Transcript Problem of the Lower GI Tract Diverticulosis & Diverticulitis

Problem of the Lower GI Tract
Diverticulosis & Diverticulitis
Diverticulum-is the outpouching of the
intestinal mucosa, which may occur at
any point in the GI Tract but more
commonly in the sigmoid colon.
Diverticulosis-is the presence of
multiple diverticula.
Diverticulitis-inflammation of
diverticula.
Problem of the Lower GI Tract
Characteristic
No symptoms unless complications
develop
Large bowel diverticula are more apt to
develop complications
Complications are perforation,
hemorrhage, inflammation, fistulas,
and abscess
Problem of the Lower GI Tract
Assessment
Assess for cramp like pain
Check for flatulence
Assess for nausea
Evaluate patterns of irregularity,
irritability any spasticity of the intestine
Assess for fever
Examine dysuria associated with bladder
involvement
Problem of the Lower GI Tract
Implementation
Provide care during acute phase
Bedrest, IV fluids,NPO, NG decompression,
Drugs:Abx, analgesic, antispasmodic.
Monitor appropriate diet.
High-residue diet-for diverticulosis
Low residue- for severe diverticulitis
Provide vitamin & iron supplements.
Administer anticholinergics: Donnatal
Provide sedatives and tranquilizers for anxiety
Monitor stool normalization
Problem of the Lower GI Tract
Ulcerative Colitis
A chronic ulcerative and
inflammatory disease of the colon
and rectum, which commonly
begins in the rectum and sigmoid
colon and spread upward. The
disease is characterized by periods
of exacerbation and remissions.
Problem of the Lower GI Tract
Assessment
Asses for gradual onset
Malaise
Early-vague abdominal discomfort
Later- cramp like abdominal pain
Bowel evacuation-pus, mucus,blood
Stools scanty and hard
painful defecation with defecation
Assess for abrupt onset
Problem of the Lower GI Tract
Assessment con’t..
Assess for complications
Dehydration, bleeding tendency
Abscesses and strictures
Hemorrhoids and anal fissures
Magnesium and calcium imbalances
Perforation, peritonitis
Evaluate results of client’s Hx &
diagnostic tests
Medical Hx.,Clinical Manifestations, Lower
GI series, Stool and blood exam.
Sigmoidoscopy
Problem of the Lower GI Tract
Implementation
Major objective-prevent acute episodes &
manage complications
Maintain nutritional status
High-protein, high-calorie, high-fiber diet
Avoid certain spices (pepper), gas-forming foods
and milk product.
All foods should be cooked to reduce cramping
and diarrhea.
Vitamins (A&E), minerals(zinc, calcium &
magnesium) and iron supplements
Eating may increase diarrhea and anorexia
Problem of the Lower GI Tract
Implementation con’t….
Replace fluid & electrolytes loss due to
diarrhea.
3 to 4 liters a day
KCL may need to be added
Correct psychological disturbances
Allow pt. to ventilate feeling
Avoid emotional probing during period of
acute illness
Help pt. Live with chronic disease
Problem of the Lower GI Tract
Implementation con’t…
Administer drugs as ordered.
Steroid therapy for inflammation
Anti-infectives-sulfa-to reduce severity of
attack.
Immunosuppressive
Tranquilizers- to relieve anxiety
Anticholinergics- relieve cramp
Maintain bed rest during acute phase
Problem of the Lower GI Tract
Characteristic Ulcerative
Colitis
Age
Young to middle
Age
Location
Starts distally &
spreads in a
cont. pattern up
to the colon
Distribution
Perforation
Continuous
Common
Crohn’s Disease
Young
Occurs anywhere
along GI tract in
characteristic skip
lesions; most
frequent site is
terminal ileum
Segmental
Common
Problem of the Lower GI Tract
Characteristic Ulcerative
Colitis
Crohn’s
Disease
Depth of
involvement
Mucosa &
submucosa
Entire thickness
of bowel wall
Small bowel
involvement
Minimal
Common
Malabsorption
Minimal
incidence
Common
Diarrhea
Possible
Common
Problem of the Lower GI Tract
Abdominal
Crampy pain
Possible
Common
Fever(intermittent) During acute
Attacks
Common
Weight loss
Common
Severe
Cobblestoning of
mucosa
Rare
Common
Carcinoma
Increased
after 10 yrs.
Slightly greater
than gen. Pop.
Recurrence after
surgery
Cure with
colectomy
70% or more
recurrence
Disorders of Liver, Biliary & Pancreatic
Function
Physical Examination
Palpation of the abdomen to
determine tenderness, size, & shape of
liver and spleen.
Visual inspection for ascites, venous
networks, and jaundice.
Disorders of Liver, Biliary & Pancreatic
Function
Hepatic Failure
Viral Hepatitis- inflammation of the liver.
1. Transmission:
a. oral-anal route
b. Blood transfusion with infected
serum or plasma.
c. Contaminated equipmentsyringes, needles.
d. Contaminated milk, water, and
food.
e. antibodies persist in serum
Disorders of Liver, Biliary & Pancreatic
Function
Prevention
Good handwashing
Good personal hygiene
Control and screening of food handlers
Passive immunization
Incubation period: 20 to 50 days(short
incubation period)
Disorders of Liver, Biliary & Pancreatic
Function
INCIDENCE
More common in fall and winter months.
Usually found in children and young
adults
Client is infectious 3 weeks prior to and 1
week after developing jaundice.
Clinical recovery: 3 to 16 weeks.
Disorders of Liver, Biliary & Pancreatic
Function
Hepatitis B-Transmission
Oral or parenteral route with infusion,
ingestion or inhalation of a blood of an
infected person.
Contaminated needles, syringes, dental
instruments.
Oral or sexual contact.
High risk individuals includes homosexual, IV
drug abusers, medical workers.
* Ranked as the 5th leading cause of death.
Disorders of Liver, Biliary & Pancreatic
Function
Prevention
Screen blood donors for HB3 AG.
Registration of all carriers
Active immunization- Hepatavax
Type C:
1. Transmission-contaminated
blood
2. Usual incubation period-7 to 8
weeks.
Disorders of Liver, Biliary & Pancreatic
Function
Hepatitis D-Transmission
Same as Hepatitis B
Hepatitis D- transmitted through oralfecal contaminated water; course of
illness resembles hepatitis A
Disorders of Liver, Biliary & Pancreatic
Function
Assessment
Assess preicteric phase
1. Lethargy and malaise
2. Anorexia, nausea,& vomiting
3. Headache
4. Abdominal tenderness and pain
5. Diarrhea or constipation
6. Low-grade temperature
Assess icteric phase
1. Dark urine and clay-colored stools
2. Jaundice
3. Pruritus
Disorders of Liver, Biliary & Pancreatic
Function
Implementation
Wash your hands, wear gloves
Use disposable equipment or sterilized
reusable equipment.
Provide diet-high calorie
Bedrest
Instruct client and family
stress never to offer to be a blood donor/
encourage gamma globulin for close
contacts.
Restricted use of alcohol
Abstain from sexual activity during
communicable period.
Cirrhosis
Definition
Cirrhosis-progressive disease of the liver
characterized by diffuse damage to the cell with
fibrosis and nodular regeneration.
1. Laennec’s portal (alcoholic/nutritional)
a. Most common in the U.S.
b. Scar tissue surrounds the portal
areas.
c. Characterized by destruction of
hepatic tissue, increased fibrous tissue(early
hepatic stage) ,in late stage, it is small and
nodular.
Cirrhosis
Types
Postnecrotic cirrhosis- a sequela to
viral hepatitis. Liver decreased in size
with nodules and fibrous tissue.
Biliary cirrhosis- Inflammation of
intrahepatic bile duct as a result of
chronic biliary obstruction and infection
in the liver and common bile duct.
There is increased skin pigmentation
resembling a deep tan, jaundice and
pruritus.
Cirrhosis
Types
Cardiac- Right-sided CHF. Liver is
swollen and changes are reversible if
CHF is treated effectively. Some
fibrosis occurs with long standing CHF.
Nonspecific, metabolic
cirrhosis- Metabolic problems,
infectious disease, infiltrative diseases,
GI diseases.Portal and liver fibrosis
may develop;liver is enlarged and firm.
Cirrhosis
Causes
Repeated destruction of hepatic cells,
replacement with scar tissue and
regeneration of liver cells.
Insidious onset with progression over
a period of years.
Occurs twice as often in males,
primarily affects 40 to 60 year old age
group.
Cirrhosis
Clinical Progression
Hepatomegaly-due to accumulation of
fat in the cell.
Anorexia, weight loss, fatigue, jaundice
Portal Hypertension-leads to esophageal
varices
Peripheral edema and ascitesaccompanied by hormone imbalance
Hepatic coma
Cirrhosis
Assessment
Evaluate client’s hx. Of failing health,weakness,
gastrointestinal distress, fatigue, weight loss, &
low resistance to infection.
Assess for ascites due malnutrition, portal
hypertension, low albumin
Check for hematemesis
Palpate liver
Assess for esophageal varices, hemorrhoids from
portal hypertension.
Evaluate skin manifestations- spider angiomas
Assess for precoma state-tremor, delirium &
dysarthia.
Cirrhosis
Complications
Portal Hypertension-pressures within the
the portal venous system become elevated
as liver damages obstructs the free flow of
blood through the organ.
Characteristics:
Causes congestion of the spleen,
pancreas and GI Tract.
As the body compensates for
increased pressure in the hepatic system,
collateral circulation develop.
Cirrhosis
Complications
Ascites-results of portal hypertension,
decreased synthesis of the albumin, increased
level of aldosterone, obstruction of hepatic
lymph flow.
LVP- removal of 5 liters or more ascitic
fluid during a single tx. Albumin IV is given
simultaneously.
PVS-one end of the catheter is implanted in
the peritoneal cavity & the tube is channeled
through SC tissue to the SVC, where the
catheter is implanted. The valve opens when
there is a pressure differential > than 3 mm of
H20 bet. The peritoneal cavity & the vein in
the thoracic cavity.
Cirrhosis
Complications
Esophageal Varices- the increased portal
venous pressures causes the blood- to be
forced into these vessels & they become
fragile & tortuous. Increased as a result of
coughing, vomiting, sneezing, or straining
during defecation. Bleeding may occurs by
mechanical trauma- ingestion of coarse foods
and acidic pepsin erosion.
Cirrhosis
Treatments
Gastric lavage-monitor frequently
Pharmacologic therapy- Administration
of vasopression,Propranolol (inderal)- beta
blocker- reduce portal pressure & thus
decrease pressure & esophageal bleed,and
Sandostatin-lowers portal pressure by
causing vasoconstriction & thus stop
blleding. Side effect-abd. cramping & pallor.
Used cautiously in persons with CAD-causes
coronary vasoconstriction.
Cirrhosis
Treatments
Endoscopic Sclerotherapy- sclerosing
agents (Na morrhuate- 5ml) injected into
the varices. Causes thrombosis and
sclerosis of the vessel and hemostasis in 3
to 5 minutes. If hemostasis does not occura second injection is given.
Monitor for perforated esophagus, asp.
Pneumonia, pleural effusion. Fever is
common for several days.
Cirrhosis
Treatments
Balloon Tamponade- (Sengstaken-Blakemore) is
inserted. Maintain proper position, care of the mouth
and nares, frequent oral suctioning and providing
comfort measures.
Shunts-Transjugular Intrahepatic
Portosystemic shunt- (TIPS) shunt created bet. The
hepatic and portal veins & kept open by placement of
a metal stent. This decompresses the portal system
and reduces portal HTN enough to control bleeding.
ADV. Non-invasive .
Cirrhosis
Treatments
Surgical Shunts-last measures to treat
esophageal varices. Portal blood is being
shunted away from the liver-toxins are not
being metabolized. Risk for PSE-portal
systemic encephalopathy @ 25% to 100%.
Administartion of fresh whole blood- has
more coagulation factors-avoid increase of
NH3.
Cirrhosis
Complications
Portal-systemic Encephalopathy-result of
rising levels of toxic substances normally
metabolized & excreted by the liver.
Treatments:
Eliminating or restricting protein intake
Increase Carb. Intake to decrease metabolism
of endogenous proteins.
Administering intestinal abx. Such as neomycin
to kill bacteria in the GI tract.
Administering lactulose- decreasing the PH of
the bowel-promotes excretion of NH3 in the stool.
Stages of PSE
Stage 1
Prodromal
Stage 2
Impending
Stage 3
Stuporous
Stage 4
Coma
Change in
sleep
pattern
Lethargy
Confused
Unconscious
Disoriented
Slow
response
Irritable
Asterixis-
Paranoia
Tremors
Slurred
speech
Fetor
hepaticus(m
usty sweet
breath odor)
Cirrhosis
Complications
Hepatorenal Syndrome- sudden onset of
oliguria and azotemia- end-stage of liver
disease. The patient complains of
anorexia,fatique, & weakness. Fluid
retention leads to hyponatremia & dearease
in urine osmolality.
Fluid and lytes management
Liver transplantation
Hemodialysis for hyperkalemia and fluid
overload.
Cirrhosis
Implementation
Assist in maximizing liver function.
Diet: ample protein and carbohydrates
Restrict salts and fluids
Multivitamin
Diuretics- spironolactones
Antacids- decrease gastric distress.
Eliminate hepatotoxin intake
Completely restrict use of alcohol
avoid sedatives and opiates
Avoid all known hepatotoxic drugs
Cirrhosis
Implementation
Prevent infection by adequate rest.
Administer plasma proteins as ordered
Monitor intake and output
Provide skin care and control pruritus
Evaluate client’s response to diet therapy
Evaluate LOC, personality changes, signs of
increasing stupor.
Prevent and control complications: ascites,
bleeding esophageal varices, anemia.