MEDICAL MANAGEMENT

Drug Therapy

Analgesics (DEMEROL) to relieve pain

Smooth muscle relaxant (PAPAVERINE)to relieve pain

Anticholinergics (ATROPINE) to decrease pancreatic stimulation

Diet modification

NPO usually for a few days to promote GIT rest

Peritoneal lavage

Administer analgesics, antacids, anti cholinergic as ordered

Withhold food/fluid and eliminate odor of food from environment to ↓pancreatic stimulation

Maintain nasogastric tube and assess drainage

Institute non-pharmacologic measures to decrease pain (knee chest, fetal position)

Small frequent feedings instead of three large ones (↑CHO, ↑CHON, ↓Fat)

TPN to provide nutritional supplement during acute phase when NPO is instituted

Calcium supplements to manage hypocalcemia

Vitamin D to promote calcium absorption

Insulin to manage hyperglycemia

Eliminate ALCOHOL totally!

REVIEW QUESTIONS

8 items

The initial diagnosis of pancreatitis is confirmed if the client’s blood work shows a significant elevation in which of the following serum values?

Amylase.

Glucose.

Potassium.

Trypsin.

The initial diagnosis of pancreatitis is confirmed if the client’s blood work shows a significant elevation in which of the following serum values?

Amylase.

Glucose.

Potassium.

Trypsin.

The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that

There is a strong link between alcohol use and acute pancreatitis.

Alcohol intake can interfere with the tests used to diagnose pancreatitis.

Alcoholism is a major health problem, and all clients are questioned about alcohol intake.

The physician must obtain the pertinent facts, regardless of religious beliefs.

The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that

There is a strong link between alcohol use and acute pancreatitis.

Alcohol intake can interfere with the tests used to diagnose pancreatitis.

Alcoholism is a major health problem, and all clients are questioned about alcohol intake.

The physician must obtain the pertinent facts, regardless of religious beliefs.

Which of the following signs and symptoms would the nurse expect to see in a client with acute pancreatitis?

Diarrhea.

Jaundice.

Hypertension

.Ascites

Which of the following signs and symptoms would the nurse expect to see in a client with acute pancreatitis?

Diarrhea.

Jaundice.

Hypertension

.Ascites

The nurse evaluates the client’s most recent laboratory data. Which laboratory finding would be consistent with a diagnosis of acute pancreatitis?

Hyperglycemia.

Leukopenia.

Thrombocytopenia.

Hyperkalemia.

The nurse evaluates the client’s most recent laboratory data. Which laboratory finding would be consistent with a diagnosis of acute pancreatitis?

Hyperglycemia.

Leukopenia.

Thrombocytopenia.

Hyperkalemia.

The initial treatment plan for a client with pancreatitis most likely would focus on which of the following as a priority?

Resting the gastrointestinal tract.

Ensuring adequate nutrition.

Preventing the development of an infection.

The initial treatment plan for a client with pancreatitis most likely would focus on which of the following as a priority?

Resting the gastrointestinal tract.

Ensuring adequate nutrition.

Preventing the development of an infection.

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms?

The client may be developing hypocalcemia.

The client is experiencing a reaction to meperidine (Demerol).

The client has a nutritional imbalance.

The client needs a muscle relaxant to help him rest.

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms?

The client may be developing hypocalcemia.

The client is experiencing a reaction to meperidine (Demerol).

The client has a nutritional imbalance.

The client needs a muscle relaxant to help him rest.

Which of the following would most likely be a major nursing diagnosis for a client with acute pancreatitis?

Ineffective Airway Clearance.

Excess Fluid Volume.

Impaired Swallowing.

Imbalanced Nutrition: Less Than Body Requirements.

Which of the following would most likely be a major nursing diagnosis for a client with acute pancreatitis?

Ineffective Airway Clearance.

Excess Fluid Volume.

Impaired Swallowing.

Imbalanced Nutrition: Less Than Body Requirements.

The client with chronic pancreatitis should be monitored closely for the development of which of the following disorders?

Cholelithiasis.

Hepatitis.

Irritable bowel syndrome.

Diabetes mellitus.

The client with chronic pancreatitis should be monitored closely for the development of which of the following disorders?

Cholelithiasis.

Hepatitis.

Irritable bowel syndrome.

Diabetes mellitus.

Liver Cirrhosis

Is a chronic disease of the liver in which liver tissue is replaced by connective tissue , resulting in the loss of liver function .

Cirrhosis is caused by damage from toxins (including alcohol), metabolic problems, chronic viral hepatitis or other causes.

Cirrhosis is irreversible but treatment of the causative disease will slow or even halt the damage.

PATHOPHYSIOLOGY Alcohol abuse, malnutrition, infection, drugs, biliary, obstruction Destruction of hepatocytes Obstruction of blood flow, Increase pressure in the venous and sinusoidal Channel, Fatty infiltration fibrosis / scarring Portal hypertension Fibrosis / scarring

Assessment Findings

Anorexia, N/V, changes in bowel patterns (altered ability of the liver to metabolized CHO, CHONS, and fats)

Hepatomegaly (early/initially), atrophy of the liver (later, as fibrosis replaces the liver parenchyma)

Jaundice, pruritus, tea colored urine (due to ↑ serum bilirubin in the blood)

Fever (response to tissue injury)

Bleeding tendencies (liver unable to store vitamin K)

Assessment Findings

Splenomegaly (due to ↑ back pressure of the blood)

Spider angioma (red spots on the upper body)

Palmar erythema

Portal obstruction and ascites (due to increasing pressure, low level of serum albumin)

Esophageal varices

Infection

Hepatic Encephalopathy

Due to ↑increased AMMONIA levels

The liver cannot convert ammonia by products of protein metabolism into Urea.

This will accumulate and cause the hepatic coma.

The initial manifestations are BEHAVIORAL changes and MENTAL changes.

Hepatic Encephalopathy

Other findings in advanced stages are:

Asterixis  flapping tremors of the hands

Constructional Apraxia  deterioration of handwriting and inability to draw a simple star figures

Confusion / disorientation

Delirium / hallucination

Fetor hapaticus  disagreeable odor from the mouth.

Summary of Collaborative Management

Rest. To reduce metabolic demands of the liver.

Diet

HIGH calorie, HIGH carbohydrates

LOW protein

Moderate fats.

Skin care

Avoid trauma/injury

Prevent infection

Manage Ascites

Monitor weight, intake and output, abdominal girth

Restrict sodium and fluid intake

Administer diuretics as ordered

Administer albumin / IV as ordered assist in paracentesis

Manage Esophageal Varices

Avoid the following to prevent rupture of the varices:

Shouting, yelling, screaming

Straining at stool

Bending, stooping

Hot, spicy foods.

Lifting heavy objects

If bleeding esophageal varices occur:

Place in semi-Fowler’s position to prevent aspiration

Suction the mouth

Administer vasopressin as ordered. This produce vasoconstriction of splanchnic arterial bed.

Gastric lavage with tap water (room temperature saline) as ordered.

Sclerotherapy

Balloon tamponade with the use of Sengstaken – Blakemore tube

Variceal band ligation

Decrease Ammonia formation

Restrict protein in the diet

Duphalac (lactulose) to lower pH in the colon and reduce formation of alkaline ammonia. It also increases peristalsis so, excretion of ammonia via feces is enhanced.

Neomycin sulfate to reduce colonic bacteria which are responsible for ammonia formation.

Tap water or NSS enema to remove digested blood from the colon . Blood is protein and will produce ammonia.

Summary of Collaborative Management

Avoid sedatives and paracetamol. These are hepatotoxic agents.

Avoid ASA. This causes bleeding. Eliminate alcohol.

Provide sufficient rest and comfort.

Provide bed rest with bathroom privileges.

Encourage gradual, progressive, increasing activity with planned rest periods.

Institute measures to relieve pruritus.

Do not use soaps and detergents.

Bath with tepid water followed by application of an emollient lotion.

Provide cool, light, nonrestrictive clothing.

Keep nails short to avoid skin excoriation from scratching.

Apply cool, moist compresses to pruritic areas.

Promote nutritional intake.

Encourage small frequent feedings.

Promote a high calorie, low to moderate protein, high carbohydrate, low fat diet, with supplemental vitamin therapy (vitamins A, B-complex, C, D, K and folic acid)