Transcript Nursing Care of Clients with Upper Gastrointestinal Disorders

By
Ni Ketut Alit A
Faculty Of Nursing Airlangga University
4/10/2016
1
Function of G I system
 The Primary Digestive Functions are
1. Break down food particles “molecular
forms”
2. Absorb into the bloodstream the small
molecules
3. Eliminate waste products & undigested
food
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Function of G I system
 Chewing & Swallowing
1. 1.5 L of saliva are secreted daily
2. Ptyalin “salivary amylase” starch digestion
3. Saliva lubricate food as it chewed & swallowed
 Gastric function
1. Hydrochloric acid to destruct most ingest
bacteria ,& break down food
2. Pepsin for initiation of protein digestion
3. Intrinsic factors
4. The food mixed with gastric secretions is
called chyme
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Function of G I system
 Small Intestine function
1. Pancreas :
-Trypsin aids in digestion of proteins
-Amylase aids in digestion starch
-Lipase aids in digestion of fats
2. Liver : bile aids in emulsifying ingested fats
3. Intestinal Glands :secrete mucus ,hormones
,electrolytes ,and enzymes
4. Two types of contractions
 Segmentation contraction
 Intestinal peristalsis
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Function of G I system
 Colonic Function
1. Two types of colonic secretion
-Mucus: protect colonic mucosa
-Electrolytes: mainly “HCo3” neutralize
the end products
2. Slow peristaltic to allow absorption of
water & electrolytes
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Assessment
 Health history ( diet history ,appetite ,
weight gain & loss , stool ch.ch.,& eating
pattern
 Clinical Manifestations :1. Pain
2. Indigestion
3. Intestinal Gas
4. Nausea & Vomiting
5. Change in Bowel Habits &Stool ch.ch.
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Assessment

1.
2.
3.
4.
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Physical Assessment
Inspection
Auscultation
Palpation
Percussion
7
Assessment

1.
2.
3.
4.
5.
6.
7.
8.
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Diagnostic Evaluation
Upper GI tract study
Lower GI tract study
Gastric Analysis
Endoscopy
Laparoscopy (Peritoneoscopy )
Anoscopy ,proctoscopy ,&Sigmoidscopy
Colonoscopy
Abdominal U/S , Abd CT scan ,&Abd MRI
8
Assessment
 Stool Tests
-Analysis & culture
-occult blood test
 Hydrogen Breath Test
 Urea Breath Test
 Tagged Red Blood Cells & Leukocytes
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Disorders of the Jaw
 Abnormal conditions affecting the mandible
(Jaw)& the tempomandibular joint include
congenital malformation, fractures , chronic
dislocation , cancer , & syndrome ch.ch pain &
limited motion
 Tempomandibular Disorders
Are a group of conditions that cause pain &\or
dysfunction of the tempomandibular joint &/or
the muscle of mastication, as well as contiguous
tissue components
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Disorders of the Jaw
 Clinical Manifestations
1. Pain (from dull to throbbing )
2. Debilitating pain radiated to the ears,
teeth, neck muscle & facial sinuses
3. Restricted jaw motion & clicking
4. Difficulty chewing & swallowing
5. Depression may accompany
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Disorders of the Jaw

1.
2.
3.
4.
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Management
Patient education in stress Management
Range of motion exercises
Pain Management (NSAID)
Muscle relaxant &/or mild antidepressant
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Parotitis
 Inflammation of the parotid gland is the most
common inflammatory condition of the salivary
gland
 Mumps (epidemic Parotitis) viral seen in
children
 Clinical Manifestations
1.
2.
3.
4.
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Fever & red shiny skin
The gland swells ,tense ,&tender
Pain felt in ear
Swollen gland interfere with swallowing
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Parotitis
 Medical Management
1. Preventive Measures (dental care, oral
hygiene, adequate fluid& nutrition ,& D/C of
medication that may diminished salivary
secretion)
2. Antibiotics for infection
3. Analgesic for pain
4. Drainage of gland
5. Parotidectomy
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Impaired Esophageal Motility
Achalasia
 Achalasia: characterized by impaired
peristalsis of smooth muscle of esophagus
and impaired relaxation of lower
esophageal sphincter
 Manifestations:
1.
2.
3.
4.
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Dysphagia
chest pain (pyrosis)
Sensation of food stick in lower esophagus
Food regurgitation
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Achalasia
Treatment
1. Eat slowly &drink fluids with meals
2. Calcium channel blockers
3. Endoscopically guided injection of
botulinum toxin
4. Balloon dilation of lower esophageal
sphincter or pneumatic dilation
5. Esophageal myotomy (abdominal or
thoracic approach
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Gastroesophageal Reflux Disease
(GERD)
1. Definition
1. GERD common, affecting 15 – 20% of
adults
2. Because of location near other organs
symptoms may mimic other illnesses
including heart problems
3. Gastroesophageal reflux is the
backward flow of gastric content into
the esophagus.
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Gastroesophageal Reflux Disease
(GERD)
2. Pathophysiology
 a. Gastroesophageal reflux results from transient
relaxation or incompetence of lower esophageal
sphincter, sphincter, or increased pressure within
stomach
 b. Factors contributing to Gastroesophageal reflux
1.Increased gastric volume (post meals)
2.Position pushing gastric contents close to
Gastroesophageal juncture (such as bending or
lying down)
3.Increased gastric pressure (obesity or tight
clothing)
4.Hiatal hernia
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Gastroesophageal Reflux Disease
(GERD)
1.
2.
3.
4.
5.
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Manifestations
Heartburn after meals, while bending
over, or recumbent
Dyspepsia or indigestion
May have regurgitation of sour
materials in mouth, pain with
swallowing
Atypical chest pain
Sore throat with hoarseness
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Gastroesophageal Reflux Disease
(GERD)
6.Diagnostic Tests
a. Barium swallow (evaluation of
esophagus, stomach, small intestine)
b. Upper endoscopy: direct
visualization; biopsies may be done
c. 24-hour ambulatory pH monitoring
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Gastroesophageal Reflux Disease
(GERD)
7.Medications
 a. Antacids for mild to moderate symptoms, e.g.
Maalox, Mylanta, Gaviscon
 b. H2-receptor blockers: decrease acid
production; given BID or more often, e.g.
cimetidine, ranitidine, famotidine, nizatidine
 c. Proton-pump inhibitors: reduce gastric
secretions, promote healing of esophageal
erosion and relieve symptoms, e.g. omeprazole
(prilosec); lansoprazole
 d. Promotility agent: enhances esophageal
clearance and gastric emptying
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Gastroesophageal Reflux Disease
(GERD)
Dietary and Lifestyle Management
 a. Elimination of acid foods (tomatoes, spicy, citrus
foods, coffee)
 b. Avoiding food which relax esophageal sphincter
or delay gastric emptying (fatty foods, chocolate,
alcohol)
 c. Maintain ideal body weight
 d. Eat small meals and stay upright 2 hours post
eating; no eating 3 hours prior to going to bed
 e. Elevate head of bed on 6 – 8 blocks to decrease
reflux
 f. No smoking
 g. Avoiding bending and wear loose fitting clothing
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Gastroesophageal Reflux Disease
(GERD)
9.Surgery indicated for persons not
improved by diet and life style changes
a. Laparoscopic procedures to tighten
lower esophageal sphincter
b. Open surgical procedure: fundoplication
10. Nursing Care
a. Pain usually controlled by treatment
b. Assist client to institute home plan
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Hiatal Hernia
1. Definition
 Part of stomach protrudes through the
esophageal hiatus of the diaphragm into
thoracic cavity
 Types
1. Sliding hiatal herni
2. Paraesophageal hiatal hernia:
( hernia can become strangulated; client
may develop gastritis with bleeding)
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Hiatal Hernia


1.
2.
Manifestations: Similar to GERD
Diagnostic Tests
a. Barium swallow
b. Upper endoscopy

Treatment
1. Similar to GERD: diet and lifestyle
changes, medications
2. If medical treatment is not effective or
hernia becomes incarcerated, then
surgery; usually
3. Fundoplication by thoracic or abdominal
approach
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Diverticulum
 It is an outpouching of mucosa&
submucosa that protrudes through a
weak portion of the musculature

Clinical Manifestations
1.
2.
3.
4.
5.
6.
Difficulty of swallowing & neck fullness
Belching
Regurgitation of undigested food
Gargling noise after eating
Halitosis & sour taste in the mouth
May dysphagia & chest pain
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Diverticulum
 Management
1. Diverticulectomy &myoectomy for muscle
2. NPO until x-ray show no leakage at
surgical site
3. During O.P. avoid trauma to carotid
artery and jugular vein
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Perforation
 May result from stab or bullet wounds of
the neck & the chest as well as from
accidental puncture by surgical
instrument
 Clinical Manifestations
1. Persistent pain followed by dysphagia
2. Infection ,fever ,& leukocytosis
3. May sign of Pnuemothorax
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Perforation

1.
2.
3.
Management
Broad spectrum antibiotics
Nasogastric tube & suctioning
NPO – total parenteral nutrition
“gastrostomy”
4. Closed the wound &post op
management
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Gastritis
1. Definition: Inflammation of stomach lining
from irritation of gastric mucosa (normally
protected from gastric acid and enzymes by
mucosal barrier)
2. Types
 a. Acute Gastritis
1.Disruption of mucosal barrier allowing
hydrochloric acid and pepsin to have contact
with gastric tissue: leads to irritation,
inflammation, superficial erosions
2.Gastric mucosa rapidly regenerates;
self-limiting disorder
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•Gastritis
Causes of acute gastritis
 a. Irritants
include aspirin and other NSAIDS,
corticosteroids, alcohol, caffeine
 b.Ingestion of corrosive substances: alkali or acid
 c.food contamination (microorganisms)
Manifestations
 headache, mild epigastric discomfort,
 abdominal pain, nausea anorexia, vomiting
 Belching, heart burn , &sour taste in mouth
 If perforation occurs, signs of peritonitis
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Gastritis
Treatment
 As a rule the patient recover in a day
 NPO status to rest GI tract for 6 – 12 hours,
reintroduce clear liquids gradually and progress;
intravenous fluid and electrolytes if indicated
 b. antacids If gastritis from corrosive substance:
immediate dilution and removal of substance by
gastric lavage (washing out stomach contents
via nasogastric tube),
 If extreme condition Gastrojejunostomy or
gastric resection
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Gastritis

1.
2.
3.
4.


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Nursing Management
Reducing anxiety
Promoting optimal nutrition
Promoting fluid balance
Relieving pain
Chronic Gastritis
Progressive disorder beginning with
superficial inflammation and leads to atrophy
of gastric tissues (prolong Gastritis)
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Peptic Ulcer Disease (PUD)
Definition and Risk factors
Break in mucous lining of GI tract comes
into contact with gastric juice , referred to
as gastric ,duodenal , or esophageal ulcer
Duodenal ulcers: most common; affect
mostly males ages 30 – 55 ulcers found
near pyloris
Gastric ulcers:affect older persons(ages
55 – 70)
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Peptic Ulcer Disease (PUD)
2. Pathophysiology
 a. Ulcers or breaks in mucosa of GI tract occur with
1.H. pylori infection (spread by oral to oral, fecaloral routes) damages gastric epithelial cells reducing
effectiveness of gastric mucus
2.Use of NSAIDS: interrupts prostaglandin
synthesis which maintains mucous barrier of gastric
mucosa
 b. Chronic with spontaneous remissions and
exacerbations associated with trauma, infection,
physical or psychological stress
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Peptic Ulcer Disease (PUD)
Manifestations
 Pain is classic symptom: burning, aching
hunger like in epigastric region possibly radiating
to back; occurs when stomach is empty and
relieved by food (pain: food: relief pattern)
 Vomiting , nausea , constipation &diarrhea
 Symptoms less clear in older adult; may have
poorly localized discomfort, dysphagia, weight
loss; presenting symptom may be complication:
GI hemorrhage or perforation of stomach or
duodenum
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Peptic Ulcer Disease (PUD)
 Treatment

1.
2.
3.
4.



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Pharmacologic therapy
H2 receptor antagonist
Proton pump inhibitors
Cytoprotective agents
Antacid
Stress Reduction & Rest
Smoking Cessation
Dietary Modification
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Peptic Ulcer Disease (PUD)


1.
2.


1.
2.
3.
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Surgical Management
Vagotomy
Truncal
Selective
Pyloroplasty
Antrectomy
Gastroduodenostomy
Gastrojejunostomy
Subtotal gastroectomy with anastomosis
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Gastric Surgery
 Gastric surgery : may be performed on patient
with peptic ulcers who have life threatening
hemorrhage , obstruction , perforation ,or
whose condition dose not respond to medical
treatment
 Nursing Care
1.
2.
3.
4.
5.
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Reducing Anxiety
Increasing Knowledge
Resuming enteral Intake
Relieving pain &prevent complications
Teaching Dietary self Management
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Intestinal and rectal disorders
Constipation
 Abnormal hardening of stool that makes
difficult & some time painfull,decrease in stool
volume , or retention of stool on rectum for
prolonged period of time
 Clinical Manifestations
1.
2.
3.
4.
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Abdominal distention & intestinal rumbling
Pain & pressure
Anorexia fatigue & headache
Incomplete emptying & strain defecation
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Intestinal and rectal disorders
Constipation

1.
2.
3.
4.
5.

Medical Management
Treatment of the underlying cause
High Fiber Diet & increase fluid intake
Maintain regular pattern of exercises
Laxatives & bulk forming Agents
Bran 6-12 tsp
Complications:
-hypertension
- hemorrhoid & fissure
- fecal impaction & megacolon
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Intestinal and rectal disorders
Diarrhea
 It is an increase frequency of bowel
movement more than three times /day
 Causes : 1.
2.
3.
4.
5.
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Certain medications
Tube feeding formula
Certain metabolic disease
Viral & bacterial infectious disease
Ulcerative colitis .enteritis & chrons
disease
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Intestinal and rectal disorders
Diarrhea
 Clinical Manifestations
1. Abdominal cramps, distention, intestinal
rumbling
2. Increase frequency & fluid content of stool
3. Anorexia , thirst , & dehydration
4. Fluid electrolytes imbalance
 Complications:-cardiac arrhythmia due to fluid & K loss
-drowsiness & hypotension
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Intestinal and rectal disorders
Diarrhea

1.
2.
3.
4.

1.
2.
3.
4.
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Medical Management
Treatment of underlying cause
Controlling symptoms & preventing complications
Antibiotics & antinflammatory agents
Antidiarrheal & antispasmoic agents
Nursing Managements
Assessment the ch.ch. & pattern of diarrhea
Bed rest & monitoring of fluid status
Serum electrolytes (K)
Perenial care
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Fecal Incontinence
 The involuntary passage of stool from
the rectum
 Clinical Manifestations
1. Minor soiling
2. Occasional Urgency & loss of control
3. Poor Control of flatus
4. Diarrhea ,or constipation may be present
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Fecal Incontinence
 Medical Management
1.
2.
3.
4.
Bowel training program
Surgical reconstruction
Sphincter repair
Fecal diversion
 Nursing Management
1.
2.
3.
4.
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Assessment & Health History
Bowel Training program
Maintain skin integrity
Assist patient & family to cope with illness
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Irritable Bowel Syndrome
 Functional disorder of intestinal motility ,the
change may be related to neurologic
regulatory system, infection or irritation or a
vascular or metabolic disturbances
 The peristaltic waves are affected at specific
segment
 Clinical Manifestations
1. Alteration in bowel pattern
2. Pain , bloating , & abd distention
3. Pain precipitated by eating & relieved by
defecation
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Irritable Bowel Syndrome

1.
2.
3.

1.
2.
3.
4.
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Medical Management
Controlling symptoms & reducing stress
Anticholonergic & antidepressant agents
Well balanced diet
Nursing Management
teaching &reinforcing good dietary habits
Encourage eat regular time & chew slowly
Fluids should not taken with meal
Discourage smoking & alcohol
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Acute Inflammatory Intestinal Disorders
(Appendicitis)


1.
2.
3.
4.
5.


Acute inflammation of appendix
Clinical Manifestations
Rt Lower Quadrant pain
Low Grade Fever, nausea , vomiting anorexia
Rebound & Revosing signs
Local tenderness when pressure applied
Increase W.B.C.s count
Complications:
perforation
peritonitis or abdominal abscess
,occurs after 24 hrs after onset of symptoms
(pain Tenderness ,fever,& toxic appearance)
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Acute Inflammatory Intestinal Disorders
(Appendicitis)
 Medical Management
1. Surgery is indicated if surgery diagnosed
(laprascopic or open appendectomy)
2. NPO ,IVF , antibiotics
3. Analgesic after diagnosis is made
 Nursing Management
1. Relieving pain &preventing FVD
2. Elimination of potential infection
3. Maintaining skin integrity
4. Reducing anxiety
5. Pre&post care
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Acute Inflammatory Intestinal Disorders
Ulcerative Colitis
 Recurrent ulcerative & inflammatory
disease of the mucosal layer
 Clinical Manifestations
1. Diarrhea & abdominal pain
2. Intermittent tenesmus
3. Rectal bleeding
4. Anorexia , weight loss , fever
5. Vomiting & dehydration
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Acute Inflammatory Intestinal Disorders
Ulcerative Colitis
 Medical Management
1. Nutritional therapy :
- oral fluid
- low residue caloric protein diet
with supplementary vit & Iron
2. Pharmacological therapy :
- antibiotics& corticosteroids (enema)
-sedatives , antidiarrheal ,& antiperstaltic agents
-Immunosuppressive agents
3. Surgical Managements:
-colectomy segmental ,subtotal
- total colectomy with ilioanal anastomosis
-fecal diversion
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Ulcerative Colitis
 Nursing Management
1.
2.
3.
4.
5.
6.
7.
8.
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Maintaining normal elimination pattern
Relieving pain
Maintaining fluid Intake
Maintaining optimal nutrition
Promoting rest
Reducing anxiety
Preventing skin breakdown
Monitoring complications
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INTESTINAL OBSTRUCTION
Blockage prevents the normal flow of
intestinal contents through the intestinal
tract
A- mechanical: obstruction from pressure on
the intestinal walls occurs due to adhesion,
tumor & hernias
B- functional: obstruction when intestinal
musculature can’t propel the contents
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Small Bowel Obstruction
Clinical manifestation
Crampy pain wave like & colicky
Pass of blood & mucus without feces
Vomiting ( reverse peristalsis )
Thirst & generalized malaise
Management
Decompression of bowel through N/G tube
IVF to replace H2O, electrolytes deplession
Surgical treatment of the cause
Resection & end to end anastomosis
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Large Bowel Obstruction
Clinical manifestations
Abdominal distension, Crampy lower abdomen
Fecal vomiting
Symptoms of shock may occur
Medical management
Colonoscopy, to untwist or decompress bowel
Cecostomy to relief pressure
Rectal tube to decompress the lower part
Surgical resection
Temporary or permanent colostomy
Ilio-anal anastomosis
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Nursing management
Administer IV fluids & electrolytes as prescribed
Emotional support
Pre & post operative care for abdominal surgery
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ANO-RECTAL DISORDERS
1- Anal Fistula
Definition: tubular tract extends into anal
canal from an opening beside the anus,
from infection, abscess, trauma & fissure
S & S
Pus or stool leakage
Passage of flatus or feces from vagina or
bladder depends on site of fistula
Treatment
Fistulectomy ( excision of fistulous tract )
Untreated fistula causes systematic infections
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2- Anal Fissure
Definition: tear or ulceration in the lining of
anal canal results from constipation, child
birth & trauma
S & S
Painful defecation
Burning & bleeding
Treatment
Conservative treatment ( stool softener, sitz
bath, analgesics )
Anal dilatation & fissure excision
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3- Hemorrhoids ( piles )
Definition: dilated portion of veins in the
anal canal
Types
Internal: above the internal sphincter
External: out side the external sphincter
S & S
Itching & pain
Bright red bleeding with defecation
Piles come out side anus
Complications
Massive bleeding results in anemia
Thrombosis & infection
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Treatment
Conservative treatment (sitz bath, laxative, high
residual diet, anesthetic ointments & rest)
Injection of sclerosing solutions
Rubber band ligation procedure
Hemorrhoidectomy
Nursing management
Pre-operative: cleansing enema, shaving &
cross match, Hb + IV fluids
Post-operative: analgesia ½ hour before
defecation, sitz bath in warm saline & remove
the back
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4- Pilonidal Sinus / cyst
Definition: found on the posterior surface
of the lower sacrum results from the
penetration of hair into the epithelium &
subcutaneous tissue lead to recurrent
abscess formation
Treatment
Excision & drainage, antibiotic & analgesia
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 Nursing management (Ano -Rectal condition )
Relieving constipation
Reducing anxiety
Relieving pain
Promoting urinary elimination
Monitoring & managing complications
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
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Nursing Care of Clients with Bowel
Disorders
Factors affecting bodily function of elimination
A. GI tract
 1. Food intake
 2. Bacterial flora in bowel
B. Indirect
 1. Psychologic stress
 2. Voluntary postponement of defecation
C.Normal bowel elimination pattern
 1.
 2.
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Varies with the individual
2 – 3 times daily to 3 stools per week
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Irritable Bowel Syndrome (IBS) (spastic
bowel, functional colitis)
Definition
a. Functional GI tract disorder without
identifiable cause characterized by
abdominal pain and constipation, diarrhea,
or both
b. Affects up to 20% of persons in
Western civilization; more common in
females
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Irritable Bowel Syndrome (IBS)
(spastic bowel, functional colitis)
Pathophysiology
 a. Appears there is altered CNS regulation of motor
and sensory functions of bowel
1.Increased bowel activity in response to food
intake, hormones, stress
2.Increased sensations of chyme movement
through gut
3.Hypersecretion of colonic mucus
 b. Lower visceral pain threshold causing
abdominal pain and bloating with normal levels of
gas
 c. Some linkage of depression and anxiety
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Irritable Bowel Syndrome (IBS)
(spastic bowel, functional colitis)
Manifestations
 a. Abdominal pain relieved by defecation; may be
colicky, occurring in spasms, dull or continuous
 b. Altered bowel habits including frequency, hard
or watery stool, straining or urgency with stooling,
incomplete evacuation, passage of mucus;
abdominal bloating, excess gas
 c. Nausea, vomiting, anorexia, fatigue, headache,
anxiety
 d. Tenderness over sigmoid colon upon palpation
4. Collaborative Care
 a. Management of distressing symptoms
 b. Elimination of precipitating factors, stress
reduction
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Irritable Bowel Syndrome (IBS)
(spastic bowel, functional colitis)
5. Diagnostic Tests: to find a cause for client’s abdominal pain,




changes in feces elimination
a.Stool examination for occult blood, ova and parasites, culture
b.CBC with differential, Erythrocyte Sedimentation Rate (ESR): to
determine if anemia, bacterial infection, or inflammatory process
c.Sigmoidoscopy or colonoscopy
1.Visualize bowel mucosa, measure intraluminal pressures,
obtain biopsies if indicated
2.Findings with IBS: normal appearance increased mucus,
intraluminal pressures, marked spasms, possible hyperemia
without lesions
d.Small bowel series (Upper GI series with small bowel-follow
through) and barium enema: examination of entire GI tract; IBS:
increased motility
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Irritable Bowel Syndrome (IBS)
(spastic bowel, functional colitis)
Medications
 a. Purpose: to manage symptoms
 b. Bulk-forming laxatives: reduce bowel spasm,
normalize bowel movement in number and form
 c. Anticholinergic drugs (dicyclomine (Bentyl),
hyoscyamine) to inhibit bowel motility; given before
meals
 d. Antidiarrheal medications (loperamide
(Imodium), diphenoxylate (Lomotil): prevent diarrhea
prophylactically
 e. Antidepressant medications
 f. Research: medications altering serotonin
receptors in GI tract
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Irritable Bowel Syndrome (IBS)
(spastic bowel, functional colitis)
Dietary Management
 a. Often benefit from additional dietary fiber: adds
bulk and water content to stool reducing diarrhea
and constipation
 b. Some benefit from elimination of lactose,
fructose, sorbitol
 c. Limiting intake of gas-forming foods, caffeinated
beverages
8. Nursing Care
 a. Contact in health environments outside acute
care
 b. Home care focus on improving symptoms with
changes of diet, stress management, medications;
seek medical attention if serious changes occur
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Peritonitis
Definition
a. Inflammation of peritoneum, lining
that covers wall (parietal peritoneum)
and organs (visceral peritoneum) of
abdominal cavity
b. Enteric bacteria enter the peritoneal
cavity through a break of intact GI tract
(e.g. perforated ulcer, ruptured
appendix)
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Peritonitis
Pathophysiology
 a. Peritonitis results from contamination of normal
sterile peritoneal cavity with infections or chemical
irritant
 b. Release of bile or gastric juices initially causes
chemical peritonitis; infection occurs when bacteria
enter the space
 c. Bacterial peritonitis usually caused by these
bacteria (normal bowel flora): Escherichia coli,
Klebsiella, Proteus, Pseudomonas
 d. Inflammatory process causes fluid shift into
peritoneal space (third spacing); leading to
hypovolemia, then septicemia
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Peritonitis
3. Manifestations
 a. Depends on severity and extent of
infection, age and health of client
 b. Presents with “acute abdomen”
1.Abrupt onset of diffuse, severe
abdominal pain
2.Pain may localize near site of infection
(may have rebound tenderness)
3.Intensifies with movement
 c. Entire abdomen is tender with boardlike
guarding or rigidity of abdominal muscle
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Peritonitis
 d. Decreased peristalsis leading to paralytic ileus;
bowel sounds are diminished or absent with
progressive abdominal distention; pooling of GI
secretions lead to nausea and vomiting
 e. Systemically: fever, malaise, tachycardia and
tachypnea, restlessness, disorientation, oliguria with
dehydration and shock
 f. Older or immunosuppressed client may have
1.Few of classic signs
2.Increased confusion and restlessness
3.Decreased urinary output
4.Vague abdominal complaints
5.At risk for delayed diagnosis and higher
mortality rates
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Peritonitis
4. Complications
 a. May be life-threatening; mortality rate overall
40%
 b. Abscess
 c. Fibrous adhesions
 d. Septicemia, septic shock; fluid loss into
abdominal cavity leads to hypovolemic shock
5. Collaborative Care
 a. Diagnosis and identifying and treating cause
 b. Prevention of complications
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Peritonitis
6. Diagnostic Tests
 a. WBC with differential: elevated WBC to 20,000; shift
to left
 b. Blood cultures: identify bacteria in blood
 c. Liver and renal function studies, serum electrolytes:
evaluate effects of peritonitis
 d. Abdominal xrays: detect intestinal distension, airfluid levels, free air under diaphragm (sign of GI
perforation)
 e. Diagnostic paracentesis
7. Medications
 a. Antibiotics
1.Broad-spectrum before definitive culture results
identifying specific organism(s) causing infection
2.Specific antibiotic(s) treating causative pathogens
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 b. Analgesics
Peritonitis
8. Surgery
 a. Laparotomy to treat cause (close
perforation, removed inflamed tissue)
 b. Peritoneal Lavage: washing out
peritoneal cavity with copious amounts of
warm isotonic fluid during surgery to dilute
residual bacterial and remove gross
contaminants
 c. Often have drain in place and/or incision
left unsutured to continue drainage
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Peritonitis
9. Treatment
 a. Intravenous fluids and electrolytes to maintain
vascular volume and electrolyte balance
 b. Bed rest in Fowler’s position to localize infection
and promote lung ventilation
 c. Intestinal decompression with nasogastric tube
or intestinal tube connected to suction
 1. Relieves abdominal distension secondary to
paralytic ileus
 2. NPO with intravenous fluids while having
nasogastric suction
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Peritonitis
10.
Nursing Diagnoses
 a. Pain
 b. Deficient Fluid Volume: often on hourly output;
nasogastric drainage is considered when ordering
intravenous fluids
 c. Ineffective Protection
 d. Anxiety
11.
Home Care
 a. Client may have prolonged hospitalization
 b. Home care often includes
 1. Wound care
 2. Home health referral
 3. Home intravenous antibiotics
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Client with Inflammatory Bowel
Disease
Definition
 a. Includes 2 separate but closely related
conditions: ulcerative colitis and Crohn’s
disease; both have similar geographic
distribution and genetic component
 b. Etiology is unknown but runs in families;
may be related to infectious agent and
altered immune responses
 c. Peak incidence occurs between the ages
of 15 – 35; second peak 60 – 80
 d. Chronic disease with recurrent
exacerbations
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Ulcerative Colitis
Pathophysiology
 1. Inflammatory process usually confined to
rectum and sigmoid colon
 2. Inflammation leads to mucosal
hemorrhages and abscess formation, which
leads to necrosis and sloughing of bowel
mucosa
 3. Mucosa becomes red, friable, and
ulcerated; bleeding is common
 4. Chronic inflammation leads to atrophy,
narrowing, and shortening of colon
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Ulcerative Colitis
Manifestations
1. Diarrhea with stool containing blood
and mucus; 5 – 10 stools per day leading
to anemia, hypovolemia, malnutrition
2. Fecal urgency, tenesmus, LLQ
cramping
3. Fatigue, anorexia, weakness
4. Severe cases: arthritis, uveitis
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Ulcerative Colitis
Complications
 1. Hemorrhage: can be massive with severe attacks
 2. Toxic megacolon: usually involves transverse
colon which dilates and lacks peristalsis
(manifestations: fever, tachycardia, hypotension,
dehydration, change in stools, abdominal cramping)
 3. Colon perforation: rare but leads to peritonitis
and 15% mortality rate
 4. Increased risk for colorectal cancer (20 – 30
times); need yearly colonoscopies
 5. Sclerosing cholangitis
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Crohn’s Disease (regional enteritis)
Pathophysiology
 1. Can affect any portion of GI tract, but terminal
ileum and ascending colon are more commonly
involved
 2. Inflammatory aphthoid lesion (shallow
ulceration) of mucosa and submuscosa develops
into ulcers and fissures that involve entire bowel
wall
 3. Fibrotic changes occur leading to local
obstruction, abscess formation and fistula formation
 4. Fistulas develop between loops of bowel
(enteroenteric fistulas); bowel and bladder
(enterovesical fistulas); bowel and skin
(enterocutaneous fistulas)

5. Absorption problem develops leading to protein 90
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loss and anemia
Crohn’s Disease (regional enteritis)
Manifestations
1. Often continuous or episodic diarrhea;
liquid or semi-formed; abdominal pain and
tenderness in RLQ relieved by defecation
2. Fever, fatigue, malaise, weight loss,
anemia
3. Fissures, fistulas, abscesses
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Crohn’s Disease (regional enteritis)
Complications
 1. Intestinal obstruction: caused by
repeated inflammation and scarring causing
fibrosis and stricture
 2. Fistulas lead to abscess formation;
recurrent urinary tract infection if bladder
involved
 3. Perforation of bowel may occur with
peritonitis
 4. Massive hemorrhage
 5. Increased risk of bowel cancer (5 – 6
times)
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Crohn’s Disease (regional enteritis)
Collaborative Care
 a. Establish diagnosis
 b. Supportive treatment
 c. Many clients need surgery
Diagnostic Tests
 a. Colonoscopy, sigmoidoscopy: determine area and
pattern of involvement, tissue biopsies; small risk of
perforation
 b. Upper GI series with small bowel follow-through,
barium enema
 c. Stool examination and stool cultures to rule out
infections
 d. CBC: shows anemia, leukocytosis from inflammation
and abscess formation
 e. Serum albumin, folic acid: lower due to
malabsorption
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 f. Liver function tests may show enzyme elevations
Crohn’s Disease (regional enteritis)
Medications: goal is to stop acute attacks quickly and
reduce incidence of relapse
 a. Sulfasalazine (Azulfidine): sulfonamide antibiotic
with topical effect in colon; used with ulcerative
colitis
 b. Corticosteroids: reduce inflammation and induce
remission; with ulcerative colitis may be given as
enema; intravenous steroids are given with severe
exacerbations
 c. Immunosuppressive agents (azathioprine
(Imuran), cyclosporine) for clients who do not
respond to steroid therapy
 d. New therapies including immune response
modifiers, anti-inflammatory cyctokines

e. Metronidazole (Flagyl) or Ciprofloxacin (Cipro) 94
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 f. Anti-diarrheal medications
Crohn’s Disease (regional enteritis)
Dietary Management
 a. Individualized according to client; eliminate
irritating foods
 b. Dietary fiber contraindicated if client has
strictures
 c. With acute exacerbations, client may be made
NPO and given enteral or total parenteral nutrition
(TPN)
Surgery: performed when necessitated by
complications or failure of other measures
a. Crohn’s disease
 1. Bowel obstruction leading cause; may have
bowel resection and repair for obstruction,
perforation, fistula, abscess
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 2. Disease process tends to recur in area remaining95
after resection
Ulcerative Colitis
1. Total colectomy to treat disease,
repair complications (toxic megacolon,
perforation, hemorrhage, prophylactic
for cancer risk)
2. Total colectomy with an ileal pouchanal anastomosis (initially has
temporary ileostomy)
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Ulcerative Colitis
Ostomy
 1. Surgically created opening between intestine
and abdominal wall that allows passage of fecal
material
 2. Stoma is the surface opening which has an
appliance applied to retain stool and is emptied at
intervals
 3. Name of ostomy depends on location of stoma
 4. Ileostomy: opening in ileum; may be permanent
with total proctocolectomy or temporary (loop
ileostomy)
 5. Ileostomies: always have liquid stool which can
be corrosive to skin since contains digestive
enzymes
 6. Continent (or Kock’s) ileostomy: has intraabdominal reservoir with nipple valve formation to 97
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allow catheter insertion to drain out stool
Ulcerative Colitis
Nursing Care: Focus is effective management of
disease with avoidance of complications
Nursing Diagnoses
 a. Diarrhea
 b. Disturbed Body Image; diarrhea may control all
aspects of life; client has surgery with ostomy
 c. Imbalanced Nutrition: Less than body
requirement
 d. Risk for Impaired Tissue Integrity: Malnutrition
and healing post surgery
 e. Risk for sexual dysfunction, related to diarrhea
or ostomy
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Ulcerative Colitis
Home Care
a. Inflammatory bowel disease is chronic
and day-to-day care lies with client
b. Teaching to control symptoms,
adequate nutrition, if client has ostomy:
care and resources for supplies, support
group and home care referral
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Client with Intestinal Obstruction
Definition
 a. May be partial or complete obstruction
 b. Failure of intestinal contents to move
through the bowel lumen; most common site
is small intestine
 c. With obstruction, gas and fluid
accumulate proximal to and within
obstructed segment causing bowel
distention
 d. Bowel distention, vomiting, third-spacing
leads to hypovolemia, hypokalemia, renal
insufficiency, shock
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Client with Intestinal Obstruction
Pathophysiology
a. Mechanical
1. Problems outside intestines: adhesions (bands
of scar tissue), hernias
2. Problems within intestines: tumors, IBD
3. Obstruction of intestinal lumen (partial or
complete)
 a. Intussusception: telescoping bowel
 b. Volvulus: twisted bowel
 c. Foreign bodies
 d. Strictures
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Client with Intestinal Obstruction
Functional
1. Failure of peristalsis to move intestinal contents:
adynamic ileus (paralytic ileus, ileus) due to
neurologic or muscular impairment
2. Accounts for most bowel obstructions
3. Causes include
 a. Post gastrointestinal surgery
 b. Tissue anoxia or peritoneal irritation from
hemorrhage, peritonitis, or perforation
 c. Hypokalemia
 d. Medications: narcotics, anticholinergic
drugs, antidiarrheal medications
 e. Renal colic, spinal cord injuries, uremia
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Client with Intestinal Obstruction
Manifestations Small Bowel Obstruction
a. Vary depend on level of obstruction and speed of
development
b. Cramping or colicky abdominal pain, intermittent,
intensifying
c. Vomiting
 1. Proximal intestinal distention stimulates vomiting
center
 2. Distal obstruction vomiting may become feculent
d. Bowel sounds
 1. Early in course of mechanical obstruction:
borborygmi and high-pitched tinkling, may have visible
peristaltic waves
 2. Later silent; with paralytic ileus, diminished or
absent bowel sounds throughout
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e. Signs of dehydration
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Client with Intestinal Obstruction
Complications
 a. Hypovolemia and hypovolemic shock can
result in multiple organ dysfunction (acute
renal failure, impaired ventilation, death)
 b. Strangulated bowel can result in
gangrene, perforation, peritonitis, possible
septic shock
 c. Delay in surgical intervention leads to
higher mortality rate
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Client with Intestinal Obstruction
Large Bowel Obstruction
 a. Only accounts for 15% of obstructions
 b. Causes include cancer of bowel,
volvulus, diverticular disease, inflammatory
disorders, fecal impaction
 c. Closed-loop obstruction: competent
ileocecal valve causes massive colon
dilation
 d. Manifestations: deep, cramping pain;
severe, continuous pain signals bowel
ischemia and possible perforation; localized
tenderness or palpable mass may be noted
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Client with Intestinal Obstruction
Collaborative Care
 a.
Relieving pressure and obstruction
 b.
Supportive care
Diagnostic Tests
a. Abdominal Xrays and CT scans with contrast media
 1.
Show distended loops of intestine with fluid and /or gas in small
intestine, confirm mechanical obstruction; indicates free air under
diaphragm
 2.
If CT with contrast media meglumine diatrizoate (Gastrografin),
check for allergy to iodine, need BUN and Creatinine to determine
renal function
b. Laboratory testing to evaluate for presence of infection and electrolyte
imbalance: WBC, Serum amylase, osmolality, electrolytes, arterial
blood gases
c. Barium enema or colonoscopy/sigmoidoscopy to identify large bowel
obstruction
Gastrointestinal Decompression
 a.
Treatment with nasogastric or long intestinal tube provides
bowel rest and removal of air and fluid
 b.
Successfully relieves many partial small bowel obstructions
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Client with Intestinal Obstruction
Surgery
 a. Treatment for complete mechanical obstructions,
strangulated or incarcerated obstructions of small bowel,
persistent incomplete mechanical obstructions
 b. Preoperative care
 1. Insertion of nasogastric tube to relieve vomiting,
abdominal distention, and to prevent aspiration of
intestinal contents
 2. Restore fluid and electrolyte balance; correct acid
and alkaline imbalances
 3. Laparotomy: inspection of intestine and removal of
infarcted or gangrenous tissue
 4. Removal of cause of obstruction: adhesions, tumors,
foreign bodies, gangrenous portion of intestines and
anastomosis or creation of colostomy depending on
individual case
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Client with Intestinal Obstruction
Nursing Care
 a. Prevention includes healthy diet, fluid intake
 b. Exercise, especially in clients with recurrent
small bowel obstructions
Nursing Diagnoses
 a. Deficient Fluid Volume
 b. Ineffective Tissue Perfusion, gastrointestinal
 c. Ineffective Breathing Pattern
Home Care
 a. Home care referral as indicated
 b. Teaching about signs of recurrent obstruction
and seeking medical attention
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Gastrointestinal Intubation


It is the insertion of a rubber or plastic tube
into the stomach ,duodenum ,or intestine .
The tube may inserted through the mouth ,
nose , or the abdomen
 Intubation may be performed to:1.
2.
3.
4.
5.
6.
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Decompress the stomach & remove gas &fluid
Lavage the stomach & remove toxic ingested
substances
Diagnose GI motility & other disorders
Administer medication & feedings
Treat an obstruction
Compress a bleeding site
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Gastrointestinal Intubation
 Types
1. Short tubes
2. Medium :
3. Long (nasoenteric)
 Nursing care includes
 Providing instructions
 Inserting the tube
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Gastrointestinal Intubation
 Confirming placement
 Securing the tube
 Advancing the nasoenteric decompression
tube
 Providing oral & nasal Hygiene
 Monitoring the patient & maintaining tube
function
 Monitoring & managing potential complications
 Removing the tube
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Gastrointestinal Intubation
Gastrostomy
Is surgical procedure to create an opening
into the stomach for the purpose of
administer food & fluids
Elderly & debilitated patients
Comatose patients
Percutaneous endoscopic gastrostomy
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TPN
 Is a method of supplying nutrients to the
body by an IV rout
 Clinical Indications
1. Insufficient intake to maintain anabolic
2. Impaired ability to ingest food
3. Ingestion unwilling
4. prolonged pre & post op. nutritional needs
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TPN
 Types of nutritional solutions
1. TPN (aminoacids + dextrose formula )
2. Total nutrient admixture (aminoacids
+dextrose formula + intralipids )
 Methods of Administration
1. Peripheral Partial Method
2. Central line Method
 D/C gradually
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