alterations of the gastrointestinal system post

8/7/2019 Alterations of the Gastrointestinal System Post

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NUR 250 Complex Health Alterations II

L. Taylor

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P icaFood picasNonfood picas

Foreign bodiesNursing considerations

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First meconium should be passed within24 to 36 hours of life; if not assess for:

Hirschsprung disease, hypothyroidismMeconium plug, meconium ileus (CF)

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InfancyOften related to dietConstipation in

exclusively breastfedinfant almost unknownInfrequent stool mayoccur because of minimal residue from

digested breast milkFormula-fed infantsmay developconstipation

ChildhoodOften due toenvironmental

changes or controlover body functionsEncopresis:inappropriate passageof feces, often with

soilingMay result from stress

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Also called congenital aganglionic megacolon

Mechanical obstruction from inadequatemotility of intestineIncidence: 1 in 5000 live births; morecommon in males and in Down syndrome

Absence of ganglion cells in colon

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Most common congenital malformation of the GI tract

Occurs in 1% to 3% of populationP athophysiology

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Constriction of the pyloric sphincter with obstruction of the gastric outlet

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Telescoping or invagination of oneportion of intestine into another

Occasionally due to intestinal lesionsOften cause is unknown

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Malrotation is due to abnormal rotationaround the superior mesenteric artery

during embryonic development Volvulus occurs when intestine is twistedaround itself and compromises bloodsupply to intestinesMay cause intestinal perforation,peritonitis, necrosis, and death

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Imperforate anusP ersistent cloaca

Cloacal exstrophyGenitalia may be indefinite

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Fig. 42-1


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Reflux of gastric contents into esophagus1 to 2 hrs after eating

Cleared in 1 to 3 minutesInflammatory responseCharacteristic of contentsLength of time in esophagus

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Inflammatory responseIncreased capillary permeability

EdemaTissue fragilityErosionFibrosis

Basal cell hyperplasiaP recancerous lesions (Barrett esophagus)

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Fig. 42-6


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Nursing assessmentNursing diagnosesP lanningNursing implementation

Health promotion Acute interventionx P reoperative carex P ostoperative care Ambulatory and home care

Evaluation

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Fig. 42-9


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AcuteErodes surface epitheliumDrugs NSAIDS ASA ChemicalsH. P ylori

Chronic

Thinning and degeneration of stomach wall

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Type A Fundal - atopic gastritis

Type B AntralH. P yloriBile reflux

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Esophagus stomach or duodenumSuperficial erosionDeep

RisksH. P ylori, smoking, NSAIDS, ETOH emphysema,arthritis, cirrhosis, stress

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Fig. 42-16


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H P yloriIncreased secretion of acid and pepsin

P enetrate mucosaClinical Manifestations

Epigastric pain p.c. 30 to 2 hrNocturnal

P ain food - relief

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Management AntacidsH2 receptor blockers inhibit secretion of acidTriple AntibioticsUlcer coating

Anticholinergic drugsP

roton pump inhibitors

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Duodenal reflux of bileBile salt disrupts mucosa

P ain Immediately p.c.More anorexia, wt loss, vomiting

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Decreased blood flowIschemic Curlings ulcer after burnsCushing ulcerx Over stimulation of vagal nucleix Increase acid production

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LGIUltrasoundCT

MRIColonoscopy

P roctosigmoidoscopyLaparoscopyFecal Analysis

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Average risk screening After age 50 Annual FOBT Flexible sigmoidoscopy every 5yr

Annual FOBT plus flexible sigmoidoscopy every5 yr Double-contrast barium enema every 5-10 yr

Colonoscopy every 10 yr

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Diarrhea AcuteChronic

AssessP lanImplementation

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Decreased fiberDecreased fluidsMedication

Altered exerciseDietComplications

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Assess Vitals immediatelyP ain location, duration, intensity, frequency

N/VBowel and bladder Vaginal drainage

P lan

Decrease inflammationDecrease pain Avoid complications

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InterventionsP re-op CBC, T&X, P T, P TT, N P OP ost opx NP Ox NG LISx I&O, acid basex NG out when peristalsis resumes

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IBSP UDDiverticulitisP IDHepatitis

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P ain AnorexiaN/VMcBurneys pointRovsing signComplications

Treatment

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Chemical or bacterialTenderness with reboundMuscular rigidity spasmComplicationsP lanImplement

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Etiology inflammation of the mucosa of the stomach and small intestine (virus orinfection)Clinical Manifestations N&V diarrheaabd cramping, distentionOther poss. Manifestations-fever

leukocytosis, blood/mucous in stool

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N/VDiarrhea

Abd crampingDiarrheaManagement

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GOALS maintain fluid volume atfunctional level

Verbalize understanding of causativefactors and therapeutic interventionsDemonstrate behaviors to monitor andcorrect deficit

Fluid volume deficit R/T diarrhea

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Restrict oral intake if orderedGradually progress from fluids to smallmealsIVF if indicatedInfection precautions wash handsSkin care (oral, rectal)

Monitor VS

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Chronic with exacerbationsDiffuse inflammation

Abscess ulcerationP seudopolypsBloody diarrhea

Abd painSevere can indicate perforation

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Mild2 stools / day

Moderate4 5 stools / day

Severe10-20 stools / day

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Etiology unknown inflammation andulceration of colon and rectumClinical manifestations bloody diarrheaIncrease stools

Abd pain, fever, malaise, anorexia, wtloss, anemia, tachycardia, dehydration

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Drug Therapy AntibioticsCorticosteroidsBowel rest IVFImmunosuppressive drugs

Anticholinergicantidiarrheal

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SurgicalIlleostomyContinent IlleostomyTotal colectomy with Illeal reservoir

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GOALS decrease number and severityof exacerbationsMaintain fluid and elyte balanceP ain managementComply with medical regimenMaintain nutritional balance

Risk for fluid volume deficit R/T diarrhea

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Nursing diagnosisDiarrhea R/T irritated bowelP ain R/T inflamed intestine

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ImplementationP ainI&OSkin careMonitor stoolsEmotional support

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Maintain food and fluid restrictionsMonitor signs of anxietyExplain treatments, test, and meds

Assess and document signs of malnutritionDaily wtNutritional supplementsSmall bites and eat slowlyIdentify ineffective behaviors

Monitor hypovolemia

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Inflammatory Bowel sections All layers of bowel wallUlcerations deep cobblestonesNon-bloody diarrheaComplications

Fistula, stricture, perforation, peritonitis,

absorption

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EtiologyInflammation of segments of GI tractMost often affects terminal ileum,

jejunum and colonInflammation involves all layers of bowel

wallThickening of bowel wall and narrowingof lumen with stricture

Abscesses and fistuals may develop

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Clinical manifestationsNon-bloody diarrhea

Abdominal pain

FatigueWeight loss

Abdominal cramping and tendernessFever

pain at umbilicus and RLQ

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Goal Develop healthy coping behaviorIneffective individual coping R/T chronicdisease, lifestyle changes, stressGoal Correct informationIneffective management of therapeutic regimenR/T lack of knowledgeGoal adequate nutritional intake

Altered nutrition: less than body requirementsR/T decrease intake and nutrient loss

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Drug therapy

Nutrition Therapy

Surgical therapy

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MechanicalOcclusion of the lumen of the intestine.

Non-mechanicalNeuro or vascularP aralytic illeus

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P ain VomitingBowel movements

Abdominal distention

NG insertionDiagnosticsIV Fluids

Surgical interventions

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Adenocarcinoma most commonStaging

DukesTNM

Surgical therapyRadiation and chemo

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Etiology unclearRisk factors age (40+), familialpolyposis, colorectal polyps, Chronic IBD,family history, previous history, History of genital or breast cancer (women),High fat and/or low fiber diet

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LeftRectal bleeding

Alternate

constipation anddiarrheaChange in stoolcaliber

Sensation of incompleteevacuation

RightUsuallyasymptomatic

Vague discomfort orcolicky painIron deficiencyanemia

Occult bleedingWeakness andfatigue

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GOAL P t understands disease processKnowledge deficit R/T new diagnosis andpreop preparationGOAL bowel sounds w/in 9 6 hrs postop

Altered bowel elimination R/T generalanesthesia and manipulation of bowel

during surgery

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Teach pt about Colon Cancer: riskfactors, signs and symptoms, method of spread

Teach pt about diagnostic procedures:colonoscopy, CEA, CT, CBC, types of surgery.Teach pt about steps to prepare thebowel for surgery: CL diet, antibiotics,Colyte, Golytely and other osmoticagents

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IlleostomyColostomy

End stomaHartmans pouchLoop stomaDouble barrel stoma

Kock P ouchIlleoanal reservoir

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END STOMA divide the bowel and bringout proximal end. Distal portion of GItract removed. End colostomy orileostomy distal bowel removed topermanent stomaDOUBLE BARREL 2 separate stomas

proximal functioning distal isnonfunctioning and temporary

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LOO P STOMA loop of bowel through abdsurface. Open anterior wall of bowel asfecal diversion. One stoma. TemporaryKOCK P OUCH eliminates use of deviceover stoma. Covered with cap ordressing. Continent ileostomy

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ILEOANAL RESERVOIR combination of 2procedures colectomy, recatalmucosectomy, ileal reservoirconstruction, ileoanal anastomosis withtemporary ileostomy. Then closure of ileostomy.

HARTMANNS P OUCH distal bowelremains intact and oversewn potential forreanastomosis and stoma closure

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Stoma pinkSkin barriers

ApplianceColostomy irrigation

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GOALS normal bowel function,verbalizeacceptance of self in situation, relief of anxiety to altered body image, seekinformation and pursue growth, useadaptive devices appropriately, developsocial support system.

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Risk for impaired skin integrityRisk for diarrhea/constipationBody image disturbanceImpaired social interactionRisk for sexual dysfunctionKnowledge deficit R/T changes in

physiological functions

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Assess peristomal skin for erythema, burning,itching, leakage. Skin careInstruct on odor control

Assess pt ability to care for stoma Assess nutritional intake Assess pt attitude about impact of ostomy onsexual functioning

Assess signs weakness, poor skin tugor,

hypokalemia, hyponatremia, oliguria

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EtiologyNo known cause but deficiency in dietaryfiber is associated. Cause related toretention of stool and bacterial in thediverticulum and forms a massprogressing to inflammation and small

perforations

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Clinical manifestationsMajority have no symptomsCrampy abd pain in LLQ

Alternating constipation and diarrheaFever, chills nausea anorexiaLeukocytosis

Bleeding is a complication of diverticulitis

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GOAL P t will maintain adequatenutrition with minimal trauma to thebowel and cope with lifestyle changes

Altered nutrition: less than bodyrequirements R/T decrease intake andmalabsorption

Anxiety R/T management of chronicdiseaseDiarrhea related to inflammatorychanges in LGI tract

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Record IO Assess anorexiaTotal bowel restP rovide optimum nutrition

Assess abd pain Assess for signs of anemiaP hysical and mental restObserve for skin breakdownP revent and control infection

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TypesClinical manifestationsNursing andcollaborative management:Hernias


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Fig. 43-17


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Etiology and pathophysiologyClinical manifestationsDiagnostic studies and collaborativecare


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Clinical manifestationsCollaborative care


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Etiology and pathophysiologyClinical manifestationsDiagnostic studies andcollaborative careNursing management:Hemorrhoids

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Fig. 43-18

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Fig. 43-20

alterations of the gastrointestinal system post

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