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8/4/2019 Alteration in Nurtition and Metabolism Short Bowel Syndrome
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ALTERATIONIN NUTRITION
AND
METABOLISM
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REVIEW OF GI TRACT
GI tract 23-26 feet-long
passageway that extends from the
mouth up to anus
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FUNCTIONS :
- To break down food particles into themolecular form for digestion
- To absorb into the bloodstream the small
molecules produced by digestion To eliminate undigested & unabsorbed
foodstuff & other waste products from the
body
Provide environment for microorganisms to
synthesize nutrients such as Vit. K & B
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CHEWING/
MASTICATION Start of digestion Aided by teeth, tongue & salivary glands
Saliva 1st
secretion that comes incontact with food
- secreted from submandibular, parotid
& sublingual glands- contains ptyalin (salivary amylase)digest starch
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SWALLOWING/
DEGLUTITION
Swallowing voluntary act
-occurs in the throat
-food is pushed from mouth to pharynxto esophagus
- regulated by medulla oblongata
(swallowing center)
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GASTRIC FUNCTION Stomach stores & mixes food with
secretions
-Gastric fluid (2.4L/day)
a. HCl; break down foods & destroy mostingested bacteria
-b. pepsin enzyme for CHON digestion
-c.mucin-d.gastrin- hormone
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- Intrinsic factor secreted by gastric
mucosa to combine with Vit B12 to be
absorbed in the ileum
- Peristalsis & contraction of pyloric
sphincter enter of partially digested foodin the small intestine
- Chyme- food mixed with gastric secretion
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ACCESSORY DIGESTIVE
ORGANS Pancreas, liver & gallbladder
PANCREAS contains pancreatic juice withalkaline pH neutralizes acid entering
duodenum
- serves as Exocrine & endocrine gland
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Pancreatic enzymes:
- Amylase digests starch to maltose- Maltase reduce maltose to glucose
- Lactase split lactose to galactose &
glucose- Nucleoses split nucleic acid to
nucleotides
- Enterokinase activates trypsinogen totrypsin
- Lipase digest fats
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LIVER largest gland in the body
- contains Kupffers cells remove bacteria inthe portal circulation
- removes excess glucose & amino acids from theportal blood
- synthesize glucose, amino acids & fats- stores & filters blood (200-400ml)
- stores Vit. A, D, B and iron
- secretes bile for emulsifying ingested fats (500-1000 ml/day)
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GALLBLADDER- stores & concentrates bile
- it contracts to force bile into theduodenum
- Sphincter of Oddi guards the entrance
into the duodenum
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SMALL INTESTINE FUNCTION
Primary function: Absorption
Secretes the ff: Enteric juice
- Mucus coats the cell & protects themucosa
- Hormones control rate of intestinal
secretions & influence GI motility
- Electrolytes
- Enzymes
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Two types of contraction in the small
intestine:1. Segmentation produces mixing waves
that move contents back & forth in
churning motion2. Intestinal peristalsis propels the
content of small intestine into the colon
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COLONIC FUNCTION Primary function: 1.reabsorption of water
& electrolytes 2. fecal formation
Bacteria make up major component of
the contents of large intestine Electrolyte solution (bicarbonate) &
mucus colonic secretions that are
added to residual material in the colon
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WASTE PRODUCT OF
INGESTION Feces undigested foodstuff, inorganic
material, water & bacteria- 75% fluid & 25% solid material
Flatus contains methane, hydrogen
sulfide & ammonia (150 ml)
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Defecation - spinal reflex
(parasympathetic nerve fibers) that can
be inhibited voluntary by keeping the
external anal sphincter closed
Contracting abdominal muscle facilitatesemptying of the colon
Normal defecation: once daily
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ASSESSMENT OF
GIT
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HEALTH HISTORY
1. Pain
- OPQRST, location, frequency, duration,
relieving factors2. Indigestion/Dyspepsia
- Upper abdominal discomfort or distress
associated with eating
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3. Intestinal gas
- Belching expulsion of gas from the stomachthru mouth
- Flatulence expulsion of gas from the rectum
Excessive flatulence may be a symptom ofgallbladder disease or food intolerance
4. Nausea & vomiting
- triggered by odor, activity or food intake- Emesis/vomitus contains undigested food
particles or blood (hematemesis)
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5. Change in bowel habits & stool
characteristics
- may signal colon disease
- Diarrhea abnormal increase in
frequency & liquidity of stool- Constipation decrease in frequency of
stool; or stools that are hard, dry, and of
smaller volume than usual
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Stool color can be greatly affected by
medications & certain foods
Melena- black tarry stool
- upper GI bleeding
Hematochezia fresh blood in the stool
- lower GI bleeding
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PHYSICAL ASSESSMENT
Includes assessment of mouth, abdomen & rectumAbdomen Inspection, auscultation, percussion,
palpation (IAPP)
Inspect for abdominal skin color, scars, veins, hernia,
contour
Bowel sounds heard every 5-20 seconds
- HYPOACTIVE 1-2 sounds in 2 minutes
- HYPERACTIVE - 5-6 sounds in < 30 sec
- ABSENT no sound in 3-5 minutes
Percussion: flatness, dullness , tympany, hyperresonancePalpation: Mass, tenderness, rebound tenderness, muscle
guarding, abdominal rigidity
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DIAGNOSTIC &
LABORATORY
EXAMINATIONS
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NON INVASIVETESTS
ABDOMINAL
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ABDOMINAL
ULTRASOUND Use of high frequency sound waves
Image of abdominal organs & structures is produced on theoscilloscope
Useful in detecting cholelithiasis, cholecystitis, appendicitis &diverticulitis
Advantage: requires no ionizing radiation, no side effects &inexpensive
Disadvantage: cannot be used to examine structures that liebehind bony tissues
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Nursing Management
Maintain pt on NPO 8-12 hours before
the test decrease amount of gas in the
bowel
Fat-free meal in the evening before the
test for gallbladder studies
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STOOL EXAM
Inspecting for consistency, color,
parasites, fat, nitrogen, food substances
& testing for occult (not visible) blood
Some specimen requires certain diet to
be followed
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INVASIVETESTS
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ESOPHAGOGASTRODUODENOSCOPY
(EGD)
Upper gastrointestinal fiberoscopy
Following sedation, an endoscope is
passed down the esophagus to view thegastric wall, sphincters & duodenum
Tissue specimen can be obtained
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Preprocedure
The client must be NPO for 6-12 hours
before the test
A local anesthetic is administered alongwith midazolam IV (provides conscious
sedation & relieves anxiety) just before
the scope is inserted
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Position the client left side to facilitate
saliva drainage & provide easy access ofthe endoscope
Airway patency is monitored during the
test & pulse oximetry is used to monitoroxygen saturation
Emergency equipment should be readily
available
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Postprocedure
Client must be on NPO until the gag reflex
returns (1-2 hours)
Monitor for signs of perforation (pain,bleeding, unusual difficulty swallowing,
elevated temp)
Lozenges, saline gargles or oral analgesiccan relieve minor sore throat after the
gag reflex returns
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COLONOSCOPY, PROCTOSIGMOIDOSCOPY,
PROCTOSCOPY, ANOSCOPY
It requires the use of flexible scope to examine the
lower GIT
Client is placed on the left side with the right leg
bent Biopsies & polypectomies can be performed
Preprocedure: Enemas are given until the returns are
clear Postprocedure: Monitor for rectal bleeding & signs
of perforation
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BARIUM SWALLOW
Examination of upper GIT under fluoroscopy
after the client drink barium sulfate
PREPROCEDURE: NPO post midnight before
the day of the test
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POSTPROCEDURE:
1. A laxative may be prescribed
2. Instruct the client to increase oral fluid intake
to help pass the barium
3. Monitor stool for passage of barium (stool
may appear chalky white) because barium can
cause bowel obstruction
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BARIUM ENEMA
Examination of lower GIT under fluoroscopy
after the client is given barium sulfate solution
via a rectal tube
PREPROCEDURE: clear diet for 3 days, NPO
post midnight before the day of the test,
enema, laxatives
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POSTPROCEDURE:
1. A laxative may be prescribed
2. Instruct the client to increase OFI to help pass
the barium
3. Monitor stool for passage of barium (stool
may appear chalky white) because barium can
cause bowel obstruction
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GASTRIC SECRETION ANALYSIS
Analysis of gastric juice
To know the secretory activity of the gastric
mucosa & presence of gastric retention for
client with pyloric or duodenal obstruction.
Ph, Helicobacter pylori, AFB
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Preprocedure
NPO 8-12 hours before the procedure
Drugs that affect gastric secretions are
withheld 24-48 hours before the test.
Do not do oral care(gargle, brush)
Do not smoke
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NGT is inserted entire stomach content are
aspirated by gentle suction into a syringe &
gastric samples are collected every 15 min forthe next hour
Gastric acid stimulation test is usually
performed in conjunction with gastric analysis.
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COMMON
HEALTH
PROBLEMS
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DISORDERS OF THEESOPHAGUS
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GASTROESOPHAGEAL
REFLUX DISEASE (GERD)
Back-flow of gastric or duodenalcontents into the esophagus
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Causes
1. Incompetent lower esophageal
sphincter
In cases likea.Congenital - pyloric stenosis,Motility
disorder, prematurity
c.Acquired-aging, tumor
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2. Increased Abdominal pressure
In cases of
a. Overeating or eating while drinking or
eating while talking
b. Lying down after eating, bending forward
c. Straining-weightlifting, defecation,urination
d. Obesity, tight clothings
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Clinical Manifestations
Pyrosis (burning sensation in the chest,heartburn)
Burning epigastric pain
Dyspepsia (indigestion)
Regurgitation, belching
Dysphagia (difficulty swallowing)
Odynophagia (pain on swallowing)
Hypersalivation, acidic vomitus
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Complications
GastritisUlcershemorrhage and shock
Esophagitisulcershemorrhage and shock
Scars, Strictures obstructionrupture
Baretts esopahgus
Esophageal Carcinomaobstruction
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Diagnostic Tests
Endoscopy
Barium swallow
Ambulatory 12 or 24 or 36-houresophageal pH monitoring- check ph in
esophagus
Esophageal Manometry- check pressuresand peristalsis
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Nursing Management
Low fat diet, small frequent feeding
avoid caffeine, tobacco, beer, milk, spicy
foods & carbonated drinks, acidic, ASA,NSAIDS
Avoid eating or drinking 2-3 hours before
bedtime, remain upright after meals
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Maintain normal body weight
Avoid tight fitting clothes
Elevate head of bed 6-8 inch blocks &upper body on pillows.
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Medical Management
Antacids- 1-3 hrs after meals and at bedtime, checkRFT
Histamine receptor blockers (e.g. Ranitidine)-beforemeals and at bedtime, take with water,
Proton pump inhibitor (e.g. Omeprazole)- DOC forsevere GERD, 8 wks up to 3-6 months, before mealsand bedtime, check LFT
Prokinetic agents (e.g. Domperidone)- before meals
and bedtime, cause drowsiness and EPS Cytoprotective-( eg. Sucralfate)- before meals and at
bedtime, take IOF and fibers to prevent constipation
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Surgical Management
FUNDOPLICATION
- Wrapping of a portion of the gastric
fundus around the sphincter area of theesophagus
- Can be performed by laparoscopy
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HIATAL HERNIA
Presence of opening(hiatus) in the
diaphragm thru which part of the upper
stomach tends to move up into the lower
portion of the thorax.
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Types
1. SLIDING (TYPE I)
- Occurs when the upper stomach &
gastroesophageal junction are displacedupward & slide in and out of the thorax
- may occur if have short esophagus,
weak anchor, inc. abd pressure
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2. PARAESOPHAGEAL HERNIA (TYPE
II,III,IV)- Occurs when all or part of the stomach
pushes thru the wider diaphragmatic
hiatus beside the esophagus
-stomach remains in its original position
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Clinical Manifestations
PARAESOPHAGEAL HERNIA: with GERD
- Heartburn
- Regurgitation- Dysphagia
- Feeling of fullness
* 50% asymptomatic
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SLIDING HERNIA
- May be asymptomatic May have no GERD
C li i
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Complications Hemorrhage
Obstruction Strangulationischemiainfarctiongangre
nous necrosis
DIAGNOSTIC TESTS X-ray studies
Barium swallow
Fluoroscopy
Management most px need
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Management most px need
no txMEDICAL:manage like GERD
Frequent small feedings
Avoid lying 1 hour after eating
Elevate head of head 4-8 -inch blocks
SURGICAL:
- Herniorrhaphy, Nissen Fundoplication
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ACHALASIA
Esophageal Motility Disorder
Unknown etiology
Increased peristalsis of the whole ordistal esophagus(spasms) accompanied
by failure of the esophageal sphincter to
relax in response to swallowing
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Clinical Manifestations
Dysphagia to both solid and liquids-
primary symptom
Heartburn Chest pain severe and usually at rest
Chest fullness
Nighttime cough
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Diagnostic Tests
X-ray
Barium swallow
CT Scan Endoscopy
MANOMETRY confirmatory test
- esophageal pressure is measured by
radiologist or gastroenterologist
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Medical Management
Instruct pt to eat slowly and drink fluids
with meals.
Calcium channel blocker & nitrates -temporary measure to decrease
esophageal pressure & improve
swallowing
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Surgical Management
BOTOX (Botolinum toxin) injection to
quadrants of esophagus via endoscopy
MOA: lower LES pressureDone q 6-9 months
PNEUMATIC DILATION stretch the
narrow area of esophagus using air
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BALLON DILATATION OF LES
LAPAROSCOPIC ESOPHAGOMYOTOMY- Separates esophageal muscle fibers
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ESOPHAGEALDIVERTICULA
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DIVERTICULUM
Outpouching of mucosa & submucosathat protrudes thru a weak portion ofmuscle
DIVERTICULOSIS: asymptomatic
DIVERTICULITIS: with inflammation
Exact cause is unknown; predisposingfactors congenital (younger than 40),low intake of dietary fiber
ZENKERS DIVERTICULUM (PHARYNGEAL
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ZENKERS DIVERTICULUM (PHARYNGEAL
POUCH) most common type
- people older than 60 yrs old
Other types: midesophageal, epiphrenic
& intramural diverticula
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Clinical Manifestations
Dysphagia
Fullness in the neck
Belching Regurgitation of undigested foods
Gurgling noises after eating
Halitosis- accumulation of undigested
food
Sour taste in the mouth
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Complications
Inflammation
Obstruction
Abscess
Perforation with peritonitis
Bleeding and shock
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Diagnostic Tests
Barium swallow
Manometric studies
* Avoid esophagoscopy & NGT Insertion
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Surgical Management
DIVERTICULECTOMY - Surgical removal
of diverticulum
MYOTOMY the muscle is dilated orreleased surgically
END-TO END ANASTOMOSIS if with
inflammation of surrounding GI mucosa
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DISTURBANCE INDIGESTION
GASTRITIS
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GASTRITISInflammation of gastric mucosa
Acute or chronic
Causes :ACUTE GASTRITIS:
- Contaminated foods
- Spicy foods
- Overuse of aspirin & NSAIDS
- Excessive alcohol intake
- Bile reflux
- Radiation therapy- Ingestion of strong acid or alkali
CHRONIC GASTRITIS
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CHRONIC GASTRITIS:
- Benign or malignant ulcers of stomach
- Helicobacter pylori
- Associated with autoimmune disease
- Use of caffeine- NSAIDS
- Smoking
- Reflux of untestinal content in thestomach
li i l if i
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Clinical Manifestations
ACUTE:
Abdominal discomfort
Headache
Nausea & vomiting
Anorexia
hiccups
CHRONIC:
-Anorexia
-Heartburn
-Belching-Sour taste in the mouth
-Nausea & vomiting
-Evidence of malabsorption
of Vit. B12
Di i T
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Diagnostic Tests
ENDOSCOPY
Upper GI series
Biopsy & histologic exam of tissuespecimen for H. pylori
M di l M
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Medical Management
ACUTE:- Instruct the pt to refrain from alcohol
& food until the symptoms subside
- Non-irritating diet
- Parenteral fluids
- Analgesics & Antacids (e.g. Maalox)
- Nasogastric intubation
CHRONIC:
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CHRONIC:
- Modifying the diet
- Promoting rest
- Reducing stress
- Antibiotic- for H. pylori- Proton pump inhibitor
N i P
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Nursing Process
Assessment:
- Pt history s/sx, 72-hour diet recall, hx of
previous disease, medications taken
Nursing Diagnosis:
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Nursing Diagnosis:
- Imbalance Nutrition less than body reqts
r/t inadequate intake of nutrients
- Risk for imbalance fluid volume r/t
insufficient intake & excessive fluid loss
subsequent to vomiting
- Acute pain r/t irritated stomach mucosa
- Anxiety r/t treatment
Promoting Optimal Nutrition
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Promoting Optimal Nutrition NPO until symptoms subside
Monitor IV therapy Discourage the intake of caffeinated
beverages, alcohol & smoking
Promoting Fluid Balance Daily I&O monitoring
IV fluids are prescribed at 3L/day
Assess electrolyte values
Relieving Pain
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Relieving Pain
Instruct client on the diet to avoid irritation of gastricmucosa
Instruct about medications as prescribed
Assist in non pharmacologic pain mngt
Reduce Anxiety
Use a calm approach to assess the client.
Answer all questions as completely as possible. Explain all procedures & treatments to clients level
of understanding.
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PEPTIC ULCERDISEASE (PUD)
PUD
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PUD
An excavation (hollowed-out area) that
forms in the mucosal wall of the
stomach, in the pylorus, duodenum &
esophagus
Gastric, duodenal, esophageal
depending on location
COMPAIRING DUODENAL &
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GASTRIC ULCERDUODENAL
Incidence:
Age: 30-60
Male:female = 2-3:1
80% are duodenal
GASTRIC
Usually 50 and over
1:1
15% are gastric
Cli i l M if t ti
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Clinical Manifestations
DUODENAL
- Hypersecretion of
HCl
- Weight gain
- Pain occurs 2-3
hours after meal
- Pain awakens px
between 1-2 am
GASTRIC
- Hyposecrretion of
HCl
- Weight loss
- Pain occurs to 1
hour after meal
- No nighttime pain
DUODENAL GASTRIC
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- Ingestion of food
relieves pain- Vomiting is
uncommon
- Bleeding less likely, ifpresent melena is
common
- More likely toperforate than gastric
ulcer
- Vomiting relieves
pain- Vomiting is common
- Bleeding more likely
hematemesis
DUODENAL GASTRIC
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Malignancy
possibility: Rare
Risk factors:
H. pylori, alcohol,smoking, cirrhosis,
stress
Occasionally
H. pylori, gastritis,
alcohol, smoking,NSAIDs, stress
Assessment & Diagnostic
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g
Tests Physical exam: pain, epigastric
tenderness, abdominal distention
Barium study of upper GI
Endoscopy
Biopsy
Gastric analysis
Stool exam for occult blood
Medical Management
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Medical Management
Combinations of the ff:
-Antibiotics
- Proton pump inhibitor- Bismuth salts
H2 receptor antagonist & proton pump
inhibitor for NSAIDs induced ulcer & notassociated with H. pylori
Reduce environmental stress
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Reduce environmental stress
Smoking cessation
Dietary modifications:
-Avoid extremes of temp.
- Avoid overconsumption of meat extracts,coffee, alcohol & other caffeinated
beverages & diet rich in milk & cream
SURGICAL MANAGEMENT
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SURGICAL MANAGEMENT
PYLOROPLASTY- dilatation of pyloric sphincter
ANTRECTOMY-removal of distal third of
stomach
VAGOTOMY resection or removal of CN 10to
decrease stimulation of parietal cells that form
HCl and decrease gastric motility
BILLROTH I-gastroiduodenostomy
BILLROTH II-gastrojejunostomy
Nursing Process
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Nursing Process
ASSESSMENT:
- Describe the pain, methods used to
relieve pain
- Describe emesis if present
- 72-hour food recall
- Lifestyle & medications- Vital signs tachycardia & hypotension
DIAGNOSIS
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- Acute Pain r/t the effect of gastric acid
secretion on damaged tissue
- Imbalance Nutrition r/t changes in diet
- Anxiety r/t coping with an acute disease
- Deficient Knowledge about prevention of
symptoms & management of the
condition
NURSING INTERVENTIONS
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NURSING INTERVENTIONS
RELIEVING PAIN
- Taking prescribed medications.
- Avoid aspirin, foods that contain caffeine- Meals should be eaten regularly
- Relaxation techniques
MAINTAINING OPTIMAL NUTRITIONAL
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MAINTAINING OPTIMAL NUTRITIONAL
STATUS
- Assess for malnutrition & weight loss
- Advise to comply on medication regimen
& dietary restrictions.
FOOD POISONING
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FOOD POISONING
Sudden illness that occurs after ingestionof contaminated food or drink.
BOTULISM - serious form of food
poisoning that requires continual
surveillance.
Assessment
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Assessment
Nausea
Vomiting
Diarrhea
Medical Management
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Medical Management
Food, vomitus, gastric contents, serum &feces are collected for examination
Monitor VS, sensorium, CVP (if indicated)
& muscular activity
Monitor for electrolyte & acid-base
imbalance Antiemetic given parenteral
GASTRIC LAVAGE
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GASTRIC LAVAGE
Aspiration of stomach content & washingout of stomach by means of a large-bore
gastric tube.
Contraindicated for acid or alkali
ingestion, seizures or after ingestion of
hydrocarbons or petroleum distillates
Purpose:
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Purpose:
Urgent removal of ingested substance ordecrease systemic absorption
Empty the stomach before endoscopic
procedure
To diagnose gastric hemorrhage & to
arrest hemorrhage
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DISTURBANCE INABSORPTION ANDELIMINATION
DISORDERS OF
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DISORDERS OF
INTESTINAL
MOTILITY
DIARRHEA
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DIARRHEA
Increased frequency of bowel movement (more than 3x per day)
Increased amount of stool ( more than 200 g
per day) Altered consistency (looseness) of stool
Increased intestinal secretions
Decreased mucosal absorption
Altered motility
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Underlying Disease Process
- Irritable Bowel Syndrome (IBS)
- Inflammatory Bowel Disease (IBD)- Lactose Intolerance
Types
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Types
ACUTE
- Associated with infection
- Self-limiting CHRONIC
- Persist for longer period of time
- May return sporadically
Causes
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Causes Medications (laxatives, thyroid hormone
replacement, antibiotics, chemotherapy, antacids) Tube feeding formula
Metabolic & endocrine disorders (DM, Addisons)
Viral or bacterial infection (Dysentery, shigellosis,food poisoning)
Anal sphincter defect
Zollinger- Ellison syndrome
Paralytic ileus
Intestinal obstruction
AIDS
Clinical Manifestations
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Clinical Manifestations
Increased frequency of stool fluid content of stool
Abdominal pain or cramps
Abdominal distention Intestinal rumbling (borborygmus)
Anorexia
Thirst Tenesmus (ineffectual straining
Diagnostic Tests
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Diagnostic Tests
Stool Exam
CBC
Endoscopy
Barium enema
COMPLICATIONS:
Dehydration
Cardiac dysrhythmia
Medical Management
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Medical Management
Antibiotic
Anti-inflammatory
Antidiarrheal IV therapy
Nursing Management
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Nursing Management
Assess & monitor the characteristic &pattern of diarrhea
Health history
Abdominal auscultation & palpation
Obtaining stool samples
Encourage bed rest
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Encourage bed rest.
Advise intake of liquids & foods low in bulk
Bland diet of semi solid & solid foods
Avoid caffeine, carbonated drinks, very hot or
very cold foods, milk products, fat, whole grain,
fresh fruits & vegetables
Administer medication as prescribed.
Monitor electrolyte levels Report immediately presence of dysrhythmia or
change in LOC
CONSTIPATION
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CONSTIPATION
Abnormal infrequency or irregularity indefecation
Abnormal hardening of stool that makes
the passage difficult or painful
Decrease in stool volume
Retention of stool in the rectum for aprolonged period
Causes
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Causes Medications (tranquilizer, antidepressant, antiHPN,
opioids, antacid with aluminum, iron) Rectal or anal disorder (hemorrhoids)
Obstruction (e.g.cancer of bowel)
Metabolic, neuroligic & neuromuscular condition (DM,
Hirschsprungsdisease, Parkinsons, multiple sclerosis) Endocrine disorders (hypothyroidism,
pheochromocytoma)
Lead poisoning
Connective tissue disorders (eg. SLE)
Other Causes
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Other Causes
Weakness
Immobility
Fatigue Inability to
increase intra
abdominal pressure(emphysema)
Low fiber diet
Inadequate fluid
intake
Lack of exercise
Stress
Clinical Manifestations
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Clinical Manifestations Abdominal distention
Borborygmus from passage of gas thru the intestine
Pain & pressure
Decrease appetite
Headache
Fatigue
Indigestion
A sensation of incomplete emptying
Straining at stool
Elimination of small-volume, hard, dry stools
Assessment & Diagnostic
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Tests Patients Hx
Physical exam
Barium enema Sigmoidoscopy
Stool exam
Occult blood
Complications
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Complications
Hypertension
Fecal impaction
Hemorrhoids Megacolon (dilated colon)
Medical Management
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Medical Management
Bowel habit training
Increased fiber & fluid intake
Use of laxatives Routine exercise
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IRRITABLE BOWEL( )
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SYNDROME (IRS) Presence of spastic bowel contraction
One of the most common GI problems
Common in women Cause is unknown
Risk Factors
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Risk Factors
Heredity
Psychological stress (depression, anxiety)
High fat diet Alcohol intake
Smoking
Clinical Manifestations
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Clinical Manifestations
Alteration in bowel patternsconstipation, diarrhea or combination of
both
Pain, bloating & abdominal distention
Pain is precipitated by eating and
relieved by defecation
Diagnostic Tests
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Diagnostic Tests
Stool exam
Barium enema
Colonoscopy Manometry
Medical Management
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Medical Management
High fiber diet
Exercise
Stress reduction program
Antidiarrheal drugs
Andtidepressant
Anticholinergic & calcium channel blocker
decrease smooth muscle spasm, cramping &
constipation
FECAL INCONTINENCE
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C CO C Involuntary passage of stool from the rectum
Factors:
- Ability of the rectum to sense and
accommodate stool
- Amount & consistency of stool
- Integrity of the anal sphincter & musculature
- Rectal motility
Clinical Manifestations
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Minor soiling
Occasional urgency & loss of control
Complete incontinence Poor control of flatus
Diarrhea
Constipation
Diagnostic Tests
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Rectal examination
Sigmoidoscopy Barium enema
CT Scan
Medical Management
Treat the diarrhea or fecal impaction
Biofeedback Bowel training program
Surgical Management
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Surgical reconstruction Sphincter repair
Fecal diversion
Nursing Management Setting schedule for bowel training
Maintain skin integrity
Assist in the use of incontinence briefs
STRUCTURAL &
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STRUCTURAL &
OBSTRUCTIVE BOWEL
DISORDERS
INTESTINAL OBSTRUCTION
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Presence of blockage that prevents the
normal flow of intestinal contents
through the intestinal tract
Two types of process that
impede the flo
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impede the flow:
1. MECHANICAL OBSTRUCTION
- Intraluminal or mural obstruction from
pressure of intestinal wall
- E.g. intussusception, polypoid tumor &
neoplasm, stenosis, stricture, adhesion,hernia & abscess
2. FUNCTIONAL OBSTRUCTION
h l l l
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- The intestinal musculature cannot propel
its content along the bowel- E.g. amyloidosis, DM, Parkinsons disease
SMALL BOWELOBSTRUCTION
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OBSTRUCTION- Intestinal contents, fluid & gas
accumulate above the intestinal
obstruction
CAUSES:
1. Intussusception
2. Volvulus3. Hernia
Clinical Manifestations
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Crampy, colicky pain
Blood & mucus without fecal matter &
flatus
Vomiting (fecal vomiting)
Abdominal distention
Signs of dehydration
Diagnostic Tests
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g
Abdominal x-ray Abdominal UTZ
Lab studies (electrolyte level, CBC)
Medical Management
DECOMPRESSION use of NGT
IV therapy Antibiotic
Surgical Management
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Repairing hernia (Herniorrhapy)
Dividing the adhesionNursing Management
Maintaining the function of NGT
Assess & measure NGT output
Assess F&E imbalance
If pts condition doesnt improve, the nurse
prepare the pt for surgery
LARGE BOWELOBSTRUCTION
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OBSTRUCTION Results in accumulation of intestinal
contents, fluids & gas proximal to the
obstruction
Leads to severe distention & perforation
Dehydration occurs more slowly
Intestinal strangulation & necrosis ifblood supply is cut-off
Clinical Manifestations
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*Symptoms progress slowly
Constipation
Abdominal distention
Crampy low abdominal pain
Fecal vomiting
Diagnostic Tests
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g
Abdominal x-ray (flat & upright)
Abdominal UTZ
Surgical Management
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COLONOSCOPY - to untwist &decompress the bowel
CECOSTOMY- surgical opening in thececum
Rectal tube to decompress area lower
in the bowel
SURGICAL RESECTION remove the
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obstructing lesion
Temporary or permanent colostomy
ILEOANAL ANASTOMOSIS
Nursing Management
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Administer IV fluids & meds asprescribed
Prepare the pt for surgery
General abdominal wound care & post-
op care after surgery
CONTINENT ILEOSTOMY
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Surgical creation of a pouch of small
intestine that can serve as internalreceptacle for fecal discharge.
A nipple valve is constructed at the
outlet.
IRRIGATING A COLOSTOMY
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Select suitable time for irrigation
Irrigation should be performed at the same timeeach day.
Before the procedure, the pt will sit on the chair infront of the toilet or the toilet itself.
Hang 500-1500ml ml irrigating solution (lukewarmtap water) 18-20 above the stoma.
The dressing on pouch is removed
Allow pt to participate to learn to perform itunassisted.
DIVERTICULAR DISEASE
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DIVERTICULUM saclike outpouching of thelining of the bowel that extends to a defectin the muscle layer
DIVERTICULOSIS multiple diverticula arepresent without inflammation or symptoms
DIVERTICULITIS infection & inflammationin diverticula
- Food & bacteri retained in diverticulum
- leads to perforation or abscess
Clinical Manifestations
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Bowel irregularity Intervals of
diarrhea
Crampy pain in LLQ
Low-grade fever
Nausea Anorexia
Abdominaldistention
Diagnostic Tests
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CT Scan procedure of choice- reveals abscess
Abdominal X-ray
Barium enema (diverticulosis)
Colonoscopy
Lab tests (CBC, ESR)
Complications
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Peritonitis
Abscess formation
Bleeding
Shock
Medical Management Bedrest
Analgesic
Antispasmodic
Diet :
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- clear liquid until inflammation subsides;then a high-fiber low-fat is recommended
Antibiotics 7 to 10 days
Bulk-forming laxative (e.g Metamucil)
IV fluids
Surgical Management
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g g
ONE-STAGE RESECTION- Inflamed area is removed & a primary
end-to-end anastomosis is completed
MULTIPLE STAGED PROCEDURE
- For complications such as obstruction or
perforation
Nursing Process
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ASSESSMENT- Assess the pain
- Review dietary habits
- Ask about Hx of constipation, tenesmus,distention
- Auscultation & palpation
- Stool inspection
- VS
NURSING DIAGNOSIS
C i i / i f h l
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- Constipation r/t narrowing of the colon
from thickened segment & stricture
- Acute pain r/t inflammation & infection
MAINTAINING NORMALEMIMINATION PATTERN
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EMIMINATION PATTERN
Fluid intake of 2L/day
High fiber diet
Exercise program
Set time for defecation
Stool softeners & oil retention enema asprescribed
RELIEVING PAIN
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Analgesics & antispasmodics as
prescribed
Records the intensity, duration &
location of pain
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MALABSORPTIONSYNDROME
CELIAC DISEASE OR SPRUE
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Also known as GLUTEN ENTEROPATHY orTROPICAL SPRUE
Intolerance to GLUTEN CHON
component of wheat, barley, rye & oats
Accumulation ofglutamine (amino acid)
toxic to intestinal mucosa
Clinical Manifestations
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Acute diarrhea Anorexia
Abdominal pain &
distention
Muscle wasting
(buttocks &extremities)
Vomiting Anemia
Irritability
CELIAC CRISIS
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Precipitated by infection, fasting &ingestion of gluten
Lead to electrolyte imbalance, rapid
dehydration & severe acidosis
Causes profuse watery diarrhea &
vomiting
Medical Management
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Gluten-free diet Substitute corn & rice as grain sources
Mineral & vitamin supplements (A,D,E,K)
Read food labels carefully
LACTOSE INTOLERANCE
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Inability to tolerate lactose as a result of
absence or deficiency oflactase
Clinical Manifestations
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Symptoms occurring after ingestion of milkproducts
Abdominal distention
Crampy, abdominal pain
Diarrhea
Excessive flatus
Medical Management
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Eliminate the offending dairy product oradminister enzyme replacement.
In infants, soy-based formula can be a
substitute. Provide calcium & Vit. D supplement
Encourage consumption of hard cheese,
cottage cheese or yogurt instead of
drinking milk
SHORT BOWEL SYNDROME
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Cause: resection of portions of small intestinesdue to tumors, infarction, incarcerated hernias, Crohnsdse, trauma, enteropathy from radiation
Effects:
More severe malabsorption after duodenum, jejunum,proximal and distal ileum resection vs mid-ileumresection
Transit time reduced
Impaired digestion
Adaptive process-villi enlarge and lengthen to increaseabsorptive surface
Nursing Diagnosis Fluid Volume Deficit
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Fluid Volume Deficit
Impaired Nutrition: Less than Body Requirements Diarrhea
For many clients, absorption and bowel functionsreturn to preop or near-normal levels
Some have diarrhea, weight loss and nutrientdeficiencies
Diagnostics: serum protein, albumin, folate, iron,
electrolytes, vitamins, minerals, Hct,Hgb, PT
Mgmt
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GOAL: ALLEVIATE SYMPTOMS
Diagnostics:
Vital signs
I and O
Daily wt
Skin turgor, mucous membranes Number and character of stools
Tx :
Provide adequate fluid intake
esp during hot weather and strenous exercise
Provide perianal careRefer to dietitian or counselor
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Diet: frequent, small,high calorie, high-proteinfeedings with vitamin and mineral
supplements TPN if severe
Meds: Antidiarhheals to reduce bowelmotility, allowing greater amount of time for
nutrient absorption
PPI as omeprazole(Prilosec) todecrease gastric acidity
ANORECTAL DISORDERS
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HEMORRHOIDS
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Dilated portions of veins in the analcanal.
50% of people age 50 yrs
Predisposing factors
Anal intercourse
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Hatching, sneezing, vomiting
Hereditary
Anal infection, rectal surgery, or episiotomy
Pregnancy, prolonged sitting/standing Liver cirrhosis
Loss of muscle tone due to old age
Oh alcohol
Straining of stool
4/13/2012 171
Types
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1. INTERNAL HEMORRHOIDS above theinternal sphincter
2. EXTERNAL HEMORRHOIDS outside
the external sphincter
Clinical Manifestations Infection, mucus drainage
i ( l h h id )
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Pain (more on external hemorrhoids)
Anal itching
Sensation of incomplete fecal evacuation
Sudden rectal pain due to thrombosis
Ulceration
Constipation
Kitang-kita at palpable mass (if external)
Bleeding during defecation
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Diagnostic Tests
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Rectal exam
Stool exam
Medical Management
High-residue diet
Good personal hygiene
Avoid excessive straining during defecation
Increase fluid intake
Warm compress
Sit b th
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Sitz bath
Analgesic ointment & suppositories
(Faktu)
Bedrest
NON SURGICAL TREATMENT
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Infrared photocoagulation
Bipolar diathermy Laser therapy
Injecting sclerosing solution
Surgery - Indications
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D
isabling pain Prolonged bleeding
Intolerable itching
General unrelieved discomfort
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SURGICAL MANAGEMENT
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RUBBER-BAND LIGATION PROCEDURE
- Hemorrhoid is visualized thru anoscope,
a rubber band is slipped over thehemorrhoid
- Distal tissues becomes necrotic & slough
off
CRYOSURGICAL HEMORRHOIDECTOMY
- Freezing the hemorrhoid for sufficient
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Freezing the hemorrhoid for sufficient
time to cause nercrosis HEMORRHOIDECTOMY
- Surgical excision of hemorrhoid
- Rectal sphincter is dilated & hemorrhoid is
removed with a clamp & cautery and
excised.
Complications Hemorrhage
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g
Incontinence
Prolapse
Strangulation
AnemiaPatient Education
Encourage regular exercise, high-fiber diet, and
adequate fluid intake to avoid straining &
constipation
4/13/2012 180
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LESIONS
ANAL FISSURE
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Longitudinal tear or ulceration in thelining of anus
CAUSES:
- Trauma (passing large, firm feces)
- Stress & anxiety leads to constipation
- Childbirth- Overuse of laxatives
Clinical Manifestations Extreme painful defecation
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Extreme painful defecation
Burning sensation
Bleeding
Medical Management
Stool softeners & bulk agents
Increase OFI
Sitz bath
Emolient suppositories
Surgical Management
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Lateral internal sphincterotomy withexcision of fissure
ANAL FISTULA
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Tiny, tubular, fibrous tract that extend inthe anal canal from an opening located
beside the anus
Causes
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Infection
Trauma
Fissure
Regional enteritis
Clinical Manifestations
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Leakage of pus or stool
Passage of flatus or feces from the vagina
or bladder
Surgical Management
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FISTULECTOMY excision of the fistuloustract
- Probe is inserted to indentify the sinus
tract
- Fistula is dissected by incision from
rectal opening
Recommended