7. Gastrointestinal

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GASTROINTESTINAL

SYSTEM

FUNCTION: DIGESTION, ABSORPTION,

ELIMINATION

COMPOSITION: ALIMENTARY CANAL,ACCESSORY ORGANS

PERISTALSIS ± wavelike motion that propels substances within the GIT

SPHINCTERS / VALVES: controls rate of

peristalsis / prevents regurgitation



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NURSING AND PATIENT CARECONSIDERATION:

Common practices are the following; for 3 days

before the test and during the stool collection period:

1. Diet should have a high fiber content.2. Avoid red meat in the diet.

Avoid food with a high peroxide content, such as

turnips,cauliflower,broccoli,horseradish,and melon.

Avoid enemas or laxatives before the stool specimencollection.

Avoid iron preparations,iodides,bromides,aspirin,no

steroidal anti-inflammatory drugs (NSAIDs), or

vitamin C supplements greater than 250 mg/day

DIAGNOSTIC TESTS:

�LABORATORY TESTS:

�A. HEMOCCULT GUAIAC TESTS:



B. HYDROGEN BREATH TEST

1. It is used to evaluate carbohydrate absorption.

2. A radioactive substance is ingested, and after acertain time period, exhaled gases are measured.

3.the test measures the amount of hydrogen

produced in the colon,absorbed in the blood,and

then exhaled in the breath.

4. This test is used as a diagnostic test for short

bowel syndrome,lactose intolerance, and bacterial

overgrowth of the intestine( blind loopsyndrome,Crohn's disease,distal ilea disease).



B. HYDROGEN BREATH TEST

NURSING CONSIDERATIONS:The patient should be NPO 12 hours before the

procedure.

The patient should not smoke after midnight

before the test.

Antibiotics and laxative/enemas should not be

used for 1 week before the test. These products

may alter the laboratory results.



RADIOLOGY AND IMAGING STUDIES

UPPER GASTROINTESTINAL SERIES AND SMALLBOWEL SERIES

1. Upper GI series and small-bowel series arefluoroscopic x-ray examinations of theesophagus, stomach, and small intestine afterthe patient ingests barium sulfate.

2. As the barium passes through the GI tract,fluoroscopy outlines the GI mucus and organs.

3. Spot films record significant findings.

4. Double-contrast studies administer barium

first followed by a radio lucent substance, suchas air, to produce a thin layer of barium to coatthe mucusa.

This allows for better visualization of any type

of lesion..



UPPER GASTROINTESTINAL SERIES AND SMALL

BOWEL SERIES

NURSING AND PATIENT CARECONSIDERATIONS

1. Explain procedure to patient.

2. Instruct patient to maintain low-residue dietfor 2 to 3 days before test and a clear liquiddinner the night before the procedure.

3. Emphasize NPO after midnight before thetest.

4. Encourage patient to avoid smoking, alcohol,caffeine before the test.



5. Explain that the health care provider mayprescribe all narcotics and anticholinergics to

be held 24 hours before the test.6. Tell the patient that he or she will beinstructed at various times throughout theprocedure to drink the barium (480 to 600 mL).

7. Explain that a cathartic will be prescribedafter the procedure.

8. Instruct the patient that stool will be light incolor for the next 2 to 3 days from the barium.

9. Instruct patient to notify health careprovider if he or she has not passed the bariumin 2 to 3 days

10. Note that water-soluble iodinated contrast



NURSING AND PATIENT CARE CONSIDERATIONS

1. Explain to the patient:

A. What the x-ray procedure involves.

B. That proper preparation provides a more accurate view

of the tract and that preparations may vary.

C. That it is important to retain the barium so all surfaces of

the tract are coated with opaque solution.

2. Instruct the patient on the objective of having the largeintestine as clear of fecal material as possible:

A. The patient may be given a low-residue, low-fat diet, 1 to

3 days before the examination.

B. The day before the examination, intake may be limited toclear liquids (no drinks with red dye).

C. The day before the examination, an oral laxative,

suppository, and/or cleansing enema may be prescribed



3. The patient will be NPO after midnight the day of procedure.

4. An enema or cathartic may be ordered after thebarium enema.

5. Inform the patient that barium may cause light-colored stools for several days after the procedure.

ULTRASONOGRAPHY1. A noninvasive test focuses high-frequency soundwaves over an abdominal organ to obtain an imageof the structure.

2. Ultrasound can detect small abdominal masses,fluid-filled cysts, gallstones, dilated bile ducts,ascites, and vascular abnormalities.

3. Ultrasound with Doppler may be ordered for

vascular assessment.



NURSING AND PATIENT CARE CONSIDERATIONS

1. If indicated, prepare the patient before the procedure with

a special diet, laxative, or other medication to cleanse thebowel and decrease gas.

2. Abdominal ultrasound usually requires the patient to be

NPO for at least 6 hours before the procedure.

3. Change position of patient, as indicated, for bettervisualization of certain organs.

COMPUTED TOMOGRAPHY (CT) SCAN

1. This is an x-ray technique that provides excellent

anatomic definition and is used to detect tumors, cysts, andabscesses.

2. The CT can also detect dilated bile ducts, pancreatic

inflammation, and some gallstones.



3. It identifies changes in intestinal wall

thickness and mesenteric abnormalities.

4. Ultrasound and CT can be used to perform

guided needle aspiration of fluid or cells from

lesions anywhere in the abdomen. The fluid or

cells are then sent for laboratory tests (such as

cytology or culture).

NURSING AND PATIENT CARE

CONSIDERATIONS

1. Instruct the patient that fasting for 4 hoursbefore the procedure and an enema or

cathartic may be necessary. This is to cleanse

the bowel for better visualization.



2. Ask the patient if she is pregnant. If yes, do not

proceed with scan and notify health care provider.

3. Ask if there are known allergies to iodine or

contrast media. A contrast medium may be given

intravenously (IV) to provide better visualization of

body parts. If allergic, notify the technician and

health care provider immediately.

4. Instruct the patient to report symptoms of itching

or shortness of breath if receiving contrast media,

and observe patient closely.

ENDOSCOPIC PROCEDURESEndoscopy is the use of a flexible tube (the

fiberoptic endoscope) to visualize the GI tract and

to perform



certain diagnostic and therapeutic procedures.Images are produced through a video screen ortelescopic eyepiece. The tip of the endoscope moves

in four directions, allowing for wide-anglevisualization. The endoscope can be insertedthrough the rectum or mouth, depending on whichportion of the GI tract is to be viewed.

Endoscopes contain multipurpose channels thatallow for air insufflation, irrigation, fluidaspiration, and the passage of special instruments.These instruments include biopsy forceps, cytologybrushes, needles, wire baskets, laser probes, andelectrocautery snares.

Endoscopic functions other than visualizationinclude biopsy or cytology of lesions, removal of foreign objects or polyps, control of internal

bleeding, and opening of strictures.



ESOPHAGOGASTRODUODENOSCOPY

(EGD)

1. This allows for visualization of the esophagus,stomach, and duodenum.

2. EGD can be used to diagnose acute or chronicupper GI bleeding, esophageal or gastric varices,polyps, malignancy, and gastroesophageal reflux.

3. Instruments passed through the scope can beused to perform a biopsy or cytologic study,

remove polyps or foreign bodies, control bleeding,or open strictures.

NURSING AND PATIENT CARECONSIDERATIONS

1. Explain the following to the patient:



A. The type of procedure to be performed on the patient. As

an outpatient, advise that someone must accompany the

patient to drive home due to the patient being sedated.

B. NPO for 8 to 12 hours before the procedure to preventaspiration and allow for complete visualization of the

stomach.

C. Remove dentures and partial plates to facilitate passing

the scope and preventing injury.

2. Inform the health care provider of any known allergies

and current medications. Medications may be held until the

test is completed.

3. Obtain prior x-rays, and send with the patient.

4. Describe what will occur during and after the procedure:

A. The throat will be anesthetized with a spray or gargle.



B. An IV sedative will be administered.

C. The patient will be positioned on the left side with a towel

or basin at the mouth to catch secretions.

D. A plastic mouthpiece will be used to help relax the jaw

and protect the endoscope. Emphasize that this will not

interfere with breathing.

E. The patient may be asked to swallow once in a while asthe endoscope is being advanced. The patient should not

swallow, talk, or move tongue. Secretions should drain from

the side of the mouth, and the mouth may be suctioned.

F. Air is inserted during the procedure to permit better

visualization of the GI tract. Most of the air is removed at

the end of the procedure. The patient may feel bloated, burp,

or pass flatus from remaining air.



G. Keep patient NPO according to protocol until patient isalert and gag reflex has returned.

H. May resume regular diet after gag reflex returns and

tolerating fluids.I. May experience a sore throat for 24 to 36 hours after theprocedure. When the gag reflex has returned, throatlozenges or warm saline gargles may be prescribed forcomfort.

5. Monitor vital signs every 30 minutes for 3 to 4 hours, andkeep the side rails up until the patient is fully alert.

6. Monitor the patient for abdominal or chest pain, cervicalpain, dyspnea, fever, hematemesis, melena, dysphagia,lightheadedness, or a firm distended abdomen. These mayindicate complications.

7. Instruct the patient on the above listed signs andsymptoms, and advise to report immediately should anyoccur, even after discharge.

8. Possible complications include perforation of the



esophagus or stomach, pulmonary aspiration,

hemorrhage, respiratory depression or arrest,

infection, cardiac arrhythmias or arrest.PROCTOSIGMOIDOSCOPY AND COLONOSCOPY

1. Proctosigmoidoscopy (rectosigmoidoscopy) is the

visualization of the anal canal, rectum, and sigmoid

colon through a fiberoptic sigmoidoscope.2. Colonoscopy is the visualization of the entire large

intestine, sigmoid colon, rectum, and anal canal.

3. Sigmoidoscopy or colonoscopy can be used to

diagnose malignancy, polyps, inflammation, or

strictures.

4. Colonoscopy is used for surveillance in patients with

a history of chronic ulcerative colitis, previous colon

cancer, or colon polyps.



5. Lower GI endoscopy can be used to perform

biopsy, remove foreign objects, or obtain

specimen for culture or cytology.

6. Colonoscopy, a more extensive procedure

than proctosigmoidoscopy, requires several

days of bowel preparation and use of conscioussedation during the procedure. The bowel

preparation includes approximately 1 gallon or

less iso-osmolar electrolyte solution to consume

over a 3- to 4-hour period the day before theprocedure, clear liquid diet the day before the

procedure, and an oral laxative the night

before the procedure. Protocols may vary.



NURSING CARE:

1. Verify the patient¶s compliance with the

pretest bowel preparation the day before theprocedure, usually an oral laxative (such as

magnesium citrate) and a clear liquid diet.

2. The patient must be NPO after midnight.3. Explain to the patient that a feeling of

fullness will occur when water is introduced

into the GI tract. This eliminates air space

and provides for high resolution.



4. Observe the patient for a change in vital signs,

bleeding, pain, vomiting, abdominal distention or

rigidity.5. Ensure that patients who have had endoscopic

procedures requiring sedation have a caregiver to

drive home after the procedure.



PURPOSES OF ENEMA ADMINISTRATION

1. Bowel preparation for diagnostic tests or surgery

to empty the bowel of fecal content.2. Delivery of medication into the colon ( such asenemas containing neomycin to decrease thebowel¶s bacteria count or a kayexalate enema to

decrease the serum potassium level)3. To soften the stool ( oil-retention enemas)

4. To relieve gas( tidal,milk and molasses,or fleetenemas)

5. Promote defecation and evacuate feces from thecolon for patients with constipation or animpaction.



NASOGASTRIC AND NASOINTESTINAL

INTUBATION

Nasogastric intubation refers to the insertion of atube through the nasopharynx into the stomach.

Nasointestinal intubation is performed by insertinga small-bore tube, that is carried by way of peristalsis into the duodenum or jejunum. It isprimarily used for intestinal decompression,administering feedings and maintaining nutritionalintake.

PURPOSES OF NASOGASTRIC INTUBATION

Remove fluid and gas from the stomach(decompression).

Prevent or relieve nausea and vomiting aftersurgery or traumatic events by decompressing thestomach.



Determine the amount of pressure and motor

activity in the GI tract (diagnostic studies).Irrigate the stomach (lavage) for active bleeding orpoisoning.

Treat mechanical obstruction.

Administer medications and feeding (gavage)directly into the GI tract.

Obtain a specimen of gastric contents for laboratorystudies when pyloric or intestinal obstruction is

suspected.



Administer TPN at a constant rate, using an infusion pump.

The infusion should never be stopped abruptly. Administer

dextrose 10% in water if you must stop the infusion. During

the TPN administration, the pancreas secretes increasedinsulin; abrupt cessation can cause hypoglycemia.

Maintain strict asepsis. Use an occlusive dressing and change

the dressing,tubing and filter every 48 hours.

Monitor blood glucose levels or check urine for glucose every6 hours. Note that the client might need insulin.

Observe the client for headache,nausea,vomiting and fever.

These indicate an allergy to the protein.

Closely monitor intake and output.

Weigh the client daily. Expect a weight gain of ¼ lb per day.

Never use a filter with fat emulsions. Monitor for nausea

and fever, which are common adverse reactions.



GASTRITISGASTRITIS is an inflammation of the gastric mucosa

(the stomach lining). It may be acute or chronic.

Acute gastritis produces mucosal reddening, edema,hemorrhage, and erosion. Chronic gastritis is

common among elderly people and people with

pernicious anemia. In chronic atrophic gastritis, all

stomach mucosal layers are inflamed.



POSSIBLE CAUSES:

Acute gastritis

Chronic ingestion of irritating foods, spicy foods or

alcohol

Drugs, such as aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)(in large doses),cytotoxic agents, caffeine, corticosteroids,

antimetabolites, phenylbutazone, and indomethacinIngestion of poisons, especiallydichlorodiphenyltrichloroethane (DDT), ammonia,mercury, carbon tetrachloride, and corrosive

substancesEndotoxins released from infecting bacteria, suchas staphylococci, Escherichia coli, and salmonella,viruses (gastroenteritis)



CHRONIC GASTRITIS:

1. Alcohol ingestion2. Cigarette smoke

3. Environmental irritants

4. Peptic ulcer diseaseASSESSMENT FINDINGS:

- Abdominal cramping

- Epigastric discomfort- Hematemesis

- Indigestion



DIAGNOSTIC EVALUATION:

1. Fecal occult blood test can detect occult

blood in vomitus and stools if the clienthas gastric bleeding.

2. Blood studies show low Hgb level andHct when significant bleeding hasoccurred.

3. Upper GI endoscopy with biopsyconfirms the diagnosis when performed

within 24hrs of bleeding.4. Upper GI series may be performed to

exclude serious lesions.



TREATMENT:

-Blood transfusion

-I.V. fluid therapy-NG lavage to control bleeding

-Oxygen therapy, if necessary

-Partial or total gastrectomy (rare)-Vagotomy and pyloroplasty (limitedsuccess when conservative treatments havefailed)

IMPLEMENTATION:

1.If the client is vomiting, give antiemeticsand I.V. fluids to prevent dehydration and

electrolyte imbalance.



2. Monitor fluid intake and output and electrolytelevels.

3. Provide a bland diet to prevent recurrence.

4. Offer smaller, more frequent meals to reduceirritating gastric secretions. Eliminate foods thatcause gastric upset.

5. If surgery is necessary, prepare the client

preoperatively and provide appropriatepostoperative care to decrease preoperative anxietyand prevent intraoperative and postoperativecomplications.

6. Administer antacids and other prescribedmedications

7. Urge the client to take prophylactic medications asprescribed to prevent recurring symptoms.

8. Provide emotional support.



HIATAL HERNIA

A. ETIOLOGY

1. Portion of the stomach protruding througha hiatus (opening) in the diaphragm into the

thoracic cavity.

2. May result from a congenital weakness of the diaphragm or from injury, pregnancy, orobesity.

3. Function of the cardiac sphincter is lost,gastric juices enter the esophagus causinginflammation.



Signs/symptoms



B. CLINICAL FINDINGS:

1. Subjective: substernal burning pain or

fullness after eating; dyspepsia in therecumbent position; nocturnal dyspnea.

2. Objective: GI series and endoscopy showprotrusion of the stomach through thediaphragm; regurgitation

C. THERAPEUTIC INTERVENTIONS:

1. Small, frequent, bland feedings.

2. Pharmacologic management: antacids,

antisecretory agents, antiemetics, especiallythose that promote gastric emptying

3. Surgical repair (done infrequently)

Fundoplication



PEPTIC ULCER DISEASE

(PUD)

A. ETIOLOGY:

1. Ulcerations of the gastrointestinal mucus

and underlying tissues caused by gastric

secretions that have a low pH (acid)

2. Causes include conditions that increase the

secretion of hydrochloric acid by the gastricmucosa or that decrease the tissue¶s resistance

to the acid.



a. infection of the gastric and / or duodenal

mucusa by Campylobacter pylori or

Helicobacter pylori.

b. Zollinger ± Ellison syndrome: tumors

secreting gastrin, which will stimulate the

production of excessive hydrochloric acid.

c. certain drugs such as aspirin,steroids, andindomethacin will decrease tissue resistance.

d. smoking

3. Peptic ulcers may be present in the esophagus,

stomach, or duodenum ( most common site ).

4. Complication include pyloric or duodenal

obstruction, hemorrhage and or perforation.




1. Bland foods, and restriction of irritating

substances.2. Antibiotic therapy if microorganism isidentified; tetracycline, metronidazole, andbismuth

3. Histamine H2 receptor antagonists orproton pump inhibitors, antacids

4. Sedatives, tranquilizers, anticholinergics,and analgesics

5. Antiemetics6. A nasogastric tube for decompression,

installation of vasocontrictors, and/or salinelavages when hemorrhage occurs.



g. Common complications of total or partial

gastric resection:

(1) Dumping syndrome

(2) Hemorrhage

(3) Pneumonia

(4) Pernicious anemia

GASTRIC SURGERIES



GASTRIC SURGERIES



NURSING CARE:

1. Allow ample time for the client toexpress feelings and concerns.

2. Administer and assess effects of

sedatives, antacids, anticholinergics, H2

receptor antagonists, antibiotics, and

dietary modifications.

3. Encourage hydration to reduce

anticholinergic side effects and dilutethe hydrochloric acid in the stomach.



4. Instruct client to:

a.Eat small to medium-sized meals becausethis helps prevent gastric distention;

encourage between-meal snacks to achieve

adequate calories when necessary.

b.Avoid foods that increase gastric acidsecretion or irrigate gastric mucosa.

c.Avoid foods that cause distress; varies for

individuals but common offenders are the

gas producers (legumes, carbonated

beverages, vegetables).



d. eat meals in pleasant, relaxing

surrounding to reduce acid secretions.

e. administer calcium and iron

supplements as ordered if client's

medication increases gastric pH.

5. Refrain from administering drugs such

as salicylates, NSAIDS, steroids,and

ACTH.

6. Observe for complications such asgastric hemorrhage,perforation and drug

toxicity.



WOW!!! BEACH

BREAK MUNA ! ! !

MAG COCA COLA ! ! !



DIVERTICULAR DISEASE



DIVERTICULAR DISEASE

Diverticular disease has 2 clinical forms:

DIVERTICULOSIS andDIVERTICULITIS. Diverticulosisoccurs when the intestinal mucosaprotrudes through the muscular wall.

The common sites for diverticula are inthe descending and sigmoid colon, butthey may develop anywhere from theproximal end of the pharynx to the anus.

Diverticulitis is an inflammation of thediverticula that may lead to infection,

hemorrhage, or obstruction.



POSSIBLE CAUSES:

Age (most common in people over age 40)

Chronic constipation, more common in

obese individuals

Congenital weakening of the intestinal wallLow intake of roughage and fiber

Straining during defecation

Stress

Men affected more than women

ASSESSMENT FINDINGS:




- Anorexia

- Stool with blood and mucus

- Change in bowel habits

- Constipation and diarrhea

- Fever

- Flatulence

- Intermittent left lower quadrant pain

or midabdominal pain that radiates to the

back - Nausea

- Rectal bleeding



DIAGNOSTIC EVALUATION:

1)Barium enema (contraindicated in clients with

acute diverticulitis) shows inflammation, narrowlumen of the bowel, and diverticula.

2)Hematologic study shows increased WBC count

and ESR.

3)Sigmoidoscopy (contraindicated in clients with

acute diverticulitis) shows a thickened wall in

the diverticula.

4)Computed tomography scan shows abscesses or

thickening of the bowel.

TREATMENT:



TREATMENT:

- Generally no treatment for asymptomaticdiverticulosis

- Colon resection (for diverticulitis refractory tomedical treatment)

- High residue diet with no seeds for diverticulosis

- Low residue diet with diverticulitis

- Bland diet, stool softeners, and occasional doses of mineral oil for diverticulosis with pain, mild GIdistress, constipation, or difficult defecation.

- Bland diet (for diverticulosis after pain subsides)

or liquid diet (for mild diverticulitis ordiverticulosis before pain subsides); low-fiber dietindicated following the liquid diet; when the client isasymptomatic, low-fat, high-fiber diet

recommended.

Temporary colostomy possible for perforation peritonitis



- Temporary colostomy possible for perforation, peritonitis,

obstruction, or fistula that accompanies diverticulitis.

� IMPLEMENTATION:1. Asses abdominal distention and bowel sounds to determine

baseline and detect changes in the clients condition.

2. Monitor and record vital signs, intake and output, and

laboratory studies to assess fluid status.3. Monitor stools for occult blood to detect bleeding.

4. Maintain the clients diet to improve nutritional status and

promote healing.

5. Maintain position, patency, and low suction of NG tube toprevent nausea and vomiting

6. Keep the client in semi-Fowler¶s position to promote

comfort and GI emptying.



7. Prepare the client for surgery, if necessary

(administer cleansing enemas, osmoticpurgative, and oral and parenteral antibiotics),

to avoid wound contamination from bowel

contents during surgery.

8. Provide postoperative care (watch for signs of infection; perform meticulous wound care;

watch for signs of postoperative bleeding; assist

with turning, coughing, and deep breathing;

teach ostomy self-care) to promote healing andprevent complications.



CROHN¶s DISEASE

(Regional Enteritis)

CROHN¶sDISEASE is a chronic inflammatorydisease of the small intestine, usually affectingthe terminal ileum. It also sometimes affectsthe large intestine, usually in the ascendingcolon. It¶s slowly progressive withexacerbations and remissions.

POSSIBLE CAUSES:

Emotional upsets

Fried foods

Milk and milk products

Unknown



Antidiarrheal: diphenoxylate (Lomotil)

Antiemetic: prochlorperazine (Compazine)

Anti-inflammatory: olsalazine (Dipentum)

Corticosteroid: prednisone (Deltasone)

Immunosupressant: mercaptopurine(Purinethol), azathioprine (Imuran)

Potassium supplement: potassium chloride (K-

Lor) administered with food, potassium

gluconate (Kaon)

IMPLEMENTATION:



IMPLEMENTATION:

Bedrest, weigh daily

NPO in acute stage, TPN as ordered.High CHON, calorie, bland, low residue diet.

Avoid gas-producers, irritating food, andmilk products.

Offer small frequent feedings.

Vitamin replacement ADEK.

IVF, I/O, tepid fluids up to 3L/day.

Perianal care with lubricants and ointments.

Hot sitz baths, monitor stools.

Emotional support esp. family members.



Administer medications, as prescribed, tomaintain or improve the client¶s condition.

Maintain the client¶s diet; withhold food andfluid as necessary to minimize GI discomfort.

Minimize stress and encourage verbalization of feelings to allay the client¶s anxiety.

If surgery is necessary, provide postoperativecare (monitor vital signs; monitor dressings fordrainage; monitor ileostomy drainage andperform ileostomy care as needed; assessincision for signs of infection; assist withturning, coughing, and deep breathing; get theclient out of bed on the 1st postoperative day if stable) to promote healing and preventcomplications.



Autoimmune disease



Emotional stress

Viral and bacterial infections


Abdominal cramping, distention, and tenderness

Anorexia

Bloody, purulent, mucoid, watery stools (15 to 20per day)

Dehydration

Fever

Hyperactive bowel soundsNausea and vomiting

Weakness

Weight loss



IMPLEMENTATION:



Assess GI status and fluid balance to determinedeficient fluid volume.

Monitor and record vital signs, intake andoutput, laboratory studies, daily weight, urinespecific gravity, calorie count, and fecal occultblood to determine deficient fluid volume.

Monitor the number, amount, and character of stools to determine status of nutrientabsorption.

Maintain the client¶s diet; withhold food and

fluid as necessary to prevent nausea andvomiting.

Administer I.V. fluids and TPN to maintainhydration and improve nutritional status.



Maintain position, patency, and low suction of

NG tube to prevent nausea and vomiting.

Keep the client in semi-Fowler¶s position to

promote comfort.

Administer medications, as prescribed, to

maintain or improve the client¶s condition.Provide skin, mouth, nares, and perianal care

to promote comfort and prevent skin

breakdown.

OSTOMY CARE



OS O C

Referral to enterostomal therapist.

Encourage verbalization of fears/concerns.

Teach character of drainage: ileostomy ± liquid 4-6x/day,transverse colostomy ± mushy OD, descending/sigmoid ± soft

formed q 2-3 days

Skin care ± nystatin, karaya powder, soap/H2O pat dry

Odor control ± deodorant drops, bismuth tabs, mouthwashsolutions, spinach, parsley added to ostomy bag.

Odor ± avoid gas-formers (cabbage, beans, broccoli,

cauliflower, corn, onions, eggs, fish, condiments.

Diet ± ileostomy (clear liquids, strained fruits/veggiesprogress to regular diet, Na/K rich food, avoid fried,

seasoned food, nuts, raisins, raw fruits)

colostomy ± clear liquid, solid low-residue 1st 6 weeks

Ileostomy drainage q 4-6 hrs emptied, pouch 5-7 days max



OSTOMY IRRIGATION

Only colostomies are irrigated; ileostomy no need

Purposes ± stimulate emptying of colon to avoid use

of appliance

Started 5-7 days post-op in the bathroom preferably

Equipment: irrigating solution, catheter with stomatip, irrigating sleeve

Tepid water used 18-24 in above stoma (shoulder

height)

500-1000ml irrigated slowly

Done same time everyday / as preferred

Return flow expected within 15-45 mins

INTESTINAL OBSTRUCTIONS



INTESTINAL OBSTRUCTIONS

HEMORRHOIDS



HEMORRHOIDSA. GENERAL INFORMATION:

1. Congestion and dilation of the veins of therectum and anus; usually result from impairment of flow of blood through the venous plexus.

2. May be internal (above the anal sphincter) or

external (outside anal sphincter).3. Most commonly occur between ages 20-50.

4. Predisposing conditions include occupationsrequiring long periods of standing; increased intra-

abdominal pressure caused by prolongedconstipation, pregnancy, heavy lifting, obesity,straining at defecation; portal hypertension.



2 Assess for rectal bleeding; inspect rectal



2. Assess for rectal bleeding; inspect rectalarea/dressings every 2-3hours and report significantincreases in bloody drainage.

3. Promote comfort.

a. Assist client to side-lying or prone position,provide flotation pad when sitting.

b. Administer analgesics as ordered

4. Promote elimination: administer stool softeners asordered and, if possible, administer analgesicsbefore first post-op bowel movement.

5. Provide client teaching and discharge planningconcerning

a. Dietary modification (low-residue, soft progressto high fiber/fresh fruits, force fluids 2.5-3L/day)



b. Defecate when urge is felt

c. Use of stool softeners as needed untilhealing occurs.

d. Sitz baths after each bowel movement.

e. Perineal care with antiseptic solutions.

f. Recognition and reporting immediately to

physician of the following signs and symptoms:

1. Rectal bleeding

2. Continued pain on defecation

3. Puslike drainage from rectal area

HEPATIC CIRRHOSIS



HEPATIC CIRRHOSIS

A. ETIOLOGY AND PATHOPHYSIOLOGY

1. Irreversible fibrosis and degeneration of the liver

2. Several types of cirrhosis; Laënnec¶s (alcoholic cirrhosis,

nutritional cirrhosis) most common

3. Incidence higher in alcoholics, who are often

malnourished, and in those who have had hepatitis4. As liver failure progresses, there is increased secretion of

aldosterone, decreased absorption and utilization of the

fat-soluble vitamins (A, D, E, K), and ineffective

detoxification of protein wastes5. Hepatic coma (hepatic encephalopathy) may result from

high blood ammonia levels when the liver is unable to

convert the ammonia to urea



7. Surgical intervention to decrease portal



g phypertension: a portacaval shunt

8. Esophageal varices management

Sengstaken-Blakemore tube:

9 P id h S t k Bl k



9. Provide care when a Sengstaken - Blakemore

tube is in place

a. Maintain traction once the tube is passedand the gastric balloon is inflated to ensure

proper placement, elevate bed 30-45 degrees

b. Maintain the esophageal balloon at

inflated level (30-35mm Hg) up to 48 hrs

c. Deflate gastric balloon for a few minutes

at specific intervals if ordered to prevent

necrosis

d. Gastric lavage as ordered

e. Suction orally as necessary because the

client is unable to swallow saliva

10 Dietary modification:



10. Dietary modification:

a. Cirrhosis:

1. Protein as tolerated (80-100g); withincreasing liver damage, protein metabolism ishindered

2. High carbohydrate, moderate fat;

provides for energy; vitamin, mineral, andelectrolyte supplements

3. Low sodium (500-1000mg daily); helpscontrol increasing ascites

4. Soft foods if esophageal varices arepresent; prevents danger of rupture andbleeding

5. Alcohol contraindicated to avoidirritation and malnutrition



b. Hepatic coma

1. Protein: reduced according totolerance; 15-30g

2. High calorie (1500-2000g) to

prevent catabolism and liberation of nitrogen

3. Fluid carefully controlled according

to output



CHOLELITHIASIS /



CHOLELITHIASIS /

CHOLECYSTITISA. ETIOLOGY AND PATHOPHYSIOLOGY:

1. Inflammation of the gallbladder; usuallycaused by the presence of stones(cholelithiasis), which are composed of

cholesterol, bile pigments, and calcium.2. Diseased gallbladder is unable to contract in

response to fatty foods entering the duodenumbecause of obstruction by calculi or edema.

3. When the common bile duct is completelyobstructed, the bile is unable to pass into theduodenum and is absorbed into the blood.

4. Incidence is highest in obese women

in the fourth decade.




1.Medical management

- Nasogastric suctioning to reduce nauseaand eliminate vomiting

- Narcotics to decrease pain

- Antispasmodics and anticholinergics toreduce spasms and contractions of the

gallbladder

- Antibiotic therapy if infection issuspected

- NURSING CARE:



NURSING CARE:

-Teach dietary modification to achieve a low-fat

intake because reduced bile flow will reduce fatabsorption; supplementation with water-miscible

forms of vitamins A and E may be prescribed.

-Relieve pain both preoperatively and

postoperativelyObserve for signs of bleeding (vitamin K is fat

soluble and is not absorbed in the absence of

bile); administer vitamin K preparations as

ordered

Provide care following a cholecystectomy:

surgical / laparoscopic laser

a. Monitor nasogastric tube attached to suction to

di i



prevent distention

1. Maintain patency of the tube

2. Assess and measure drainage

b. Provide fluids and electrolytes via intravenous

route

c. Keep the client in a low-Fowler¶s positiond. Have the client cough and deep breathe; splint the

incision (incision is high and midline, making

coughing extremely uncomfortable)

e. Provide care for the client with a T-tube (if thecommon bile duct has been explored, a T-tube is

inserted to maintain patency)

TREATMENT OF STONES:

CHOLESTEROL DISSOLVENT



� CHOLESTEROL DISSOLVENT:

Moctanin is administered through a nasal

biliary catheter to dissolve stones left in the bileduct after cholecystectomy. Dissolution maytake 1 to 3 weeks. Observe the client foranorexia, nausea, vomiting, and abdominalpain.

ORAL BILE ACIDS:

Chenodiol ( chenix ) and ursodiol ( actigall )are administered to dissolve small stones. Side

effects include diarrhea ( especially withchenodiol ), elevation of hepaticenzymes,gastritis, and gastric ulcers.Dissolution takes between 6 months and 2years, and the success rate is only about 30 %

Extracorporeal shockwave lithotripsy

E d i hi t t / t d h l i



Endoscopic sphincterotomy/retrograde cholangio-pancreatography

Percutaneous transhepatic dissolutionNasal biliary dissolution



6 Duodenal ulcer



6.Duodenal ulcer

7. Hyperlipidemia

ASSESSMENT FINDINGS:a. Abrupt onset of pain in the epigastric / LUQ area

that radiates to the shoulder, substernal area,

back, and flank

b. Abdominal tenderness and distention

c. Aching, burning, stabbing, pressing pain

d. Knee-chest position, fetal position, or leaning

forward for comfort d/t abdominal paine. Mental confusion, hypocalcemia ± mm irritability

f. Nausea and vomiting



g. Tachycardia, shock, hypotension

h. Dyspnea

i. Low grade fever

j. Elevated serum amylase / lipase / glucose

k. Grey Turner¶s, Cullens¶s sign

l. Chronic steatorrhea

m. Jaundiceo. Hyperglycemia



9. Keep the client in semi-Fowler¶s position (if

his blood pressure allows) to promote

comfort and lung expansion.

11. Keep the client in bed and turn him every

2hrs, or utilize a specialty rotation bed to

prevent pressure ulcers.12. Provide a quiet, restful environment to

conserve energy and decrease metabolic

demands.

7. Gastrointestinal

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