CHAPTER EIGHTEEN - Nursing Ed · PDF fileCHAPTER EIGHTEEN PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM Digestion, Absorption, and Elimination Process A. Digestion ... Nursing Interventions

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Gastrointestinal System

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CHAPTER EIGHTEEN

PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM

Digestion, Absorption, and Elimination ProcessA. Digestion:physicalandchemicalbreakdownoffood.

1. Lengthoftimefoodremainsinstomachdependsontypeoffood,gastricmotility,andpsychologicfactors;averagetimeis3to4hours.

2. The pH of the stomach is acidic, which promotesproductionofpepsintobegintheinitialbreakdownofproteins.

3. Chyme (food mixed with gastric secretions) movesthroughthepylorusintothesmallintestine.

4. Intestinaldigestiveenzymesarereleasedfromthevilliinthesmallintestine.

B. Absorption: transfer of food products into circula-tion.1. Occursinsmallintestine,wherevilliprovideabsorp-

tive surface area; minimal amount of nutrients areabsorbedinthestomach.

2. Carbohydrates are broken down into monosaccha-rides,fatstoglycerolandfattyacids,andproteinstoaminoacids;allareabsorbedthroughthevilliofthesmallintestine.

3. Intrinsic factor is secreted in the stomach and pro-motes absorptionof vitaminB12 (cobalamin) in thesmallintestine.

4. Presence of chyme in small intestine stimulatescontraction of the gallbladder and relaxation of thesphincterofOddi;thisprocessreleasesbilefordiges-tionoffats.

C. Elimination:excretionofwasteproducts.1. Large intestine absorbs water and electrolytes and

formsfeces.2. Serves as a reservoir for fecal mass until defecation

occurs.

System AssessmentA. Evaluateclient’shistory.

1. Dietaryandbowelhabits.2. Nausea,vomiting,diarrhea,indigestion,constipation,

flatulence:precipitatingandalleviatingfactors.3. Painrelatedtogastrointestinal(GI)tract.

4. PreviousproblemsassociatedwithGItract,includinggastritis,hepatitis, colitis,gallbladderdisease,pepticorduodenalulcer,hernia,andhemorrhoids.

5. Unexplainedorunplannedweightgainorloss.6. Medication history, including over-the-counter

(OTC)andprescriptiondrugs.7. PrevioussurgeriesrelatedtoGIsystem.

B. Assessvitalsignsforclient’soverallstatus.C. Assess for presence and characteristics of abdominal

pain.D. Assessclient’smouth.

1. Presence of adequate saliva, condition of teeth andtongue.

2. Presenceofthegagreflex.3. Presenceoforallesions.

E. Evaluatetheabdomen(clientshouldbelyingflat).1. Inspect:dividetheabdomenintofourquadrantsand

performvisual inspection for contour, scars,masses,and movement (aortic pulsation may be visible).Figure18-1showsanatomicdivisionsoftheabdomen.

2. Auscultate: eachquadrant shouldbeauscultated forbowelsounds.a. Bowelsoundsareconsideredabsentifnosoundis

heardfor5minutesinanyonequadrant.b. Normally,softgurglesshouldbeheardevery5to

20seconds.c. Borborygmi: loud, gurgling bowel sounds; may

precedediarrhea.

ALERT To determine characteristics of bowel sounds, note presence in each quadrant, as well as frequency and pitch.

3. Percussion:purposeistodeterminepresenceoffluid,distentionand/ormasses.a. Tympany is a high-pitched hollow sound com-

monlyheardoverareasdistendedwithair.b. Dullnessisashorthigh-pitchedsoundwithlittle

resonance;heardoverfluidorsolidmasses.4. Palpation: purpose is to determine areas of tender-

ness,resistance,andswelling;deeppalpationisusedtoidentifyorgansandpossiblemasses.a. Begin with light palpation of each quadrant;

observefacialexpressionforanyareaofdiscomfortand/orguarding.

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356 CHAPTER 18 Gastrointestinal System

b. Begin in area of least discomfort; if there is aproblemarea,palpateitlast.

c. Check for rebound tenderness by pressing twofingersfirmlyoverpainfulsiteandwithdrawthemrapidly;painoccursonreleaseofpressure.

F. Assess rectal area for lesions, hemorrhoids, orulcerations.

G. EvaluateeliminationpatternsandeffectsofagingonGItract(Box18-1).

H. Evaluatedietarypatternandfluidintake. I. Assessstoolspecimen.

1. Color,consistency,odor.2. Presenceofbloodormucus.

DISORDERS OF THE GASTROINTESTINAL (GI) SYSTEM

Nausea and VomitingNausea is an unpleasant feeling that vomiting is imminent. Vomiting is an involuntary act in which the stomach contracts and forcefully expels gastric contents.A. Lossoffluidandelectrolytesistheprimaryconsequence

of repeated vomiting; the very young and the olderadult are more susceptible to complications of fluidimbalances.

B. Prolongedvomitingwillprecipitateametabolicproblem.1. Metabolicalkalosisisassociatedwithprolongedvom-

itingandlossofhydrochloricacid.2. Metabolicacidosisoccurswithsevereprolongedvom-

iting of contents of the small intestine, resulting inlossofbicarbonate.

AssessmentA. Precipitatingcauses.

1. Pathogenic:relatedtoadiseaseprocess(GIobstruc-tion,toxicsubstances,etc.).

2. Iatrogenic:resultingfromadiseasetreatment.a. Chemotherapy/radiation.b. Medications.c. Surgery(postoperativecomplication).

3. Pregnancy: vomiting most often occurs in themorning.

4. Vomitinginchildreniscommon.5. Further investigationandinterventionisneededfor

progressively severe vomiting, persistent vomitingover24hours,and/orsymptomsofdehydration.

FIGURE 18-1 Anatomic Divisions of the Abdomen. Left, Abdomen divided into four quadrants. Right, Abdomen divided into nine topographic regions: 1, epigastrium; 2, umbilical; 3, suprapubic; 4, right hypochondrium; 5, right lumbar or flank; 6, right inguinal or iliac; 7, left hypochondrium; 8, left lumbar or flank; 9, left inguinal or mac. (From Monahan FD et al: Phipps’ medical-surgical nursing: health and illness perspectives, ed 8, St. Louis, 2007, Mosby.)

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Box 18-1 OLDER ADULT CARE FOCUS

Changes in Gastrointestinal System Related to Aging

• Decreased hydrochloric acid and decreased absorption ofvitamins;encouragefrequentsmallfeedingsthatarehighinvitamins.

• Decreased peristalsis and decreased sensation to defecate;encouragediethighinfiberandminimumof2000mLoffluiddaily;encouragephysicalactivity.

• Decreased lipase from pancreas to aid in fat digestion;encouragesmallermealsbecausediarrheamaybecausedbyincreasedfatintake.

• Decreased liver activity with decreased production ofenzymes fordrugmetabolism, tendencytowardaccumula-tionofmedications;instructclientsnottodoubleupontheirmedications,especiallycardiacmedications.

ALERT Monitor client’s hydration status; modify client’s care based on results of diagnostic tests.

B. Assessment.1. Identifyprecipitatingcause.2. Assess frequency of vomiting, amount of vomiting,

andcontentsofvomitus.

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CHAPTER 18 Gastrointestinal System 357

3. Hematemesis:presenceofbloodinvomitus.a. Brightredbloodisindicativeofbleeding.b. Coffee-ground material is indicative of blood

retainedinthestomach;thedigestiveprocesshasbrokendownthehemoglobin.

4. Projectilevomiting:vomitingnotprecededbynauseainwhichvomitusisexpelledwithexcessiveforce.

5. Presenceoffecalodorandbileinvomitusindicatesabackflowofintestinalcontentsintostomach.

6. Vomitinginchildrenisusuallyself-limiting;assessforfever, diarrhea, and abdominal pain accompanyingnauseaandvomiting.

C. Diagnostics:clinicalmanifestations.

TreatmentA. Eliminatetheprecipitatingcause.B. Antiemetics(seeAppendix18-2).C. Parenteral replacement of fluid if loss is excessive

(Chapter6).

Nursing InterventionsGoal: To prevent recurrence of nausea and vomiting and

ensuingcomplications.A. Prophylacticantiemetics fortheclientwithatendency

tovomit.B. Promptremovalofunpleasantodors,usedemesiscon-

tainer,andsoiledlinens.C. Goodoralhygiene.D. Place conscious client on side or in semi-Fowler’s

position; place unconscious client on side with headof bed slightly elevated to promote drainage of oralcavity.

E. Withhold food and beverages initially after vomiting;begin oral intake slowly—for adults, begin with tea,water,ororalrehydratingsolutionsatroomtemperature;for infants and children, begin with oral rehydratingsolutions.

F. Assesssurgicalclientforpresenceofbowelsoundsanddistention;donotbeginoraladministrationoffluidsifabdomenistenderordistendedornobowelsoundsarepresent.

G. Support abdominal and thoracic incisions duringvomiting.

ConstipationConstipation exists when there is a decrease in frequency of bowel movements; stool is hard and difficult to pass, and there is less than one bowel movement every 3 days.


1. Decreasedfiberandfluidintake.2. Immobility,inadequateexercise.3. Medications:narcotics,antidepressants, ironsupple-

ments,anticonvulsants.4. Olderadultclient.5. Overuseoflaxatives.6. Ignoringtheurgetodefecate.7. Diverticulosis,tumors,intestinalobstructions.

ALERT Identify client potential for aspiration; intervene to prevent aspiration.

Goal: Torelievenauseaandvomiting.A. Administerantiemetics.B. Evaluateprecipitatingcauses;relieveifpossible.C. Gastricdecompressionwith anasogastric tubemaybe

usedforprolongedvomiting.Goal: Toassessclient’sresponsetoprolongedvomiting.A. Monitorfluidandelectrolytestatus(Chapter6).B. Assessforcontinuedpresenceofgastricdistention.C. Assessforadequatehydration.D. Assessforpresenceofothersymptoms.

ALERT Evaluate client’s use of home remedies and OTC drugs. Assess what the client is using to treat constipation; frequently, the older adult client is using harsh laxatives.

B. Clinicalmanifestations.1. Abdominaldistention.2. Decreaseintheamountofstool.3. Dry,hardstool;strainingtopassstool.4. Impaction.

a. Constipation,rectaldiscomfort.b. Anorexia,nausea,vomiting.c. Diarrheaaroundimpactedstool.

C. Diagnostics:clinicalmanifestations.

TreatmentA. Change dietary intake: increase intake of high-fiber

foodsandfluids.B. Bulklaxatives,stoolsofteners,orenemasforoccasional

constipationproblem(seeAppendix18-3).C. Instruct client tomaintainnormalbowel scheduleand

nottoignoreurgetodefecate.D. Discouragelong-termuseoflaxativesandenemas.E. Encourageregularexercise.

Nursing Interventions

ALERT Assess and intervene when client has a problem with elimination.

Goal: Toidentifyclientatriskfordevelopingconstipationandinstitutepreventivemeasures(Box18-2).

Goal: To implement treatment measures for fecal impac-tionremoval.

A. Animpactionmaybepresentifclienthashadnobowelmovementfor3daysorhaspassedonlysmallamountsofsemisoftorliquidstool.

B. Stepsinremovingimpaction:1. Manuallycheckforpresenceofimpactionwithnon-

sterile,lubricatedglovedfinger.

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2. Gentlyattempttobreakupimpactionusingascissormotionwiththefingers.

3. Emphasis is on prevention of impaction (see Box18-2).

3. Medications(antibioticsandantacids).4. Foodintolerance(lactose intolerance)orallergies to

certainfoods.5. Malabsorption problems: celiac disease and cystic

fibrosis.B. Clinicalmanifestations.

1. Frequent, loose, watery bowel movements; sense ofurgency.

2. Stoolsmaycontainundigested food,mucus,pus,orblood;frequentlyarefoulsmelling.

3. Abdominalbloating,cramping,distention,andvom-itingfrequentlyoccurwithdiarrhea.

4. Hyperactivebowelsounds.5. May precipitate dehydration, hypokalemia, and

hypovolemia,progressingtoshock.C. Diagnostics: stool examination; enzyme immunoassay

(EIA)forrotavirus.

TreatmentA. Identifyandtreattheunderlyingproblem.B. Decrease activity and irritation of the GI tract by

decreasingintake.C. Parenteralreplacementoffluidsandelectrolytes,ifdiar-

rheaissevere.D. Donotadministerantidiarrhealmedicationsifcausative

agent is bacterial or parasitic. Antidiarrheals preventclientfrompurgingthebacteriaorparasiteandtrapsthecausativeorganism(s)intheintestinesandprolongstheproblem(Appendix18-4).

E. Viralinfectionsareeithertreatedwithmedicationorlefttoruntheircourse,dependingontheseverityandtypeofvirus.

F. Rotavirus vaccine (RotaTeq) should not be given toseverelyimmunocompromisedinfants.

Nursing InterventionsGoal: Todecreasediarrheaandpreventcomplications.A. Identifyprecipitatingcausesandeliminate,ifpossible.B. Offer soft, easily digestible food; does not have to be

clearliquids.C. Fluidandelectrolytereplacement.

1. Administeroralrehydratingsolutions(ORSs);prog-ressfluidsanddietastolerated.

2. Frequently offer ORSs in small amounts at roomtemperature; do not offer high-carbohydrate fluids(juices),carbonatedfluids,broth,orsportsdrinks.

3. Nausea and vomiting are not contraindications toofferingORSs.

D. Maintaingoodhygieneintherectalareatopreventskinexcoriation.

Goal: Toevaluateclient’sresponsetodiarrhea.A. Evaluatechangesinvitalsignscorrelatingwithfluidloss

andhydrationstatus(Chapter6).B. Evaluateelectrolytechangesandurinespecificgravity.C. Recordintakeandoutputanddailyweightifdiarrheais

progressive.D. Inspect abdomen for distention, auscultate for bowel

sounds,andpalpateforareasoftenderness.

Box 18-2 OLDER ADULT CARE FOCUS

Preventing Fecal Impaction

• Increase intakeofhigh-fiberfoods:rawvegetables,whole-grainbreadsandcereals,freshfruits.

• Increasefluidintake.• Maintain regular activity: daily walking, swimming,

or biking. If confined to wheelchair, change positionfrequently, perform leg raises and abdominal musclecontractions.

• Discourageuseoflaxativesandenemas:clientmaybecomedependenton them. If absolutelynecessary,warmmineraloilenemasmaysoftenandlubricatestool.

• Encourageuseofbulk-formingproductstoprovideincreasedfiber(methylcellulose,psyllium).

• Encouragebowelmovementatsametimeeachday.• Trytopositionclientonbedsidecommoderatherthanon

abedpan.• If client is experiencing diarrhea, check to see if stool is

oozingaroundanimpaction.

NURSING PRIORITY Monitor client’s heart rate during and after digital removal of feces; vagal stimulation can precipitate bradycardia.

DiarrheaDiarrhea is the rapid movement of intestinal contents through the small bowel.A. Significant increase innumberofstools,alongwithan

increaseinloosenessofstool.B. Infantsandolderadultsaremostsusceptibletocompli-

cationsofdehydrationandhypovolemia.C. Acutediarrheaismostoftencausedbyaninfectionand

isself-limitingwhenallcausativeagentsorirritantshavebeenevacuated.

D. Rotavirusisthemostcommonpathogeninyoungchil-drenhospitalizedfortreatmentofdiarrhea.1. Affects all agegroups and ismost common in cool

weather.2. Incubationperiodis48hours.3. Important source of nosocomial infections in

hospital.4. Children6to24monthsoldareatincreasedriskfor

complications.


1. Bacteria(Escherichia coli, Salmonella),viruses(rotavi-rus),andparasites(Giardia lamblia).

2. Foodpoisoning(frequently,infectionbybacteria).

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Goal: Topreventspreadofdiarrhea.A. Goodhandhygiene.B. Initiatecontactprecautions(Appendix6-8).

1. Properdisposalofdiapersandsoiled linensclosetobedside.

2. Instructfamilyregardinghandhygienetechniques.3. Maintainseparatecleananddirtyareasintheroom;

keepbedpans,soiledlinens,andsoileddiapersawayfromcleanareas.

C. Instructparents regarding importanceofhandhygieneandhowtocareforinfantorchildathome.

AssessmentA. Riskfactors.

1. Lifestyle factors: obesity; smoking; excess alcoholintake; consumption of high-fat or acidic foods;eatinglargemeals;consumptionofcaffeineandcar-bonatedbeverages;stress.

2. Pathologicpredisposingfactors:PUD,asthma,cysticfibrosis,cancer.

3. Medications decreasing LES pressure: calciumchannelblockers,nitrates,anticholinergics.

4. Anatomic factors: eating heavy meal before lyingdown,strenuousexerciseaftereating,scoliosis,pooresophageal sphincter tone, consuming an excessiveamountoffoodandbeverage.

5. Clients with prolonged chronic GERD are atincreasedriskforcancer.

B. Clinicalmanifestations.1. Refluxesophagitis(heartburn,dyspepsia).2. Increased pain after meals; may be relieved by

antacids.3. Activities that increase intraabdominal pressure

increaseesophagealdiscomfort.4. Painmayradiatetobackandneck.5. Regurgitation not associated with belching or

nausea.C. Complications.

1. Aspiration of gastric contents: pneumonia, chronicbronchitis.

2. Dentalerosion.D. Diagnostics: 24-hour pH monitoring, esophageal

manometry,esophagoscopy(Appendix18-1).

TreatmentA. Medical.

1. Diet therapy: avoid intake of fatty foods; eat small,frequentmeals; trychewinggumafterandbetweenmeals.

2. Avoidwineandotheralcoholicbeverages,caffeinateddrinks,chocolate.

3. Medications:histamine-2receptorantagonists(H2Rblockers),protonpumpinhibitors(PPIs)(Appendix18-5), and GI stimulants or promotility drugs(Appendix18-2).

B. Surgical:fundoplicationorantirefluxsurgery.C. Endoscopicinterventionatloweresophagusandgastro-

esophageal sphincter (fundoplication, radiofrequency,sclerosingagents).

Nursing InterventionsGoal: Todecreaseesophagealreflux.A. Avoid drinking beverages during meals, including

alcoholandcarbonatedbeverages.B. Avoidtemperatureextremesinfoods.C. Avoiddrinkingfluids3hoursbeforebedtime.D. Elevatetheheadofthebedon6-to8-inchblocks.E. Ifoverweight, loseweight todecreaseabdominalpres-

suregradient.F. Avoidtobacco,NSAIDs,andsalicylates.

NURSING PRIORITY Consider acute onset diarrhea as infectious until the cause is determined.

Gastroesophageal Reflux DiseaseGastroesophageal reflux disease (GERD) is caused by the backward flow or reflux of gastric contents into the esophagus (esophageal reflux). Amount of damage depends on the amount and composition of gastric con-tents, as well as the ability of the esophagus to remove the acidic fluids.A. Gastriccontentsareabletomovefromareaofincreased

pressure(stomach)toareaoflowerpressure(esophagus)throughthemalfunctioningloweresophagealsphincter(LES), reflux occurs, and the esophagus is exposed toacid(Figure18-2).

B. The acid breaks down the esophageal mucosa, and aninflammatoryresponseisinitiated.

C. Hiatalhernia:aherniationofaportionofthestomachintotheesophagus;frequentlypresentswithsamesymp-toms as GERD; clinical course and management arethesame.

FIGURE 18-2 Factors involved in the pathogenesis of gastroesopha-geal reflux disease (GERD) (From Lewis SL et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby.)

LESdysfunction

Defective mucosaldefense

Impairedesophageal

motility

Delayedgastric

emptying

Reflux ofgastriccontents

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G. Decrease intake of highly seasoned foods and tomatoproducts.

H. Eat small, frequent meals (up to 5 per day at 3-hourintervals)topreventgastricdilation.

I. Avoid any food that precipitates discomfort (fats,caffeine, chocolate, nicotine will decrease esophagealsphinctertone).

J. Donotliedownfor2to3hoursaftereating.

GastritisGastritis is an inflammation and breakdown of the normal gastric mucosa barrier.A. Acutegastritisisgenerallyself-limitingwithnoresidual

damage.B. Maybechronicoracute,diffuseorlocalized.

AssessmentA. Riskfactors/etiology.

1. Oftencausedbydietaryindiscretion(gastricirritants:coffee,aspirin,alcohol).

2. Smoking or exposure to radiation, psychologicstress.

3. Microorganisms: Helicobacter pylori, contaminatedfoods(StaphylococcusorSalmonellaorganisms).

4. Medicationscausinggastricirritation(aspirin,corti-costeroids,chemotherapy).

5. Prolongedalcoholabuse,bingedrinking.6. Acutegastritisisacommonprobleminintensivecare

units because of stress. Clients with burns, uremia,sepsis, shock, mechanical ventilation, or multiorgandysfunctionwhoarenotreceivingenteralfeedingareatsignificantlyincreasedrisk.

TreatmentA. Eliminatecause.B. Medicalmanagement.

1. Antiemetics, antacids, PPIs and H2R blockers(Appendix18-5).

2. TreatmentforH. pyloriwithantibioticsandPPIs.C. Surgicalintervention,ifmedicaltreatmentfailsorhem-

orrhageoccurs.

Nursing InterventionsGoal: Todecreasegastricirritation.A. Nothingbymouth(NPOstatus)initially,withIVfluid

andelectrolytereplacement.B. Planofcarefornauseaandvomiting.C. BeginORSsasclienttoleratesthem.Goal: To monitor fluid status and prevent dehydration

(Chapter6).Goal: To assist client to identify and avoid precipitating

causes.

GastroenteritisGastroenteritis is the irritation and inflammation of the mucosa of the stomach and small bowel.


1. Equalincidenceinmenandwomenbutmoresevereininfantsandolderadults.

2. Salmonella: fecaloraltransmissionbydirectcontactorviacontaminatedfood.

3. Staphylococcal: transmission via foods that werehandledbycontaminatedcarrier.

4. Dysentery:E.coliandShigella.

NURSING PRIORITY Best practice for the prevention of gastritis in clients who are ventilator dependent is the routine administration of antiulcerative medication (Appendix 18-5).

B. Clinicalmanifestations(maybeasymptomatic).1. Epigastrictenderness.2. Anorexia,nausea,vomiting.3. Chronic gastritis: frequently caused by the Helico-

bacter pylori.a. Mayprecipitateperniciousanemia.b. Associatedwithpepticulcerdisease.

C. Diagnostics(Appendix18-1).1. Endoscopy with biopsy to rule out gastric

carcinoma.2. Stoolexaminationforoccultblood.3. Gastric analysis for decreased acid production

(achlorhydria).4. Serum,stool,andgastricbiopsyforH. pylori.

D. Complications.1. Ulcerationandhemorrhaging(Figure18-3).2. Cancerofthestomach.

Esophagealcancer

Duodenalulcer

Esophagealvarices

Gastritis

Gastriculcer

Gastriccancer

FIGURE 18-3 Common causes of gastrointestinal bleeding. (From Ignatavicius DD, Workman ML: Medical-surgical nursing: patient-centered collaborative care, ed 6, Philadelphia, 2010, Saunders.)

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B. Clinicalmanifestations.1. Abdominalcramping,distention,andpain.2. Nausea,vomiting,anddiarrhea.3. Anorexia,feverandchills.

C. Diagnostics:stoolculture.

TreatmentA. Nothingbymouthuntilnauseasubsides.B. RehydratewithwaterandORSs.C. Clientresumeseatingwithbland,easilydigestiblefoods.D. Appropriatemedicationforcausativeagents.

Nursing InterventionsSee Nursing Interventions section under Nausea andVomiting.

ObesityAn imbalance between energy expenditure and caloric intake that results in an abnormal increase in fat cells.A. According to the CDC, 65% of people in the United

Statesoverage20areobese.B. Childrenareconsideredoverweightiftheirweightisin

the95thpercentileorhigherfortheirage,gender,andheightonthegrowthchart.

C. Classifiedaccordingtothebodymassindex(BMI);seeChapter2.

AssessmentA. Riskfactors.

1. Geneticpredisposition.2. Sedentary lifestyle: energy intake (food) exceeds

energyexpenditure.3. Sociocultural: environment conducive to excessive

caloricintake.4. Obesityputsclientatincreasedriskforcardiovascu-

lar,respiratory,andmusculoskeletalproblems,aswellasincreasedriskfordevelopmentofdiabetes.

B. Clinicalmanifestations.1. ABMIof25to29.9kg/m2isconsideredoverweight.2. ABMIofover30kg/m2isconsideredobese.3. Androidobesity:fatisdistributedovertheabdomen

andupperbody(apple-shaped).4. Gynecoid obesity: fat is distributed over the upper

legs(pear-shaped).5. Androidobesityisconsideredtobeahigherriskfor

obesity-relatedproblems, especially elevated triglyc-eride and lipid levels aswell as thedevelopmentoftype2diabetes.

TreatmentA. Lifestylechangesandmodificationofdietaryintake.B. Bariatricsurgery.

1. Laproscopicadjustable-bandedgastroplasty(LABG)involves placing a band around the fundus of thestomach;bandmayormaynotbeinflatable.

2. Malabsorptive:Roux-en-Ybypass (REG)or gastricbypassinvolvesbypassingsegmentsofsmallintestinesolessfoodisabsorbed.

3. Combinationofrestrictiveandmalabsorptivesurgery:thestomachisdecreasedinsizewithformationofagastricpouchthatemptiesdirectlyintothejejunum;greatestlossofweightisusuallyachievedoverthefirstyear.

Nursing InterventionsGoal: Toprepareclientforsurgery(Chapter3).A. Discuss the importance of early ambulation to reduce

complications.B. Lengthoftimeinhospitaldependsonprocedure.C. Dietarychanges.Goal: Tomaintainhomeostasispostoperatively(Chapter3).A. Immediately postoperative airway may be a problem;

maintaingoodpulmonaryhygiene;positiveendexpira-torypressure(PEEP)andorventilatorsupportmaybenecessary.

B. Increasedrisksforthromboembolicproblems:sequentialcompressionstockings,encourageearlyambulationandadminister thromboprophylaxis with low-molecular-weightheparin.

C. DonotadjustanNGtube,anddonotinsertNGtubeevenifthereisprotocoltodosofornauseaandvomiting;notifysurgeon.

D. Observe client for development of anastomotic leaks:increasingback,shoulderandorabdominalpain,unex-plained tachycardia or decrease urine output; notifysurgeonofthesefindings.

E. Mayuseabdominalbindertoprotectincision.F. Inclientwithdiabetes,assessforfluctuationsinserum

bloodglucose;mayrequirelessantihypoglycemics.G. Client with malabsorption surgery may experience

dumpingsyndrome(Box18-3).

Home CareA. Diet.

1. Eatatleast3mealsaday;chewfoodcompletely.2. Drink fluids throughout the day, but do not drink

fluidswithmeals.3. Avoidhigh-calorie,high-sugar,andhigh-fatfoods.4. Stopeatingwhenyoufeelfull.5. Try toget50 to60gofproteindaily;mayneedto

takeaproteinsupplement.6. Learn how to avoid dumping syndrome (see Box

18-3).B. Takeachewableorliquidmultivitaminwithiron.C. Canexpect to lose50% to70%of excessbodyweight

over5years.D. For women, do not try to get pregnant for about 18

monthsaftersurgery.E. Join a support group for long-term psychosocial

implications.

Peptic Ulcer DiseasePeptic ulcer disease (PUD) is an erosion of the GI mucosa by hydrochloric acid and pepsin. Any location in the GI tract that comes in contact with gastric secretions is sus-ceptible to ulcer development.

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symptomsmayoverlapfromonetypeofulcertoanother.(1) Gastriculcers:painishighinepigastricarea;

occurs1to2hoursaftereating.(2) Duodenalulcers:painisinmidepigastricarea,

justbelowthexiphoidprocess,orintheback;occurs2to4hoursaftereatingandisrelievedbyantacidsoreating.

Cardia

Fundus

Greatercurvature

Body

GastriculcerLesser

curvature

Pyloricsphincter

Duodenalulcer

Antrum

FIGURE 18-4 The most common sites for peptic ulcers. (From Ignata-vicius DD, Workman ML: Medical-surgical nursing: patient-centered col-laborative care, ed 6, Philadelphia, 2010, Saunders.)

A. Typesofpepticulcers(Figure18-4).1. Duodenal(mostcommon).2. Gastric.3. Physiologicstressulcers.

B. Histaminereleaseoccurswiththeerosionofthegastricmucosainbothduodenalandgastriculcers.Thisresultsin vasodilation and increased capillary permeability,whichfurtherstimulatesthesecretionofgastricacidandpepsin.The continued erosion will eventually damagethe blood vessels, leading to hemorrhage or erosionthroughgastricmucosa.

C. Characteristics.1. Riskfactors.

a. Helicobacter pylori: most common factor in bothtypesofulcers.

b. Medications: aspirin, NSAIDs, corticosteroids,reserpine.

c. Alcoholabuse,smoking.d. Chronicgastritis.e. Hot,rough,orspicyfoodsarenotafactor.f. Duodenalulcersareassociatedwithhighsecretion

ofHCLacid.g. Physiologicstressulcersareassociatedwithphysi-

calstress:burns,sepsis,andtrauma.2. Clinicalmanifestations.

a. Burning pain lasting minutes to hours; the painassociated with ulcers may be confusing, and

NURSING PRIORITY Be careful to avoid confusing ulcer pain and indigestion with angina; do not administer antacids to cardiac clients complaining of midepigastric distress or “heartburn.”

DiagnosticsA. Helicobacter pylori:breathtest;serumandstoolanalysis;

differentiation is made between colonization andinfection.

B. Gastricanalysiswithpossiblebiopsy.

TreatmentA. Medications(seeAppendix18-5).

1. MedicationstoeliminateH. pyloribacteria.a. Metronidazole(Flagyl).b. Omeprazole(Prilosec).c. Clarithromycin(Biaxin),amoxicillin,tetracycline.

2. Antacids.3. Histamine-2receptor(H2R)antagonists.4. Prostaglandin analogs and proton pump inhibitors

(PPIs).B. Lifestylemodifications.

1. Eat a nonirritating or bland diet; avoid foods thatcausediscomfort.

Box 18-3 DUMPING SYNDROME

Condition occurs when a large bolus of gastric chyme andhypertonicfluidentertheintestine.Goal: Toassessforsymptomsofcondition.• Weakness,dizziness,tachycardia.• Epigastricfullness,abdominalcramping,hyperactivebowel

sounds.• Diaphoresis.• Generallyoccurswithin15to30minutesaftereating.• Usuallyself-limitingandresolvesinabout6to12months.Goal: Topreventdumpingsyndrome.• Decreaseamountoffoodeatenatonemeal;eatsmallmeals

at3-hourintervals.• Decreasesimplecarbohydrates;increaseproteinsandhigh-

fiberfoodsastolerated.• No added fluid with meal; fluids can be taken 30 to 45

minutesbeforemealsor1houraftermeals.• Decrease concentrated sweets; add fruitshigh inpectin to

diet (peaches,plums,apples) toslowcarbohydrateabsorp-tioninsmallintestine.

• Position client in semi-recumbent position during meals;clientmay lie downon the left side for 20 to30minutesaftermealstodelaystomachemptying.

• Hypoglycemiamayoccur2to3hoursaftereating,causedbyrapidentryofcarbohydratesintojejunum.

ALERT Implement measures to improve client’s nutritional intake. Prevent dumping syndrome and/or care for client experiencing dumping syndrome.

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2. Decreaseorstopsmoking.3. Minimize use of NSAIDs and antiinflammatory

medications.4. Decreaseoreliminatealcoholconsumption.

ComplicationsA. Frequently result in an emergency situation—initially

treated conservatively; however, surgery may benecessary.

B. Hemorrhage: bleeding when ulcer erodes through avessel(seeFigure18-3).1. Clinicalmanifestations.

a. Pain,nausea,vomiting.b. Hematemesis,melena,orboth.c. Morecommoninduodenalulcers.d. Vital signs may reveal symptoms of shock

(Chapter16).2. Treatment.

a. Fluid volume replacement: blood, normal saline,Ringer’slactate.

b. Medicationstodecreaseacidproduction(Appen-dix18-5).

c. NPO,nasogastrictube;salinelavagemaybedone.d. Surgeryifunresponsivetoconservativetherapy.

b. Fluidvolumereplacement.c. Antiulcermedications.d. Pyloroplastytoenlargeopeningofpyloricvalve.

E. Surgical interventions for intractable ulcers and/orcomplications.1. Partialgastrectomy:removalofmajorityofstomach

(antrumandpylorus)withanastomosistoeithertheduodenumorthejejunum.

2. Vagotomy: severing of the vagus nerve to decreaseacid-secretingstimulustogastriccells.

3. Pyloroplasty(pyloricstenosisrepair):enlargementofpyloricvalve to facilitatepassageofgastriccontentsintothesmallintestine;maybedoneincombinationwithvagotomy.

F. Postoperativecomplications.1. Dumpingsyndrome:affectsuptohalfofclientswho

haveundergonegastrectomy(seeBox18-3).2. Postprandial hypoglycemia: results from dumping

syndrome; concentrated carbohydrates cause hyper-glycemia, and excessive insulin is released, causinghypoglycemiaabout2hoursaftermeals.

NURSING PRIORITY Recognize and implement measures to manage potential circulatory complications (e.g., occurrence of a hemorrhage); carefully evaluate the client’s blood pressure. Orthostatic hypotension (a blood pressure decrease of 10 mm Hg or more) may be indicative of hypovolemia.

C. Perforation.1. Clinicalmanifestations.

a. Sudden,severe,unrelentingabdominalpain.b. Rigid,“board-like”abdomen.c. Hyperactivetoabsentbowelsounds.d. Severity of peritonitis is proportional to size of

perforation and amount of gastric spillage (seeFigure18-6).

2. Treatment.a. Antibiotics.b. Perforationmayseal,ifnot,laparoscopicorsurgi-

calclosure.c. Fluidvolumereplacement.

D. Gastric outlet obstruction: more common in duodenalulcersintheareaofthepyloricvalve.1. Clinicalmanifestations.

a. Gradualonsetofsymptoms.b. HistoryofPUD.c. Swelling,dilationofstomach.d. Vomiting:foul-smellingandfrequentlyprojectile.e. Reliefmaybeobtainedbyvomiting.

2. Treatment.a. Decompress the stomach with NG suctioning;

maintain continuous decompression to allow forhealing.

ALERT Teach client methods to prevent and/or manage complications associated with diagnosis.

Nursing InterventionsGoal: To promote health and prevent reoccurrence of

PUD.A. Identifyfactorsinlifestylecontributingtodevelopment

ofulcer.B. Identifyfactorsthatprecipitatepainanddiscomfort.C. AvoidaspirincompoundsandNSAIDs.D. IdentifypresenceofH. pyloriandfollowtherapy;ulcers

tend to reoccur, so discontinuation or interruption oftherapycanbedetrimental.

E. Clientshouldnot takeanyothermedicationsorOTCdrugsthatarenotprescribed.

ALERT Evaluate use of home remedies and OTC drugs. The client with PUD may have been using antacids for a prolonged time.

Goal: Torelieveacutepainandpromotehealing.A. Dietarymodifications.

1. MaybeNPOwithNGsuctioningforacuteepisodeofgastricpainwithnauseaandvomiting(Appendix18-8).

2. Nonirritating, bland foods are generally toleratedbetterduringhealingofacuteepisodes.

3. Encouragesmall,frequentmeals.4. Helpclientidentifyspecificdietaryhabitsthatexac-

erbateorprecipitatepain.B. Identifycharacteristicsofpainandactivitiesthatincrease

ordecreasepain.Goal: To promote homeostasis for client with gastric

obstruction.

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A. Nasogastricsuctioningandcarefulassessmentofhydra-tionstatus;IVfluidreplacement.

B. Reposition client from side to side to maintain goodgastricsuctioning.

C. After severaldaysofdecompression,NG tubemaybeclampedforshortperiodsandgastricresidualmeasured;lessthan200mLresidualiswithinnormalrange.

D. When gastric residual is within normal amount, oralfeedings may begin at 30 mL per hour and graduallyincreased;closelymonitorforsignsofobstruction.

Goal: To promote homeostasis when client ishemorrhaging.

A. Assessclientresponsetohemorrhage.1. Evaluatehemoglobinandhematocritlevels.2. Assess for distention, increase in pain, and

tenderness.3. Correlate vital signswith changes in client’s overall

condition.4. Assessstoolsandnasogastricdrainageforpresenceof

blood.B. Maintain nasogastric decompression and suctioning

(Appendix18-8).1. Insertnasogastrictubeforremovalofgastriccontents

andmaintaingastricsuction.2. Mayimplementsalinesolutionlavage.

C. Monitorforhypovolemiaandmaintainhydrationstatus(Chapter6).1. Establish peripheral infusion line, preferably with

large-gaugeneedleforbloodinfusion.2. Insertindwellingurinarycathetertomonitorurinary

output;evaluateurinespecificgravity.3. Prepare to administer whole blood transfusion (see

Appendix14-3)andIVfluids.D. Hemodynamicmonitoring(Appendix17-9).E. Maintain NPO status, begin oxygen administration,

maintainbed rest, andpositionclient supinewith legsslightlyelevated.

Goal: Toassessforcomplicationsofperforationandperi-tonitis(seeAcuteAbdomensection).

Goal: Toassistclienttoreturntohomeostasisaftergastricresection.

A. Provide general postoperative care as indicated (seeChapter3).

B. Maintainnasogastricsuctionuntilperistalsisreturns(seeAppendix18-8).

F. Based on client’s condition, total parenteral nutritionmay be necessary to maintain adequate nutrition(Appendix18-7).

G. Encourageambulationtopromoteperistalsis.Goal: Toidentifydumpingsyndrome(seeBox18-3).Goal: To prevent the development of pernicious anemia

aftertotalgastricresection(seediscussionofvitaminB12deficiency,Chapter14).

AppendicitisAppendicitis is the inflammation and obstruction of the appendix, leading to bacterial infection. If appendicitis is not treated, the appendix can become gangrenous and burst, causing peritonitis and septicemia, which could progress to death. It is the most common reason for emer-gency abdominal surgery in children.A. Obstructionoftheblindsacoftheappendixprecipitates

inflammation,ulceration,andnecrosis.B. Ifthenecroticarearuptures,intestinalcontentsspillinto

theperitonealcavity,causingperitonitis.


1. Age: peak at 10 to 12 years of age; uncommon inchildrenyoungerthan2years.

2. Diet:riskassociatedwithadietlowinfiberandhighinrefinedsugarsandcarbohydrates.

3. Obstructiontoopeningofappendix:hardenedfecalmatter,foreignbodies,ormicroorganisms.

B. Clinicalmanifestations(Figure18-5).1. Abdominal cramping and pain, beginning near the

navel and thenmigrating towardMcBurney’spoint(rightlowerquadrant);painworsenswithtime.

2. Rovsingsign:paininrightlowerquadrantwhenpal-patingorpercussingotherquadrants.

3. Anorexia,nausea,vomiting,diarrhea.4. Low-gradefever.

ALERT Monitor and maintain GI drainage. Distention and obstruction of the nasogastric tube is a common problem for this client.

C. Assesscontinuouslyfor:1. Increasingabdominaldistention.2. Nausea,vomiting.3. Changesinbowelsounds.

D. No oral fluids until client tolerates clamping and/orremovalofnasogastrictube.

E. Beginoralfluidsslowly:clearliquidsfirst;thenprogresstobland,softdiet.

FIGURE 18-5 Appendicitis. (From Zerwekh J, Claborn J: Memory note-book of nursing, vol 2, ed 3, Ingram, Texas, 2007, Nursing Education Consultants)

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5. Side-lyingpositionwithkneesflexed.6. Clientcomplainsofpainwhenaskedtocough;asking

clienttocoughisbetterassessmentmethodthanpal-patingforreboundtenderness.

7. Sudden relief from pain may indicate rupture ofappendix.

C. Diagnostics:nospecificdiagnostictool;diagnosismadefromcompilationoffindings.1. Clinicalmanifestations.2. Urinalysistoruleouturinarytractinfection.3. AbdominalultrasonographyandCTtodifferentiate

fromotherabdominalproblems.4. CBCrevealselevatedwhitebloodcellcount.5. Pregnancy test for adolescent females to rule out

ectopicpregnancy.D. Complications:ruptureandperitonitis.

TreatmentA. Presurgery: fluid resuscitation, prophylactic antibiotic

therapy;afterdiagnosisofappendicitishasbeenestab-lished,painmanagementwithanalgesics.

B. Openappendectomyorlaparoscopicappendectomy.C. Abdominallaparotomyandperitoneallavageifappendix

hasruptured.

Nursing InterventionsGoal: To assess clinicalmanifestations and toprepare for

surgery.A. Careful nursing assessment for clinical manifestations

(Box18-4).B. MaintainNPOstatusuntilotherwiseindicated.C. Maintainbedrestinpositionofcomfort.

E. Donotadministerenemas.F. Avoidunnecessarypalpationofabdomen.

Box 18-4 UNDIAGNOSED ABDOMINAL PAIN

DO NOTGiveanythingbymouth.Putanyheatontheabdomen.Giveanenema.Givestrongnarcotics.Givealaxative.

DOMaintainbedrest.Placeinapositionofcomfort.Assesshydration.Assess abdominal status:distention,bowel sounds,passageof

stoolorflatus,generalizedorlocalpain.KeepclientNPOuntilnotifiedotherwise.

ALERT Determine need for administration of pain medications. Do not give narcotics for pain control before a diagnosis of appendicitis is confirmed, because this could mask signs if the appendix ruptures.

D. Do not apply heat to the abdomen; cold applicationsmayprovidesomerelieforcomfort.

ALERT Determine whether client is prepared for surgery or procedures. Appendicitis is a very common problem; know how to care for client during diagnostic phase.

Goal: To maintain homeostasis and healing after appen-dectomy(seeChapter3).

Goal: Topreventabdominaldistentionandtoassessbowelfunctionafterabdominallaparotomy.

A. MaintainNPOstatus;thenbeginclearliquiddiet,pro-gressingtosoftdietastolerated.

B. Gastric decompression by nasogastric tube; maintainpatencyandsuction(Appendix18-8).

C. Monitorabdomenfordistentionandincreasedpain.D. Assessperistalticactivity.E. Evaluateandrecordcharacterofbowelmovements.Goal: To decrease infection and promote healing after

abdominallaparotomy.A. Place client in semi-Fowler’s position to localize and

prevent spread of infection and reduce abdominaltension.

B. Antibiotics are usually administered via IV infusion;monitorresponsetoantibioticsandstatusofIVinfusionsite.

C. Monitorvitalsignsfrequently(every2to4hours)andevaluateforescalationofinfectiousprocess.

D. Provideappropriatewoundcare;evaluatedrainagefromabdominalPenrosedrainsandincisionalarea.

Goal: To maintain adequate hydration and nutrition andtopromotecomfortafterabdominallaparotomy.

A. MaintainadequatehydrationviaIVinfusion.B. Evaluatetoleranceoforalliquidswhennasogastrictube

isremoved.C. Beginoraladministrationofclearliquidswhenperistal-

sisreturns.D. Progressdietastolerated.E. Administeranalgesicsasindicated.

ALERT Identify infection; peritonitis is common after surgery for a ruptured appendix.

Acute AbdomenAcute abdomen encompasses a broad spectrum of urgent pathologies frequently requiring emergent surgical intervention. Also called peritonitis, this condition is char-acterized by a generalized inflammation of the peritoneal cavity, resulting in an intraabdominal infection.A. Intestinal motility is decreased, and fluid accumulates

as a result of the inability of the intestine to reabsorbfluid.

B. Fluid leaks into the peritoneal cavity, precipitatingfluid, electrolyte, and protein losses, as well as fluiddepletion.

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1. Chemical peritonitis may result from an infection,theperforationofpepticulcer,orarupturedectopicpregnancy.

2. Bacterial peritonitis results from traumatic injury(abdominaltrauma,rupturedappendix).

3. Chemicalperitonitis is rapidly followedbybacterialperitonitis.

4. Pancreatic necrosis, pyelonephritis, ectopic preg-nancy,malignancy,bileductobstruction,andduode-nalulcermaycauseacuteabdomen.

2. AbdominalCTandultrasonography.3. Peritoneal lavage (aspiration) to evaluate abdominal

fluid.

TreatmentA. Identifyandtreatprecipitatingcause;frequentlyrequires

surgicalintervention.B. Narcoticanalgesicmaybeadministeredduringdiagnos-

ticphasetoensureclientcooperation.C. Antibiotics.D. IVfluidsandelectrolytereplacement.E. Decreaseabdominaldistention:NPO,NGtube.

Nursing InterventionsGoal: Toprovidepain control,woundcare,prevent com-

plications of immobility, and monitor postoperativeprogress(Chapter3).

Goal: Tomaintainfluidandelectrolytebalancesandreducegastricdistention.

A. Maintainnasogastricsuction(Appendix18-8).B. Maintain IV fluid replacement: normal saline or

lactated Ringer’s solution to maintain hydrationand urine output of 30 mL/hr; assess urine specificgravity.

C. Administerpotassiumsupplementswithcautionbecauseofpossiblerenalcomplications.

D. Assess level of distention and return of peristalsis andbowelfunction.

E. Maintainintakeandoutputrecords.F. Assess for problems of dehydration and hypovolemia

(Chapter6).G. Encourage activities to facilitate return of bowel

function.1. Encourageambulation.2. Attempt to decrease analgesics and maintain ade-

quatepaincontrol.3. Maintainadequatehydration.

ALERT Monitor status of client who has undergone surgery; identify infection. Peritonitis is a potential complication any time the abdomen is entered, either through trauma or for surgery.

B. Clinicalmanifestations(Figure18-6).1. Presenceofprecipitatingcause.2. Sharporknife-likepainand/ordullanddeep-seated

pain over involved area; rebound tenderness; painmayradiatetoback,shoulder,orscapula.

3. Sudden,excruciatingpainsuggeststhepossibilityofrupture.

4. Abdominal mass or distention: note color andcontourofabdomen.

5. Abdominalmusclerigidity(“board-like”abdomen),guarding.

6. Unexplainedpersistentorlabilefever.7. Anorexia,nausea,vomiting.8. Tachycardia, hypotension, shallow respirations:

signsofimpendingoractualshock.9. Decreasedorabsentbowelsounds.

10. Hypovolemia,dehydration.11. Shallowrespirationsinattempttoavoidpain.

C. Diagnostics.1. CBCforelevatedwhitebloodcellcountandhemo-

concentrationoffluidshifts(Chapter6).

FIGURE 18-6 Peritonitis. (From Zerwekh J, Claborn J: Memory notebook of nursing, vol 2, ed 3, Ingram, Texas, 2007, Nursing Education Consultants.)

PERITONITIS “HOT BELLY”

Risk Factors Nursing Care• Abdominal Surgery• Ectopic Pregnancy• Perforation:

I.D. Cause• AntibioticsIV Fluids Abd Distention

PulseBP

Dehydration

•••

PainBowel Sounds

• Fever• N & V

• Anorexia

• ReboundTenderness

• “Board-like” Abdomen• Abd Distention & Rigidity

• WBCDX

NS.K’

Rx

SHHH...BowelsSleeping

••

100° FPlus

• IV’s & Electrolyte Balance & GI Distention• Decrease Pain: Position w/ Knees Flexed Analgesics Quiet Environment• Prevent Complications: Immobility Pulmonary Fluid Balance

TraumaUlcerAppendix RuptureDiverticulum

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Goal: Toreduceinfectiousprocess.A. Administer antibiotics via IV infusion; assess client’s

toleranceofantibioticsandstatusofinfusionsite.B. Evaluatevitalsignsandcorrelatewithprogressofinfec-

tiousprocess.C. Maintaininsemi-Fowler’spositiontoenhancerespira-

tions,aswellastolocalizedrainageandpreventforma-tionofsubdiaphragmaticabscess.

Diverticular DiseaseWhen a diverticulum (a pouch-like herniation of superfi-cial layers of the colon through weakened muscle of the bowel wall) becomes inflamed, it is known as diverticuli-tis. Multiple diverticula are known as diverticulosis. Meckel’s diverticulum is diverticular disease of the ileum in children. It is the most common congenital anomaly of the GI tract in children.


1. Diet.a. Low-fiberdiet;highintakeofprocessedfoods.b. Constipation.c. Indigestiblefibers(corn,seeds,etc.)mayprecipi-

tatediverticulitis,buttheydonotcontributetothedevelopmentofdiverticula.

2. Age:50%ofadultsareaffectedbyage80years.3. As diverticula form, the colon wall becomes thick-

ened;diverticulitisresultsfromretentionofstoolandbacteriainthediverticulum.

4. Inactivityandconstipation.B. Clinicalmanifestations.

1. Diverticular disease is frequently asymptomatic;symptomsvarywithdegreeofinflammation.

2. Diverticulitisoccurswhenundigestedfoodandbac-teriaaretrappedinthediverticula.a. Fever.b. Leftlowerquadrantpain;maybeaccompaniedby

nauseaandvomiting.c. Abdominal distention and increased pain on

palpation.d. May progress to abscess, intestinal obstruction,

and/orperforation.C. Diagnostics(Appendix18-1).

1. Computedtomographyand/orultrasound.2. Bariumenemaorcolonoscopyarecontraindicatedin

acutediverticulitis.

TreatmentA. Managementofuncomplicateddiverticulum.

1. High-fiberdiet.2. Decreasedintakeoffatandredmeat.3. Stoolsofteners,bulklaxatives.4. Increasedactivity:walking,exercise.

B. Diverticulitis.1. Oralantibioticswhensymptomsaremild.2. Antispasmodicmedications.3. Liquidorlow-fiberdiet.

C. Severediverticulitis.1. Broad-spectrumantibiotics.2. Bowelrest:NPO;mayhaveanNGtube;hydration

withIVfluids.3. Pain management with opioids; avoid morphine

(decreasesperistalsis).4. Surgery for obstruction, abscess, hemorrhage, or

perforation.Goal: To help client understand dietary implications and

maintainprescribedtherapytopreventexacerbations.A. Teach client about eating a high-fiber diet when

asymptomatic.B. Maintainhighfluidintake.

ALERT Adapt the diet to the special needs of the client; determine client’s ability to perform self-care.

C. Weightreduction,ifindicated.D. Avoid activities that increase intraabdominal pressure

(e.g.,strainingatstool,bending,lifting);avoidwearingtightrestrictiveclothing.

E. Usebulklaxatives,avoidenemasandharshlaxatives.Goal: To decrease colon activity in client with

diverticulitis.A. MaintainclearliquidsorNPOstatus.B. Bedrest.C. Adequatehydrationviaparenteralfluids.D. As attack subsides, gradually introduce food and

fluids.

Home CareA. High-fiberdiettopreventdiverticulitis.B. Ifclienthasanyabdominaldistress,allfibershouldbe

avoideduntiltendernessresolves.C. Reportfevers,constantabdominalpain,anddark,tarry

stools.

Inflammatory Bowel Disease (IBD)IBD is characterized by chronic inflammation of the intestine with periods of remission and exacerbation. It is considered an autoimmune disease; tissue damage is due to overactive sustained inflammatory response.A. Crohn’s disease (ileitis or enteritis) is inflammation

occurring anywhere along the GI tract; patches ofinflammationoccurnext tohealthybowel tissue;mostfrequentsiteistheterminalileum.

B. Ulcerative colitisisaninflammationandulcerationthatmostcommonlyoccursinthesigmoidcolonandrectum;inflammation frequently begins in the rectum andspreadsinacontinuousmannerupthecolon;seldomisthesmallintestineinvolved.

C. Clientsfrequentlyexperienceperiodsofcompleteremis-sionthatalternatewithexacerbations.

D. Eventhoughthetwoconditionshavedifferentcriteriafor diagnosis, a clear differentiation cannot be madebetweentheminaboutone-thirdofthecases.

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1. Familialtendency.2. Commonly occur in the teenage years, with a

second peak in occurrence in clients 60 years oldandolder.

3. Alteredinflammatoryresponse.B. Clinicalmanifestations—Crohn’sdisease.

1. Steatorrhea,multiplediarrheastoolsperday.2. Weight loss; nutritional deficiencies; impaired

absorptionofvitaminB12(cobalamin).3. Intermittentfever.4. Entirethicknessofbowelwallisinvolved;fistulasare

notuncommon.5. Nausea,cramping,flatulence.

C. Clinicalmanifestations—ulcerativecolitis.1. Rectalbleeding.2. Diarrhea, one to two diarrhea stools per day; may

containsmallamountsofblood.3. Numberofstoolsincreaseswithexacerbationofcon-

dition;10-20stoolsperdayinacuteexacerbation.4. Increased in systemic symptoms (fever, malaise,

anorexia)withexacerbation.5. Tenesmus(uncontrollablestraining).6. Minimalsmallbowelinvolvement.

D. Diagnostics(seeAppendix18-1).

ComplicationsA. Crohn’sdisease.

1. Perirectal and intraabdominal fistulas; fissures andrectalabscesses.

2. Perforationandperitonitis.3. Nutritional deficiencies, especially of fat-soluble

vitamins.B. Ulcerativecolitis.

1. Perforationandperitonitiswithtoxicmegacolon.2. Increasedriskforcancerafter10years.

TreatmentA. Dietary modifications: increased calories, protein, and

fluids. Encourage client to eat small servings severaltimesaday.

B. MedicationsforCrohn’sdisease.1. Antiinflammatory: aminosalicylates (sulfasalazine;

seeAppendix6-9)andcorticosteroids(seeAppendix6-7).

2. Antimicrobials:preventortreatinfection.3. Immunosuppressants to decrease or suppress the

immuneresponse(seeAppendix23-3).4. Antidiarrheals.

C. Medications for ulcerative colitis: aminosalicylates andcorticosteroidstodecreaseinflammation.

D. Surgical interventionmaybenecessaryifclientfailstorespondtomedicalmanagementandiffistulas,perfora-tion,bleeding,orintestinalobstructionoccur.1. Total removal of colon, rectum, and anus with

formation of permanent ileostomy (Appendix18-12).

2. Totalremovalofcolon,rectum,andanuswithforma-tionofcontinentileostomy(Kock’spouch).

3. Minimallyinvasivesurgery(MIS)involvesalaparos-copy to removesmallareasofdiseased tissue in theileumandileocecalareas.

Nursing InterventionsGoal: To promote hemodynamic stability and hydra-

tion.A. Evaluateandmaintainadequatehydrationstatus.B. Encouragegoodfluidintake(3000mL/day).C. Evaluateelectrolytestatus;monitorpotassiumlevelifon

corticosteroids.D. Assesscharacteristicsinpatternsofstool.Goal: Topromotenutrition.A. Balanceddietwithincreasedproteinandcalories.B. Assessforirondeficiencyanemiaduetobloodlossand

reducedintakeofiron.C. Assessforanemiaduetolackofabsorptionofvitamin

B12(cobalamin);monthlyinjectionsordailyoralornasalspraymaybenecessary.

D. Help client identify and avoid foods that precipitatediarrhea.

E. Parenteralnutritionorenteralfeedingmaybenecessarybecause of malabsorption (Appendix 18-7, Appendix18-9).

F. Supplemental folic acid for clients on long-term sul-fasalazinetreatment.

G. Supplementalliquidnutrition.Goal: Topromoteemotionalandpsychosocialstability.A. Frequent bowel movements, rectal discomfort, and

uncontrollablediseaseresult inanxiety,frustration,anddepression—promotecomfortbykeepinganalareacleanandkeepingroomclearofoffensiveodors.

B. Establishtrust,encourageself-carestrategies,explainallproceduresandtreatments.

C. Encourageresttopreventfatigue.D. Symptoms of reoccurrence of the problem—call the

physicianiftheseoccur.1. Continueddiarrheaandweightloss.2. Chills,fever,malaise.

Home CareA. Dietary modifications, avoidance of foods that cause

diarrhea.B. Medication regimen: precautions regarding steroids or

immunosuppressivemedications.C. Dressingsandwoundcareiffistulaispresent.D. Identify appropriate measures to decrease stress in

lifestyle.E. Acutesymptomsmaybeexacerbatedor,asdiseasepro-

gresses,maybecomechronic.

Intestinal ObstructionInterference with normal peristalsis and impairment to forward flow of intestinal contents is known as intestinal obstruction.

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A. Typesofobstruction(Figure18-7).1. Mechanicalobstruction.

a. Strangulatedhernia.b. Intussusception:thetelescopingofoneportionof

the intestine into another (occurs most often ininfantsandsmallchildren).

c. Volvulus:twistingofthebowel.d. Tumors: cancer (most frequentcauseofobstruc-

tioninolderadults).e. Adhesions.

2. Neurogenic: interference with nerve supply in theintestine.a. Paralytic ileus or adynamic ileus occurring as a

result of abdominal surgery or inflammatoryprocess.

b. Potentialsequelaefromspinalcordinjury.3. Vascular obstruction: interference with the blood

supplytothebowel.a. Infarctionofsuperiormesentericartery.b. Bowelobstructions related to intestinal ischemia

may occur very rapidly and may be life-threatening.

B. Regardlessoftheprecipitatingcause,theensuingprob-lemsarearesultoftheobstructiveprocess.

C. The higher the obstruction in the intestine, the morerapidlysymptomswilloccur.

D. Fluid,gas,andintestinalcontentsaccumulateproximalto the obstruction.This causes distention proximal tothe obstruction and bowel collapse distal to theobstruction.

E. Asfluidaccumulationincreases,sodoespressureagainstthebowel.Thisprecipitates extravasationoffluidsandelectrolytesintotheperitonealcavity.Increasedpressuremaycausetheboweltorupture.

F. Increasedpressurecausesanincreaseincapillaryperme-abilityandleakageoffluidsandelectrolytesintoperito-nealfluid;thisleadstoaseverereductionincirculatingvolume.

G. Intussusceptionisthemostcommoncauseofintestinalobstructioninchildrenfromages3monthsto6years.

H. The location of the obstruction determines theextentoffluidandelectrolyte imbalanceandacid-baseimbalance.1. Dehydrationandelectrolyteimbalancedonotoccur

rapidlyifobstructionisinthelargeintestine.2. If the obstruction is located high in the intestine,

dehydrationoccursrapidlybecauseoftheinabilityofthe intestine to reabsorb fluids; metabolic alkalosisdevelopsfromlossofgastricacidduetovomitingorNGsuctioning.

AssessmentA. Risk factors/etiology: identify type of obstruction and

precipitatingcause.B. Clinicalmanifestations.

1. Vomiting.a. Occursearlyandismoresevereiftheobstruction

ishigh.b. Higherobstructionmaycontainbile,andvomit-

ingmaybeprojectile.c. Vomiting caused by lower obstructions occurs

moreslowlyandmaybefoulsmellingduetothepresenceofbacteriaandfecalmaterial.

2. Abdominaldistention.3. Bowel sounds initiallymaybehyperactive proximal

to theobstructionanddecreasedor absentdistal totheobstruction; eventually, allbowel soundswillbeabsent.

FIGURE 18-7 Bowel obstructions. (From Lewis SL et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby.)

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4. Colicky-typeabdominalpain.5. Fluidandelectrolyteimbalances,dehydration.6. Intussusception.

a. Childishealthywithsuddenoccurrenceofacuteabdominalpain.

b. Childmaypassonenormalstool;thenasconditiondeteriorates,thechildmaypassastooldescribedas“currantjelly”(amixtureofbloodandmucus).

c. A“sausage-shaped”massmaybepalpated intheabdomen.

H. Measureabdominalgirthtodeterminewhetherdisten-tionisincreasing.

I. Encourage activities to facilitate return of bowelfunction.1. Encouragephysicalactivity,astolerated.2. Attempttodecreaseamountofmedicationrequired

foreffectivepaincontrol.3. Maintainhydration.

J. Frequently, the position of comfort is side-lying withkneesflexed.

Goal: To provide appropriate preoperative preparationwhensurgeryisindicated(seeChapter3).

Goal: Tomaintainhomeostasisandpromotehealingafterabdominallaparotomy(seeChapter3).

Goal: To decrease infection and promote healing aftersurgery.

A. Monitorclient’sresponsetoantibiotics.B. Monitorvitalsignsfrequentlyandevaluateforpresence

orescalationofinfectiousprocess.C. Providewoundcare.Evaluatedrainageandhealingfrom

abdominal Penrose or Jackson-Pratt drains, as well asfromabdominalincisionalarea.

ALERT Determine characteristics of bowel sounds. This is particularly important for the client with intestinal problems.

C. Diagnostics(Appendix18-1).a. Abdominal x-ray to differentiate obstruction from

perforation.b. Barium enema to identify area of obstruction; only

doneafterabowelperforationhasbeenruledout.

ComplicationsA. Infection/septicemia.B. Gangreneofthebowel.C. Perforationofthebowel.D. Severedehydrationandelectrolyteimbalances.

TreatmentA. Mechanicalandvascularintestinalobstructionsaregen-

erallytreatedsurgically;ileostomyorcolostomymaybenecessary.

B. Conservative treatment includesnasogastric suctioninganddecompression(Appendix18-8).

C. Fluidandelectrolytereplacement.D. Intussusception:hydrostatic reductionbywater-soluble

contrast,air,orbariumenema.

Nursing InterventionsGoal: To prepare client for diagnostic evaluation and to

maintainongoingnursingassessmentforpertinentdata(seeAppendix18-1).

A. Monitor all stools; passage of normal stool may indi-cate reduction of the obstruction, especially anintussusception.

B. Classicsignsandsymptomsofintussusceptionmaynotbepresent;observechild fordiarrhea,anorexia,vomit-ing,andepisodicabdominalpain.

Goal: Todecreasegastricdistentionandtomaintainhydra-tionandelectrolytebalance.

A. MaintainNPOstatus.B. Maintainnasogastricsuction(Appendix18-8).C. MonitorIVfluidreplacement:mostoftennormalsaline

orlactatedRinger’ssolution.D. Administerpotassiumsupplementswithcautionbecause

ofcomplicationsofdecreasedrenalfunction.E. Evaluateperistalsis,presenceofanybowelfunction.F. Maintainaccurateintakeandoutputrecords.G. Assess for dehydration, hypovolemia, and electrolyte

imbalance(Chapter6).

ALERT Empty and reestablish negative pressure of portable wound suction devices (Hemovac and Jackson-Pratt drains).

Goal: Toreestablishnormalnutritionandpromotecomfortafterabdominallaparotomy.

A. Evaluate tolerance of liquids when nasogastric tube isremoved.

B. Beginadministrationofclear liquids initiallyandcon-tinuetoevaluateforperistalsisand/ordistention,nausea,andvomiting.

C. Progressdietastolerated.D. Administeranalgesicsasindicated.E. Promotepsychologiccomfort.

1. Respondpromptlytorequests.2. Carefullyexplainprocedures.3. Encourage questions and ventilation of feelings

regardingstatusofillness.4. Encourageparents toaskquestionsand to room-in

with infantor child; rapidityof theonsetof child’sconditionchallengesparents’abilitytocope.

HerniaA hernia is a protrusion of the intestine through an abnor-mal opening or weakened area of the abdominal wall.A. Types.

1. Inguinal:aweaknessinwhichthespermaticcordinmenandtheroundligamentinwomenpassesthroughtheabdominalwallinthegroinarea;morecommoninmen;mostcommontypeofherniainchildren.

2. Femoral: protrusion of the intestine through thefemoralring;morecommoninwomen.

3. Umbilical: occurs most often in children when theumbilical opening fails to close adequately; most

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commonherniaininfants;mayoccurinadultswhentherectusmuscleisweakfromsurgicalincision.

4. Incisionalorventral:weaknessintheabdominalwallcausedbyapreviousincision.

5. Classification.a. Reducible: hernia may be replaced into the

abdominalcavitybymanualmanipulation.b. Incarcerated or irreducible: hernia cannot be

pushedbackintoplace.c. Strangulated:bloodsupplyand intestinalflowin

the herniated area are obstructed; strangulatedhernialeadstointestinalobstruction.

B. Riskfactors.1. Chronic cough, such as smoker’s cough or cough

associatedwithcysticfibrosis.2. Obesityorweakenedabdominalmusculature.3. Straining during bowel movement or lifting heavy

objects.4. Pregnancy.

AssessmentA. Clinicalmanifestations.

1. Hernia protrudes over the involved area when theclientstandsorstrains,orwhentheinfantcries.

2. Severepainoccursifherniabecomesstrangulated.3. Strangulatedherniaproducessymptomsofintestinal

obstruction.B. Diagnostics(Appendix18-1).

TreatmentA. Preferablyelectivesurgerythroughabdominalincision.B. Laparoscopicherniarepair.C. Emergency surgery for strangulated hernias producing

intestinalobstruction.

Nursing InterventionsGoal: To prepare client for surgery, if indicated (see

Chapter3).Goal: Tomaintainhomeostasisandpromotehealingafter

herniorrhaphy.A. Generalpostoperativenursingcare(seeChapter3).B. Repairofanindirectinguinalhernia:assessmaleclients

fordevelopmentofscrotaledema.C. Encouragedeepbreathingandactivity.D. If coughing occurs, teach client how to splint the

incision.E. Refrain from heavy lifting for approximately 6 to 8

weeksaftersurgery.F. Woundcare.

a. Keepwoundcleananddry:useocclusivedressingorleaveopentoair.

b. Change diapers frequently and/or prevent irritationandcontaminationinincisionalarea.

Pyloric StenosisPyloric stenosis is the obstruction of the pyloric sphincter by hypertrophy and hyperplasia of the circular muscle of the pylorus.


1. Occurs most often in first-born, full-term maleinfants(infantilehypertrophicpyloricstenosis).

2. SeenmorefrequentlyinCaucasianinfants.3. First-bornmaleinfantofamotherwhowasaffected

isatincreasedrisk.B. Clinicalmanifestations.

1. Onsetofvomitingmaybegradual,usuallyoccursat3weeksoraslateas5months;isprogressiveandmaybeprojectile.

2. Emesis isnotbile stainedbutmaybecurdled fromlengthoftimeinstomach.

3. Vomitingoccursshortlyafterfeeding.4. Infantishungryandirritable.5. Infant does not appear to be in pain or acute

distress.6. Weightlossoccurs,ifuntreated.7. Stoolsdecreaseinnumberandinsize.8. Dehydration occurs as condition progresses; hypo-

chloremia and hypokalemia occur as vomitingcontinues.

9. Upperabdomen isdistended,andan“olive-shaped”massmaybepalpatedintherightepigastricarea.

C. Diagnostics(Appendix18-1).D. Treatment: surgical release of the pyloric muscle

(pyloromyotomy).

Nursing InterventionsGoal: To maintain hydration and gastric decompression;

to initiate appropriate preoperative nursing activities(Appendix18-8).

A. Maintain nasogastric decompression if NG tube is inplaceandrecordtypeandamountofdrainage.

B. Assess hydration status and electrolyte balance—espe-ciallyserumcalcium,sodium,andpotassiumlevels.

C. NPO status with continuous IV infusion (most oftensalinesolutions)mayberequired.

D. Accurate intake and output records: complete descrip-tionofallvomitusandstools.

E. Monitorvitalsignsandcheckforsignsofperitonitis.F. Preoperativeteachingforparents.Goal: Tomaintainadequatehydrationandpromotehealing

afterpyloromyotomy.A. Postoperativevomitinginthefirst24to48hoursisnot

uncommon; maintain IV fluids until infant toleratesadequateoralintake.

B. Continue to monitor infant in the same manner as inthepreoperativeperiod.

C. Feedingsareinitiatedearly;bottle-fedinfantmaybeginwith clear liquids containing glucose and electrolytes,smallamountsofferedfrequently.

D. Breastfedinfants:mothercanexpressbreastmilkandoffersmallamountsinabottleorinitiallylimitnursingtime.

Goal: Tohelpparentsprovideappropriatehomecareafterpyloromyotomy.

A. Noresidualproblemsareanticipatedaftersurgery.B. Instructparentsregardingcareoftheincisionalarea.

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Cancer of the StomachTumors in the cardia and fundus of the stomach are asso-ciated with a poor prognosis.A. Cancer (adenocarcinoma) occurs in the wall of the

stomach.B. Metastasis generally occurs by direct extension of the

malignant growth into adjacent organs and structures(esophagus,spleen,pancreas,etc.).

C. Becauseof theabilityof the stomach toaccommodatethegrowingtumor,symptomsmaynotbeevidentuntilmetastasishasoccurred.


1. Increasedincidenceinmen.2. Peakincidenceinseventhdecade.3. PresenceofH. pylori isconsideredan increasedrisk

factor4. Increased incidence in presence of other chronic

gastricproblems.B. Clinicalmanifestations.

1. Earlysymptoms.a. Lossofappetite,persistentindigestion.b. Earlysatiety,dyspepsia.c. Nausea,vomiting.d. Bloodinstool.

2. Latersymptoms.a. Painoftenexacerbatedbyeating.b. Weightloss,anemia.c. Nausea and vomiting due to impending GI

obstruction.d. Presenceofapalpablemassinthestomach;ascites

frominvolvementofperitonealcavity.C. Diagnostics(Appendix18-1).

1. Gastroscopyandbiopsy.2. Full-bodyimagingformetastasis.

TreatmentGastrectomyisthepreferredmethodoftreatment.

Nursing InterventionsSeeNursingInterventionsforgastricresectionunderPepticUlcerDisease.

Cancer of the Colon and Rectum (Colorectal Cancer)

Colorectal cancer (cancer of the colon and/or the rectum) is the third most common cancer in the United States and the second leading cause of cancer-related deaths.A. 85%ofcolorectalcancersarisefromadenomatouspolyps

thatcanbedetectedandremovedbysigmoidoscopyorcolonoscopy.

B. Symptoms frequently do not appear until condition isadvancedwithmetastaticsites.

C. Most common areas of metastasis include regionallymphnodes,liver,lungs,andperitoneum.


1. Family history (first-degree relative) of colorectalcancer.

2. Incidence increases significantly after the ageof50.

3. Historyofinflammatoryboweldisease.4. High-fat, high-calorie, low-residue diet with high

intake of red meat increases anaerobic bacteria inbowel,whichconvertbileacidsintocarcinogens.

5. Alcohol,tobaccouse,andobesityarealsoassociatedwithincreasedrisk.

B. Clinicalmanifestations.1. Symptoms are vague early indisease state andmay

takeyearstopresent.2. Bloodystools,melena(darktarry)stools.3. Changeinbowelhabits:constipationanddiarrhea.4. Change in shapeof stool (pencil-or ribbon-shaped

insigmoidorrectalcancer).5. Weakness and fatigue from iron deficiency anemia

andchronicbloodloss.6. Pain, anorexia, and unexpected weight loss are late

symptoms.7. Bowel obstruction may lead to perforation and

peritonitis.C. Diagnostics(Appendix18-1).

1. Sigmoidoscopyandcolonoscopywithbiopsies.2. Carcinoembryonic antigen (CEA) tumor marker

detectedinblood.

TreatmentA. Colon resection:mayhave resectionwithorwithouta

colostomyormayhaveanabdominal-perinealresectionthatincludesresectionofthesigmoidcolon,rectum,andanus.

B. Laserphotocoagulation:destroyssmalltumorsandpal-liativeforlargetumorsobstructingbowel.

C. Endoscopic excision or electrocoagulation for small,localized tumors or for clients who are poor surgicalcandidates.

D. Radiation therapy: external, intracavity, or implanted;maybeusedpreoperativelytoshrinktumorsize.

E. Chemotherapy:reducesrecurrenceandprolongssurvivalinstageIIandIIIrectaltumors.

Nursing InterventionsGoal: Toprovideinformationtohigh-riskclients.A. Diet:high-fiber,low-fatdietwithadecreasedintakeof

redmeat.B. Digitalrectalexamsyearlyafterage40.C. Annualfecaloccultbloodtestingafterage50.D. Flexiblesigmoidoscopyorcolonoscopyevery3or5years

afterage50forhighrisk;otherwiseevery10years foraveragerisk.

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Goal: Toprovidepreoperativecare.A. Determine extent of surgery anticipated; colostomy is

notalwaysdone.B. Bowelpreparation:low-residuediet,cathartics24hours

before surgery; enemas may or may not be used theeveningbeforesurgery.

C. Oralneomycintodecreasebacteriainthebowel.D. If colostomy is to be done, discuss implications and

identify appropriate area for stoma on abdomen (seeAppendix18-12).

E. Prepareclientforchangeinbodyimageifcolostomyisindicated.

Goal: Toprovideappropriatewoundcareafterabdominal-perinealresection.

A. Clientwillhavethreeincisionalareas.1. Abdominalincision.2. Incisionalareaforcolostomy.3. Perinealincision.

C. Keeproomcleanandfreeofoffensivesmells;clientmaybe very self-conscious regarding open wound and/orstoma;provideopportunityforquestionsanddiscussion.

Home CareA. Recoveryperiodislong;helpclientandfamilyidentify

communityresources.B. Help client and family identify resources and obtain

equipmentforcolostomycare(seeAppendix18-12).C. Instruct client in care of perineal wound if it is not

healed.1. Sitzbaths:alwayschecktemperatureofwater;wound

tissuecanbeeasilydamaged.2. Presence of continuous drainage may indicate a

fistula.D. Identify community resources for client: home health

visits,socialservices,etc.E. Assessclient’sabilitytocareforstoma;helpclientbegin

self-carebeforedischarge(Appendix18-12).

Celiac Disease (Malabsorption Syndrome)Celiac disease is also known as sprue, gluten enteropathy, and malabsorption syndrome. This disease is an immune reaction to rye, wheat, barley, and oat grains that leads to an inflammatory response, causing damage to the villi of the small intestines and resulting in the inability to absorb nutrients (malabsorption).A. Previouslyconsideredadiseaseofchildhoodwithsymp-

tomsbeginningbetweentheagesof1yearand5years;celiac disease is now commonly seen at all ages withmeanageofdiagnosisbeing40years.

B. Symptoms frequently begin in early childhood, butcondition may not be diagnosed until client is anadult.

C. Developmentofceliacdisease isdependentongeneticpredisposition, ingestionofgluten,and immune-medi-atedresponse.

AssessmentA. Cause:congenitaldefectoranautoimmuneresponsein

glutenmetabolism.B. Clinicalmanifestations.

1. Symptomsmaybeginwhenchildhasincreasedintakeof foods containinggluten: cereals, crackers,breads,cookies,pastas,etc.

2. Foul-smelling diarrhea with abdominal distentionandanorexiaininfantsandtoddlers.

3. Poorweightgaininchildren,failuretothrive.4. Constipation,vomiting,andabdominalpainmaybe

theinitialpresentingsymptomsinadults.5. Vitamin deficiency leads to central nervous system

impairmentandbonemalformation.6. Maybeassociatedwithotherautoimmuneconditions

(rheumatoid arthritis, type 1 diabetes, thyroiddisease).

C. Diagnostics:biopsyofduodenumandsmallintestine.

ALERT Identify factors interfering with wound healing and/or symptoms of infection.

B. Perinealwound.1. Woundmaybeleftopentohealbysecondaryinten-

tion:providewarmsitzbaths(100.4°to100.6°F)for10 to20minutes topromotedebridement, increasecirculationtothearea,andpromotecomfort.

2. Woundmaybepartiallyclosedwithdrains( Jackson-Prattand/orHemovac)inplace:assessthewoundforintegrity of suture line and presence of infection;drainageshouldbeserosanguineous;drainsremaininplace until drainage is less than 50 mL/24 hour(Chapter3).

3. Woundmaybeopenandpacked:drainageisprofusefirstseveralhoursaftersurgery;mayrequirefrequentreinforcement and dressing change; drainage isserosanguineous.

C. Positionclientwithaperinealwoundonhisorherside;do not allow client to sit for prolonged period untilwoundishealed.

D. Assessstatusofstomaandhealingofabdominalincision(seeAppendix18-12).

Goal: Tomaintainhomeostasisandpromotehealingafterabdominal-perineal resection or colon resection (seeChapter3).

A. Infections, hemorrhage, wound disruption, thrombo-phlebitis, and stoma problems are the most commoncomplications.

B. Help client begin to become independent with colos-tomycareearlyinrecoveryperiod(seeAppendix18-12).

Goal: Toprovidepsychosocialsupport.A. Emotional support is essential with cancer diagnosis;

recoveryislongandfrequentlypainful.B. Sexualdysfunctionmayoccur;determinefromphysician

ifnervepathsforerectionandejaculationwere inareaofresection;provideopportunityforquestions.

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TreatmentPrimarilydietarymanagement:gluten-freediet.

Nursing InterventionsGoal: To help client and family understand diet therapy

andpromoteoptimalnutritionintake.A. Writteninformationregardingagluten-freediet;corn,

rice, potato, and soy products may be substituted forwheatindiet.

B. Dietshouldbewellbalancedandhighinprotein.C. Teachclientand/or familyhowto read food labels for

gluten content; thickenings, soups, instant foods maycontainhiddensourcesofgluten.

D. Importanttodiscussthenecessityofmaintainingalife-longgluten-restricteddiet;problemsmayoccurinclientswho relax theirdiet and experience an exacerbationofthediseasestate.

E. Lackofadherencetodietaryrestrictionsmayprecipitategrowthretardation,anemia,andbonedeformities.

B. Thefinal repaircloses thecolostomy,andthebowel isreanastomosed.

Nursing InterventionsGoal: To promote normal attachment and prepare infant

andparentsforsurgery.A. Allowparentstoventilatefeelingsregardingcongenital

defectofinfant.B. Fosterinfant-parentattachment.C. Generalpreoperativepreparationoftheinfant;neonate

doesnotrequireanybowelpreparation.D. Carefulexplanationofcolostomytoparents.Goal: SeeNursingInterventionsforclientwhohasunder-

gone abdominal surgery in the Intestinal Obstructionsectionofthischapter.

Goal: Tohelpparentsunderstandandprovideappropriatehome care for their infant/child after colostomy (seeAppendix18-12).

A. Colostomyismostoftentemporary.B. Parents should be actively involved in colostomy care

beforedischarge.

HemorrhoidsDilated hemorrhoidal veins of the anus and rectum; may be internal ( above the internal sphincter) or external (outside of the external sphincter).

AssessmentA. Riskfactors/etiology:conditionsthatincreaseanorectal

pressure.1. Pregnancy,obesity,prolongedconstipation.2. Prolongedstandingorsitting.3. Portalhypertension.4. Strainingatbowelmovement.

B. Clinicalmanifestations.1. External hemorrhoids appear as protrusions at the

anus.2. Prolapsed hemorrhoids may bleed or become

thrombosed.3. Thrombosedhemorrhoid: a blood clot in ahemor-

rhoidthatcausesinflammationandpain.4. Rectalbleedingduringdefecation.

C. Diagnostics:rectalexamination.

TreatmentA. Conservativetreatment.

1. Sitz baths, stool softeners, ointments, topicalanesthetics.

2. Prevent constipation: diet high in fiber (bran) androughagewithincreasedwaterintake.

3. Avoidstrainingwithbowelmovement;keepanalareaclean.

B. Aggressivetreatment.1. Ligationofprolapsed,thrombosedhemorrhoidswith

smallrubberband.2. Infraredcoagulationforbleedinghemorrhoids.3. Surgeryforpainful,large,bleedinghemorrhoids.

ALERT Adapt the diet to meet client’s specific needs.

Hirschsprung’s DiseaseHirschsprung’s disease (congenital aganglionic megaco-lon) is characterized by a congenital absence of ganglionic cells that innervate a segment of the colon wall.A. Clinical symptoms vary depending on the age when

symptoms are recognized, the length of the affectedbowel,andpresenceofinflammation.

B. Most common site is the rectosigmoid colon; colonproximaltotheareadilates(i.e.,megacolon).

AssessmentA. Riskfactors/etiology:congenitalanomaly.B. Clinicalmanifestations.

1. Maybeacuteandlife-threateningormaybeachronicpresentation.

2. Internalsphincterlosesabilitytorelaxfordefecation.3. Newborn.

a. Failure to pass meconium within 48 hours afterbirth.

b. Vomiting,abdominaldistention.c. Reluctancetotakefluids.

4. Olderinfantandchild.a. Chronicconstipation,impactions.b. Passage of ribbon-like, foul-smelling stools and

diarrhea.c. Failuretothrive.d. Lackofappetite.

C. Diagnostics:rectalbiopsytoconfirm.

TreatmentA. Surgicalcorrectionusuallyinvolvesresectionofagangli-

onic bowel with creation of a temporary colostomy torelievetheobstruction.

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Appendix 18-1 GASTROINTESTINAL SYSTEM DIAGNOSTICS

X-RayUpper Gastrointestinal Series or Barium SwallowX-rayexaminationinwhichbariumisusedasacontrastmaterial;used to diagnose structural abnormalities and problems of theesophagusandstomach.Astheclientswallowsthebarium,x-rayfilmsareobtained to showthestructures, function,position,andabnormalitiesoforgansfrommouththroughjejunum.Nursing Implications1. Explainproceduretoclient(usuallynotdoneonclientwithacute

abdomenuntilpossibilityofperforationhasbeenruledout).2. Maintain client’s nothing by mouth (NPO) status 8 hours

beforeprocedure.3. ClientwillswallowbariumtocoattheGItractforvisualization

ofvariouslandmarksandstructures.4. After examination, promote normal excretion of barium to

preventimpaction.Bariumcancauseconstipation,soencourageextrafluid.Itmaybenecessarytouseastoolsoftenerorlaxativetopromoteevacuationofbarium.

5. Stoolshouldreturntonormalcolorwithin72hours.

Lower Gastrointestinal Series or Barium EnemaX-rayexaminationofthecoloninwhichbariumisusedasacon-trastmedium;bariumisadministeredrectally.Nursing Implications1. Maintainclient’sNPOstatusfor8hoursbeforetest.Clientmay

haveclearliquidstheeveningbeforethetest.2. Colonmustbefreeofstool;laxativesandenemasareadminis-

teredtheeveningbeforethetest.3. Explaintoclientthatheorshemayexperiencecrampingand

theurgetodefecateduringtheprocedure.4. Aftertheprocedure,increasefluidsandadministeralaxativeto

assistinexpellingthebarium.

EndoscopyGastroscopy, Esophagogastroduodenoscopy (EGD), Colonoscopy, SigmoidoscopyEndoscopy is thedirectvisualizationof thegastrointestinal tract(GI)viaaflexible,fiberoptic,lightedscope.Upper GI: inflammation, ulcerations, tumors; evaluation and

treatmentofesophagealvarices.Lower GI: evaluation of diverticular disease or irritable bowel

syndrome;treatmentofactivebleedingorulceration;identifica-tionofpolyps,tumors,inflammation,fissures,orhemorrhoids.

Theendoscopeiscapableofobtainingbiopsyspecimensandclip-pingbenignpolyps.Nursing Implications Before Procedure1. UpperGI:NPOforupto12hoursbeforeprocedure.2. LowerGI:bowelprep—catharticsand/orenemas,clearliquid

dietfor24hoursbeforetest.

3. Client should avoid aspirin, NSAIDs, iron supplements, andgelatincontainingredcoloringforaweekbeforeprocedure.

4. Maygivepreoperativemedicationforrelaxationandtodecreasesecretions.

5. ForupperGIstudies,atopicalanesthesiawillbeusedtoanes-thetizethethroatbeforeinsertionofthescope.

6. UpperGIstudies:assessclient’smouthfordenturesandremov-ablebridges.

7. LowerGIstudies:helpclientintotheleftside-lying,knee-chestposition; explain the need to take a deep breath during theinsertionofthescope;clientmayfeelurgetodefecateasscopeispassed.

8. Conscious sedation frequently used for lower GI studies orcolonoscopy.

Nursing Implications During Procedure1. Verifyinformedconsentandclientidentification.2. ForupperGIstudies,confirmNPOstatusforpast8hours;for

lowerGIstudies,confirmbowelpreparation.3. Assess for presence of GI bleeding; notify physician if any

bleedingispresent.4. Maintainsafety:airwayprecautionsduringsedation;position-

ing,monitorlevelofsedation(Chapter3).Nursing Implications After Procedure1. UpperGI:maintain client’s NPO status until the gag reflex returns;

positionclientonhisorhersidetopreventaspirationuntilgagorcoughreflexreturns;usethroatlozengesorwarmsalinesolu-tiongarglesforreliefofsorethroat.

2. MonitorvitalsignsandO2saturationduringrecovery.3. Observeforsignsofperforation:upperGIbleeding—dyspha-

gia, substernal or epigastric pain; lower GI bleeding—rectalbleeding,increasingabdominaldistention.

4. Assist client to upright position: observe for orthostatichypotension.

5. Warmsitzbathforanyanaldiscomfort.

Analysis of SpecimensParacentesis; Diagnostic Peritoneal LavageProcedure:Acatheterisinsertedintotheperitonealcavity,mostoftenjustbelowtheumbilicus.Purposes1. Todetermineeffectofbluntabdominaltrauma.2. Toassessforpresenceofascites.3. To identify cause of acute abdominal problems (e.g., perfora-

tion,hemorrhage).• To assess for intraabdominal bleeding after a blunt trauma

to the abdomen. If no blood is aspirated, normal saline isinfused into the peritoneal cavity.The fluid is aspirated orallowedtodrainbygravity.Fluidshouldreturnclearwithaslightyellowcastifthereisnoinjury.Bloodyfluids,presence

Nursing InterventionsGoal: To provide appropriate information to help client

manageproblemathome.A. Avoidprolongedstandingorsitting.B. Takesitzbathstodecreasediscomfort.C. UseOTCointmentstodecreasediscomfort.D. Applyicepack,followedbyawarmsitzbath, ifsevere

discomfortoccurs.E. Avoidconstipationandstrainingatstool.

Home CareA. Encourage bulk laxatives and increased fluid intake to

promotesoftstoolforfirstbowelmovement.B. Rectalpainmaybesevere;analgesicsandlocalapplica-

tionofmoistheatmaybeused.C. Reviewpreventivetechniques;weightlossandavoidance

ofconstipation.

Continued

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of bacterial or fecal material, high white or red blood cellcountoccurwithapositivetestresult;immediatesurgerymayberequired.

• Ifclienthasabdominalfluidfromascitesorotherabdominalpathologic conditions, a specimen of the fluid is obtainedwithoutinstillingfluid.

Nursing Implications1. Anasogastrictubemaybeusedtomaintaingastricdecompres-

sionduringprocedure.2. Have the client voidbefore theprocedure, if clienthas a full

bladderatthetimeofinsertionofthecatheter,riskforbladderperforationandperitonitisisincreased.

3. In clients with chronic liver problems, assess coagulation labvaluesbeforeprocedure.

4. Placeclientinsemi-Fowler’sposition.5. Maintainsterilefieldforpuncture.6. Inclientswithascites,usuallydonotdrainmorethan1L.Complications1. Perforationofbowel:peritonitis.2. Introduction of air into abdominal cavity; client may com-

plainof right referred shoulderpain (causedby air under thediaphragm).

3. Contraindicated inpregnancy and in clientswith coagulationdefectsorpossiblebowelobstruction.

Stool ExaminationStool is examined for form and consistency and to determinewhetheritcontainsmucus,blood,pus,parasites,orfat.Stoolwillbeexaminedforpresenceofoccultblood.Nursing Implications1. Collect stool in sterile container if examining for pathologic

organisms.2. A fresh, warm stool is required for evaluation of parasites or

pathogenicorganisms.3. Collectthesamplefromvariousareasofthestool.4. Theresultoftheguaiactestforoccultbloodispositivewhen

thepaperturnsblue.5. Document medications and over-the-counter drugs client is

takingwhensampleisobtained.6. Sampleshouldbeapproximatelythesizeofawalnutor30mL,

ifsoft.

Appendix 18-2 ANTIEMETICS

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSDopamine Antagonists Depress or blocks dopamine receptors chemoreceptor trigger zone of the brain.

Phenothiazines—suppressemesisChlorpromazinehydrochloride

(Thorazine):PO,suppository,IMPromethazine(Phenergan):PO,

IM,suppositoryHigh-AlertMedicationforIVrouteProchlorperazine(Compazine):PO,

suppository,IMThiethylperazinemaleate(Torecan):

PO,suppository,IM

Centralnervoussystemdepression,drowsiness,dizziness,blurredvision,hypotension,photosensitivity

1. Subcutaneousinjectionorintravenousadministrationmaycausetissueirritationandnecrosis.

2. Usewithcautioninchildren;donotadministerThorazinetoinfantslessthan6monthsold,Compazinetochildrenweighinglessthan20lborlessthan2yearsold,orTorecantochildrenlessthan12yearsold.

3. Thorazineshouldbeusedonlyinsituationsofseverenauseaorvomiting.Canalsobeusedforintractablehiccups.

4. Torecan:cautioususeinclientswithliverandkidneydiseases.

Prokinetics—stimulatemotilityMetoclopramide(Reglan):PO,IM,

IV

Restlessness,drowsiness,fatigue,anxiety,headache

1. Usedtodecreaseproblemswithesophagealrefluxandnauseaandvomitingassociatedwithchemotherapy.

2. Usewithcautioninclientswhenincreaseinperistalsismaybedetrimental(perforation,obstruction).

Antihistamines Depress the chemoreceptor trigger zone, block histamine receptors.

Hydroxyzine(Atarax, Vistaril):PO,IM

Dimenhydrinate(Dramamine, Marmine):PO,suppository,IM

Sedation;anticholinergiceffects—blurredvision,drymouth,difficultyinurinationandconstipation;paradoxicalexcitationmayoccurinchildren

1. Cautionclientregardingsedation:shouldavoidactivitiesthatrequirementalalertness.

2. Administerearlytopreventvomiting.3. Usewithcautioninclientswithglaucomaandasthma.4. Subcutaneousinjectionmaycausetissueirritationand

necrosis;useZ-trackinjectiontechnique.

GI,Gastrointestinal;IM,intramuscular;IV,intravenous;PO,bymouth(oral).

Appendix 18-1 GASTROINTESTINAL SYSTEM DIAGNOSTICS—cont’d

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Appendix 18-3 LAXATIVES

General Nursing Implications—Laxativesshouldbeavoidedinclientswhohavenausea,vomiting,undiagnosedabdominalpainand

cramping,and/oranyindicationsofappendicitis.—Dietaryfibershouldbetakenforpreventionof,andasfirst-linetreatmentfor,constipation.—Dailyintakeoffluidsshouldbeincreased.—Constipationisdeterminedbystoolfirmnessandfrequency.—Increasingactivitywillincreaseperistalsisanddecreaseconstipation.—Narcoticanalgesicsandanticholinergicswillcauseconstipation.—Alaxativeshouldbeusedonlybrieflyandinthesmallestamountnecessary.—Uselaxativeswithcautionduringpregnancy.

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSBulk laxatives—stimulateperistalsisand

passageofsoftstoolMethylcellulose(CITRUCEL)Psyllium(Metamucil, Perdiem)FiberconBran

Esophagealirritation,impaction,abdominalfullness,flatulence

1. Notimmediatelyeffective;12to24hoursbeforeeffectsareapparent.

2. Usewithcautioninclientswithdifficultyswallowing.3. Administerwithfullglassoffluidtopreventproblems

withirritationandimpaction.

Surfactants—decreasesurfacetension,allowingwatertopenetratefeces

Docusate(Colace, Surfak)

Occasionalmildabdominalcramping

1. Donotuseconcurrentlywithmineraloil.2. Notrecommendedforchildrenlessthan6yearsold.

Stimulants—stimulateandirritatethelargeintestinetopromoteperistalsisanddefecation

Bisacodyl(Dulcolax):suppository,POSennaconcentrate(Senokot, Ex-Lax):

PO,suppository

Diarrhea,abdominalcramping

1. Useforshortperiodoftime.2. Donotuseinpresenceofundiagnosedabdominal

painorGIbleeding.

Bowel evacuants—nonabsorbableosmoticagentsthatpullfluidintothebowel

Polyethyleneglycol(GoLYTELY, Colyte):PO,NG

Magnesiumcitrate:PO

Nausea,bloating,abdominalfullness.

1. Primaryuseisinpreparingthebowelforexamination.2. Clearliquidsonly(nogelatinwithredcoloring)after

administration.3. GoLYTELYrequirestheclienttodrinkalarge

amountoffluid(4L);provide8to10ozchilledatatimetoincreaseclientconsumptionandenhancetaste.

4. Bestifconsumedover3to4hours.5. Evacuantscausefrequentbowelmovements;advise

clienttoplanaccordingly.

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Appendix 18-4 ANTIDIARRHEAL AGENTS

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSAnhydrousmorphine(Paregoric):

POLightheadedness,dizziness,

sedation,nausea,vomiting,paralyticileus,abdominalcramping

1. Opioidderivatives,suppressperistalsis.2. Notrecommendedduringpregnancyor

breastfeeding.3. Canproducedrugdependenceandmild

withdrawalsymptoms.4. Encourageincreasedfluids.5. Avoidactivitiesthatrequirementalalertness.

DiphenoxylateHClAtropine(Lomotil):POLoperamideHCl(Imodium,

Kaopectate II caplets):POBismuthsubsalicylate(Kaopectate,

Pepto-Bismol):PO

Mayprecipitateconstipationandanimpaction

1. Absorbent,hassoothingeffect,andabsorbstoxicsubstances.

2. Mayinterferewithabsorptionoforalmedications.3. Shouldnotbegiventoclientswithfever>101°.4. Donotgiveinpresenceofbloodydiarrhea.

PO,bymouth(orally).

Appendix 18-5 ANTIULCER AGENTS

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSAntacid An alkaline substance that will neutralize gastric acid secretions; nonsystemic. Some combination antacids also relieve gas, and some work as laxatives. Several antacids form a protective coating on the stomach and upper GI tract.

Aluminumhydroxide(Amphojel)Aluminumhydroxideand

magnesiumsaltcombinations(Gelusil, Maalox, Gaviscon)

Constipation,phosphorusdepletion

withlong-termuseConstipationordiarrhea,

hypercalcemia,renalcalculi

1. Avoidadministrationwithin1to2hoursofotheroralmedications;shouldbetakenfrequently—beforeandaftermealsandatbedtime.

2. Instructclientstotakemedicationeveniftheydonotexperiencediscomfort.

3. Clientsonlow-sodiumdietsshouldevaluatesodiumcontentofvariousantacids.

4. Administerwithcautiontotheclientwithcardiacdisease,becauseGIsymptomsmaybeindicativeofcardiacproblems.

Sodium preparationsSodiumbicarbonate(Rolaids,

Tums):PO

Reboundacidproduction,alkalosis

1. Discourageuseofsodiumbicarbonatebecauseofoccurrenceofmetabolicalkalosisandreboundacidproduction.

Histamine H2 Receptor Antagonists Reduce volume and concentration of gastric acid secretion.

Cimetidine(Tagamet):PO,IV,IM Rash,confusion,lethargy,diarrhea,dysrhythmias

1. Take30minutesbeforeoraftermeals.2. Maybeusedprophylacticallyorfortreatmentof

PUD.3. Donottakewithoralantacids.

Ranitidine(Zantac):PO,IM,IV Headache,GIdiscomfort,jaundice,hepatitis

1. Usewithcautioninclientswithliverandrenaldisorders.

2. Donottakewithaspirinproducts.3. Wait1hourafteradministrationofantacids.

Nizatidine(Axid):POFamotidine(Pepcid):PO,IV

Anemia,dizzinessHeadache,dizziness,

constipation,diarrhea

1. Usewithcautioninclientswithrenalorhepaticproblems.

2. Dosingmaybedonewithwithoutregardtofoodortomealtime.

3. CautionclientstoavoidaspirinandotherNSAIDs.

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MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSProton Pump Inhibitors Inhibit the enzyme that produces gastric acid.

Omeprazole(Prilosec):POLansoprazole(Prevacid):PO

Headache,diarrhea,dizziness 1. Administerbeforemeals.2. Donotcrushorchew;donotopencapsules.3. SprinklegranulesofPrevacidoverfood;do

notchewgranules.4. Thecombinationofomeprazole(Prilosec)

withclarithromycin(Biaxin)effectivelytreatsclientswithHelicobacter pyloriinfectioninduodenalulcer.

Cytoprotective Agents Bind to diseased tissue provides a protective barrier to acid.

Sucralfate(Carafate):PO Constipation,GIdiscomfort 1. Avoidantacids.2. Usedforpreventionandtreatmentofstressulcers,

gastriculceration,andPUD.3. Mayimpedetheabsorptionofmedicationsthat

requireanacidmedium.

Prostaglandin Analogues Suppresses gastric acid secretion; increases protective mucus and mucosal blood flow.

Misoprostol(Cytotec) GIproblems,headache 1. Contraindicatedinpregnancy.2. IndicatedforpreventionofNSAID-inducedulcers.

GI,Gastrointestinal;IM,intramuscular;IV,intravenous;NSAID,nonsteroidalantiinflammatorydrug;PO,bymouth(orally);PUD,pepticulcerdisease.

Appendix 18-5 ANTIULCER AGENTS—cont’d

Appendix 18-6 INTESTINAL MEDICATIONS

Intestinal Antibiotics Decrease bacteria in the GI tract; used to sterilize bowel before surgery.

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSKanamycinsulfate(Kantrex):PONeomycinsulfate(Mycifradin

sulfate):PO

Suprainfectionofthebowel 1. Donothavesideeffectsofparenterallyadministeredaminoglycosides.

Paromomycin(Humatin):PO Vomitinganddiarrhea 1. Administerwithmeals.2. Administerwithcautioninclientswithulcerative

boweldisease.

5 Aminosalicylates (5 ASA) Antiinflammatory effect in small bowel and colon; used to treat ulcerative colitis and Crohn’s disease.

Sulfasalazine(Azulfidine):PO Nausea,feverrash,arthalgia 1. Assessclientforallergytosulfur.2. Shouldnotbeusedwiththiazidediuretics.3. MonitorCBC;maintainadequatehydration.4. Maycontinueonmedicationtomaintainremission.

Mesalamine(Asacol):PO,(Pentasa):POentericcoated

tablet(Rowasa)Suppositoryorenema

GIsymptoms,headache 1. Suppositoryorenemahasminimalsystemiceffects.2. Rectaladministrationisusuallyatnight.

Balsalazide(Colazal):PO Abdominalpain,headache

PO,Bymouth(orally).

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Appendix 18-7 PARENTERAL NUTRITION

Parenteral Nutrition (PN) An intravenous (IV) delivery ofhighlyconcentratednutrientsandvitamins.1. Goal is toprovideadequatenutritionandto facilitatehealing

andgrowthofnewbodytissue.2. Conditionsthat interferewiththeprocessofnutrition: inges-

tion,digestion,absorption.Goal: To maintain client in positive nitrogen balance and

promotehealing.

Routes of Administration1. Peripheral:Partialparenteralnutrition(PPN)isadministered

viaalargeperipheralveinorperipherallyinsertedcentralcath-eter (PICC)whennutritional support is indicated for a shortperiod;mayuseIVfat(lipid)emulsions.

2. Central:Totalparenteralnutrition (TPN) isadministeredviaa parenteral line (PICC, Hickman, Broviac, central line)inserted in the antecubital, jugular, or subclavian vein andthreadedintothevenacava;usedfornutritionalsupportintheclient who requires in excess of 2500 calories per day for anextended period. Solutions used are hypertonic with highglucosecontentandrequirerapiddilution.

Nursing Implications1. PNmaybecommerciallypreparedandthencustomizedinthe

hospitalpharmacyspecificallyfortheclient’smostrecentbloodanalysisfindings;nothing should be added to solution after it has been prepared in the pharmacy.

2. Orders are written daily, based on the current electrolyte andproteinstatus;alwayscheckthedoctor’sorderforcorrectfluidfortheday.

3. Solutionmaybe refrigerated forup to24hours, but solutionshouldbetakenoutofrefrigeration30minutespriorto infu-sion. If solution has been hanging for 24 hours, it should bediscardedandanewbagofsolutionhung.

4. BeginPNataslowrate(40to60mLperhour)andthengradu-allyincreaseratetoprescribedinfusionrate.Maintainconstantflowrate;ifinfusionofsolutionisbehind,determinehowmuch,dividethatamountoverabout24hours,andgraduallyincreaseratetolevelofpreviousinfusionorder.Donotrandomlyaccel-eratetheinfusionto“catchup”overanhour;PN must be admin-istered via an infusion pump.

5. Monitor serum blood glucose levels on a regular basis; someinstitutionsrequireglucosetestingevery4to6hours.Maybelessfrequentafterfirstweekofadministration.

6. Infusionisinitiatedanddiscontinuedonagradualbasistoallowthepancreastocompensateforincreasedglucoseintake.IfTPN

istemporarilyunavailable,giveD10WorD20WuntilPNsolu-tionisavailable.

7. Monitor intake and output and compare daily trends. Bodyweight is an indication of the adequacy of hydration.Tissuehealing is an indication of adequacy of protein and positivenitrogenbalance.

8. Check label onbagof solution against orders; check solutionforleaks,clarity,orcolorchanges.

Maintenance1. Asterileocclusivedressingshouldbeusedatthecathetersite;

change site dressing every 48 to 72 hours or per facilityprotocol.

2. ChangeIVtubingevery24hoursorperfacilityprotocol.3. Donotdrawbloodormeasurecentralvenouspressure(CVP)

fromthePNline.4. Maintainrecordofdailyweight;desiredweightgainisapproxi-

mately2poundsperweek.

ALERT Evaluate client’s nutritional status: monitor client’s response to TPN.

Complications1. Hyperglycemiamaybecausedbytoorapidinfusionofsolution.

Blood glucose is monitored every 4 to 6 hours during initialinfusion,andslidingscaleinsulinmaybeordered.

2. Fat emulsion syndrome may occur in clients receiving IV fat(lipid)emulsion.Monitorforfever,increasedtriglycerides,andclottingproblems.

3. Refeedingsyndromeischaracterizedbyfluidretention,electro-lyte imbalances, and hyperglycemia; occurs in clients withchronic malnutrition states. Hypophosphatemia occurs and isassociatedwithdysrhythmiasandrespiratorycomplications.

4. Site infection:Monitor site andchangedressingaccording topolicy;clientsmaybeimmunosuppressedandsignsofinfectionmaybemasked.Ifinfectionissuspected(erythema,tenderness,exudates), a culture should be done and health care providernotifiedimmediately.Septicemia: Strong glucose solutions provide good media for

bacteria;strictaseptictechniquesindressingchanges.5. Airembolusorriskforpneumothorax(centralline):Increased

tendencytooccurduringinsertionofcentralcatheterlineandduringdressingchanges;placeclientinTrendelenburgpositionduring insertion and during dressing changes (see Appendix6-10forcareofcentralline).

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1. Levin tube:Singlelumen.a. Suctioninggastriccontents.b. Administeringtubefeedings.c. Connecttointermittentsuction.

2. Salem sump tube:Doublelumen(smallerbluelumenventsthetube and prevents suction on the gastric mucosa, maintainsintermittentsuction,regardlessofsuctionsource).a. Suctioning gastric contents and maintaining gastric

decompression.b. Donotclamp,irrigate,orapplysuctiontoairventtube.c. Connecttocontinuouslowsuction.

✓ KeY POINTS

Appendix 18-8 NURSING PROCEDURE: NASOGASTRIC TUBES

d. Always validate placement of a nasogastric tube prior toinstillinganythingintotube.

• Characteristicsofnasogastricdrainage.a. Normallyisgreenishyellow,withstrandsofmucus.b. Coffee-ground drainage: old blood that has been broken

downinthestomach.c. Bright red blood: indicates bleeding in the esophagus, the

stomach,orthelungs.d. Foul-smelling(fecalodor):occurswithreverseperistalsis in

bowel obstruction; increase in amount of drainage withobstruction.

• Ifduodenalplacementisrequired,haveclientlayinrightlateralpositionforseveralhours.Provideenoughexcessinthetubetoallowthetubetomigratedownintoduodenum.

Clinical Tips for Problem Solving• Abdominal distention: Check for patency and adequacy of

drainage,determinepositionof tube, assesspresenceofbowelsounds,andassessforrespiratorycompromisefromdistention.

• Nausea and vomiting around tube:Placeclientinsemi-Fowl-er’spositionor turn to side toprevent aspiration; suctionoralpharyngealarea.Attempttoaspirategastriccontentsandvali-date placement of tube. Tube may not be far enough intostomach for adequate decompression and suction; try reposi-tioning. If tubepatency cannotbe established, tubemayneedtobereplaced.

• Inadequate or minimal drainage: Validate placement andpatency;tubemaybeintoofarandbepastpyloricvalveornotinfarenoughandintheupperportionofthestomach.Reassesslengthoftubeinsertionandcharacteristicsofdrainage,requestx-rayforvalidation.

ALERT Insert feeding/nasogastric tubes and determine whether characteristics of nasogastric drainage are with in normal limits.

• Before insertion, position the client inhigh-Fowler’s position,ifpossible.(Ifclientcannottoleratehigh-Fowler’s,placeinleftlateralposition.)

• Useawater-solublelubricanttofacilitateinsertion.• Measurethetubefromthetipoftheclient’snosetotheearlobe

and from the nose to the xiphoid process to determine theapproximateamountoftubetoinserttoreachthestomach.

• Insertthetubethroughthenoseintothenasopharyngealarea;flextheclient’sheadslightlyforward.

• Securethetubetothenose;donotallowthetubetoexertpres-sureontheupperinnerportionofthenares.

• Validatingplacementoftube.a. Aspirategastriccontents.b. Measure pH of aspirated fluid (pH of gastric secretions is

usuallylessthan4).c. Itisno longer recommendedtodetermineplacementbyinject-

ingair and listeningwitha stethoscope for soundof air inthestomach.

ALERT ALWAYS check the placement of a gastric tube before injecting or irrigating it; placement should be checked each shift; do not adjust or irrigate the nasogastric tube on a client after a gastric resection.

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Appendix 18-9 NURSING PROCEDURE: ENTERAL FEEDING

• Aspirate gastric contents to determine residual. If residual ismorethan200mL,andtherearesignsofintolerance(nausea,vomiting,distention),holdnextfeedingfor1hourandrecheckresidualor,ifresidualisgreaterthanhalfoflastfeeding,delaynextfeedingfor1to2hours.

• Return aspirated contents to stomach to prevent electrolyteimbalance.

• Flushthetubewith30to50mLofwater:a. Aftereachintermittentfeeding.b. Every4to6hoursforcontinuousfeeding.c. Beforeandaftereachmedicationadministration.

• WhenaPEGorPEJtubeisplaced,immediatelyafterinsertionmeasure the length of the tube from the insertion site to thedistalendandmarkthetubeattheskininsertionsite.Thistubeshouldbe routinely checked todeterminewhether the tube ismigratingfromtheoriginalinsertionpoint.

• Preventdiarrhea:a. Slow,constantrateofinfusion.b. Keepequipmentcleantopreventbacterialcontamination.c. Checkfor fecal impaction;diarrheamaybeflowingaround

impaction.d. Identifymedicalconditionsthatwouldprecipitatediarrhea.

• For continuous feeding, change feeding reservoir every 24hours.

Appendix 18-10 NURSING PROCEDURE: ENEMAS

Short-Term1. Nasogastric:Providesalternativemeansofingestingnutrients

forclients.2. Nasointestinal:Aweighted tubeof softmaterial isplaced in

thesmallintestinetodecreasechanceofregurgitation.Astyletorguidewireisusedtoprogressthetubeintotheintestine.Donot remove stylet until tube placement has been verified viax-ray.Donotattempttoreinsertstyletwhile tube is inplace;thiscouldresultinperforationofthetube.

Long-Term1. Percutaneous endoscopic gastrostomy (PEG): A tube is

insertedpercutaneouslyintothestomach;localanesthesiaandsedationareusedfortubeplacement.

2. Percutaneous endoscopic jejunostomy (PEJ): A tube isinsertedpercutaneouslyintothejejunum.

3. Gastrostomy:Asurgicalopeningismadeintothestomach,andagastrostomytubeispositionedwithsutures.

Methods of Administering Enteral Feedings• Continuous:Controlledwithafeedingpump.Decreasesnausea

anddiarrhea.• Intermittent: Prescribed amount of fluid infuses via a gravity

driporfeedingpumpoverspecifictime.Forexample,350mLisgivenover30minutes.

• Cyclic:Involvesfeedingsolutioninfusedviaapumpforapartofaday,usually12to16hours.Thismethodmaybeusedforweaningfromfeedings.

Nursing Implications• Theclientshouldbesittingorlyingwiththeheadelevated30

to45°.Headofbedshouldremainelevatedfor30to60minutesafterfeedingifintermittentorcyclicfeedingisused.

• Iffeedingsareintermittent,tubeshouldbeirrigatedwithwaterbeforeandafterfeedings.

NURSING PRIORITY If in doubt of a tube’s placement or position, stop or hold the feeding and obtain x-ray confirmation of location.

ALERT Change rate and amount of tube feeding based on client’s response.

Types of EnemasSoap suds enema: Castile soap is added to tap water or normal

saline.Dilute5mLofcastilesoapin1literofwater.Tap water enema: Request order for specific quantity when

administered to infants or children; should not be repeatedbecauseofriskforwatertoxicity.Usecautionwhenadminister-ingtoadultswithalteredcardiacandrenalreserve.

Saline enemas: Are the safest enemas to administer; safe forinfantsandchildren.

Retention enema:Anoil-basedsolutionthatwillsoftenthestool.Shouldberetainedbyclient30to60minutes.Typically150to200mL.Maybemineraloilorsimilaroil;ormayincludeanti-bioticsornutritivesolution.

Hyptertonic enema:Usedwhenonly a small amountoffluid istolerated(120-180mL).CommerciallypreparedFleetsenema.

Carminative enema:AnagentusedtoexpelgasfromtheGItract.Exampleismagnesiumsulfate/glycerin/water(MGW).

Harris flush or return flow enema:Mildcolonicirrigationof100to200mLoffluidintoandoutoftherectumandsigmoidcolon

tostimulateperistalsis.Repeatedmultipletimesbyraisingandloweringcontaineruntilflatusisexpelledandabdominaldisten-tionisrelieved.

✓ KeY POINTS: Administering an Enema• Fillenemacontainerwithwarmedsolution.• Allowsolutiontorunthroughthetubingbeforeinsertinginto

rectumsothatairisremoved.• PlaceclientonleftlateralSims’position.• Generously lubricate the tip of the tubing with water-soluble

lubricant.• Gentlyinserttubingintoclient’srectum(3to4inchesforadults,

1inchforinfants,2to3inchesforchildren),pasttheexternalandinternalsphincters.

• Raisethesolutioncontainernomorethan12to18inchesabovetheclient.

• Allowsolutiontoflowslowly.Iftheflowisslow,theclientwillexperiencefewercramps.Theclientwillalsobeabletotolerateandretainagreatervolumeofsolution.

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ALERT Assist and intervene with client who has an alteration in elimination.

Appendix 18-12 NURSING PROCEDURE: CARE OF THE CLIENT WITH AN OSTOMY

Types of Ostomies (Figure18-8)Colostomy: Opening of the colon through the abdominal wall; stool is generally semisoft and bowel control may be achieved.

Ileostomy: Opening of the ileum through the abdominal wall; stool drainage is liquid and excoriating; drainage is fre-quently continuous; therefore it is difficult to establish bowel control. Fluid and electrolyte imbalances are common complications.

Kock’s ileostomy: May be referred to as a “continent” ileos-tomy; an internal reservoir for stool is surgically formed. Decreases problem of skin care caused by frequent irritation of stoma by drainage. Primary complications are leakage at the stoma site and peritonitis.

Goals1. Maintainphysiologicandpsychologicequilibrium.2. Assist client to maintain total care of colostomy or ileostomy

beforedischarge.

Preoperative Care1. Preoperative education: Actively involve family and client;

encouragequestionsconcerningtheprocedure.2. Placementofstomaisevaluated,andsiteisselectedwithclient

standing.Selectasitethatiseasilyseenandaccessibletoclient;selectaflatareaoftheabdomen,avoidingskincreasesandfolds;selectsitethatdoesnotinterferewithclothing.

✓ KeY POINTS: Postoperative Nursing Implications—Initial Care

• Evaluate stoma every 8 hours after surgery. It should remainpinkandmoist;darkbluestomaindicatesischemia.

• Measurethestomaandselectanappropriatelysizedappliance.Mildtomoderateswellingiscommonforthefirst2to3weeksafter surgery, which necessitates changes in size of theappliance.

• Appliance should fit easily around the stoma and cover allhealthyskin.

Appendix 18-10 NURSING PROCEDURE: ENEMAS—cont’d

Clinical Tips for Problem SolvingIfclientexpelssolutionprematurely:• Placeclientinsupinepositionwithkneesflexed.• Slowthewaterflowandcontinuewiththeenema.Iftheenemareturnscontainfecalmaterialbeforesurgeryordiag-

nostictesting,repeatenema.If,afterthreeenemas,returnsstillcontainfecalmaterial,notifyphysician.

If client complains of abdominal cramping during instillation offluid:

• Slowtheinfusionratebyloweringthefluidbag.

Appendix 18-11 NURSING PROCEDURE: STOOL SPECIMEN

Types of Stool• Normal→semisofttosemisolid,browncolor• Narrow, ribbon-like stool → spastic or irritable bowel, or

obstruction• Diarrhea→spasticbowel,viralinfection• Bloodandmucus,softstool→bacterialinfection• Mixedbloodorpus→colitis• Yelloworgreenstool→severe,prolongeddiarrhea;rapidtransit

throughbowel• Black stool → gastrointestinal bleeding or intake of iron

supplements• Tan, clay-colored, or white stool → liver or gallbladder

problems• Red stool → colon or rectal bleeding; some medications and

foodsmayalsocausearedcoloration• Fattystool,pastyorgreasy→intestinalmalabsorption,pancre-

aticdisease

✓ KeY POINTS: Collecting the Specimen• Alwayswearglovesduringprocedure.• Usecleanbedpanorbedsidecommodetocollectstool;donot

usestoolthathasbeenincontactwithtoiletbowlwaterorurine.

• Collectstoolspecimeninaclean,drycontainer.Ifstoolistobeevaluated for organisms, use a sterile container. Use a tongueblade to obtain specimens from several areas of the stool andplaceinthestoolcollectioncontainer.

• Theclientcollectingastoolspecimenforanoccultbloodtestneeds to follow directions regarding diet restrictions (no redmeat,beets,orfoodsthatmaycausethestooltoturnredorleadtoafalse-positiveresult).

• Stoolspecimenshouldbeapproximatelysizeofawalnut.Ifstoolisliquid,approximately30mLisneeded.

• Takethespecimentothelaboratory.Donotallowittoremaininunit.

ALERT Obtain specimen from client for laboratory tests.

Continued

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ALERT Provide ostomy care.

FIGURE 18-8 Types of colostomies. (From Monahan FD et al: Phipps’ medical-surgical nursing: health and illness perspectives, ed 8, St. Louis, 2007, Mosby.)

The ascending colostomyis done for right-sided tumors.

The transverse (double-barreled) colostomy isoften used in such emergen-cies as intestinal obstructionor perforation because itcan be created quickly.There are two stomas. Theproximal one, closest to thesmall intestine, drains feces.The distal stoma drainsmucus. Usually temporary.

The transverse loopcolostomy has two openingsin the transverse colon, but one stoma. Usually temporary.

Descending colostomy Sigmoid colostomy

• Placetheclientinasittingpositionforirrigation,preferablyinthebathroomwiththeirrigationsleeveinthetoilet.

• Elevate the solution container approximately 12 to 20 inchesandallowsolutiontoflowingently.Ifcrampingoccurs, lowerfluidorclampthetubing.

• Allow25to45minutesforreturnflow.Clientmaywanttowalkaroundbeforethereturnstarts.

• Encourageclienttoparticipateincareofhisorherowncolos-tomy.Haveclientperformreturndemonstrationof colostomyirrigationbeforeleavingthehospital.

Appendix 18-12 NURSING PROCEDURE: CARE OF THE CLIENT WITH AN OSTOMY—cont’d

• Assisttheclienttocontrolodors:dietandodor-controltablets.• Kock’sileostomyisdrainedwhenclientexperiencesfullness.A

nipplevalveiscreatedinsurgeryanddrainedbyinsertionofacatheter.

Clinical Tips for Problem SolvingIfwaterdoesnotfloweasilyintocolostomystoma:• Checkforkinksintubingfromcontainer.• Checkheightofirrigatingcontainer.• Encourageclienttochangepositions,relax,andtakeafewdeep

breaths.If client experiences cramping, nausea, or dizziness during

irrigation:• Stopflowofwater,leavingirrigationconeinplace.• Donotresumeuntilcrampinghaspassed.• Checkwater temperature andheight ofwater bag; ifwater is

toohotorflowstoorapidly,itcancausedizziness.Ifclienthasnoreturnofstoolorwaterfromirrigation:• Besuretoapplydrainablepouch;solutionmaydrainasclient

movesaround.• Have client increase fluid intake; he or she may be

dehydrated.• Repeatirrigationnextday.Ifdiarrheaoccurs:• Donotirrigatecolostomy.• Check client’s medications; sometimes they may cause

diarrhea.• Ifdiarrheaisexcessiveand/orprolonged,notifyphysician.

NURSING PRIORITY Use a cone tipped ostomy irrigator; do not use an enema tube/catheter.Do not irrigate more than once a day.Do not irrigate in the presence of diarrhea.

• Keeptheskinaroundthestomaclean,dry,andfreeofstoolandintestinal secretions. Prevent contamination of the abdominalincision.

• Change the skin appliance only when it begins to leak orbecomesdislodged.

• Ostomybagsshouldbechangedwhenaboutone-third full toavoidweightofbagdislodgingskinbarrier.

✓ KeY POINTS: Irrigation• Donot irrigateanileostomyormaintainregular irrigations in

childwithcolostomy.• Irrigatecolostomyatsametimeeachdaytoassistinestablishing

anormalpatternofelimination.• Involveclientincareasearlyaspossible.• Inadults,irrigatewith500to1000mLofwarmtapwater.

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Study Questions Gastrointestinal System More questions on companion CD!

6. An obese client has had a combination restrictivemalabsorptivebariatricsurgery.Whatwillbeimportantfor thenurse to include indischarge teaching for thisclient?1 Increase intakeoffoodshighiniron,calcium,and

vitaminB12topreventdeficiencies.2 Donottakeanyaddedfluidswithmealsorimme-

diatelyaftermeals.3 Elevatebedtopreventdevelopmentofgastroesoph-

agealrefluxduringsleep.4 Plan intake of three balanced meals a day with

increasedfluidsbetweenmeals.7. Inplanningdischarge teaching for theclientwhohas

undergoneagastrectomy,thenurseincludeswhatinfor-mationregardingdumpingsyndrome?1 Thesyndromewillbeapermanentproblem,andthe

clientshouldeat5to6smallmealsperday.2 Theclientshoulddecreasetheamountoffluidcon-

sumed with each meal and for 1 hour after eachmeal.

3 Theclientshould increase theamountofcomplexcarbohydratesandfiberinthediet.

4 Activity will decrease the problem; it should bescheduledabout1houraftermeals.

8. Thenurseisassessingachildwithatentativediagnosisof appendicitis.Thenursing assessment ismost likelytorevealwhatcharacteristicsconcerningthepain?1 Rebound tenderness in the right lower quadrant,

associated with decreased bowel sounds andvomiting

2 Gnawingpain,radiatingthroughtothelowerback,withsevereabdominaldistention

3 Sharppainwithseveregastricdistention,frequentlyassociatedwithhemoptysis

4 Pain on light palpation in midepigastric area,chroniclow-gradefever,anddiarrhea

9. Thenurseiscaringforaclientwhohasbeendiagnosedwithableedingduodenalulcer.Whatdataidentifiedonanursingassessmentwould indicatean intestinalper-forationandrequireimmediatenursingaction?1 Increasing abdominal distention, with increased

painandvomiting2 Decreasinghemoglobinandhematocritwithbloody

stools3 Diarrhea with increased bowel sounds and

hypovolemia4 Decreasing blood pressure with tachycardia and

disorientation10. Thenurseiscaringforaclientwhoisscheduledfora

gastricendoscopy.Whichofthefollowingactionsmustthenurseperformbeforetheclientisabletoeatordrinkaftertheendoscopy?1 Checkoxygensaturation.2 Givesmallsipsofwater.3 Checkallvitalsigns.4 Assesstheclient’sgagreflex.

1. On the second day after gastric resection, the client’snasogastrictubeisdrainingbile-coloredliquidcontain-ing coffee-ground material. What is the best nursingaction?1 Continue to monitor the amount of drainage and

correlateitwithanychangeinvitalsigns.2 Repositionthenasogastrictubeandirrigatethetube

withnormalsalinesolution.3 Call the physician and discuss the possibility that

theclientisbleeding.4 Irrigate thenasogastric tubewith iced saline solu-

tionandattachthetubetogravitydrainage.2. Thenurseisprovidingpreoperativecareforaclientwho

willhaveagastricresection.Whatwillthepreoperativeteachinginclude?1 Anasogastrictubewillbeinplaceseveraldaysafter

surgery.2 The client will be started on a low-residue, bland

dietabout2daysafterthesurgery.3 Explaintheanticipatedprognosisandimplications

thattheclientmayhaveamalignancy.4 Aurinary retention catheterwill be inplace for1

weekaftersurgery.3. The nurse is planning care for a client scheduled for

gastroduodenoscopyandabariumswallow.Whatwillthenursingcareplaninclude?1 Anticipating the client will receive a low-residue

diet in the evening and then receive nothing bymouth(NPOstatus)6to12hoursbeforethetest.

2 Discussingwiththeclientthenasogastrictubeandtheimportanceofgastricdrainagefor24hoursafterthetest.

3 Explainingtotheclientthathewillreceivenothingbymouth(NPOstatus)for24hoursafterthetesttomakesurehisstomachcantoleratefood.

4 Discussingthegeneralanesthesiaandexplainingtotheclientthathewillwakeupintherecoveryroom

4. Inpreparingapediatricclientforanappendectomy,thenursewouldquestionwhichdoctor’sorders?1 Penicillin600,000unitsIVPB,now2 Obtainsignedconsentformfromparents.3 Administerenemasuntilclear.4 500mLRinger’slactatesolutionat50mL/hr

5. Whatarethebestnursingactionsincaringforaclientwithappendicitisbeforesurgery?Selectallthatapply:______ 1Maintainbedrest.______ 2Offerfullliquidstomaintainhydration.______ 3Position client on side, legs flexed to the

abdomenwiththeheadslightlyelevated.______ 4Position client on left side; apply a warm

K-Padtotheabdomen.______ 5Administernarcoticforpainandallowclient

toassumepositionofcomfort.______ 6MaintainNPOandbeginaperipheralIVfor

fluidreplacement.

L



11. A client is admitted with duodenal ulcers. What willthenurseanticipatetheclient’shistorytoinclude?1 Recentweightloss2 Increasingindigestionaftermeals3 Awakeningwithpainatnight4 Episodesofvomiting

12. Thenurse ispreparingdischarge teaching for a clientwith a diagnosis of gastroesophageal reflux disease(GERD). What would be important for the nurse toincludeinthisteachingplan?Selectallthatapply:______1Elevatetheheadofthebed.______2Decreaseintakeofcaffeineproducts.______3Takeanantacidbeforebedtime.______4Increasefluidintakewithmeals.______5Takeranitidine(Zantac)atbedtime.______6Eatabedtimesnackofmilkandprotein.

13. Thenurseisconductingdischargedietaryteachingfora client with diverticulosis who is recovering from anacuteepisodeofdiverticulitis.Whichstatementbytheclientwouldindicatetothenursethattheclientunder-stoodhisdietaryteaching?1 “I will need to increase my intake of protein and

complexcarbohydratestoincreasehealing.”2 “I need to eat foods that contain a lot of fiber to

preventproblemswithconstipation.”3 “Iwillnotputanyaddedsaltonmyfood,andIwill

decrease intakeof foods thatarehigh in saturatedfat.”

4 “Milkandmilkproductscancausealactoseintoler-ance.Ifthisoccurs,Ineedtodecreasemyintakeoftheseproducts.”

14. What istheprioritynursingactionfortheclientwhois complaining of nausea in the recovery room aftergastricresection?1 Evaluatethenasogastrictubeforpatency.2 Callthephysicianforanantiemeticorder.3 Placeclientinsemi-Fowler’spositionsothathewill

notaspirate.4 Medicatetheclientwithanarcoticanalgesic.

15. The nurse is assisting a client immediately before acolonoscopy.Thenursewilldirect the client andhelphimmoveintowhatposition?1 Prone2 Sims’lateral3 SlightTrendelenburg4 Flatwithlithotomystirrups

16. Whatwillbeimportantforthenursetodowhencol-lectinga stool specimen for anoccultblood (Hemoc-cult)test?1 Samplesshouldbetakenfromtwoareasofthestool.2 Three separate stool samples will be required for

accuracyoftest.3 The nurse should collect about 20 mL of stool

sample.4 Anyredcoloronornearthespecimenisconsidered

positive.17. Aschool-agechildwithadiagnosisofceliacdiseaseasks

thenurse,“Whichfoodswillmakemesick?”Whichofthefollowingfooditemswouldthenurseteachthechildtoavoid?1 Ricecereals,milk,andtapioca2 Corncereals,milk,andfruit3 Cornorpotatobreadandpeanutbutter4 Maltedmilk,whitebread,andspaghetti

18. The nurse practitioner orders half-strength enteralformula at a rate of 55 mL/hr. A can holds 250 mL.Howmanycanswouldthenurseneedforthenext24hours?Answer:______cans

Answers and rationales to these questions are in the section at the end of the book titled Chapter Study Questions: Answers and Rationales.

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CHAPTER EIGHTEEN - Nursing Ed · PDF fileCHAPTER EIGHTEEN PHYSIOLOGY OF THE GASTROINTESTINAL SYSTEM Digestion, Absorption, and Elimination Process A. Digestion ... Nursing Interventions