Metoclopramide

antiemetic and/or prokinetic agent that promotes gastrointestinal motility and gastric
emptying
used to treat nausea/vomiting and gastroparesis
can cause tardive dyskinesia (TD), a condition characterized by unusual uncontrollable
movements of the arms, legs, head, face, or entire body. Examples include protruding and
twisting tongue movements, lip smacking, torticollis, and "piano-playing" finger
movements. TD is irreversible in many cases, and the risk for developing metoclopramide-
induced TD is greater with advanced age, long-term therapy, and high drug doses.
Common side effects of metoclopramide such as sedation, fatigue, restlessness, headache,
sleeplessness, dry mouth, constipation, and diarrhea need not be reported to the health care
provider.
TD symptoms develop, including uncontrollable movements such as:

 Protruding and twisting of the tongue

 Lip smacking
 Puffing of cheeks
 Chewing movements
 Frowning or blinking of eyes
 Twisting fingers
 Twisted or rotated neck (torticollis)
Sucralfate
oral medication that forms a protective layer in the gastrointestinal mucosa, which provides
a physical barrier against stomach acids and enzymes.
should be taken on an empty stomach with a glass of water. Sucralfate forms a better
protective layer at low pH. Therefore, acid-reducing agents (eg, antacids, proton pump
inhibitors, H2 blockers) should be avoided 30 minutes before and after administration to
avoid altered absorption. Other medications should be administered 1-2 hours before or
after sucralfate.

Hepatic encephalopathy
in cirrhosis results from higher serum ammonia levels that cause neurotoxic effects,
including mental confusion.
Lactulose is a laxative used to trap and expel ammonia and is given orally with juice, milk,
or water or rectally via enema to produce 2-3 soft bowel movements a day. For faster
results, it can be administered on an empty stomach. Therapeutic dose should not be held but
instead should be maintained until the desired outcomes are reached (improved mental
status, decreased ammonia levels
Improved mental status implies reduction of ammonia levels.
Hypokalemia, high protein intake, gastrointestinal bleeding, constipation, hypovolemia, and
infection can precipitate hepatic encephalopathy
HE manifests with sleep disturbances, altered mental status, and lethargy. Asterixis
(flapping tremors of the hands) and elevated ammonia are characteristic of HE.

Lab abnormalities common in liver failure include low albumin, elevated INR, and elevated
liver function tests.

Pancrelipase
a medication containing lipase, protease, and amylase. In cystic fibrosis, the client's
pancreas does not excrete these necessary enzymes. To prevent malabsorption syndrome,
the enzymes must be taken with every snack and every meal.

Sulfasalazine (Azulfidine)
used as a topical gastrointestinal anti-inflammatory and immunomodulatory agent in
inflammatory bowel disease (IBD).
Dehydration is a concern with sulfasalazine and most other "sulfa" medications due to the
risk of crystal formation in the kidney. It is also a potential complication of inflammatory
bowel disease.
Mild to moderate anemia is common with most chronic inflammatory conditions (eg,
rheumatoid arthritis, IBD) IBD exacerbation usually includes bloody stools, resulting in
blood loss iron deficiency anemia. This needs follow-up but is not a priority.

Hepatitis B
disease of the liver characterized by inflammation, necrosis, and cirrhosis
The transmission of hepatitis B occurs through parenteral or sexual contact with body fluids
such as blood, semen, or vaginal secretions (mnemonic: B for body fluids).
insidious onset of illness, and clients may be asymptomatic carriers. Early symptoms are
often nonspecific (eg, malaise, nausea, vomiting, abdominal pain). Hepatitis B may produce
jaundice, weight loss, clay-colored stools, and thrombocytopenia in late stages of
illness. An effective vaccine is widely available for hepatitis B.
** transmission of hepatitis A occurs through the fecal-oral route via poor hand hygiene and
improper food handling.

Proton pump inhibitors (PPIs)

Long-term use of PPIs (Prazoles – omeprazole, lansoprazole, pantoprazole, rebeprazole)
has been associated with decreased bone density (calcium malabsorption) and increased risk
for C difficile-associated diarrhea and pneumonia.
impair intestinal calcium absorption and therefore are associated with decreased bone
density, which increases the possibility of fractures of the spine, hip, and wrist
Clients should be encouraged to increase calcium and vitamin D intake to help prevent
osteoporosis.The medication should be taken prior to meals

Refeeding syndrome
serious complication of nutritional replenishment. It is marked by declines in serum
phosphorus, potassium, and/or magnesium (mnemonic PPM). Clients can also develop fluid
overload. Low-calorie feedings and a gradual increase in calories can prevent refeeding
syndrome. Electrolytes should be monitored frequently.

unipolar major depression

likely to have reduced appetite and unintentional weight loss
promote adequate nutritional intake include providing small frequent meals and snacks that
are dense in protein and calories
Foods that are protein and/or calorie dense include:

 Whole milk and dairy products (eg, milkshakes), fruit smoothies

 Granola, muffins, biscuits
 Potatoes with sour cream and butter
 Meat, fish, eggs, dried beans, almond butter
 Pasta/rice dishes with cream sauce

peptic ulcer disease (PUD)

Client teaching: avoid NSAIDs, smoking, and excess use of alcohol or caffeine.
H pylori treatment includes antibiotics and proton-pump inhibitors for acid suppression
initial treatment is 7-14 days of triple-drug therapy with omeprazole (Prilosec), amoxicillin,
and clarithromycin (Biaxin)
Beverages with few or no calories, including:

 Water
 Club soda (flavored or unflavored)
 Club soda or sparkling water with a splash of fruit juice
 Unsweetened tea and/or coffee
 Non-fat or low-fat milk (in limited amounts)
 Diet beverages are not recommended
 vegetable juice is very high in sodium and is not the healthiest choice.

Total parenteral nutrition (TPN)

Hyperglycemia is a complication. hyperglycemia, as evidenced by excessive thirst,
increased urination, abdominal pain, headache, fatigue, and blurred vision
assess the client's blood sugar before implementing an intervention.
Interventions to resolve TPN-associated hyperglycemia include reducing the amount of
carbohydrate in the TPN solution, slowing down the infusion rate, and administering
subcutaneous insulin.

Diverticular disease
there are sac-like protrusions in the large intestine (diverticula). occurs when diverticula
become infected and inflamed.
Complications of diverticulitis include abscess, fistula formation, intestinal obstruction,
peritonitis, and sepsis. Diverticular bleeding occurs when a blood vessel next to one of
these pouches bursts; this may cause blood in the stool.
Measures to prevent constipation include a diet high in fiber (whole grains, fruits,
vegetables), daily intake of at least 8 glasses of water or other fluids, and exercise. A fiber
supplement such as psyllium or bran may be advised.
The etiology of diverticular disease has been linked to chronic constipation, a major cause of
excess intracolonic pressure. Preventing constipation may help reduce the risk of diverticula
forming and becoming inflamed
Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to
resolve. This includes:

 NPO status – more acute cases require complete rest of the bowel. Less severe cases
may be handled at home, and clients may tolerate a low-fiber or clear liquid diet.
 IV fluids to prevent dehydration when NPO
 Pain relief via IV medications to maintain NPO status
 Preventing increased intraabdominal pressure to avoid perforation and rupture
 Preventing increased intestinal motility – avoid laxatives and enemas

Management of acute diverticulitis focuses on bowel rest (NPO status, NG suction, bed
rest), and drug therapy (IV antibiotics, analgesics). Any procedure or treatment that
increases intraabdominal pressure or may cause rupture of the inflamed diverticula should
be avoided.
A low-residue diet, which avoids all high-fiber foods, may be used in treating acute
diverticulitis. However, after symptoms have resolved, a high-fiber diet is resumed to
prevent future episodes. Increased consumption of red meat and other high-fat foods can
increase the risk of diverticulitis.

ulcerative colitis
A low-residue, high-protein, high-calorie diet with supplemental vitamins and minerals is
recommended
well-balanced diet includes small, frequent meals and at least 2000-3000 mL/day of fluid to
maintain fluid and electrolyte balance and hydration.
Easily digested foods such as enriched breads, rice, pastas, cooked vegetables, canned fruits,
and tender meats are included in the diet. Raw fruits and vegetables, whole grains, highly
seasoned foods, fried foods, and alcohol are avoided.
Management of acute diverticulitis focuses on bowel rest (NPO status, bed rest) and drug
therapy (IV antibiotics, analgesics). Any procedure or treatment that increases
intraabdominal pressure or may cause rupture of the inflamed diverticula should be avoided.

Gastroesophageal reflux disease (GERD)

develops when the reflux of stomach contents causes inflammation of the esophageal
mucosa.
Lifestyle and dietary measures that prevent GERD or reduce it effects include the following:

1. Weight loss, as excessive belly fat can increase gastric pressure

2. Abdominal breathing exercises to strengthen the LES
3. Small, frequent meals (Option 3) with sips of water or fluids (Option 5) to help
facilitate passage of stomach contents into the small intestine
4. Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods,
chocolate, spicy foods, peppermint, and carbonated beverages (Options 1 and 2)
 5. Chewing gum to promote salivation, which may help neutralize and clear acid from
the esophagus
6. Elevating the head of the bed
7. Refraining from eating at bedtime and/or lying down immediately after eating
8. Loose clothing

Most individuals are treated effectively with acid suppression using antacids (eg, calcium
carbonate, magnesium hydroxide), proton pump inhibitors (omeprazole), and histamine 2
receptor antagonists (ranitidine)

guaiac fecal occult blood test

The steps for collecting a sample include:

1. Assess for recent ingestion (within last 3 days) of red meat or medications (eg,
vitamin C, aspirin, anticoagulants, iron, ibuprofen, corticosteroids) that may interfere
and produce false test results.
2. Obtain supplies (Hemoccult test paper, wooden applicator, Hemoccult developer),
wash hands, and apply nonsterile gloves
3. Open the slide's flap and use the wooden applicator to apply 2 separate stool
samples to the boxes on the slide. Collect from 2 different areas of the specimen as
some portions of the stool may not contain microscopic blood
4. Close the slide cover and allow the stool specimen to dry for 3-5 minutes.
5. Open the back of the slide and apply 2 drops of developing solution to the boxes on
the slide
6. Assess the color of the Hemoccult slide paper within 30-60 seconds. A positive
guaiac result will turn the test paper blue, indicating presence of microscopic blood
in the stool
7. Dispose of used gloves and the wooden applicator and perform hand hygiene.
8. Document the results

partial gastrectomy
Dumping syndrome is a complication surgically reduced gastric capacity
results in hypotension, abdominal pain, diarrhea, nausea, vomiting, dizziness,
generalized sweating, and tachycardia. The symptoms usually diminish over time
Dietary recommendations aimed at delaying gastric emptying include the following:

 Consume small, frequent meals to reduce the amount of food in the stomach at any
one time
 Eat slowly in a relaxed environment.
 Avoid meals high in simple carbohydrates (eg, sugar, syrup) as these may trigger
dumping syndrome when carbohydrates are broken down into simple sugars
 Consume meals high in protein, fat, and fiber, which take longer to digest and remain
in the stomach longer than carbohydrates
 Separate fluids from meals. If fluids are taken with meals, stomach contents pass
more easily into the jejunum and worsen symptoms. Fluid intake should occur only
after or between meals, separated from solid intake by at least 30 minutes
 Avoid sitting up after a meal. Gravity increases gastric emptying. Lying down after
meals slows down the gastric emptying and is preferred.
inguinal hernia
protrusion of abdominal contents through the inguinal canal, which appears as a bulge in the
lateral groin occurs spontaneously or results from increased intraabdominal pressure
After repair surgery, clients should avoid coughing and heavy lifting, ambulate early, turn
and deep breathe every 2 hours, and stand when voiding. Scrotal elevation and ice packs
help decrease pain and swelling.

Paracentesis
invasive procedure for removing fluid from the abdominal cavity to improve symptoms or
collect a specimen for testing.
Prior to a paracentesis, nursing actions include:

 Verify that the client received necessary information to give consent and
witness informed consent
 Instruct the client to void to prevent puncturing the bladder
 Assess the client's abdominal girth, weight, and vital signs
 Place the client in the high Fowler position or as upright as possible
 NPO status is not required

acute pancreatitis
sudden onset of unrelenting, severe pain in the left upper quadrant or midepigastric area of
the abdomen that often radiates to the back. Pain improves with leaning forward and
worsens with lying flat. often preceded or made worse by a high-fat meal. Nausea and
vomiting are common due to severe pain. Clients are at risk of developing hypovolemia
(third spacing of fluids), acute respiratory distress syndrome (due to intense systemic
inflammatory response), and hypocalcemia (necrosed fat binding calcium).

A high-grade fever or abrupt increase in temperature with worsening abdominal pain could
be an indication of a pancreatic abscess, a significant complication
requires immediate intervention (eg, antibiotics, surgical drainage) must be reported to the
health care provider immediately
Complications of acute severe pancreatitis include hyperglycemia, hypocalcemia,
hypovolemia, and ARDS. Trousseau's (carpal spasm) and Chvostek's (facial twitching)
signs are an indication of hypocalcemia from the decrease in threshold for contraction.

Dicyclomine hydrochloride (Bentyl)

anticholinergic medication/antispasmodic
prescribed to manage symptoms of intestinal hypermotility in clients with irritable bowel
syndrome and used to relax smooth muscle and dry secretions. Anticholinergic side
effects include pupillary dilation, dry mouth, urinary retention, and constipation. Therefore,
the classic contraindications are closed-angle glaucoma, bowel ileus, and urinary retention.
Dicyclomine is contraindicated in clients with paralytic ileus as it decreases intestinal
motility and would exacerbate the condition
Celiac disease
an autoimmune disorder in which chronic inflammation caused by gluten damages the small
intestine
All sources of gluten must be eliminated from the diet of a client with celiac
disease. Consuming small amounts, even in the absence of clinical symptoms, will increase
the risk for damage to the intestinal villi. Clients can have foods containing rice, corn, and
potatoes. They should read food labels and follow the diet for the rest of their lives.
gluten, a protein in barley, rye, oats, and wheat (mnemonic: BROW)

Small-bowel obstruction
Mechanical obstruction is commonly caused by obstruction of the bowel resulting from
surgical adhesions, hernias, intussusception, or tumors. Paralytic ileus, a non-mechanical
obstruction, may occur after abdominal surgery or narcotic use.
Common symptoms include rapid onset of nausea and vomiting, colicky intermittent
abdominal pain, and abdominal distension. Absolute constipation and lack of flatus are
usually seen with large-bowel obstruction. Initial treatment of an obstruction includes
placing the client on NPO status, inserting a nasogastric tube, administering IV fluids, and
instituting pain control measures.

Hemorrhoids
(distended, inflamed veins located in the anus or lower rectum)
Post-hemorrhoidectomy pain is excruciating. Providing pain relief and preventing
constipation are the primary goals for these clients. Sitz baths should begin 1-2 days
postoperatively. Hemorrhoids may recur with increased anorectal pressure. Therefore,
clients should maintain a high-fiber diet, use stool softeners, and drink adequate fluids (at
least 1500 mL/day) to prevent constipation.

barium enema
or lower gastrointestinal series, uses fluoroscopy to visualize the colon outlined by contrast
to detect polyps, ulcers, tumors, and diverticula.
contraindicated for clients with acute diverticulitis
Preprocedure instructions include:

 Take a cathartic (eg, magnesium citrate, polyethylene glycol) to empty stool from the
colon.
 Follow a clear liquid diet the day before the procedure to aid in bowel preparation
and to prevent dehydration; avoid red and purple liquids.
 Do not eat or drink anything 8 hours before the test
 Expect to be placed in various positions during the procedure. You may experience
abdominal cramping and an urge to defecate

Postprocedure instructions include:

 Expect the passage of chalky, white stool until all barium contrast has been expelled
 Take a laxative (eg, magnesium hydroxide [Milk of Magnesia]) to assist in expelling
the barium. Retained barium can lead to fecal impaction
  Drink plenty of fluids to promote hydration and eat a high-fiber diet to prevent
constipation.

small bowel follow-through (SBFT)

Uses sequential x-ray images to visualize the structure and function of the small
intestine. The client should fast for 8 hours prior to the examination. Stools may be chalky
for up to 72 hours. Black, tarry stools indicate a potential gastrointestinal bleed and should
be reported immediately.

Dietary fiber
increases stool bulk and makes stool softer and easier to pass. A fiber-rich diet helps
prevent constipation; decreases risk of colorectal cancer; promotes weight loss; improves
blood glucose control; and decreases serum cholesterol levels, which reduces the risk of
coronary artery disease and stroke.

acute appendicitis
Pain typically begins in the periumbilical region and migrates to the right lower quadrant
centering at McBurney's point (one-third of the distance from the right anterior superior iliac
spine to the umbilicus){ lower abdomen above right hip}
The client will attempt to decrease pain by lying still with the right leg flexed and preventing
increased intraabdominal pressure (eg, avoiding coughing, sneezing, deep inhalation).

balloon tamponade tube

Sengstaken-Blakemore, Minnesota
used to compress bleeding esophageal varices. Tube displacement may result in airway
obstruction. The nurse should keep scissors at the bedside so that the tube can be
emergently cut and removed if respiratory distress develops due to tube displacement.

General interventions to maintain gastric suction when using a Salem sump tube include:
 Maintaining client in semi-Fowler's position
 Keeping the air vent (blue pigtail) open and above the level of the client's stomach
 Providing mouth care every 4 hours to maintain moisture of oral mucosa and
promote comfort
 Inspecting the drainage system for patency
 Turn off suction briefly during auscultation as the suction sound can be mistaken for
bowel sounds

Laparoscopic cholecystectomy
Gallbladder removal. Postoperative teaching includes:
 Diet – a low-fat diet is recommended postoperatively as it is well tolerated. A
regular diet can be resumed after a few weeks although weight loss may be
recommended
 Activity and work – resume normal activity slowly, as tolerated. Most individuals
can return to work within a week
 Incision care and hygiene - dressings can be removed the day after surgery, and
showering is permitted at this time. Baths are not permitted as they may introduce infection
into the surgical sites. Once the incisions are healed, baths may be resumed. Signs and
 symptoms of infection (redness, edema, pus, severe pain, nausea, fever, chills) should be
reported immediately
The highest postoperative priority is prevention of any respiratory complications potentiated
by carbon dioxide administration during surgery.
The client is placed in the Sims' position to facilitate movement of carbon dioxide (CO2)
utilized during surgery to fill the abdominal cavity

clear liquid diet

Unsweetened tea, chicken bouillon, and apple juice
Red dyes in clear liquids (eg, cherry popsicles, red gelatin), however, should not be given to
clients with recent gastrointestinal bleeding
Colorectal cancer
occurs most often in adults over age 50. Risk factors include history of colon polyps; family
history of colorectal cancer; inflammatory bowel disease (eg, Crohn disease, ulcerative
colitis); and history of other cancers (eg, gastric, ovarian). Symptoms of colorectal cancer
may include:

 Blood in the stool (eg, positive occult blood, melena) from fragile, bleeding polyps
or tumors
 Abdominal discomfort and/or mass (not common)
 Anemia due to intestinal bleeding, which may result in fatigue and dyspnea with
exertion
 Change in bowel habits (eg, diarrhea, constipation) due to obstruction by polyps or
tumors
 Unexplained weight loss due to impaired nutrition from altered intestinal absorption

often goes unnoticed, as many of the symptoms are painless and nonspecific. Clients
should be assessed for these symptoms and receive regular routine colorectal cancer
screening tests (eg, occult blood test every year, colonoscopy every 10 years).

cirrhosis
may experience pruritus (itching) due to the buildup of bile salts beneath the skin.
at an increased risk for skin breakdown due to the development of edema, which increases
skin fragility and impedes wound healing, and the loss of muscle and fat tissue from
pressure points (heels, sacrum).
Comfort measures include encouraging the client to cut nails short and wear long-sleeved
cotton shirts and cotton gloves. Baking soda baths, calamine lotion, and cool, wet cloths
also help. Cholestyramine increases the excretion of bile salts through feces, thereby
decreasing itching it is packaged in powdered form, must be mixed with food (applesauce)
or juice (apple juice), and should be given 1 hour after all other medications.
Client with discomfort and shortness of breath due to ascites should be positioned in the
semi-Fowler or Fowler position or Side-lying with the head elevated to promote comfort and
lung expansion. Music and other methods of distraction may also promote
comfort. Meticulous skin interventions (specialty mattress, turning schedule) are important
to prevent tissue breakdown.
The chronic, progressive destruction characteristic of cirrhosis causes bilirubin, ammonia,
and coagulation studies (PT/INR and aPTT) to become elevated. Hyponatremia and
hypoalbuminemia are to be expected.
Eat a high-calorie, high-carbohydrate, low-sodium, and low-fat diet; moderate protein
intake is recommended. They should avoid hepatotoxic substances (alcohol,
acetaminophen) and medications (NSAIDs) that increase bleeding risk and reduce activities
that increase intraabdominal pressure.

acute viral hepatitis

often caused by infection, toxins, or trauma (eg, drug use, viral hepatitis, acute poisoning),
resulting in impairment of liver function (eg, bile production, detoxification of blood,
metabolism). Nursing interventions for clients with acute viral hepatitis include:
Rest

 Alternate periods of rest and activity to reduce metabolic demands and avoid fatigue
 Avoid hepatotoxins (eg, alcohol, acetaminophen) as they worsen injury to liver cells
 Medications (eg, appetite stimulants, antipruritics, analgesics, sedatives) metabolized
in the liver should be used cautiously to allow hepatocytes to heal.

Nutrition
  Encourage low fat, small, frequent meals to decrease nausea and promote intake in
clients with anorexia. Anorexia is lowest in the morning; promote eating a larger
breakfast
 Provide oral care and avoid extremes in food temperature to increase appetite.
 Promote water consumption (2500-3000 mL/day) and diets adequate in
carbohydrates and calories.
 Encourage protein and carbohydrate intake to assist with liver healing.

Infection control

 Hepatitis B is transmitted through sexual contact and infected blood (eg, drug use,
accidental needle stick, perinatal mother-to-child infection). A condom should be
used during sexual intercourse. Clients should not share razors or toothbrushes

ALT/AST enzymes
enzymes released when hepatic cells are injured (hepatitis)
Besides viral hepatitis, liver injury can occur with excessive chronic alcohol intake, some
over-the-counter medications (eg, acetaminophen), and certain herbal and dietary
supplements. IV illicit drug use increases the risk for hepatitis B and C infection

Iron-deficiency anemia
Foods rich in iron include:

 Meats (eg, beef, lamb, liver, chicken, pork)

 Shellfish (eg, oysters, clams, shrimp)
 Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and
oatmeal

Eating foods rich in vitamin C (eg, citrus fruits, potatoes, tomatoes, green vegetables) with
iron-rich foods will enhance iron absorption but coffee and tea consumption interferes with
this process.

Colonoscopy
Evaluates colonic mucosa. Therefore, clients should follow instructions to keep the colon
clean with no stool left for better visualization during the procedure. These instructions
include:

1. Clear liquid diet the day before

2. Nothing by mouth 8–12 hours prior to the examination
3. The health care provider prescribes a bowel-cleansing agent such as a cathartic,
enema, or polyethylene glycol (GoLYTELY) the day before the test. The type of
prep depends on the health care provider's preference and client health status.

Fever after an esophagogastroduodenoscopy (EGD) or colonoscopy could be a sign of

infection from perforation and should be reported.
Complication risks are perforation and rectal bleeding. Abdominal cramping, flatus, and
watery stool are expected findings. Perforation can lead to peritonitis, with positive rebound
tenderness, guarding, abdominal distension, tenesmus, and/or boardlike (rigid) abdomen.

Appendicitis
presents as periumbilical pain progressing to the right lower quadrant. Tenderness
at McBurney's point is present as pressure is applied, and rebound tenderness occurs when
pressure is released.
When prioritizing multiple prescriptions, the nurse should first address issues of airway,
breathing, circulation, and then vital signs. Initial interventions for acute appendicitis may
include the following:

1. Ensure patent airway and administer oxygen if hypoxic

2. Obtain IV access and administer prescribed fluids
3. Draw blood samples for complete blood count (CBC), electrolyte levels, clotting
studies, and type and cross as prescribed
4. Insert indwelling urinary catheter and obtain urine sample for urinalysis, if
prescribed
5. Insert a nasogastric (NG) tube if necessary

Colostomy
The stool changes from liquid to more solid as it passes through the colon. Proper care of
the ostomy and pouching device in clients with a colostomy includes ensuring sufficient
fluid intake, preventing gas and odor, and changing the pouching system when it becomes
one-third full to prevent leaks.
Colostomy irrigation allows the client to create a bowel regimen and to apply a dressing or
smaller pouch device over the stoma. To properly irrigate the stoma, use 500-1000 mL of
lukewarm water, hang the bag 18-24 inches above the stoma, use the cone-tipped irrigator to
slowly infuse the solution, and allow stool to drain through the sleeve into the toilet.
A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall
for the passage of stool to bypass an obstructed or diseased portion of the colon. The stoma
should be pink to brick red, indicating vascularity and viability. Minor bleeding and oozing
may occur. Mild to moderate swelling is normal for 2-3 weeks after surgery. In the
immediate postoperative period, stool will be absent. If the bowel is cleansed prior to
surgery, the draining of stool will be delayed by several days. Otherwise, stool appears
when peristalsis resumes. Inadequate blood supply can cause a change in the stoma color.
Indications of poor vascularity include pale, dusky, or cyanotic color changes, any of which
requires immediate notification of the HCP and surgical intervention to prevent ischemia
and necrosis.

acute calculous cholecystitis

Cholecystitis (inflammation of the gallbladder) causes pain in the right upper quadrant that
often radiates to the right shoulder area.
Associated symptoms include fever, chills, nausea, vomiting, and anorexia.
The highest priority intervention for an actively vomiting client with acute cholecystitis is
maintenance of strict NPO status to avoid additional stimulation of the
gallbladder. Additional priorities include management of nausea and vomiting, pain, fluid
balance, and gastric decompression.

Lactase deficiency (lactose intolerance)

can prevent unpleasant gastrointestinal symptoms by avoiding lactose-containing dairy
products (eg, milk, ice cream), eating cheese or yogurt in moderation, and supplementing
with lactase enzymes. Vitamin D and calcium supplementation is also recommended.
Some dairy products, including aged cheeses and live-culture yogurts, contain little to no
lactose and can be tolerated by most clients
not an immune reaction (allergy) to milk products

Total parenteral nutrition (TPN)

Abrupt cessation of central total parenteral nutrition (TPN), which usually contains 20%-
50% dextrose, increases the risk for hypoglycemia, as the pancreas will continue to produce
insulin in response to the residual glucose. When TPN is discontinued, the infusion rate is
gradually reduced and then replaced with a solution containing dextrose.

Hiatal hernia
Signs and symptoms commonly associated with gastroesophageal reflux disease (GERD),
including heartburn, dysphagia, and pain caused by increased intraabdominal pressure or
supine positioning. Interventions to reduce herniation include the following:

 Diet modification—avoid high-fat foods and those that decrease lower esophageal
sphincter pressure (eg, chocolate, peppermint, tomatoes, caffeine). Eat small,
frequent meals, and decrease fluid intake during meals to prevent gastric
distension. Avoid consumption of meals close to bedtime and nocturnal eating
 Lifestyle changes—smoking cessation, weight loss
 Avoid lifting or straining
 Elevate the head of the bed to approximately 30 degrees—this can be done at home
using pillows or 4 - 6 inch blocks under the bed
  Wearing a girdle or tight clothes increases intraabdominal pressure and should be
avoided.

Misoprostol (Cytotec)
synthetic prostaglandin. prevents gastric ulcers in clients receiving long-term nonsteroidal
anti-inflammatory drug therapy. It should not be taken with antacids but can be taken with
food to reduce gastrointestinal upset. Women of childbearing age should be educated on
using reliable birth control methods as misoprostol can induce labor.

Wound evisceration protrusion of internal organs through the wall of an incision. It

typically occurs 6-8 days after surgery and is more common in clients who have had
abdominal surgery, those with poor wound healing, and those who are obese.
a medical emergency. The client should be placed in low Fowler's position with the knees
bent to reduce tension on the open wound. The nurse should remain with the client while
another staff member obtains sterile saline and gauze to cover the wound.

Irritable bowel syndrome

(IBS) is a common, chronic bowel condition caused by altered intestinal motility.
Causing abdominal discomfort with diarrhea and/or constipation. Clients can manage
symptoms by avoiding gas-producing foods (eg, broccoli), caffeine, alcohol, and
gastrointestinal irritants (eg, high-fructose corn syrup, spices, dairy products) and by
increasing fiber.
Foods that are generally well tolerated include proteins, breads, and bland foods
JP closed-wound surgical drain
general procedure for emptying the drainage device includes the following steps in order:

 Perform hand hygiene as asepsis must be maintained to prevent the transmission of

microorganisms even though there is less chance of bacteria entering the wound
using a closed-wound drainage device (eg, JP, Hemovac) than an open-drain device
(eg, Penrose)
 Pull the plug on the bulb to open the device and pour the drainage into a small,
calibrated container (eg, plastic water cup, urine specimen container) as this
facilitates recording accurate drainage output
 Empty the device every 4-12 hours unless it is 1/2 to 2/3 full before then because as
the small capacity bulb (100 mL) fills, the amount of negative pressure in the bulb
decreases
 Compress the empty bulb by squeezing it from side-to-side with 1 or 2 hands until it
is totally collapsed. Although the reservoir can be collapsed by pressing the bottom
towards the top, compressing the sides of the reservoir (bulb) is recommended as it is
more effective in establishing negative pressure (Option 3)
 Clean the spout on the bulb with alcohol and replace the plug when it is totally
collapsed to restore negative pressure
** The enteral route is preferred for feeding. Enteral feedings maintain the integrity of the
gut, prevent stress ulcers, and help prevent the translocation of bacteria into the bloodstream.
**A reduction or energy expenditure of 3500 calories (kcal) will result in a weight loss of 1
lb.
**Clients experiencing diarrhea lasting >48 hours or accompanied by fever or bloody stool
should see their health care provider for assessment of fluid status, electrolyte levels, and
identification of underlying causes.
**Kidney stones cause sudden, excruciating pain in the flank, back, or lower abdomen due
to stretching of the ureter. The pain radiates to the groin area.
**Peritonitis is a common but serious complication of peritoneal dialysis. Manifestations
include cloudy effluent, fever, abdominal pain, and rebound tenderness. Treatment is based
on culture of the peritoneal fluid. Treatment of peritonitis is antibiotic therapy based on the
culture results. Antibiotics may be added to dialysate, given orally, or administered
intravenously
** The low-residue diet of a client with a new ileostomy helps prevent obstruction of the
narrow lumen of the stoma. During the immediate postoperative period, the client should
avoid foods that are high in fiber; stringy vegetables; and fruits and vegetables with pits,
seeds, or edible peels.
**The Valsalva maneuver is contraindicated in the client diagnosed with increased
intracranial pressure, stroke, head injury, heart disease, glaucoma, eye surgery, abdominal
surgery, and liver cirrhosis.
**Postoperative care of a client with gastroduodenostomy includes initiation of
thromboembolism prophylaxis; turning, coughing, and deep breathing; and aspiration
precautions (eg, elevating the head of the bed). Clients should eat small, frequent, low-
carbohydrate meals to prevent dumping syndrome.
**Clients who follow a vegan diet should be taught about vitamin B12 deficiency and the
importance of supplementation. Vitamin B12 deficiency affects the entire nervous system,
from peripheral nerves to the spinal cord and brain.

Licorice root is an herbal remedy sometimes used for gastrointestinal disorders such as
stomach ulcers, heartburn, colitis, and chronic gastritis. Clients with heart disease or
hypertension should be cautious about using licorice root. When used in combination with a
diuretic such as hydrochlorothiazide, it can increase potassium loss, leading to hypokalemia.
Hypokalemia can cause dangerous cardiac dysrhythmias. Thiazide diuretics are considered
"potassium-wasting" diuretics, so this client is already at risk for hypokalemia. The addition
of licorice root could potentiate the potassium loss. The nurse should discourage the client
from using this herbal remedy and report the client's use to the PHCP

cleansing enemas to a client the night before bowel surgery

(During instillation of the enema, the client reports cramping and pain)
Too rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of
fullness, cramping, and pain. If the client reports any of these symptoms, instillation should be
stopped for 30 seconds and then resumed at a slower rate. Slow infusion will also decrease the
likelihood of premature ejection of the solution, which would not allow for adequate bowel
evacuation. If a client reports cramping or pain during instillation of an enema, the infusion should
be stopped for 30 seconds and then resumed at a slower rate.