Husni Rousan1 Function of G I system The Primary Digestive Functions are 1.Break down food particles “ molecular forms” 2.Absorb into the bloodstream the

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Function of G I system

The Primary Digestive Functions are

1. Break down food particles “molecular forms”

2. Absorb into the bloodstream the small molecules

3. Eliminate waste products & undigested food

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Chewing & Swallowing1. 1.5 L of saliva are secreted daily2. Ptyalin “salivary amylase” starch digestion3. Saliva lubricate food as it chewed & swallowed Gastric function1. Hydrochloric acid to destruct most ingest

bacteria ,& break down food2. Pepsin for initiation of protein digestion 3. Intrinsic factors4. The food mixed with gastric secretions is

called chyme

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Small Intestine function1. Pancreas :

-Trypsin aids in digestion of proteins -Amylase aids in digestion starch -Lipase aids in digestion of fats

2. Liver : bile aids in emulsifying ingested fats3. Intestinal Glands :secrete

mucus ,hormones ,electrolytes ,and enzymes4. Two types of contractions Segmentation contraction Intestinal peristalsis

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Colonic Function

1. Two types of colonic secretion -Mucus: protect colonic mucosa -Electrolytes: mainly “HCo3” neutralize the end products

2. Slow peristaltic to allow absorption of water & electrolytes

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Assessment

Health history ( diet history ,appetite , weight gain & loss , stool ch.ch.,& eating pattern

Clinical Manifestations :- 1. Pain2. Indigestion3. Intestinal Gas4. Nausea & Vomiting5. Change in Bowel Habits &Stool ch.ch.

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Assessment

Physical Assessment

1. Inspection

2. Auscultation

3. Palpation

4. Percussion

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Assessment

Diagnostic Evaluation1. Upper GI tract study2. Lower GI tract study3. Gastric Analysis 4. Endoscopy5. Laparoscopy (Peritoneoscopy )6. Anoscopy ,proctoscopy ,&Sigmoidscopy7. Colonoscopy8. Abdominal U/S , Abd CT scan ,&Abd MRI

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Assessment

Stool Tests -Analysis & culture -occult blood test

Hydrogen Breath Test Urea Breath Test Tagged Red Blood Cells & Leukocytes

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Disorders of the Jaw

Abnormal conditions affecting the mandible (Jaw)& the tempomandibular joint include congenital malformation, fractures , chronic dislocation , cancer , & syndrome ch.ch pain & limited motion

Tempomandibular Disorders Are a group of conditions that cause pain &\or

dysfunction of the tempomandibular joint &/or the muscle of mastication, as well as contiguous tissue components

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Clinical Manifestations

1. Pain (from dull to throbbing )

2. Debilitating pain radiated to the ears, teeth, neck muscle & facial sinuses

3. Restricted jaw motion & clicking

4. Difficulty chewing & swallowing

5. Depression may accompany

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Management

1. Patient education in stress Management

2. Range of motion exercises

3. Pain Management (NSAID)

4. Muscle relaxant &/or mild antidepressant

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Parotitis

Inflammation of the parotid gland is the most common inflammatory condition of the salivary gland

Mumps (epidemic Parotitis) viral seen in children

Clinical Manifestations1. Fever & red shiny skin2. The gland swells ,tense ,&tender3. Pain felt in ear 4. Swollen gland interfere with swallowing

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Parotitis

Medical Management 1. Preventive Measures (dental care, oral

hygiene, adequate fluid& nutrition ,& D/C of medication that may diminished salivary secretion)

2. Antibiotics for infection

3. Analgesic for pain

4. Drainage of gland

5. Parotidectomy

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Impaired Esophageal Motility Achalasia

Achalasia: characterized by impaired peristalsis of smooth muscle of esophagus and impaired relaxation of lower esophageal sphincter

Manifestations: 1. Dysphagia

2. chest pain (pyrosis)

3. Sensation of food stick in lower esophagus

4. Food regurgitation

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Achalasia

Treatment1. Eat slowly &drink fluids with meals2. Calcium channel blockers3. Endoscopically guided injection of

botulinum toxin4. Balloon dilation of lower esophageal

sphincter or pneumatic dilation 5. Esophageal myotomy (abdominal or

thoracic approach

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Gastroesophageal Reflux Disease (GERD)

1. Definition

1. GERD common, affecting 15 – 20% of adults

2. Because of location near other organs symptoms may mimic other illnesses including heart problems

3. Gastroesophageal reflux is the backward flow of gastric content into the esophagus.

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2. Pathophysiology a. Gastroesophageal reflux results from transient

relaxation or incompetence of lower esophageal sphincter, sphincter, or increased pressure within stomach

b. Factors contributing to Gastroesophageal reflux

1.Increased gastric volume (post meals) 2.Position pushing gastric contents close to

Gastroesophageal juncture (such as bending or lying down)

3.Increased gastric pressure (obesity or tight clothing)

4.Hiatal hernia

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Manifestations1. Heartburn after meals, while bending

over, or recumbent2. Dyspepsia or indigestion 3. May have regurgitation of sour

materials in mouth, pain with swallowing

4. Atypical chest pain5. Sore throat with hoarseness

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6.Diagnostic Testsa. Barium swallow (evaluation of

esophagus, stomach, small intestine)b. Upper endoscopy: direct

visualization; biopsies may be donec. 24-hour ambulatory pH monitoring

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7.Medications a. Antacids for mild to moderate symptoms,

e.g. Maalox, Mylanta, Gaviscon b. H2-receptor blockers: decrease acid

production; given BID or more often, e.g. cimetidine, ranitidine, famotidine, nizatidine

c. Proton-pump inhibitors: reduce gastric secretions, promote healing of esophageal erosion and relieve symptoms, e.g. omeprazole (prilosec); lansoprazole

d. Promotility agent: enhances esophageal clearance and gastric emptying

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Dietary and Lifestyle Management a. Elimination of acid foods (tomatoes, spicy,

citrus foods, coffee) b. Avoiding food which relax esophageal

sphincter or delay gastric emptying (fatty foods, chocolate, alcohol)

c. Maintain ideal body weight d. Eat small meals and stay upright 2 hours post

eating; no eating 3 hours prior to going to bed e. Elevate head of bed on 6 – 8 blocks to

decrease reflux f. No smoking g. Avoiding bending and wear loose fitting

clothing

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9.Surgery indicated for persons not improved by diet and life style changes

a. Laparoscopic procedures to tighten lower esophageal sphincter

b. Open surgical procedure: fundoplication

10. Nursing Carea. Pain usually controlled by treatmentb. Assist client to institute home plan

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Hiatal Hernia

1. Definition Part of stomach protrudes through the

esophageal hiatus of the diaphragm into thoracic cavity

Types1. Sliding hiatal herni2. Paraesophageal hiatal hernia:( hernia can become strangulated; client

may develop gastritis with bleeding)

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Hiatal HerniaHiatal Hernia Manifestations: Similar to GERD Diagnostic Tests1. a. Barium swallow2. b. Upper endoscopy Treatment 1. Similar to GERD: diet and lifestyle

changes, medications2. If medical treatment is not effective or

hernia becomes incarcerated, then surgery; usually

3. Fundoplication by thoracic or abdominal approach

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Diverticulum

It is an outpouching of mucosa& submucosa that protrudes through a weak portion of the musculature

Clinical Manifestations1. Difficulty of swallowing & neck fullness2. Belching 3. Regurgitation of undigested food4. Gargling noise after eating 5. Halitosis & sour taste in the mouth6. May dysphagia & chest pain

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Diverticulum

Management

1. Diverticulectomy &myoectomy for muscle

2. NPO until x-ray show no leakage at surgical site

3. During O.P. avoid trauma to carotid artery and jugular vein

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Perforation

May result from stab or bullet wounds of the neck & the chest as well as from accidental puncture by surgical instrument

Clinical Manifestations1. Persistent pain followed by dysphagia

2. Infection ,fever ,& leukocytosis

3. May sign of Pnuemothorax

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Perforation

Management

1. Broad spectrum antibiotics

2. Nasogastric tube & suctioning

3. NPO – total parenteral nutrition “gastrostomy”

4. Closed the wound &post op management

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Gastritis

1.Definition: Inflammation of stomach lining from irritation of gastric mucosa (normally protected from gastric acid and enzymes by mucosal barrier)

2.Types a. Acute Gastritis

1.Disruption of mucosal barrier allowing hydrochloric acid and pepsin to have contact with gastric tissue: leads to irritation, inflammation, superficial erosions

2.Gastric mucosa rapidly regenerates; self-limiting disorder

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•Gastritis

Causes of acute gastritis a. Irritants include aspirin and other NSAIDS,

corticosteroids, alcohol, caffeine b.Ingestion of corrosive substances: alkali or acid c.food contamination (microorganisms)

Manifestations headache, mild epigastric discomfort, abdominal pain, nausea anorexia, vomiting Belching, heart burn , &sour taste in mouth If perforation occurs, signs of peritonitis

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Gastritis

Treatment As a rule the patient recover in a day NPO status to rest GI tract for 6 – 12 hours,

reintroduce clear liquids gradually and progress; intravenous fluid and electrolytes if indicated

b. antacids If gastritis from corrosive substance: immediate dilution and removal of substance by gastric lavage (washing out stomach contents via nasogastric tube),

If extreme condition Gastrojejunostomy or gastric resection

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Gastritis

Nursing Management 1. Reducing anxiety2. Promoting optimal nutrition 3. Promoting fluid balance4. Relieving pain Chronic Gastritis Progressive disorder beginning with

superficial inflammation and leads to atrophy of gastric tissues (prolong Gastritis)

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Peptic Ulcer Disease (PUD)

Definition and Risk factorsBreak in mucous lining of GI tract comes

into contact with gastric juice , referred to as gastric ,duodenal , or esophageal ulcer

Duodenal ulcers: most common; affect mostly males ages 30 – 55 ulcers found near pyloris

Gastric ulcers:affect older persons(ages 55 – 70)

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2. Pathophysiology a. Ulcers or breaks in mucosa of GI tract occur

with 1.H. pylori infection (spread by oral to oral,

fecal-oral routes) damages gastric epithelial cells reducing effectiveness of gastric mucus

2.Use of NSAIDS: interrupts prostaglandin synthesis which maintains mucous barrier of gastric mucosa

b. Chronic with spontaneous remissions and exacerbations associated with trauma, infection, physical or psychological stress

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Manifestations Pain is classic symptom: burning, aching

hunger like in epigastric region possibly radiating to back; occurs when stomach is empty and relieved by food (pain: food: relief pattern)

Vomiting , nausea , constipation &diarrhea Symptoms less clear in older adult; may have

poorly localized discomfort, dysphagia, weight loss; presenting symptom may be complication: GI hemorrhage or perforation of stomach or duodenum

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Treatment Pharmacologic therapy1. H2 receptor antagonist2. Proton pump inhibitors3. Cytoprotective agents4. Antacid Stress Reduction & Rest Smoking Cessation Dietary Modification

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Surgical Management Vagotomy1. Truncal2. Selective Pyloroplasty Antrectomy1. Gastroduodenostomy2. Gastrojejunostomy3. Subtotal gastroectomy with anastomosis

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Gastric Surgery Gastric surgeryGastric surgery : may be performed on patient

with peptic ulcers who have life threatening hemorrhage , obstruction , perforation ,or whose condition dose not respond to medical treatment

Nursing Care1. Reducing Anxiety2. Increasing Knowledge3. Resuming enteral Intake4. Relieving pain &prevent complications5. Teaching Dietary self Management

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Intestinal and rectal disorders Constipation

Abnormal hardening of stool that makes difficult & some time painfull,decrease in stool volume , or retention of stool on rectum for prolonged period of time

Clinical Manifestations1. Abdominal distention & intestinal rumbling

2. Pain & pressure

3. Anorexia fatigue & headache

4. Incomplete emptying & strain defecation

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Intestinal and rectal disorders Constipation Medical Management 1. Treatment of the underlying cause 2. High Fiber Diet & increase fluid intake3. Maintain regular pattern of exercises4. Laxatives & bulk forming Agents5. Bran 6-12 tsp Complications: -hypertension - hemorrhoid & fissure - fecal impaction & megacolon

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Intestinal and rectal disorders Diarrhea

It is an increase frequency of bowel movement more than three times /day

Causes : -1. Certain medications2. Tube feeding formula 3. Certain metabolic disease 4. Viral & bacterial infectious disease5. Ulcerative colitis .enteritis & chrons

disease

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Clinical Manifestations1. Abdominal cramps, distention, intestinal

rumbling

2. Increase frequency & fluid content of stool

3. Anorexia , thirst , & dehydration

4. Fluid electrolytes imbalance Complications:-

-cardiac arrhythmia due to fluid & K loss

-drowsiness & hypotension

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Medical Management1. Treatment of underlying cause 2. Controlling symptoms & preventing complications3. Antibiotics & antinflammatory agents4. Antidiarrheal & antispasmoic agents Nursing Managements1. Assessment the ch.ch. & pattern of diarrhea2. Bed rest & monitoring of fluid status 3. Serum electrolytes (K)4. Perenial care

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Fecal Incontinence

The involuntary passage of stool from the rectum

Clinical Manifestations

1. Minor soiling

2. Occasional Urgency & loss of control

3. Poor Control of flatus

4. Diarrhea ,or constipation may be present

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Fecal Incontinence

Medical Management1. Bowel training program2. Surgical reconstruction3. Sphincter repair 4. Fecal diversion Nursing Management1. Assessment & Health History2. Bowel Training program3. Maintain skin integrity4. Assist patient & family to cope with illness

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Irritable Bowel Syndrome

Functional disorder of intestinal motility ,the change may be related to neurologic regulatory system, infection or irritation or a vascular or metabolic disturbances

The peristaltic waves are affected at specific segment

Clinical Manifestations1. Alteration in bowel pattern2. Pain , bloating , & abd distention3. Pain precipitated by eating & relieved by

defecation

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Irritable Bowel Syndrome

Medical Management1. Controlling symptoms & reducing stress2. Anticholonergic & antidepressant agents3. Well balanced diet Nursing Management1. teaching &reinforcing good dietary habits2. Encourage eat regular time & chew slowly3. Fluids should not taken with meal4. Discourage smoking & alcohol

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Acute Inflammatory Intestinal Disorders (Appendicitis)

Acute inflammation of appendix Clinical Manifestations1. Rt Lower Quadrant pain2. Low Grade Fever, nausea , vomiting anorexia3. Rebound & Revosing signs4. Local tenderness when pressure applied5. Increase W.B.C.s count Complications: perforation peritonitis or abdominal

abscess ,occurs after 24 hrs after onset of symptoms (pain Tenderness ,fever,& toxic appearance)

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Acute Inflammatory Intestinal Disorders (Appendicitis) Medical Management1. Surgery is indicated if surgery diagnosed

(laprascopic or open appendectomy)2. NPO ,IVF , antibiotics3. Analgesic after diagnosis is made Nursing Management1. Relieving pain &preventing FVD2. Elimination of potential infection3. Maintaining skin integrity4. Reducing anxiety5. Pre&post care

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Acute Inflammatory Intestinal DisordersUlcerative Colitis Recurrent ulcerative & inflammatory

disease of the mucosal layer Clinical Manifestations1. Diarrhea & abdominal pain2. Intermittent tenesmus3. Rectal bleeding4. Anorexia , weight loss , fever 5. Vomiting & dehydration

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Acute Inflammatory Intestinal Disorders Ulcerative Colitis

Medical Management1. Nutritional therapy :

- oral fluid - low residue caloric protein diet with supplementary vit & Iron

2. Pharmacological therapy : - antibiotics& corticosteroids (enema) -sedatives , antidiarrheal ,& antiperstaltic agents -Immunosuppressive agents

3. Surgical Managements: -colectomy segmental ,subtotal - total colectomy with ilioanal anastomosis -fecal diversion

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Ulcerative Colitis

Nursing Management1. Maintaining normal elimination pattern2. Relieving pain3. Maintaining fluid Intake4. Maintaining optimal nutrition5. Promoting rest6. Reducing anxiety7. Preventing skin breakdown8. Monitoring complications

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INTESTINAL OBSTRUCTION

Blockage prevents the normal flow of intestinal contents through the intestinal tract A- mechanical: obstruction from pressure on

the intestinal walls occurs due to adhesion, tumor & hernias

B- functional: obstruction when intestinal musculature can’t propel the contents

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Small Bowel ObstructionClinical manifestation

Crampy pain wave like & colicky Pass of blood & mucus without feces Vomiting ( reverse peristalsis ) Thirst & generalized malaise

Management Decompression of bowel through N/G tube IVF to replace H2O, electrolytes deplession Surgical treatment of the cause Resection & end to end anastomosis

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Large Bowel Obstruction Clinical manifestations

Abdominal distension, Crampy lower abdomen Fecal vomiting Symptoms of shock may occur

Medical management Colonoscopy, to untwist or decompress bowel Cecostomy to relief pressure Rectal tube to decompress the lower part Surgical resection Temporary or permanent colostomy Ilio-anal anastomosis

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Nursing management Administer IV fluids & electrolytes as prescribed Emotional support Pre & post operative care for abdominal surgery

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ANO-RECTAL DISORDERS 1- Anal FistulaDefinition: tubular tract extends into anal

canal from an opening beside the anus, from infection, abscess, trauma & fissure

S & S Pus or stool leakage Passage of flatus or feces from vagina or

bladder depends on site of fistulaTreatment

Fistulectomy ( excision of fistulous tract )Untreated fistula causes systematic infections

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2- Anal FissureDefinition: tear or ulceration in the lining of

anal canal results from constipation, child birth & trauma

S & S Painful defecation Burning & bleeding

Treatment Conservative treatment ( stool softener, sitz

bath, analgesics ) Anal dilatation & fissure excision

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3- Hemorrhoids ( piles )Definition: dilated portion of veins in the

anal canalTypes

Internal: above the internal sphincter External: out side the external sphincter

S & S Itching & pain Bright red bleeding with defecation Piles come out side anus

Complications Massive bleeding results in anemia Thrombosis & infection

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Treatment

Conservative treatment (sitz bath, laxative, high residual diet, anesthetic ointments & rest)

Injection of sclerosing solutions Rubber band ligation procedure Hemorrhoidectomy

Nursing management Pre-operative: cleansing enema, shaving &

cross match, Hb + IV fluids Post-operative: analgesia ½ hour before

defecation, sitz bath in warm saline & remove the back

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4- Pilonidal Sinus / cystDefinition: found on the posterior surface

of the lower sacrum results from the penetration of hair into the epithelium & subcutaneous tissue lead to recurrent abscess formation

Treatment Excision & drainage, antibiotic & analgesia

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Nursing management (Ano -Rectal condition ) Relieving constipation Reducing anxiety Relieving pain Promoting urinary elimination Monitoring & managing complications

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Nursing Care of Clients with Bowel Disorders

Factors affecting bodily function of eliminationA.GI tract 1. Food intake 2. Bacterial flora in bowelB. Indirect 1. Psychologic stress 2. Voluntary postponement of defecation

C.Normal bowel elimination pattern 1. Varies with the individual 2. 2 – 3 times daily to 3 stools per week

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Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)

Definitiona. Functional GI tract disorder without

identifiable cause characterized by abdominal pain and constipation, diarrhea, or both

b. Affects up to 20% of persons in Western civilization; more common in females

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Pathophysiology a. Appears there is altered CNS regulation of

motor and sensory functions of bowel1.Increased bowel activity in response to food

intake, hormones, stress2.Increased sensations of chyme movement

through gut3.Hypersecretion of colonic mucus

b. Lower visceral pain threshold causing abdominal pain and bloating with normal levels of gas

c. Some linkage of depression and anxiety

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Manifestations a. Abdominal pain relieved by defecation; may

be colicky, occurring in spasms, dull or continuous b. Altered bowel habits including frequency,

hard or watery stool, straining or urgency with stooling, incomplete evacuation, passage of mucus; abdominal bloating, excess gas

c. Nausea, vomiting, anorexia, fatigue, headache, anxiety

d. Tenderness over sigmoid colon upon palpation

4. Collaborative Care a. Management of distressing symptoms b. Elimination of precipitating factors, stress

reduction

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Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)5. Diagnostic Tests: to find a cause for client’s abdominal pain,

changes in feces elimination a.Stool examination for occult blood, ova and parasites, culture b.CBC with differential, Erythrocyte Sedimentation Rate (ESR): to

determine if anemia, bacterial infection, or inflammatory process c.Sigmoidoscopy or colonoscopy

1.Visualize bowel mucosa, measure intraluminal pressures, obtain biopsies if indicated

2.Findings with IBS: normal appearance increased mucus, intraluminal pressures, marked spasms, possible hyperemia without lesions

d.Small bowel series (Upper GI series with small bowel-follow through) and barium enema: examination of entire GI tract; IBS: increased motility

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Medications a. Purpose: to manage symptoms b. Bulk-forming laxatives: reduce bowel spasm,

normalize bowel movement in number and form c. Anticholinergic drugs (dicyclomine (Bentyl),

hyoscyamine) to inhibit bowel motility; given before meals

d. Antidiarrheal medications (loperamide (Imodium), diphenoxylate (Lomotil): prevent diarrhea prophylactically

e. Antidepressant medications f. Research: medications altering serotonin

receptors in GI tract

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Dietary Management a. Often benefit from additional dietary fiber:

adds bulk and water content to stool reducing diarrhea and constipation

b. Some benefit from elimination of lactose, fructose, sorbitol

c. Limiting intake of gas-forming foods, caffeinated beverages

8. Nursing Care a. Contact in health environments outside acute

care b. Home care focus on improving symptoms with

changes of diet, stress management, medications; seek medical attention if serious changes occur

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Peritonitis

Definitiona. Inflammation of peritoneum, lining

that covers wall (parietal peritoneum) and organs (visceral peritoneum) of abdominal cavity

b. Enteric bacteria enter the peritoneal cavity through a break of intact GI tract (e.g. perforated ulcer, ruptured appendix)

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Peritonitis

Pathophysiology a. Peritonitis results from contamination of

normal sterile peritoneal cavity with infections or chemical irritant

b. Release of bile or gastric juices initially causes chemical peritonitis; infection occurs when bacteria enter the space

c. Bacterial peritonitis usually caused by these bacteria (normal bowel flora): Escherichia coli, Klebsiella, Proteus, Pseudomonas

d. Inflammatory process causes fluid shift into peritoneal space (third spacing); leading to hypovolemia, then septicemia

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Peritonitis

3.Manifestations a. Depends on severity and extent of

infection, age and health of client b. Presents with “acute abdomen”

1.Abrupt onset of diffuse, severe abdominal pain

2.Pain may localize near site of infection (may have rebound tenderness)

3.Intensifies with movement c. Entire abdomen is tender with boardlike

guarding or rigidity of abdominal muscle

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Peritonitis

d. Decreased peristalsis leading to paralytic ileus; bowel sounds are diminished or absent with progressive abdominal distention; pooling of GI secretions lead to nausea and vomiting

e. Systemically: fever, malaise, tachycardia and tachypnea, restlessness, disorientation, oliguria with dehydration and shock

f. Older or immunosuppressed client may have1.Few of classic signs2.Increased confusion and restlessness3.Decreased urinary output4.Vague abdominal complaints5.At risk for delayed diagnosis and higher

mortality rates

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Peritonitis

4. Complications a. May be life-threatening; mortality rate overall

40% b. Abscess c. Fibrous adhesions d. Septicemia, septic shock; fluid loss into

abdominal cavity leads to hypovolemic shock5. Collaborative Care a. Diagnosis and identifying and treating cause b. Prevention of complications

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Peritonitis

6. Diagnostic Tests a. WBC with differential: elevated WBC to 20,000; shift to

left b. Blood cultures: identify bacteria in blood c. Liver and renal function studies, serum electrolytes:

evaluate effects of peritonitis d. Abdominal xrays: detect intestinal distension, air-fluid

levels, free air under diaphragm (sign of GI perforation) e. Diagnostic paracentesis7. Medications a. Antibiotics

1.Broad-spectrum before definitive culture results identifying specific organism(s) causing infection

2.Specific antibiotic(s) treating causative pathogens b. Analgesics

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Peritonitis

8.Surgery a. Laparotomy to treat cause (close

perforation, removed inflamed tissue) b. Peritoneal Lavage: washing out

peritoneal cavity with copious amounts of warm isotonic fluid during surgery to dilute residual bacterial and remove gross contaminants

c. Often have drain in place and/or incision left unsutured to continue drainage

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Peritonitis

9. Treatment a. Intravenous fluids and electrolytes to maintain

vascular volume and electrolyte balance b. Bed rest in Fowler’s position to localize

infection and promote lung ventilation c. Intestinal decompression with nasogastric

tube or intestinal tube connected to suction 1. Relieves abdominal distension secondary to

paralytic ileus 2. NPO with intravenous fluids while having

nasogastric suction

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Peritonitis

10. Nursing Diagnoses a. Pain b. Deficient Fluid Volume: often on hourly

output; nasogastric drainage is considered when ordering intravenous fluids

c. Ineffective Protection d. Anxiety11. Home Care a. Client may have prolonged hospitalization b. Home care often includes 1. Wound care 2. Home health referral 3. Home intravenous antibiotics

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Client with Inflammatory Bowel Client with Inflammatory Bowel DiseaseDisease

Definition a. Includes 2 separate but closely related

conditions: ulcerative colitis and Crohn’s disease; both have similar geographic distribution and genetic component

b. Etiology is unknown but runs in families; may be related to infectious agent and altered immune responses

c. Peak incidence occurs between the ages of 15 – 35; second peak 60 – 80

d. Chronic disease with recurrent exacerbations

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Ulcerative Colitis

Pathophysiology 1. Inflammatory process usually confined

to rectum and sigmoid colon 2. Inflammation leads to mucosal

hemorrhages and abscess formation, which leads to necrosis and sloughing of bowel mucosa

3. Mucosa becomes red, friable, and ulcerated; bleeding is common

4. Chronic inflammation leads to atrophy, narrowing, and shortening of colon

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Ulcerative Colitis

Manifestations1. Diarrhea with stool containing blood

and mucus; 5 – 10 stools per day leading to anemia, hypovolemia, malnutrition

2. Fecal urgency, tenesmus, LLQ cramping

3. Fatigue, anorexia, weakness4. Severe cases: arthritis, uveitis

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Ulcerative Colitis

Complications 1. Hemorrhage: can be massive with severe

attacks 2. Toxic megacolon: usually involves transverse

colon which dilates and lacks peristalsis (manifestations: fever, tachycardia, hypotension, dehydration, change in stools, abdominal cramping)

3. Colon perforation: rare but leads to peritonitis and 15% mortality rate

4. Increased risk for colorectal cancer (20 – 30 times); need yearly colonoscopies

5. Sclerosing cholangitis

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Crohn’s Disease (regional enteritis)

Pathophysiology 1. Can affect any portion of GI tract, but terminal

ileum and ascending colon are more commonly involved

2. Inflammatory aphthoid lesion (shallow ulceration) of mucosa and submuscosa develops into ulcers and fissures that involve entire bowel wall

3. Fibrotic changes occur leading to local obstruction, abscess formation and fistula formation

4. Fistulas develop between loops of bowel (enteroenteric fistulas); bowel and bladder (enterovesical fistulas); bowel and skin (enterocutaneous fistulas)

5. Absorption problem develops leading to protein loss and anemia

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Manifestations1. Often continuous or episodic

diarrhea; liquid or semi-formed; abdominal pain and tenderness in RLQ relieved by defecation

2. Fever, fatigue, malaise, weight loss, anemia

3. Fissures, fistulas, abscesses

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Complications 1. Intestinal obstruction: caused by repeated

inflammation and scarring causing fibrosis and stricture

2. Fistulas lead to abscess formation; recurrent urinary tract infection if bladder involved

3. Perforation of bowel may occur with peritonitis

4. Massive hemorrhage 5. Increased risk of bowel cancer (5 – 6 times)

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Crohn’s Disease (regional enteritis)Collaborative Care a. Establish diagnosis b. Supportive treatment c. Many clients need surgeryDiagnostic Tests a. Colonoscopy, sigmoidoscopy: determine area and

pattern of involvement, tissue biopsies; small risk of perforation

b. Upper GI series with small bowel follow-through, barium enema

c. Stool examination and stool cultures to rule out infections

d. CBC: shows anemia, leukocytosis from inflammation and abscess formation

e. Serum albumin, folic acid: lower due to malabsorption f. Liver function tests may show enzyme elevations

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Medications: goal is to stop acute attacks quickly and reduce incidence of relapse

a. Sulfasalazine (Azulfidine): sulfonamide antibiotic with topical effect in colon; used with ulcerative colitis

b. Corticosteroids: reduce inflammation and induce remission; with ulcerative colitis may be given as enema; intravenous steroids are given with severe exacerbations

c. Immunosuppressive agents (azathioprine (Imuran), cyclosporine) for clients who do not respond to steroid therapy

d. New therapies including immune response modifiers, anti-inflammatory cyctokines

e. Metronidazole (Flagyl) or Ciprofloxacin (Cipro) f. Anti-diarrheal medications

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Dietary Management a. Individualized according to client; eliminate

irritating foods b. Dietary fiber contraindicated if client has

strictures c. With acute exacerbations, client may be made

NPO and given enteral or total parenteral nutrition (TPN)

Surgery: performed when necessitated by complications or failure of other measures

a. Crohn’s disease 1. Bowel obstruction leading cause; may have

bowel resection and repair for obstruction, perforation, fistula, abscess

2. Disease process tends to recur in area remaining after resection

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Ulcerative Colitis

1. Total colectomy to treat disease, repair complications (toxic megacolon, perforation, hemorrhage, prophylactic for cancer risk)

2. Total colectomy with an ileal pouch-anal anastomosis (initially has temporary ileostomy)

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Ulcerative ColitisOstomy 1. Surgically created opening between intestine

and abdominal wall that allows passage of fecal material

2. Stoma is the surface opening which has an appliance applied to retain stool and is emptied at intervals

3. Name of ostomy depends on location of stoma 4. Ileostomy: opening in ileum; may be permanent

with total proctocolectomy or temporary (loop ileostomy)

5. Ileostomies: always have liquid stool which can be corrosive to skin since contains digestive enzymes

6. Continent (or Kock’s) ileostomy: has intra-abdominal reservoir with nipple valve formation to allow catheter insertion to drain out stool

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Ulcerative Colitis

Nursing Care: Focus is effective management of disease with avoidance of complications

Nursing Diagnoses a. Diarrhea b. Disturbed Body Image; diarrhea may control

all aspects of life; client has surgery with ostomy c. Imbalanced Nutrition: Less than body

requirement d. Risk for Impaired Tissue Integrity: Malnutrition

and healing post surgery e. Risk for sexual dysfunction, related to

diarrhea or ostomy

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Ulcerative Colitis

Home Carea. Inflammatory bowel disease is

chronic and day-to-day care lies with clientb. Teaching to control symptoms,

adequate nutrition, if client has ostomy: care and resources for supplies, support group and home care referral

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Client with Intestinal Obstruction

Definition a. May be partial or complete obstruction b. Failure of intestinal contents to move

through the bowel lumen; most common site is small intestine

c. With obstruction, gas and fluid accumulate proximal to and within obstructed segment causing bowel distention

d. Bowel distention, vomiting, third-spacing leads to hypovolemia, hypokalemia, renal insufficiency, shock

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Pathophysiologya. Mechanical1. Problems outside intestines: adhesions (bands

of scar tissue), hernias2. Problems within intestines: tumors, IBD3. Obstruction of intestinal lumen (partial or

complete) a. Intussusception: telescoping bowel b. Volvulus: twisted bowel c. Foreign bodies d. Strictures

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Functional1. Failure of peristalsis to move intestinal contents:

adynamic ileus (paralytic ileus, ileus) due to neurologic or muscular impairment

2. Accounts for most bowel obstructions3. Causes include a. Post gastrointestinal surgery b. Tissue anoxia or peritoneal irritation from

hemorrhage, peritonitis, or perforation c. Hypokalemia d. Medications: narcotics, anticholinergic

drugs, antidiarrheal medications e. Renal colic, spinal cord injuries, uremia

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Manifestations Small Bowel Obstructiona. Vary depend on level of obstruction and speed of

developmentb. Cramping or colicky abdominal pain, intermittent,

intensifyingc. Vomiting 1. Proximal intestinal distention stimulates vomiting

center 2. Distal obstruction vomiting may become feculentd. Bowel sounds 1. Early in course of mechanical obstruction:

borborygmi and high-pitched tinkling, may have visible peristaltic waves

2. Later silent; with paralytic ileus, diminished or absent bowel sounds throughout

e. Signs of dehydration

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Complications a. Hypovolemia and hypovolemic shock

can result in multiple organ dysfunction (acute renal failure, impaired ventilation, death)

b. Strangulated bowel can result in gangrene, perforation, peritonitis, possible septic shock

c. Delay in surgical intervention leads to higher mortality rate

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Large Bowel Obstruction a. Only accounts for 15% of obstructions b. Causes include cancer of bowel,

volvulus, diverticular disease, inflammatory disorders, fecal impaction

c. Closed-loop obstruction: competent ileocecal valve causes massive colon dilation

d. Manifestations: deep, cramping pain; severe, continuous pain signals bowel ischemia and possible perforation; localized tenderness or palpable mass may be noted

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Client with Intestinal ObstructionCollaborative Care a. Relieving pressure and obstruction b. Supportive careDiagnostic Testsa. Abdominal Xrays and CT scans with contrast media 1. Show distended loops of intestine with fluid and /or gas in

small intestine, confirm mechanical obstruction; indicates free air under diaphragm

2. If CT with contrast media meglumine diatrizoate (Gastrografin), check for allergy to iodine, need BUN and Creatinine to determine renal function

b. Laboratory testing to evaluate for presence of infection and electrolyte imbalance: WBC, Serum amylase, osmolality, electrolytes, arterial blood gases

c. Barium enema or colonoscopy/sigmoidoscopy to identify large bowel obstruction

Gastrointestinal Decompression a. Treatment with nasogastric or long intestinal tube provides

bowel rest and removal of air and fluid b. Successfully relieves many partial small bowel obstructions

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Surgery a. Treatment for complete mechanical obstructions,

strangulated or incarcerated obstructions of small bowel, persistent incomplete mechanical obstructions

b. Preoperative care 1. Insertion of nasogastric tube to relieve vomiting,

abdominal distention, and to prevent aspiration of intestinal contents

2. Restore fluid and electrolyte balance; correct acid and alkaline imbalances

3. Laparotomy: inspection of intestine and removal of infarcted or gangrenous tissue

4. Removal of cause of obstruction: adhesions, tumors, foreign bodies, gangrenous portion of intestines and anastomosis or creation of colostomy depending on individual case

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Nursing Care a. Prevention includes healthy diet, fluid intake b. Exercise, especially in clients with recurrent

small bowel obstructionsNursing Diagnoses a. Deficient Fluid Volume b. Ineffective Tissue Perfusion, gastrointestinal c. Ineffective Breathing PatternHome Care a. Home care referral as indicated b. Teaching about signs of recurrent obstruction

and seeking medical attention

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Gastrointestinal Intubation It is the insertion of a rubber or plastic tube

into the stomach ,duodenum ,or intestine . The tube may inserted through the mouth ,

nose , or the abdomen Intubation may be performed to:-1. Decompress the stomach & remove gas &fluid2. Lavage the stomach & remove toxic ingested

substances3. Diagnose GI motility & other disorders4. Administer medication & feedings5. Treat an obstruction6. Compress a bleeding site

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Gastrointestinal Intubation

Types1. Short tubes

2. Medium :

3. Long (nasoenteric) Nursing care includes Providing instructions Inserting the tube

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Confirming placement Securing the tube Advancing the nasoenteric decompression

tube Providing oral & nasal Hygiene Monitoring the patient & maintaining tube

function Monitoring & managing potential complications Removing the tube

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Gastrostomy

Is surgical procedure to create an opening into the stomach for the purpose of administer food & fluids

Elderly & debilitated patientsComatose patients Percutaneous endoscopic gastrostomy

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TPN

Is a method of supplying nutrients to the body by an IV rout

Clinical Indications

1. Insufficient intake to maintain anabolic

2. Impaired ability to ingest food

3. Ingestion unwilling

4. prolonged pre & post op. nutritional needs

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TPN

Types of nutritional solutions1. TPN (aminoacids + dextrose formula )2. Total nutrient admixture (aminoacids

+dextrose formula + intralipids ) Methods of Administration1. Peripheral Partial Method2. Central line Method D/C gradually

Documents

Husni Rousan1 Function of G I system The Primary Digestive Functions are 1.Break down food particles “ molecular forms” 2.Absorb into the bloodstream the