Transcript Treatments/Interventions

INTERFERENCES WITH ELIMINATION
CONGENITAL OBSTRUCTIVE INTERFERENCES
Anorectal Malformations
Definition: malformation of anus
and/or rectum
minor to severe forms
-rectal atresia
-imperforate anus
Assessment May Include:
- failure to pass meconium stool ( imperforate
- stools in urine ( fistula)
- ribbonlike stools (anal stenosis)
Inspection of perineal area for abnormalities
Insert lubricated rectal thermometer short distance
(check protocol of agency)
anus)
Interventions
- corrective surgery (anoplasty)
- perform manual dilation as ordered
- instruct parents in proper technique
- prevent infection keeping anal area as clean
as possible
HIRSCHSPRUNGS DISEASE:AGANGLIONIC MEGACOLON
Definition/Pathophysiology
autonomic parasympathetic ganglion cells
absent
in part of the large colon resulting in
decreased motility,
causing mechanical
obstruction
-familial disease, more common in boys and
associated with Down’s syndrome
Diagnosis:
- history of bowel patterns
- radiographic contrast studies
- rectal biopsy to check for ganglion cells
Assessment
Newborns: failure to pass meconium, refusal to suck,
abdominal distention and bile stained emesis
Older Child: failure to gain weight and delayed growth,
abdominal distention, constipation
alternating with
diarrhea and vomiting
Treatment/Interventions
Surgical removal of aganglionic bowel with a temporary
colostomy (in severe cases)
Milder case: dietary modification ( low residue), stool
softeners
-isotonic irrigations to prevent impactions
Nursing Management
Identify early through history
Monitor fluid & lyte balance; nutrition
Patient education
- teach ostomy care if needed
- teach how to perform irrigations
- teach how to prevent skin breakdown
- teach proper nutrition
Post op care/measures: monitor for infection,
pain control, measure abdominal circumference,
maintain hydration
VOLVULUS
Definition/Pathophysiology: bowel twists upon itself
causing obstruction and necrosis
Assessment: nausea, vomiting, no bowel sounds,
severe gripping pain and a tense distended
abdomen
Confirmed by x-ray
Treatment/Interventions
surgical intervention with a bowel resection follow with
post op care
INTUSSUSCEPTION
Definition/Pathophysiology:
- telescoping of the bowel into itself
- usually at the ileocecal valve
- causes inflammation and edema
-blood flow becomes decreased
- commonly in boys (2 months to 5 yrs old)
-associated with cystic fibrosis and celiac
disease
Assessment: abrupt onset with acute abdominal pain, vomiting
and the passage of brown stool
- as condition worsens stools become red and
resemble currant jelly
- possibly a palpable mass in R upper quadrant
or mid upper abdomen
Diagnosis: history of child and radiography, ultrasound of abdomen and/or barium enema
Treatments
-Barium Enema can reduce telescoping by hydrostatic pressure
-Surgery to reduce invaginated bowel and remove
necrotic tissue
Nursing Management for Intussusception
 IV’s started immediately
Post Op
 -monitor VS, bowel sounds
 -monitor abdominal distention
 -check for S&S of infection
-manage pain
- maintain NGT patency
PATIENT EDUCATION
Omphalocele
Definition/Pathophysiology:
-congenital malformation where intraabdominal
contents herniate through the umbilical cord
-covered by translucent sac-peritoneum
-may have other congenital anomalies
Nursing Management
-cover with NS soaked gauze & cover with plastic
-monitor VS especially temp
-NPO with IV’s to maintain fluid & lyte balance
Post Op Care
prevent infection
maintain fluid & lytes
control pain
ensure adequate nutritional intake
support parents in dealing with crisis
Hernias
Definition:
-protrusion of viscus from its normal
cavity through an abnormal opening
Types:
Reducible: can be manually placed back into
abdominal cavity
Irreducible: cannot be placed back into cavity
Inguinal: weakness of abdominal wall
- spermatic cord emerges in males
- round ligament in females
Strangulated: irreducible with blood flow cut off
Treatment/Interventions
manual reduction
use of supports (TRUSS)
surgery for strangulated hernia repair
Nursing Interventions -Post op
prevent bladder distention
splint incision site
deep breathe Q 2 HR (avoid coughing)
ice to scrotal area & support
avoid heavy lifting 4-6 weeks
report pain or difficulty urinating
INFLAMMATORY INTERFERENCES
Necrotizing Enterocolitis
-inflammatory disease of the intestinal tract r/t
intestinal ischemia, infection, gut immaturity
- primarily in premature infants
Assessment
-feeding intolerance ( vomiting,
abdominal distention, irritability)
-bloody diarrhea
- possible sepsis
Diagnostics
-X-rays showing free peritoneal gas
-bowel wall thickening
Interventions:
- NPO and maintain IV’s
- NGT to suction
- antibiotics
- bowel resection
- possible ileostomy, colostomy
NURSING MANAGEMENT
• ID early (monitor feedings)
• Maintain fluid & lyte balance
• Comfort infant (holding, pacifier to meet
sucking needs)
• Patient Education post op
APPENDICITIS
Definition
- inflammation of the vermiform appendix preventing
mucus
from passing into the cecum
-untreated can cause ischemia, gangrene, rupture and peritonitis (may
be caused by mechanical obstruction or
anatomical defect)
Assessment
- low grade fever
- Rt. Lower quadrant pain (McBurney’s point)
- vomiting, diarrhea, constipation
- rebound tenderness
- Rovsing’s sign: palpate Lt. abdomen, pain felt on Rt.
Diagnostics
- increased WBC count
- CAT scan
pain in children and adolescents
with appendicitis.
TREATMENTS/INTERVENTIONS
Pre Op
Post Op
NPO
check VS, monitor incision
IV’s
IV’s
Antibiotics
antibiotics
NGT (if peritonitis) coughing & deep breathing
No laxatives
drain (penrose) if ruptured
Ruptured Appendix
- fever
- sudden relief of pain
-chills, pallor
NURSING MANAGEMENT
-Promote comfort: Rt. Side lying, semi- fowler’s
with knees bent, analgesics
-Maintain hydration: I&O, skin turgor
-Support respiratory function: cough, deep
breathe / splint
-Check for S&S of infection:
check incision, check drainage,
change
dressing, antibiotics
Discharge teaching:
-how to check for infection
-no strenuous activities
INFLAMMATORY BOWEL DISEASE
CROHN’S DISEASE
Definition
- chronic, inflammatory process along the GI tract
- involves all layers of the bowel
(deep fissures & ulcerations may develop between
loops of bowel or nearby organs)
- possible genetic association
Assessment
- crampy abdominal pain (RLQ)
- fever
- diarrhea (weight loss )
- ileum involvement ( steatorrhea)
(prevalent in individuals of Jewish descent
between the ages of 15- 25 yrs. old )
Diagnostics
- CBC: increased WBC, decreased H&H
- increased ESR
- hypoalbumineria
- abdominal tenderness
- thrombocytosis
- radiologic & biopsy examination
- lower endoscopy (proctosigmoidoscopy)
- barium study of UGI tract
- CAT scan
ULCERATIVE COLITIS
Definition
-chronic disease of colon/rectal mucosa
- can involve entire length of bowel
-only involves mucosa/submucosa with
ulcerations & inflammation
- emotional/psychosocial factors may have an
-peak incidence 15 – 25 yrs & 55- 65 yrs. Old F>M
Assessment
- bloody/mucus diarrheal stools
- lower abdominal pain (cramping)
-tenesmus
- wt. loss (possible delayed growth & arthralgias)
- ID nutritional deficiencies
effect
Diagnostics
-ID the extent of involved bowel

- r/o any infectious process
(i.e. Shigella)

- radiologic studies & endoscopy
with biopsy

- decreased H&H, albumin

-increased WBC
Treatment/Management
Medications
Salicylate Compounds: Sulfasalazine
Corticosteroids: prednisone
Immunosuppressants: cyclosporine
Antidiarrheals: immodium
Antibiotics : ciprofloxacil
Nutrition Therapy
- low fiber diet
- if poor appetite (high protein)
-supplemental vitamins, iron, zinc & folic acid
-TPN
Ulcerative Colitis
Temporary colostomy/ileostomy
Crohn’s
bowel resection
DIFFERENTIAL FEATURES OF U. C. AND CROHN’S
Feature
Ulcerative Colitis
Crohn’s Disease
Location
Begins in rectum
Proceeds to cecum
Usually terminal ileum
w/ patchy involvement
through all bowel
layers
Etiology
Unknown
Unknown
Peak Incidence
Stools
15-25 & 55-65
15 - 40
10-20 liquid, bloody
stools
5-6 soft, loose stools
Per day, rarely bloody
Common
Complications
Hemorrhage
Perforation
Fistulas
Nutritional
Deficiencies
Fistulas
Nutritional
Deficiencies
GASTROENTERITIS (ACUTE DIARRHEA)
Definition
- inflammation of the stomach and
intestines
-may be accompanied by vomiting and
diarrhea (bacterial or parasitic infections)
Assessment
-mild, moderate or severe diarrhea
(loose,
watery stools)
- irritabilty, cramping
- nausea and vomiting
- fluid & lyte balance
- hx & physical exam of patient
- stool examination (ova and parasite)
Treatments/Interventions
-ID the causative factor
-moderate: maintain fluid & lytes balance
-oral replacement therapy
(pedialyte, gatorade)
-no carbonated or sugar drinks
-severe: keep NPO; give IV fluids (NS/ RL)
- start with clear liquids
- monitor lytes especially potassium for
cardiac patients
- antidiarrheals for adults
Nursing Interventions
-Provide emotional support : allow pt. to
talk
-Provide rest and comfort: quiet environment
-Ensure adequate nutrition: BRAT diet
(bananas, rice, applesauce & toast)
CRAM (complex carbohydrates
rice and milk)
milk free for 48 hrs.; caffeine free
Discharge planning: teach parents S&S of
dehydration
DIVERTICULITIS
Definition/Pathophysiology:
-a saclike outpouching of the lining of
the bowel
(If bowel contents are retained in the
sac, it becomes inflamed or infected)
Assessment:
-chronic constipation
-abdominal pain (especially LLQ)
-fever
-abdominal distention/tenderness
Diagnostics:
- Ultrasonography
-barium enema( not during acute phase)
-increased ESR & WBC
-decreased H&H
-colonoscopy (after acute phase)
Complications:
-possible peritonitis
- abscess formation & bleeding
Treatment/Management
Dietary:
-Severe stage: NPO, NGT, IV’s
-During inflammation: low fiber
clear liquids initially
-After inflammation: high fiber
-Avoid foods with seeds, nuts, alcohol
-Rest
Medications
-Broad spectrum antibiotics (Flagyl, Cipro)
- Mild analgesics
- Anticholinergics (pro banthine)
- Bulk forming laxatives (metamucil)
Surgical Management
peritonitis or abscess formations may require
surgery
- one stage: bowel resection
- multistaged: bowel resected and
temporary colostomy performed
Nursing Management
teach pt. about dietary modifications
teach pt. about the various meds
teach pt. about ostomy care if needed
PARALYTIC ILEUS
Definition/Pathophysiology: paralysis of peristaltic movement
due to effect of trauma or toxins on the nerves that regulate
intestinal movement
Assessment
-abdominal pain/distention: accumulation of gas/fluid
above the obstruction
-rigid abdomen: increased distention makes it rigid
-vomiting: earliest sign of high obstruction; bile if lower
obstruction
- constipation
-absent bowel sounds: no peristalsis with obstruction
-shock: loss of fluid/lytes from the bloodstream into intestines
IRRITABLE BOWEL SYNDROME
Definition: functional disorder of intestinal
mobility with no irritation (spasms)
Assessment: symptoms range from mild to severe in
intensity with constipation, diarrhea or both
- pain, cramps (LLQ)
- bloating, abdominal distention
-more females than males
Treatment/Management
Dietary modifications: ID food intolerances
limiting caffeine and avoiding alcohol
-dietary fiber and bulk help stools
Medications
-bulk forming laxatives (metamucil)
-antidiarrheal agents (Lomotil)
-anticholinergic agents (Bentyl)
-tricyclic antidepressants (Elavil)
-5-HT4 (Zelnorm)
Stress Management
Diagnostics: CT scan, possible endoscopy
Treatment/Interventions
NPO
NGT
Nasointestinal tube (Cantor/Harris tube
with mercury)
IV’s
Pain management
Treat shock
Nursing Interventions
ID early
Monitor pt. and all tubes
Maintain accurate I&O with monitoring of lytes
Table 24–2 Causes of diarrhea in
children.
HEMORRHOIDS
Definition/Pathophysiology
- hyperplastic areas of vascular tissue
in the anal canal
- Internal hemorrhoids above the internal
sphincter
- External hemorrhoids outside the external
sphincter.
Assessment
Internal: prolapse causing discomfort
External
-itching
- pain
- bright red bleeding with defecation
Treatment/Interventions
Conservative measures: increase fiber diet
(fruit, bran, whole grains)
-encourage plenty of water
-analgesic ointments, suppositories
-stool softeners
-Sitz baths
Teach to avoid irritating laxatives, spicy foods,
caffeine, alcohol, nuts
Surgery
Pre op: enemas & laxatives
Post op: monitor rectal bleeding
report significant bloody drainage
side lying position
Nursing Interventions
-flotation pad
-pain med before BM
-stool softener
-increased fiber in diet
-sitz bath
-perianal care
Table 24–3 Influential factors in
childhood constipation.
CONSTIPATION
Definition
- decrease in the number of stools
- stools become hard and dry
- may even have oozing of liquid stool
around impaction.
Causes
Medications: opoids, iron
Obstruction: tumors
Neuromuscular condition: Multiple
Sclerosis
Dietary habits: decreased fiber and fluid
intake
Assessment
Abdominal distention with pain
Pressure straining
Headache
Fatigue
Complications
Hypertension
Fecal impaction
Hemorrhoids and fissures
Straining causing Valsalva Manuever
Treatment
Treat underlying cause
Increase fiber & fluid in diet
Bowel habit training
Medication: stool softeners ( colace)
bulk forming agent (metamucil)
stimulants (dulcolax)
Nursing Interventions
Teach change in life style habits
PARASITIC INFECTIONS
(see Ball & Bindler )
Definition/Pathophysiology
A parasite is an organism that lives in, on or at
the expense of a host. Common GI parasites
disorders include giardia, enterobiasis and
ascariasis.
Assessment
Giardiasis(Giardia)
S&S: diarrhea
Treatment:
vomiting
furazolidine
anorexia
quinicrine
Enterobiasis (Pinworm)
S&S: perianal itching
Treatment:
irritability
antihelminthic medsrestlessness
mebendazole
pyrantel pamoate
Ascariasis ( Roundworm)
S&S
Treatment
Severe can cause intestinal
same as above
obstruction
Peritonitis
Lung involvement
Interventions
Patient Teaching
Preventative measures
Proper hygiene
Careful handwashing
Medication Education
Practice Question
 The nurse is preparing to care for a child with a
diagnosis of intussusception. The nurse reviews the
child’s record and expects to note which symptom of
this disorder documented?
 A. watery diarrhea
 B. ribbon-like stools
 C. profuse projectile vomiting
 D. bright red blood and mucus in the stools
Practice Question
 A nurse is reviewing the record of a client with
Crohn’s disease. Which of the following stool
characteristics would the nurse expect to be
documented in the client’s record?
 A. chronic constipation
 B. diarrhea
 C. constipation alternating with diarrhea
 D. stool constantly oozing from the rectum