1 Gastrointestinal System Intestinal Disorders CONDITION SPECIFIC NURSING CONSIDERATIONS Hernia Item Physiology (Normal and How it works)

Discussion
GI tract is a hollow muscular tube and is continuous from: mouth, esophagus, stomach, small and large intestines, and rectum. The salivary glands, liver, gallbladder, and pancreas secrete substances into the tract to form the GI system Main function of the GI Tract, with the aid of organs such as the liver and pancreas, is the digestion of food to meet the bodies nutritional needs and the elimination of waste resulting from digestion Secretion during digestion o stomach secretes hydrochloric acid o liver secretes bile o accessory organs release digestive enzymes Digestion mechanical and chemical process that breaks down complex foods into simpler forms that are used by the body Absorption allows for nutrients to be absorbed by the circulatory system for uptake of individual cells Motility smooth muscles moving food from mouth to anus Elimination - POOPIES Lumen (inner wall of GI tract) consists of 4 layers: Mucosa innermost layer, includes a thin layer of smooth muscle and specialized exocrine gland cells. Its surrounded by the submucosa Submucosa made up of connective tissues and surrounded by the muscularis Muscularis composed of both circular and longitudinal smooth muscles and work to keep contents moving through the GI tract Serosa outermost layer is composed of connective tissues Oral Cavity mouth includes: Buccal mucosa Lips Tongue involved in speech and mastication (chewing) Hard/Soft palate Teeth Salivary glands saliva is secreted and contains salivary amylase (ptyalin) that begins the breakdown of carbohydrates. (maybe my salivary glands dont produce this enzyme so the carbohydrates go right to my waist!) Esophagus muscular canal that extends from the pharynx to the stomach and passes through the center of the diaphragm and Moves food and fluid Upper esophageal sphincter (UES) closed when at rest to prevent air into the esophagus during respiration Lower esophageal sphincter (LES) (just above the gastroesophageal (GE) junction) closed at rest to prevent reflux of gastric contents into the esophagus o Will acquire GERD (gastroesophageal reflux disease) if the LES doesnt function properly Stomach midline and left upper quadrant (LUQ) of the abdomen and has four anatomic regions Cardia narrow portion of the stomach that is below the GE junction Fundus area nearest to the cardia Corpus (body) is the main area of the stomach Antrum (pylorus) distal (lower) portion of the stomach o Separated from the duodenum by the pyloric sphincter Cardia and pylorus aid in transport of the food through the GI tract and prevent backflow Smooth muscle cells are responsible for gastric motility and has intrinsic and extrinsic nerves
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2 Gastrointestinal System Intestinal Disorders

Parietal cells line the wall of the stomach and secrete hydrochloric acid Produce intrinsic factor substance that aids in absorption of vitamin B Absence of the intrinsic factor can lead to pernicious anemia o Chief cells secrete pepsinogen (precursor to pepsin a digestive enzyme) Stomach uses chemical and mechanical breakdown and empties into the duodenum Pancreas lies behind the stomach and extends horizontally from the duodenal C-loop to the spleen Has 3 sections head, body, tail Two major cellular bodies: o Exocrine 80% of the organ and consists of cells that secrete enzymes needed for digestion of carbohydrates, fats, and proteins (trypsin, chymotrypsin, amylase, and lipase) o Endocrine made up of the islets of Langerhans, with alpha cells producing glucagon and beta cells producing insulin o These hormones produced are essential in the regulation of the metabolism Liver largest organ in the body (other than skin) located in the right upper quadrant (RUQ) of the abdomen Right and left hepatic ducts transport bile from the liver Receives blood from the hepatic artery and portal vein 1500ml of blood flows through the liver every minute Performs more than 400 functions in 3 major categories o Storage minerals, vitamins (iron, magnesium and fat soluble vitamins A, D, E, K) o Production phagocytic Kupffer cells (part of the bodys reticuloendothelial system) and engulfs harmful bacteria and anemic RBCs and detoxifies harmful compounds (drugs, chemicals, alcohol) Drug toxicity increases with age because the liver decreases in function as we age o Metabolism metabolizes proteins needed for survival It breaks down amino acids to remove ammonia which is converted to urea and is excreted via kidneys Synthesizes plasma proteins - albumin, prothrombin, fibrinogen Carbohydrate metabolism - stores and releases glycogen as body needs it for energy Synthesizes, breaks down, and temporarily stores fatty acids and triglycerides Liver forms and secretes bile helps to break down fat o Bile is secreted from bile ducts and empty into the common bile duct and into the duodenum at the sphincter of Oddi if sphincter is closed then it is stored in the gallbladder Gallbladder located underneath the liver and drained by the cystic duct and joins the hepatic duct Releases bile when there is a presence of fat in the duodenum Small intestine longest portion of the digestive tract, 16-19 feet 3 major parts o Duodenum first 12 inches (attaches at the pylorus and it ends at the sphincter of oddi o Jejunum 8 feet follows the sphincter of oddi o Ileum 8-12 feet 3 major functions o Movement (mixing and peristalsis) intestinal villi move o Digestion circular folds of mucosa and submucosa increase the surface area for digestion (of proteins, carbohydrates, and lipids) and absorption o Absorption Large intestine 5-6 feet from ileocecal valve to anus, lined with columnar epithelium and has absorptive and mucous cells The small intestines empty into the cecum has no digestive functions 4 main parts o Ascending colon o Transverse colon o Descending colon o Sigmoid colon empties into the rectum
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3 Gastrointestinal System Intestinal Disorders

Functions are: o Movement segmental contraction (like in the small intestine) o Absorption of water and electrolytes o Elimination - POOPIES Herniation - Weakness in the abdominal wall through which a segment of the bowel or other abdominal structure protrudes Classifications of Herniation: Reducible: contents can be pushed back into the abdominal cavity Irreducible (incarcerated): contents cannot be returned to abdominal cavity o Any hernia that is not reducible requires immediate surgical evaluation o Irreducible & strangulation o Strangulated: blood supply to the protruding bowel is cut off by pressure from the hernia ring (band of muscle around the hernia) Causes ischemia and obstruction of the bowel loop and can lead to necrosis of the bowel and perforation Most Common Types of Hernias: Indirect inguinal hernia sac formed from the peritoneum and contains part of the intestine Direct inguinal hernia weak point in abdominal wall Femoral hernia protrudes through the femoral ring o Pulls the peritoneum and the urinary bladder into the sac Umbilical hernia appear in infancy and commonly seen in obese pts Incisional or ventral hernias occurs at the site of previous surgical incisions Signs of strangulation: Abdominal distention Nausea/vomiting Pain Fever Tachycardia Pt. History: - Age o Weakened collagen or widening spaces at the liguinal ligament Can be AGE or HEREDITARY - Gender o Males most commonly get inguinal hernias Risk Factors: Can occur from increase in intra-abdominal pressure as a result of: - Pregnancy - Obesity - abdominal distention - ascites - heavy lifting - coughing Assessment: Observe when pt is lying flat and when pt is standing - Reducible if not seen while pt is laying down Auscultate - for bowel sounds - Absent bowel sounds may indicated obstruction and strangulation and is a medical emergency Palpate - Hernia is never forcible reduced; that maneuver could cause strangulated intestine to rupture None Mentioned in Class
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Pathophysiology (Disease Process)

Manifestations (Signs & Symptoms)

Assessments

Nursing

4 Gastrointestinal System Intestinal Disorders Diagnosis Diagnostic Tests and Labs Medical Interventions

Modifiable risk factors - Weight loss - Avoid lifting heavy objects - Avoid anything that increases inter-abdominal pressure - Apply pressure from outside abdominal wall Type of treatment depends on the pt factors, age, and type and severity of the hernia

Treatments: Pharmaceutical Include Side Effects & Teaching Points Treatments: Medical Include Teaching Points Treatments: Surgical Include Process and Teaching Points for preop, procedure and post-op

None mentioned in class

Nutritionalist diet and exercise planning to lose weight if obese Follow all recommended plans to reduce weight and call the MD if there are any problems

Abdominal binder surgery to repair Minimally invasive inguinal hernia repair (MIIHR) herniorrhaphy - Laparoscopy Hernioplasty reinforcement of the weakened outside abdominal muscle wall with a mesh patch - NPO prior to surgery and arrange for a ride home - After surgery - Should avoid coughing - Encourage deep breathing and ambulation - Dont strain when voiding or eliminating Absent bowel sounds may indicated obstruction and strangulation and is a medical emergency

Complications Evaluate Pt

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5 Gastrointestinal System Intestinal Disorders CONDITION SPECIFIC NURSING CONSIDERATIONS Irritable Bowel Syndrome (IBS) Pathophysiology IBS functional GI Disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating (Disease - Referred to as spastic colon, mucous colon, or nervous colon Process)
Can flare up when pt is exposed to causative agents No actual pathophysiologic bowel changes occur in IBS Believed to be due to impairment in the motor or sensory function of the GI tract Motility changes associated with: o Meals o Changes in normal bowel elimination pattern to: Diarrhea patterns Constipation Mucosal lining of the bowel remains unchanged Etiology is UNKNOWN Most common digestive disorder seen in clinical practice Start to appear in young adulthood and continue throughout life - Diarrhea - Constipation - Pain - Distension - mucus in stool - generalized abdominal tenderness - belching, gas and bloating Pt. History: - weight loss - fatigue - malaise - abdominal pain - changes in bowel pattern - consistency of stool - Passage of mucous Risk Factors: Smoking NSAID use high fat diet sulfur intake milk allergy history of depression or anxiety genetic predisposition females 2:1 Assessment: Observe Distention Peristaltic waves Auscultation Bowel sounds
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Manifestations (Signs & Symptoms)

Assessments

6 Gastrointestinal System Intestinal Disorders

Palpation and percussion done by advance practice nurse Rebound tenderness None Mentioned in Class Labs -

Nursing Diagnosis Diagnostic Tests and Labs

CBC Albumin (nutritional status) erythrocyte sedimentation rate stool for occult blood

Medical Interventions

Modifiable risk factors - High fiber foods (raw fruits and veggies, whole grains) - Drink plenty of water - Food and symptom diary - Avoid stimulants will increase motility Medications to treat symptoms

Treatments: Pharmaceutical Include Side Effects & Teaching Points Treatments: Medical Include Teaching Points Treatments: Surgical Complications Evaluate Pt

Non-surgical: complimentary therapy

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7 Gastrointestinal System Intestinal Disorders CONDITION SPECIFIC NURSING CONSIDERATIONS Colorectal Cancer (CRC) aka: Colon Cancer Pathophysiology Colon cancer is cancer in the colon or rectum (part of the large intestine) - Most are adenocarcinomas tumors that arise from the grandular epithelial tissue of the colon (Disease - Arise from adenomatous polyps that present as a visible protrusion from the mucosal surface of the Process)
-

bowel 2/3 of tumors occur within the rectosigmoid region (%s on pg. 1294) Can metastasize by direct extension or by spreading through the blood or lymph Can spread into 4 layers of the bowel and into neighboring organs o Liver is most frequent site of metastasis from circulatory spread - Metastasizes to the liver, lungs, brain and bones through blood or lymphatic systems Etiology - No known predisposition cause Those who have been treated for CRC are at risk for developing a second primary disease at the site of the surgical anastomosis Certain foods may put someone at risk o Foods aid in decreasing the time the bowel is exposed to carcinogens o High animal fat diets o Fried, grilled meat, and fish o Food with large amounts of refined carbohydrates that lack fiber **inflammatory bowel disease (IBDs) such as ulcerative colitis and Crohns disease pose an increased risk for colon cancer especially if disease has had a long severe course Depends on location of the tumor however, the most common signs are rectal bleeding , anemia, and change in the stool - Nausea/vomiting - Diarrhea - Constipation - change in bowel habits or appearance of stools - blood in stool - pain - bloating - Weight loss Pt. History: - Nutritional habits - Personal cancers o breast, ovarian, endometrial o ulcerative colitis o crohns disease - familial polyposis or adenomas - frequent follow-ups on pre-cancer screenings Risk Factors: Over >50 Genetic predisposition Family history of colon cancer Low fiber High fat diet IBS IBD Men = women Assessment:
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Manifestations (Signs & Symptoms)

Assessments

8 Gastrointestinal System Intestinal Disorders

Inspect Abdominal distention Visible peristaltic waves Auscultate Wave accompanied by high-pitched or tingling bowel sounds o Could mean partial bowel obstruction Palpate & percussion Done by the advance practice nurse to determine liver and spleen enlargement or whether there are masses along the colon None mentioned in class Anticipatory grieving o Primary collaborative problem is potential for metastasis Screening - fecal blood testing after 40, colonoscopy every ten years after 50 Labs: H&H Guaiac CEA (tumor marker) CT barium enema colonoscopy the definitive test for the diagnosis of colon cancer Modifiable risk factors - modify diets o decrease fats o decrease refined carbohydrates o decrease low-fiber foods o encourage backed or broiled foods foods high in fiber and low in animal fat - aspirin therapy can protect for colon cancer o will have GI side effects such as bleeding and can cause other problems Medications non mentioned in class - those needed for post-surgical Surgical Chemo Radiation colon resection (cutting away part of the colon with colostomy) brining the colon to the abdominal wall or anastomosis (reconnection) Colostomy may be permanent or temporary allowing the bowel time to rest and heal Abdominoperineal (AP) resection

Nursing Diagnosis Diagnostic Tests and Labs

Medical Interventions

Treatments: Pharmaceutical Side Effects: Treatments: Medical Treatments: Surgical

Complications Evaluate Pt

Perforation, abscess, fistula formation, blockage, invasion into neighboring structures Colostomy Management - Clear pouch allows the health care team to observe the stoma - If no pouch petrolatum gauze may be place over the stoma to keep it moist o Pouch should be place asap o Pouch is called an APPLIANCE Allows for convenient and acceptable collection of stool than a dressing does - Assess color and integrity of stoma frequently o Should be reddish pink, moist, and protrude about 3/4 in (2cm) from abdominal wall
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9 Gastrointestinal System Intestinal Disorders

o Report o o o Small amount of bleeding is common Signs of ischemia and necrosis Unusual bleeding Mucocutaneous separation (breakdown of the suture line securing the stoma to the abdominal wall)

Assess o Check peristomal skin (skin around stoma) o Check pouch for proper fit and signs of leakage o Skin should be intact, smooth, and without redness or excoriation - Colostomy should start functioning 2-4 days post-operatively - Should be emptied frequently after b/c of gas collection - Should be emptied when it is 1/3-1/2 full of stool - Stool is liquid post-operative and will become more and more solid Ostomy Notes (from class) - Encourage use of Ostomy nurse to mark surgical site and educate patient - Remember the psychological impact of this procedure

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10 Gastrointestinal System Intestinal Disorders CONDITION SPECIFIC NURSING CONSIDERATIONS Intestinal Obstruction Pathophysiology Can be partial or complete Classified as 2 types: (Disease Mechanical Process)
o

Bowel is physically blocked by: problems outside the intestine (adhesions) in the bowel wall (crohns disease) in the intestinal lumen (tumors) Non- Mechanical (paralytic ileus) Doesnt involve physical obstruction in or outside the intestine peristalsis decreased or absent as a result of neuromuscular disturbance resulting in a slowing of the movement or a backup of intestinal content In both mechanical and non-mechanical intestinal contents accumulate at and above the area of obstruction distention results from the inability to absorb the contents and move them down the intestinal tract to compensate for the lag, peristalsis increases in an effort to move the contents forward o stimulates secretions and leads to more abdominal distention bowel becomes edematous and increases capillary permeability plasma leaks into the peritoneal cavity and fluid trapped in the intestinal lumen decreases the absorption of fluid and electrolytes into the vascular space reduces circulatory blood volume (hypervolemia) and electrolyte imbalances occur (hypovolemic shock) Obstructions: in the high small intestine can cause a loss of gastric hydrochloride and can lead to metabolic alkalosis Below the duodenum but above the large bowel results in a loss of both acids and bases (means the acid-base imbalance is not compromised) At the end of the small intestine and lower intestinal tract causes a loss of alkaline fluids which can lead to metabolic acidosis If hypovolemia is severe: Renal insufficiency or even death can occur Bacterial peritonitis with or without actual perforation can result o Bacteria can lie stagnant in the obstructed intestine NOT a problem UNLESS the blood flow to the intestine is compromised If a closed-loop obstruction (blockage in two different areas or Strangulated obstruction (with compromised blood flow) peritonitis is greatly increased **bacteria without blood supply can form and release and endotoxin into the peritoneal or systemic circulation and cause septic shock Etiology common and serious disorder caused by many conditions and associated by significant morbidity Most common site is the ileum in the small intestine (narrowest part of the intestinal tract) Mechanical obstruction can result from: Adhesions (scar tissue from surgeries or pathophysiology) Benign or malignant tumor Complications of appendicitis Hernias Fecal impactions Strictures due to crohns disease or previous radiation therapy Intussusception (telescoping of a segment of the intestine within itself) Volvulus (twisting of the intestine) Fibrosis due to disorders such as endometriosis Vascular disorders (emboli and arterisclerotic narrowing of mesenteric vessels)
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11 Gastrointestinal System Intestinal Disorders

Non-mechanical obstruction or paralytic ileus Commonly caused by handling of the intestines during abdominal surgery Electrolyte disturbances, HYPOKALEMIA, predispose the pt to this problem Ileus can be a consequence of peritonitis leakage of colonic contents causes severe irritation and triggers inflammation Vascular insufficiency to bowel (intestinal ischemia) can cause ileus o Results when arterial or venous thrombosis or an embolus decreases blood flow to the mesenteric blood vessels surrounding the intestines Can cause Heart failure or severe shock Severe insufficiency of blood supply results in infarction of surrounding organs (bowel infarction) Nausea/vomiting (color of emesis) Abdominal pain Constipation Absence of flatus Diminished or absent bowel sounds Vomiting fecal matter Pt. History: Family history Medical/surgical Blood in stool Risk Factors: Abdominal surgery Radiation therapy Inflammatory bowel disease Gallstones Hernias Trauma Peritonitis Tumors Assessment: Observe Distention Peristaltic waves Auscultation Bowel sounds Palpation and percussion done by advance practice nurse None Mentioned in Class Labs WBC ABG indicates metabolic alkalosis or metabolic acidosis H&H BUN Electrolytes CT Colonoscopy Modifiable risk factors - High fiber foods (raw fruits and veggies, whole grains) - Drink plenty of water - Dont take laxatives routinely can decrease abdominal muscle tone - Exercise regularly - Use natural foods to stimulate peristalsis )warm beverages and prune juice - Metamucil will provide added fiber
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Manifestations (Signs & Symptoms)

Assessments

Nursing Diagnosis Diagnostic Tests and Labs

Medical Interventions

12 Gastrointestinal System Intestinal Disorders Treatments: Pharmaceutical Include Side Effects & Teaching Points Treatments: Medical Include Teaching Points Treatments: Surgical
Medications None mentioned in class

Non-surgical: NPO, NG tube to suction to decompress the GI tract. Removal of obstruction by enemas or hydration, nutritional support pain management

Surgical: exploratory Laparotomy, removal of non-functioning bowel

Complications Evaluate Pt

Death and severe fecal impact Maintaining a regular diet

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13 Gastrointestinal System Intestinal Disorders

CONDITION SPECIFIC NURSING CONSIDERATIONS Hemorrhoids Pathophysiology Hemorrhoids - unnaturally swollen or distended veins in the anorectal region - Veins involved in the development of hemorrhoids are part of the normal structure in the anal region (Disease - With limited distention, veins function as a valve overlying the anal sphincter that assists in continence Process)
Increased intra-abdominal pressure causes elevated systemic and portal venous pressure and is transmitted to the anorectal region shunt blood directly to the distended anorectal veins and increases pressure - Eventually the veins separate from the smooth muscles surrounding them - PROLASPSE of the hemorrhoidal vessels can become thrombosed or inflamed or bleed - Internal hemorrhoids cant be seen and lay above the anal sphincter - External hemorrhoids - lie below the anal sphincter and can be seen on inspection of the anal region Short story hemorrhoids are common and arent important unless they cause pain or bleed Causes: - Increased abdominal pressure - Pregnancy can worsen them - Constipation with straining - Obesity - Heart failure - Prolonged sitting or standing (boy us nursing students/nurses are in trouble) - Strenuous exercise and weight lifting - Decreased fluid intake can cause hemis b/c dehydration can cause hard poops and constipation Pain and bleeding -

Manifestations (Signs & Symptoms) Assessments

Pt. History: See Risk Factors Risk Factors: - Increased abdominal pressure - Pregnancy can worsen them - Constipation with straining - Obesity - Heart failure - Prolonged sitting or standing (boy us nursing students/nurses are in trouble) - Strenuous exercise and weight lifting Decreased fluid intake can cause hemis b/c dehydration can cause hard poops and constipation Assessment: Techniques (how are you going to assess the Pt.) Observe - Inspect rectal area None Mentioned in Class Type of tests: - Digital examination - Anoscopy - Protoscopy - Proctoscopic ultrasonography

Nursing Diagnosis Diagnostic Tests and Labs

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14 Gastrointestinal System Intestinal Disorders Medical Interventions

Modifiable risk factors - Increase fiber intake - Drink plenty of water - Avoid straining at pooping time - Exercise regularly and maintain a healthy weight Medications topical anesthetics lidocane(xylocaine) severe pain stool softeners docusate sodium (Colace) softer stools topical anesthetics dibucain (Nupercainal) relieves pain and itching

Treatments: Pharmaceutical Include Side Effects & Teaching Points Treatments: Medical Include Teaching Points Treatments: Surgical

Nonsurgical (see above) - Cold packs - Tepid sitz baths 3 or 4 times per day to relieve comfort Surgical for severe cases Hemorrhoidectomy

Complications Evaluate Pt

Possible surgery may be needed if continues more than 3-5 days

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15 Gastrointestinal System Intestinal Disorders CONDITION SPECIFIC NURSING CONSIDERATIONS Appendicitis - Inflammatory Pathophysiology Appendicitis an acute inflammation of the vermiform appendix - Occurs in 5% of population, peaking young adults, especially men (Disease - Inflammation occurs when the lumen (opening) of the appendix is obstructed (blocked) leading to Process)
-

Manifestations (Signs & Symptoms) Assessments

infection as bacteria invade the wall of the appendix Initial obstruction is usually from hard pieces of feces composed of calcium phosphate-rich mucus and inorganic salts - When the lumen is blocked the mucosa secretes fluid increasing the internal pressure and restricting blood flow, resulting inpain - All complications of peritonitis are serious - Gangrene can occur within 24-36 hours and is life threatening - One of the most common indications for emergency surgery - Perforation may develop within 24 hours risk rises rapidly after 48 hours o Perforation of the appendix results in peritonitis and temps of higher than 101 and a rise in pulse rate Right lower quadrant pain Nausea/vomiting Epigastric or umbilical pain Pain with release of pressure after palpation (rebound tenderness) Pt. History/Risk Factors: - Age - Familial tendencies - Intra-abdominal tumors - anorexia Assessment: Assess Pain in abdomen and/or flank area - abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees suggests perforation and peritonitis Right lower quadrant pain - between anterior iliac crest and umbilicus o Point is called McBurneys Point Nausea/vomiting Epigastric or umbilical pain Techniques: Palpation Pain with release of pressure after palpation (rebound tenderness) - Assess for muscle rigidity and guarding

Nursing Diagnosis Diagnostic Tests and Labs Medical Interventions

None Mentioned In Class WBC CT None Mentioned In Class

Treatments: Pharmaceutical

None mentioned in class

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16 Gastrointestinal System Intestinal Disorders

Include Side Effects & Teaching Points Treatments: Medical Include Teaching Points Treatments: Surgical

Nonsurgical none mentioned in class - keep pt with suspected or known appendicitis on NPO to prepare for the possibility of emergency surgery and to avoid making the inflammation worse - the pt with suspected appendicitis should not receive laxatives or enemas, which can cause perforation of the appendix - heat should never be applied to the abdomen because it will increase circulation to the appendix and result in an increased inflammation and perforation Surgical - laproscopic appendectomy

Complications Evaluate Pt

perforation and peritonitis life threatening!

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17 Gastrointestinal System Intestinal Disorders CONDITION SPECIFIC NURSING CONSIDERATIONS Peritonitis

Pathophysiology (Disease Process) Peritonitis life-threatening, acute inflammation of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity. Primary peritonitis - rare and indicates the peritoneum is infected via the bloodstream Normally peritoneal cavity contains 50mL of sterile fluid (transudate) and prevents friction in the abdominal cavity during peristalsis - when peritoneal cavity is contaminated with bacteria the body starts having an inflammatory response walling off a localized area to fight infection - reaction involves vascular dilation and increases capillary permeability o allows for transport of leukocytes and subsequent phagocytosis of the offending bacteria if this process fails, inflammation spreads and contamination becomes massive (widespread peritonitis) - bacteria gain entry into the peritoneum by perforation from: o appendicitis o diverticulitis o peptic ulcer disease o external penetrating wound o gangrenous gallbladder o bowel obstruction or ascending infection through the genital tract - bacteria responsible: o esherichia coli o streptococcus o staphylococcus o pneumococcus o gonococcus - chemical peritonitis results from: o leakage of bile o pancreatic enzymes o gastric acid If gone untreated - blood vessels dilation continues - body responds by shunting extra blood to the area of inflammation (hyperemia) - fluid is shifted from extracellular fluid compartment into: o peritoneal cavity o connective tissues o GI tract (third spacing) - Fluid shift can decrease circulatory volume and hypovolemic shock - Severely decreased circulatory volume can result in insufficient perfusion of the kidneys; leading to kidney failure and electrolyte imbalance - Peristalsis slow or stops in response to severe peritoneal inflammation - Abdomen becomes distended with gas/fluid - Toxins or bacteria can enter the bloodstream and lead to bacteremia or septicemia - Respiratory problems can occur as a result of increased abdominal pressure against the diaphragm The cardinal signs of peritonitis are abdominal pain and tenderness Abdominal wall rigidity is a classic finding, sometimes referred to as a broadlike abdomen Distended abdomen Nausea/vomiting/anorexia Diminishing bowel sounds Inability to pass flatus or feces
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Manifestations (Signs & Symptoms)

18 Gastrointestinal System Intestinal Disorders

Rebound tenderness in the abdomen High fever Tachycardia Dehydration from fever Decreased urine output Hiccups Possible compromise in respiratory status Pt. History: Non-mentioned in class - Proper nutrition - Appendicitis - Diverticulitis - Peptic ulcer - Bowel obstruction Assessment/Techniques: Inspection Abdomen for distention Fetal position/guarding/pain Ill appearing Hiccups Broadlike abdomen Auscultation absent bowel sounds Palpation For rebound tenderness Risk Factors: Can be life threatening None Mentioned in Class Type of tests: WBC CMP H&H blood cultures abdominal x-ray CMP H&H peritoneal lavage for specimen Modifiable risk factors - Proper nutrition

Assessments

Nursing Diagnosis Diagnostic Tests and Labs

Medical Interventions

Treatments: Pharmaceutical Treatments: Medical Include Teaching Points

Medications: Antibiotics Nonsurgical NG Tube nutritional support with TRP (total parenteral nutrition)

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19 Gastrointestinal System Intestinal Disorders

Treatments: Surgical Surgical If patient is too ill surgery would be life threatening Laparotomy is used if able

Complications

Life threatening inflammation of the abdominal cavity

Evaluate Pt

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20 Gastrointestinal System Intestinal Disorders CONDITION SPECIFIC NURSING CONSIDERATIONS Gastroenteritis

Pathophysiology (Disease Process) Gastroenteritis - Inflammation of the mucosa of the lining of the stomach and intestines - Self-eliminating unless complications occur ex: dehydration Cause: - Viral (considered an epidemic) or bacterial (travelers diarrhea) transmitted fecal-oral route Symptoms Vomiting and lots and lots of diarrhea Pt. History: Travelled outside the country Good/poor hygiene Assessment: Poor skin turgor Dry mucous membranes Orthostatic blood pressure changes Hypotension Oliguria Risk Factors: Dehydration Techniques Observe Mucus membranes Palpate Skin trugor Auscultate Bowel sounds None Mentioned in Class Type of tests: None mentioned in class Modifiable risk factors - Wash hands and good hygiene

Manifestations (Signs & Symptoms) Assessments

Nursing Diagnosis Diagnostic Tests and Labs Medical Interventions

Treatments: Pharmaceutical Treatments: Medical Treatments: Surgical

Medications: Antibiotics, fluid replacement, antiemetics, anti-diarrhea meds Nonsurgical Medication, rest, lots of water None

Complications Evaluate Pt

Normally self- limiting, may lead to dehydration

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21 Gastrointestinal System Intestinal Disorders CONDITION SPECIFIC NURSING CONSIDERATIONS Ulcerative Colitis
Pathophysiology (Disease Process) Ulcerative Colitis inflammation of the rectum and recto sigmoid colon Etiology is unknown Its unknown if its an autoimmune Manifestations (Signs & Symptoms) Assessments Symptoms

Pt. History/Risk Factors: Not smoking Family history Women>men Exacerbated by stress Assessment/Techniques Observe Mucus membranes Palpate Skin trugor Auscultate Bowel sounds None Mentioned in Class Type of tests:

Nursing Diagnosis Diagnostic Tests and Labs

CBC Sed rate C-reactive protein Electrolytes colonoscopy and CT

Modifiable risk factors - Weight management - Drug and nutritional therapy Medications:

Medical Interventions

Treatments: Pharmaceutical

anti-diarrhea drugs amino salicylates (anti-inflammatory) glucocorticoids (anti- inflammatory) immunomodulators

Nonsurgical

Treatments: Medical Treatments: Surgical

TPN IV hydration colectomy

Complications Evaluate Pt
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22 Gastrointestinal System Intestinal Disorders CONDITION SPECIFIC NURSING CONSIDERATIONS Crohns Disease
Pathophysiology (Disease Process) Crohns Disease inflammatory disease of the small intestine (most often), the colon, or both. - Can affect the GI tract from the mouth to the anus but most commonly affects the terminal ileum. - Progressive, unpredictable, recurrent. Strictures and ulcerations are common creating a cobblestone appearance to the lining of the bowel Etiology unknown could a combination of genetic, immune, and environmental factors (10-20% of pts with crohns has a positive family history of the disease no predominant inheritance pattern is present) - A gene on the monocyte normally recognizes and destroys bacteria in the intestines o Those with crohns disease the gene cannot respond to bacterial liposaccharide in the cell wall and leads to an overreaction of the immune system and leads to uncontrolled inflammation and destruction of intestinal cells - Environmental factors include: o Smoking o Bacteria (mycobacteria any bacteria that is not part of the normal flora) Symptoms Severe diarrhea (malabsorption of vital nutrients) Anemia (from iron deficiencies or malabsorption issues) Pain frequent loose & sometimes bloody stools weight loss Pt. History/Risk Factors: family history (Needed to identify manifestation specific to the disease) genetic mutation causing hyperactive immune response stress is a possibility but not proven Smoking Poor nutrition/poor hydration bacterial infection and inflammation Assessment/Techniques Observe Distention, masses, visible peristalsis Perianal area for ulceration, fissures, or fistula Ascultation Bowel sounds (may be decreased or absent with severe inflammation or obstruction) An increase in high-pitched or rushing sounds may be present over areas of narrowed bowel loos Palpate Muscle guarding Masses Rigidity tenderness None Mentioned in Class Type of tests: H&H Mag K+ CRP C-Reactive Protein (identifies infection & inflammation, used to determine the effectiveness of antibiotics and anti-inflammation meds are working) CT Ultrasound
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Manifestations (Signs & Symptoms)

Assessments

Nursing Diagnosis Diagnostic Tests and Labs

23 Gastrointestinal System Intestinal Disorders

colonoscopy Modifiable risk factors - Weight management - Drug and nutritional therapy - Fistula management - Wound management Preserving and protecting the skin is the top priority. Wound drainage must never be allowed to be in direct contact with skin without prompt cleaning because intestinal fluid enzymes are caustic. Skin breakdown or fungal infection can cause major discomfort for the patient Medications: anti-diarrhea drugs amino salicylates (anti-inflammatory) glucocorticoids (anti- inflammatory) immunomodulators Nonsurgical TPN IV hydration Surgical Stricturoplasty Laparoscopy Bowel re-sectioning colectomy Similar to Ulcerative colitis - Hemorrhage (more common in Ulcerative Colitis) Pts with crohns disease can become very malnourished and debilitated fistula formation perforation mal absorption scar tissue anemia obstruction

Medical Interventions

Treatments: Pharmaceutical

Treatments: Medical Treatments: Surgical

Complications

Evaluate Pt

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24 Gastrointestinal System Intestinal Disorders

CONDITION SPECIFIC NURSING CONSIDERATIONS Diverticular Disease Diverticula pouch-like herniations of the mucosa through the muscular wall in the gut most commonly in the colon Diverticulosis presence of many abnormal pouch-like herniations (diverticula) in the wall of the intestine Diverticulitis inflammation of one or more diverticula - Muscle of the colon hypertrophies, thickens, and becomes rigid, herniation of the mucosa and submucosa through the colon wall is seen - Occurs at points of weakness in the intestine often at areas where blood vessels interrupt the muscle layer - Food becomes or bacteria becomes trapped in a diverticulum and blood supply to the area is reduced - Bacteria causes the inflammation and can perforate and develop a local abscess - Can progress to an intra-abdominal perforation with peritonitis - Minor to major hemorrhaging from blood vessel breakdown - Inflammation from recurrent diverticulitis can lead to scarring and narrowing of the bowel lumen can result in obstruction Etiology unknown Cause: - Poor muscle tone, low fiber diet Found in of adults over 60

Pathophysiology (Disease Process)

Manifestations (Signs & Symptoms)

Assessments

Usually has no symptoms In advanced stages: Pain Hemorrhage Inflammation Nausea, vomiting Tenderness Muscle spasms Pt. History/Risk Factors: Age Ask about intermittent pain (left lower quadrant) Constipation Low-grade fever Nausea Bleeding from rectum Lack of fiber in diet Assessment: Observation Distention Palpation Guarded movement Muscle spasms Abdominal tenderness None Mentioned in Class

Nursing Diagnosis

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Diagnostic Tests and Labs Medical Interventions & Pt. Teachings Type of tests: WBC, H&H, barium enema, CT Modifiable risk factors Diet/nutrition management - avoid nuts, seeds, popcorn, corn, cucumbers, tomatoes, figs, and strawberries - High Fiber Diet (wheat bran, whole-grain bread, cereal, fruits, vegetables) o 25-35g of fiber a day o Not to exceed 30% of total daily caloric intake - teach pt to add fiber gradually if not use to high fiber diets o helps to avoid flatulence and abdominal cramping o use a bulk forming laxative Metamucil - drink plenty of fluids to help prevent bloating - alcohol should be avoided irritates the bowel - avoid fiber when symptoms of diverticulitis are present (high-fiber diets are irritating) - after surgery give oral and written instructions on: o incision care o signs/symptoms to report to health care provider o colostomy care (as needed) o encourage pt to express concerns about body image o allow time and address sexual concerns regarding body image - instruct pt with any type of diverticular disease (oral and written) about signs/symptoms of acute diverticulitis: o fever o abdominal pain o bloody, mahogany, or terry stools o avoid laxatives (other than bulk kind) and enemas o reassure pt that disorder shouldnt cause problems if proper diet is followed Medications: antimicrobials: Bactrim, flagyl, cipro Nonsurgical Drug and nutritional therapy with rest to decrease inflammation and improve tissue perfusion Laxatives and enemas are NOT to be used increases motility Teaching: Rest during acute phase of illness - Refrain from lifting, straining, coughing, bending to avoid an increase in intra-abdominal pressure and can result in perforation of the diverticulum - Low fiber or clear liquids based on symptoms More severe symptoms - NPO and give NGT (nasogastric tube) if nausea, vomiting or abdominal distention is severe - (THIS IS WHAT THE BOOK SAYSI THINK IF THEY ARE NAUSEA AND VOMITING YOU WOULDNT GIVE AN NGTCHECK WITH MS. MARSHALL) - Infuse IV fluids - Nutritionalist will increase fiber diet gradually as symptoms subside Surgical Colon resectioning with or without a colostomy Teaching: -Preoperative not in acute phase bowel preparation - laxatives 1 -2 days prior to surgery -Preoperative when in acute phase low fiber diet followed by clear-liquid diet several days prior to surgery -Give pt info on possible need for colostomy and possible outcomes -Collaborate with wound nurse, ostomy nurse, and continence nurse or enterostomal therapist to describe
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Treatments: Pharmaceutical Treatments: Medical

Treatments: Surgical

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function and care -Postoperative care NPO with an NGT until peristalsis returns 2-3 days introduce clear liquids then gradually solids - laparoscopic surgery pts dont need an NGT - Discuss pts feelings about ostomy and that anger and depression are normal responses - encourage pt to look at the stoma and touch the pouching system -teach pts how to self-manage ostomy care If peritonitis is also present: Sepsis Hypotension Hypovolemic shock For manifestations of fluid and electrolyte imbalances

Complications

Evaluate Pt

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CONDITION SPECIFIC NURSING CONSIDERATIONS Anal Disorders Anal Rectal Abscess inflammation of the soft tissue near the rectum or anus - Pathophysiology o Results from an obstruction of the ducts of the glands in the rectal area o Feces, foreign bodies, or trauma can cause obstruction and stasis and leads to infection that spreads to nearby tissues o Most abscesses begin as a pocket of infection - Signs/symptoms o Pain o Localized swelling o Redness o Tenderness to touch - Chronic S/S o Discharge o Bleeding o Pruritus (itching) o Fever (for larger abscesses) - Interventions o Surgical incision and drainage (I&D) o Comfort and help pt maintain optimal perineal hygiene o Privacy o Warm sitz baths o Analgesics o Bulk producing agents & stool softeners after surgery until healing occurs/High fiber diet o Stress the importance of good perineal hygiene after all bowel movements and the maintenance of a regular bowel pattern with a high-fiber diet o Patients are often embarrassed about having anal problems. Provide privacy and maintain that patients dignity during the examination and treatment Anal Fissure tear in the anal lining causes discomfort and disability - Pathophysiology o Small fissures - Occurs when straining to have a stool with diarrhea and constipation o Larger fissures occurs as a result of another disorder Crohns disease Turberculosis Leukemia Neoplasm Trauma from foreign body rough anal intercourse (OMGoodness! LOL) perirectal surgery o Acute anal fissure superficial and usually resolves on its own o Chronic fissures reoccur surgical treatment may be needed o Usually self-limiting - Signs/symptoms o Pain during and after defecation (most common) o Bright red blood in stool (most common) o Pruritus (itching) o Urinary frequency or retention o Dysuria o Dyspareunia (painful intercourse) - Diagnosis o If no pain
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Stretching and inspecting the perianal skin Digital examination or sigmoidoscopy o If pain Only visual inspection done o May perform colonoscopy to rule out inflammatory bowel disorder - Pain management and stool softening / prevention of constipation - Patient teaching o Sitz baths o Analgesics o Bulk-producing agents o Topical anti-inflammatory (hydrocortisone cream) o Opiate suppositories All helpful if spasms occur o Explain pain control measures to pt o Pt should report pain that is not relieved in within a few days If fissures dont respond pain mgmt within days/weeks, surgical repair may be needed o Report drainage or bleeding to heath care provider Parasitic Infection - Pathophysiology o Oral-fecal route from contaminated food or waste, oral-anal sexual practices (eeeewwwww), or contact with feces from a contaminated person - Types of parasites that cause infection in humans o Entamoeba histolytica causes amebic dysentery o Giardia lamblia giardiasis (small intestinal infection from a protozoa) o Cryptosporidium o Handwashing is the best way to prevent the spread of parasitic infections - Assessment o History of travel to other countries GI symptoms related to travel 1-2 weeks after returning home o Immigrant o Nutritional history - Interventions o Teach pts the importance of keeping their follow-up appointments and taking all drugs as prescribed o Drug therapy o Explain modes of transmission and how to avoid spreading and preventing o Inform the pt that the infection can be transmitted to others until all amebicides effectively kills the parasites. Teach pt: Avoid contact with stool Keep toilet areas clean Wash hands meticulously with an antimicrobial soap after bowel movements Maintain good personal hygiene, showering daily Avoid stool from dogs beavers Helminthic Infection worm like animals that are often parasitic and capable of causing infectious disease in humans - Pinworms (Enterobiasis) o Most common helminthic infection in the US o Oral-Fecal transmission o Signs/symptoms Perianal itching (at night) Vaginitis Insomnia Restlessness GI symptoms Abdominal pain
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o Nausea/vomiting Diarrhea

Treatment Hand washing after defecating and before meals to prevent the spread Drug therapy All members of the household should be treated together, even if no signs or symptoms - Trichinosis easily treated o Signs/symptoms Usually Asymptomatic Pain Weakness Invades muscle tissues Diarrhea Nausea/vomiting o Eating raw or undercooked pork (and other meats) o Drug therapy Hospitalized and high amounts of corticosteroids - Hookworms o Pathophysiology Enter the body through the skin Infect of the worlds population Rare outside the tropics and in places with very little rain Worms are ineffective in warm climates and outside the body They can travel to the lungs through the bloodstream and enter the aveoli Cilia carry the organism up the respiratory tree to the pharynx and the mouth and swallowed This is how they enter the GI tract o Can also get the worm by ingesting contaminated food o Signs/Symptoms Itchy, red, raised, blister-like inflammation of the skin GI tract infections may not cause any symptoms Anorexia may occur along with: o Diarrhea o Mild abdominal and epigastric discomfort o Bleeding and anemia may occur if worm sucks blood at sites of attachment in GI tract o Diagnosis Ova (eggs) in feces Occult blood present in the stool Anemia with low hemoglobin and hematocrit levels Low serum iron level High iron binding capacity WBC and eosinophil counts are elevated o Interventions Iron therapy Diet high in protein and vitamins (for 3 months or until anemia is corrected) Anti-minth (worm meds) o Complications Can cause malabsorption and protein loss - Tapeworms can get from undercooked meat, fish NOTE: Erythrocyte Sedimentation Rate Sed rate, or erythrocyte sedimentation rate (ESR), is a blood test that can reveal inflammatory activity in your body. A sed rate test isnt a stand-alone diagnostic tool, but it may help your doctor diagnose or monitor the progress of an inflammatory disease
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