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Alterations III
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rapid gastric emptying happens when the lower end of the small intestine, the jejunum, fills too quickly with undigested food from the stomach Early Dumping begins during / right after 30 minutes after a meal o Clinical Manifestations: Nausea / Vomiting Bloating Cramping Diarrhea Dizziness Fatigue Abdominal failure Late Dumping happens 1 3 hours after eating o Clinical Manifestations: Weakness Sweating (Perspiration) Dizziness Hypoglycemia Pallor Drowsiness Causes
Topics Discussed Here Are: 1. Continuation of Alteration in Digestion a. Dumping Syndrome 2. Disturbance in Absorption a. Diarrhea b. Constipation c. Irritable Bowel Syndrome (IBS) 3. Structural and Obstructive Bowel Disorders a. Intestinal Obstruction b. Crohns Disease (CD) c. Ulcerative Colitis (UC)
Gastrectomy / gastric bypass surgery / Billroth I and II Esophagectomy from esophageal cancer clients Pathophysiology wala XD Management - Limit fluid intake o No fluid with meals o No salt - No CHO
Nursing Interventions
1. 2. 3. 4. Advice client to eat CHO, FAT and CHON diet ( Fiber) Instruct to eat small frequent meals, include more dry items Instruct to avoid consuming fluid with meals Instruct to LIE DOWN AFTER MEALS (OPPOSITE sa mga DATING DISORDERS) Administer antispasmodic medications to delay gastric emptying (Metoclopramide)
5.
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Osmotic Diarrhea
Presence of unabsorbable substance in the intestine causes it to be drawn into the lumen by OSMOSIS Pathophysiology Lactase deficiency is the most common cause of osmotic diarrhea!!
Non-absorbable substance Milk, sugar and lactose
Lactose remains in the intestinal lumen (Because it is not digested and absorbed)
Secretory Diarrhea
Form of large volume diarrhea caused by excessive mucosa; secretion of fluid and electrolytes due to secretions of bacterial endotoxin Some examples: o Cholera, E. coli
o Neoplasms like gastinoma/thyroid carcinoma which both can produce hormones that stimulate intestinal secretions
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Excessive motility transit timing mucosal surface contact fluid absorption Large volume of stool reaches rectum producing urgency and frequency of elimination
Motility Diarrhea
Caused by resection of small intestine Surgical bypass of an area of intestine Fistula formation between loops of intestine Causes: o Food is not mixed properly o Impaired drying o motility o Diarrhea
Frequency It is important to discover whether evacuation was stimulated by enemas / laxative Stool Constituents / Presence of Blood Blood may present as a result of bleeding, hemorrhage/neoplastic lesions of the colon Auscultate Bowel Sounds Usually hypoactive, absent
A. History and Physical Assessment History to document onset and frequency of diarrhea Physical examination To identify the underlying systemic disease Fecalysis / Stool Culture Abdominal X-ray Intestinal Biopsy B. Treatment Restoration of fluid and electrolyte imbalance IVF Management of distressing symptom Correction of nutritional deficiencies Administration of substances that solidify stool (Metamucil) Opium alkaloids like Lomotil which suppress motility, relieves cramping and reduce stool volume and frequency
Clinical Manifestations
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Constipation
Difficulty or infrequent defecation Clinical Manifestations: 1. Less frequent defecation 2. Difficulty of evacuating rectum 3. Feeling of bowel fullness and discomfort 4. Smaller stool volume Causes: 1. 2. 3. 4. 5. 6. 7. 8.
Abdominal distention Borborygmus Gurgling sound caused by passage of gas in the intestine Pain and pressure Indigestion Sense of vomiting emptying Straining Hard dry stool
Abdominal muscle weakness Medical Management: Painful anal lesions (hemorrhoids) - Draw habit training Residue diet Fiber and fluid intake Neurologic (Hirschsprungs Disease) Depression - Discontinue laxative abuse Sedentary lifestyle - Exercise to strengthen abdominal Opiates, anticholinergics, antacids muscles Systemic Diseases (Hypothyroidism, Diabetic Neuropathy) Megacolon (Enlarged dilated colon, complication of Crohns Disease)
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A. Assessment $ Due to different personal bowel habits, it must be individually defined $ Normal bowel habits 2 3 evacuations /day $ Cramping Symptom of bowel obstruction Palpation discloses colonic distention, masses, tenderness $ Digital Rectal Examination (DRE) Assess sphincter and detect anal lesion $ Functional Constipation Resulting from lifestyle / bowel habits, usually has a long history $ Dysfunctional Constipation More likely to be sudden, because it accompanies the development of organic lesions that require careful education B. Diagnostic Test 1. Proctosigmoidoscopy: Visualizing the lumen of the rectum 2. Barium Enema: May be required if no lesions is directly visualized and symptoms persisted often simple treatment C. Treatment Dysfunctional: Manage underlying disease / lesion Functional 1. Bowel retraining 2. Engage in moderate exercise, drink more fluid ( Fiber intake) 3. Stool softeners and laxative agents 4. Enemas 5. Avoidance of high-caloric irrigations with large volume of fluid to prevent rupture of bowel D. Complications 1. Valsalva maneuver may result to rupture of a major artery in the brain / elsewhere 2. Fecal impaction 3. Megacolon / dilated and atomic colon Cause by fecal mass that obstructs the passage of colon 4. Cathartic Colon Mucosa atrophy of the colon with muscle thickening subsequent to chronic use of laxatives Fecal Incontinence - Involves passage of stool from the rectum - Ability of the rectum to sense and accommodate stool - Amount and consistency of the stool - Integrity of the anal sphincter - Rectal motility Clinical Manifestations: Soiling Occasional urge and loss of control Complete incontinence Poor control of flatus Medical Management Biofeedback therapy Bowel training program Surgery: Reconstruction of the sphincter
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Pathophysiology Clinical Manifestations Diarrhea (Can be alternative) Constipation Lower left quadrant pain (morning after eating) Tenderness in the SIGMOID area Alteration in bowel pattern Pain, bloating and abdominal distention Pain is precipitated by eating Frequently relieved by defecation Other Signs and Symptoms Nausea Distention Dyspepsia Eructation Borborygmi Gas motility Diagnostic Tests It will usually take 3 months before it is diagnosed Sigmoidoscopy / colonoscopy Barium enema CBC / Stool examination ** No confirmatory test / histologic feature (NOTE: Explore technique that could eliminate the possibility that the patient) Health Promotion 1. Fiber diet (Millers bran, bran cereals, whole wheat and grains) FAT, avoidance of carbonated drinks 2. Encourage to stress 3. Limit / stop smoking and alcohol consumption 4. Regular exercise 5. 8 hour sleep 6. Oral fluid intake (8 glasses/day) 7. Limit milk / milk products Medications 1. Sedatives 2. Antispasmodics 3. Metamucil ( Bulk in diet)
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Mechanical Obstruction
A physical block at the passage of intestinal contents without disturbing the blood supply of bowel Types: 1. Extrinsic Adhesions from surgery, hernia (out pouching which may lead to necrosis), masses (colorectal cancer which can obstruct colon), volvulus (twisted loop of intestine) 2. Intrinsic Fecal impaction, tumor, intussusception, stricture / stasis, congenital Atresia (telescopic appearance which occurs with mucosal inflammation and cancer), inflammatory disease (Crohns Disease)
Non-Mechanical Obstruction
Types: 1. Paralytic Ileus (Adynamic Neurogenic) Absence of peristalsis Peristalsis is ineffective (diminished motor activity perhaps because of toxic or traumatic disturbance of the ANS) There is no physical obstruction and no interrupted blood supply Disappears spontaneously after 2 3 days Causes: 1. Major traumas (Spinal cord injuries, vertebrae fractures) 2. Post-operatively after abdominal / GI surgery particularly if the bowel has been extensively manipulated 3. Peritonitis / Sepsis 4. Electrolyte imbalance Particularly hypovolemia 2. Mesenteric Vascular Occlusion / Infarction and Strangulation Compromised blood flow Mesenteric Vascular Occlusion Infarction Result from extensive atherosclerosis of the mesenteric arteries or mesenteric thrombosis creates ischemia in the bowel 15 30 minutes after eating (usually pain occurs) CANNOT BE RELIEVED BY REST! Strangulation: Prolonged mechanical obstruction 3. Volvulus A twisting of the bowel upon itself usually at least a full 180, obstructing the intestinal lumen both proximally and distally Commonly occurs in the SIGMOID COLON 4. Intussusception The bowel segments containing the mass is propelled by peristalsis on to the adjacent bowel segment There is obstruction due to change in movement Pathophysiology
Hernia Intussusceptions Volvulus Diverticulosis Tumor Paralytic Ileum Protrusion of the intrinsic through a weak abdominal muscle or through an inguinal ring Telescoping of warm part of the intestine into another usually causes strangulation of the blood supply; more common in infants than adults (muscular structure is not yet developed) 10 15 months Twisting of the intestine with occlusion of blood supply most frequently in middle aged and elderly men Inflamed saccular herniation (diverticuli) of the mucosa most common in obese individuals older than 60 years old Growth into the intestinal lumen; adenocarcinoma of the colon, rectum is the most common tumural obstruction, common in individuals older than 60 years of age Loss of peristaltic motor activities in the intestine, assocated with abdominal surgery, peritonitis, hypokalemia, ischemic bowel, spinal trauma
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Some signs and symptoms may vary depending on the location of the intestinal obstruction
Diagnostic Evaluation
Abdominal and Chest X-Rays 1. May show presence and location of small or large intestinal obstruction 2. Bird beak lesion in colonic volvulus 3. Foreign body visualization Contrast Studies (Barium) 1. Barium enema may diagnose colon obstruction or intussusceptions 2. Ileus may be identified by oral barium:
Laboratory Tests
a. May show NA, K and Cl levels due to vomiting b. Elevated WBC count with necrosis, strangulation / peritonitis ENDOSCOPIC Studies / Proctosigmoidoscopy Direct visualization on a narrowed intestinal lumen
Management
Non-Surgical Correction of fluid and electrolyte imbalance with NS/LR with KCl solution is required NG Suction to decompress bowel Treatment of SHOCK and PERITONITIS TPN may be necessary to correct protein deficiency from chronic obstruction, paralytic ileus Analgesics and sedatives, avoiding opiates (Morphine) due to GI motility inhibition Antibiotics for peritonitis Surgical Management: Consists of relieving obstruction Closed Bowel Procedure Lysis of adhesion, reduction of volvulus, intussusceptions and incarcerated hernia Enterostomy (Opening) for removal of foreign bodies Resection of bowel obstruction lesions or strangulated bowel with end to end anastomosis (Removal of affected area and connection of good layers) Temporary ostomy
Complications
1. 2. 3. 4. Dehydration due to loss of water, Na and Cl Peritonitis Shock Death due to shock
Nursing Management
Achieving pain relief 1. Administer prescribed analgesics as prescribed LOL (redundant naman XD) 2. Provision of Diversional activities 3. Provide supportive care during NG insertion to assist with discomfort Maintaining Fluid and Electrolyte Balance 1. Monitor I&O, VS, drop in BP may indicate blood loss 2. Monitor serum electrolyte levels, blood cell counts and refer abdominal results 3. Administer IV fluid and parenteral nutrition as ordered Maintaining Normal Bowel Elimination 1. Collect stool samples to test for occult blood if ordered 2. Maintain adequate fluid balance 3. Record amount, consistency of stools
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4. Maintain NGT to decompress as ordered Maintain Proper Lung Ventilation 1. Keep client in fowlers position to promote ventilation 2. Monitor ABG for oxygenation levels if ordered Patient Education 1. Explain the rationale for NG suctioning, NPO status, and IV fluids, advise client to progress diet slowly as tolerated once home 2. Advise plenty of rest and slow progression of activity as directed by the surgeon 3. Teach wound care if indicated 4. Encourage client to follow up as directed and to notify the surgeon for: Abdominal pain Vomiting Fever
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Assessment and Diagnostic Findings - Proctosigmoidoscopy initially - Stool examination May be (+) for occult blood and steatorrhea - Barium study of the upper GI o Is confirmatory which shows classic string on X-ray film indicating constriction of the segments involved o
Nursing Interventions
1. 2. 3. 4. 5. 6. Assess frequency and characteristics of stool to evaluate losses and effectiveness of therapy Have the client describe the location, severity and onset of abdominal cramping of pain Ask the client about weight losses and anorexia. Wight daily to monitor changes Have the client describe the food eaten to elicit dietary exacerbation Determine if the client smokes, including duration and amount Ask about family history of GI diseases
Diagnostic Tests Upper GI series (Location) Flexible Sigmoidoscopy Barium enema Biopsy Lab findings WBC Hct, Hmg, ESR Fluid and electrolyte imbalance (Due to Na, Cl, K dehydration) Treatment To treat acute disease and maintain remission Involves the use of medications to treat any infection and to reduce inflammation Usually involves the use of aminosalicylate anti-inflammatory drugs and corticosteroids and may induce antibiotics Surgery Resection and anastomosis May be required for complications such as obstruction or abscesses or if the disease does not respond to drugs within a reasonable time Diet and Lifestyle Stress management techniques (Exercise) Residue diet may reduce volume of stool per day Lactose Intolerance Avoid lactose containing foods Smoking and NSAIDS drugs should be avoided Lifestyle changes Physical rest Residue diet (To slow motility / stool) Elimination of dairy products for lactose intolerance Treatment in children: If the disease is not treated before 18, of the children have short stature or delayed growth Intervention: Aggressive nutrition therapy
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Causes 1. History of exposure to bacteria 2. Allergic reaction 3. Altered immune status Recurrent ulcer and inflammatory condition of the mucosa and submucosal layers of the rectum The colon becomes edematous and develop bleeding ulcerations Scarring develops over time with impaired water absorption and loss of elasticity
Clinical Manifestations 1. Severe diarrhea (10 20 liquid stools/day) with rectal bleeding 2. Weight loss 3. Fever Assessment and Diagnostic Findings 4. Anorexia Assess for tachycardia, Tachypnea, hypotension, fever 5. Anemia and hypocalcemia and pallor, level of hydration and nutritional status 6. Dehydration Stool exam (+) for blood 7. LLQ Abdominal pain and cramping Hct and hmg and albumin 8. Tenesmus Straining on defecation WBC Nursing Diagnoses - Altered nutrition: less than body requirements related to pain, nausea - Fluid volume deficit related to diarrhea - Pain related to inflammatory disease of the small intestine
Sigmoidoscopy, colonoscopy Barium Enema MRI and CT Scan Complication Toxic megacolon Perforation Bleeding Osteoporotic fracture
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