NCMB 316 Medical Surgical Nursing 2 Week 1-5 PDF

NCMB – 316: MEDICAL SURGICAL NURSING 2 2nd SEMESTER PRELIMS 3RD YEAR NURSING WEEK 1 – Gastrointestinal Assessment Large Intestine Gastrointestinal Tract...

NCMB – 316: MEDICAL SURGICAL NURSING 2 2nd SEMESTER PRELIMS 3RD YEAR NURSING WEEK 1 – Gastrointestinal Assessment Large Intestine Gastrointestinal Tract − It consists of ascending, transverse, descending, sigmoid colon, rectum and anus (terminal portion − Is a pathway that is about 7-7.9 meters (23-26ft) of GIT). − It extends from the mouth, esophagus, stomach, − Functions is to dry out indigestible residue by small intestine, large intestine, rectum and anus absorbing water. This food residue is tried to be (terminal portion of GIT). eliminated from the body through feces. Mouth Functions of Gastrointestinal Tract: − Process of digestion begins here with the act of − Breakdown of food particles into the molecular chewing. form of digestion. − 1.5 liters of saliva is secreted. It comes from − Absorption of nutrients into the blood stream parotid gland from your submaxillary gland and which is produce by digestion. sublingual gland which helps in lubricating the − Elimination of undigested, unabsorbed food and food. waste products. − Saliva amylase (ptyalin) is the enzyme that begins the digestion. Assessment of GIT Esophagus − Any information gather during nutritional assessment may provide us insights into the − Located in the mediastinum. Anterior to the spine, client’s overall health status, identify risk factors posterior to trachea and heart. for obesity, and identify dietary deficits. − 25 cm in length. − You may also gather information regarding the Stomach health promotion and disease prevention of the GIT of the patient. − It is located in left upper portion of the abdomen Subjective Data: and under the left lobe of the liver and diaphragm. − It covers most of the pancreas. A. Nutritional Problems − It is hallow, muscular and it has a capacity of 1500 mL. Characteristics: 24 hr. food intake; Usual − Functions of the stomach includes, storage of weight; Weight gain; Weigh loss; Weight change; food, secretion of digestive fluids and propels How many pounds and Appetite. (push) digestive food (chyme) in to the small Associate Factors: Food preferences; Eating intestine. routines or Religious values; Psychological factors; Physical factors; Access to grocery Small Intestine stores; Eating habits; Self-imposed dietary restrictions; Body images; Nutritional knowledge. − This is the longest segment of GIT (70 meters or History: Eating disorders; Family history 230ft). (diabetes, heart problems). − It is the absorption of nutrients. − It has three sections: B. Abdominal Pain – It can be a major symptom of GI Duodenum (proximal) – It has duodenal disease; A frequent presenting problem; Take note of time papilla (emptying of all secretions coming of pain. from the liver and pancreas that would help in the metabolism). Characteristics: Describe s/sx; Started when; Jejunum (middle) Location; How long does it last; Pain scale; What Ileum (distal) makes it better or worse; Distribution of referred o It terminates at the ileocecal abdominal pain. valve. Associated Factors: Fever; N/V; Weight loss, o It controls the flow of digested Diarrhea. material from the ileum into the History: Family history: cancer, ulcer cecal portion of large intestine. Inflammatory bowel disease. o Is where vermiform appendix C. Dyspepsia (Indigestion) – Associated with eating. located. Is an appendage attached to the cecum which is Characteristics: Using COLDSPA: Distribution characterized by having a little or of referred abdominal pain; Discomfort; Fullness; no physiologic function. 1 | JK LEI - IRIS  Bloating; Early satiety; Belching; Heartburn; Associated Factors: Periods; Pain or distention; Regurgitation. Stress; Activity level; Regular time; Use of Associated Factors: Fatty foods (It stays longer antacids with calcium (It has a side effect of in the stomach); Highly seasoned foods; Coarse constipation) or anticholinergic (They block the vegetables; Salads; N/V; Diarrhea; Alcohol effect of acetylcholine which can lead to less intake; Medications (aspirin). muscle movement) History: Hereditary (IBD). History: Cancer; Depression (less activity); Metabolic disorders such as Hypercalcemia may D. Nausea and Vomiting – Distention of duodenum or lead to a manifestation of constipation; DM has a upper intestinal tract. nerve damage which affects the vagus nerve that controls the movement of the food in the GI tract; Characteristics: Stimuli; Food; Odor; Activity; Hyperparathyroidism increases calcium; All of Time of the day; Before or after food intake; How which leads to constipation. many times; What food/fluid is tolerated; Amount; Color; Odor; Consistency. G. Dysphagia – Difficulty in swallowing. Associated Factors: Fever; Headache; Dizziness; Weakness; Diarrhea; Weight loss. Characteristics – Using COLDSPA: Onset History: Gall bladder diseases; Ulcer; Cancer. gradual or acute; With swallowing intermittent; Continuous; Associated with solid foods; Liquids. Nature of Vomitus Associated Factor: Regurgitation (common manifestation of GERD) Heartburn; Chest or back o Undigested food particles – may suggest pain; Weight loss; Hoarseness; Voice change or tumor, ulcers and obstructions. sore throat. o Blood (hematemesis) – may be due to hemorrhage; If bright red (arterial bleeding), and History: Cancer; Stroke; Palsy; Neurologic if dark red (venous bleeding). disorders; Alcohol or tobacco intake. o Bilious material – it may taste bitter. NOTE: If there is swallowing difficulties, we have to o Gastric contents – it may taste sour (acid). complete nutritional assessment, and if we noticed any o Bright Red Vomitus – Mallory-Weiss tear or symptoms of dysphagia, refer the patient and expect for a laceration in the mucosal lining of the gastro barium swallow. esophageal junction which indicates upper GI bleeding. o Coffee Ground Vomitus – it may indicate digested blood from slow bleeding. o Yellowish Vomitus – It may indicate bile leakage, medication (Senna – it treats constipation and remove bowel contents). o Fecal Contents Vomitus – It may indicate intestinal obstruction. E. Diarrhea – Abnormal increase in the frequency and liquidity of the stool leading to fluid and electrolyte imbalances. Physical Examination Characteristics: Using COLDSPA: How long; Frequency; Consistency; Color; Quantity and 1. Inspection odor; Blood; Mucus; Pus; Food particles; Change 2. Auscultation in bowel habits; Nocturnal diarrhea; What makes 3. Percussion if worse or better; Weight loss. 4. Palpation Associated Factors: Fever; N/V; Abdominal − Position – supine with knees flexed slightly pain and distention; Flatus; Cramping; Urgency with straining; Antibiotics; Recent travel; NOTE: IAPP is used when examining the abdomen, to Emotional stress (anxiety). prevent altering the result, because any changes on the History: Cancer; Ulcerative colitis; Chron’s order of the assessment will alter bowel sound. disease; Malabsorption. F. Constipation – Decrease in the frequency of stools which are hard, dry and in smaller volume. Characteristics: Using COLDSPA: Frequency; Consistency; Color; Change in bowel habits; Gradual or sudden change; Size of stool; Diet change; Bloor or mucus. 2 | JK LEI - IRIS Abdominal Mapping – 4 Quadrants, 9 Regions. 3. Percussion 4 Quadrants − This assess the size and density of abdominal organ. − Note for presence of abdominal masses, tympany (sound of air in the stomach and intestine) and dullness (sound of air in organs and solid masses). − Light percussion to produce mild localized response to determine peritoneal irritation. − NOTE: Percussion is used independently or concurrently with palpation because it validated palpation findings. 4. Palpation 9 Regions − Light Palpation – to identify for tenderness or muscular resistance. − Deep Palpation – to identify masses. Additional: Rectal Inspection and Palpation − Final part of the GI tract. − Is used to assess for the rectum. Nursing Considerations: Prepare equipment (prepare everything you think is needed): gloves, water soluble lubricant (KY jelly), penlight and drapes. Provide comfort and privacy Position: Knee chest, left lateral with hips and knees flexed, standing with hips flexed while Assessment Proper: upper body is supported by an examination table. 1. Inspection Inspect for lumps, rashes, inflammation, abscess, fissures, fistulas, rectal prolapse and − Note for skin changes, nodules, lesions, hemorrhoids (spread the buttocks to assess the inflammation, symmetry, bulging, distention, and inner part of the rectum). contours (if it’s flat, round or scaphoid) over the Palpate sphincter tone, presence of nodules. abdomen. Instruct patient how to perform deep breathing exercises and visualize pleasant things. 2. Auscultation Objectives of Physical Assessment: − Using stethoscope, note for character, location and frequency of bowel sounds, heard over ✓ Tenting of the skin → Dehydration stethoscope. (Use Diaphragm for soft clicks and ✓ Mouth lesions, missing teeth, swollen or gurgling sounds; Use Bell for low pitch sounds bleeding gums → Weight loss and nutritional such as bruits). deficiency − Note for friction rubs (high-pitched) which is ✓ Body weight → Obesity, anorexia or malignancy usually heard over liver and spleen during ✓ Palpable mass → Enlarged organ, inflammation, respiration. malignancy or hernia − Note for borborygmus (loud, prolonged gurgle); It ✓ Rebound tenderness, guarding, rigidity → is when the stomach gurgles or growling. Appendicitis, cholecystitis, peritonitis, − NOTE: Auscultation always precedes percussion pancreatitis, duodenal ulcer and palpation to prevent alteration of bowel ✓ Protuberant or bulging abdomen or flanks → sounds. Ascites (shifting of fluids from any organs towards abdomen) 3 | JK LEI - IRIS  ✓ Distention and absence of bowel sounds → Stool Examinations Intestinal obstruction Purposes: Common Abnormalities in Stool Characteristics: o Inspect consistency and color (normal color is light to dark drown; Foods and Upper GI Bleeding (UGIB) – Melena (black tarry medications can affect the color of stool) stool) o Determine fecal urobilinogen (to Lower GI Bleeding (LGIB) – Bright or dark red determine presence of bilirubin; If Lower Rectal or Anal Bleeding – Blood streaks urobilinogen is diminished, it may on the surface of the stool or blood on toilet paper. suggest an obstructive jaundice). Steatorrhea (Presence of fats) – Bulky, greasy, o Measures fecal fat foamy, foul smelling stool which may or may not o Determine bacteria, parasites and other float. pathogens Decrease or absence of conjugated bilirubin – o Identify fecal leukocytes (a response of Light gray or clay-colored stool. the body to invading microorganisms Chronic ulcerative colitis, shigellosis – such as shigellosis and amebiasis). Presence of mucus threads or pus. Hemoccult Guaiac Test (FOBT) Constipation or intestinal obstruction – Small, o Most common stool examination and is dry, rock-hard masses with occasional blood used in early screening for GI tract streaks in the stool. cancer. Spastic colon syndrome (IBS) – Marble sized stool pellets. Nursing Responsibilities: NOTE: Normal color of stool is light to dark brown; Color To avoid false positive: of stool can change by abnormalities of the body, or ✓ Don’t perform when there is hemorrhoidal ingestion of foods and medications. bleeding Diagnostic Tests ✓ 3 days before the test, instruct to take a high fiber diet Blood tests are ordered initially ✓ Avoid red meats ✓ Avoid aspirin and NSAIDs (ibuprofen, naproxen) Complete Blood Count (CBC) ✓ Avoid foods high in peroxidase (radish, cabbage, Liver Function Test (LFT) cauliflower, broccoli, melons) Complete Metabolic Panel (determines sodium, ✓ Avoid iron supplements (can cause black tarry potassium, magnesium, electrolytes and other stool) substances and chemicals) ✓ Avoid laxatives, enemas, rectal suppositories Prothrombin Time (PT) and Partial (can cause slight injuries and abrasions). Thromboplastin Time (PTT) Triglycerides To avoid false negative: Amylase and Lipase (determines pancreatitis) Carcino Embryonic Antigen (CEA) (determines ✓ 3 days before the test, instruct to avoid Vitamin C cancer) supplements (it interferes with chemical reaction CA-19-9 (tumor marker for GI tract cancer) that occurs when there is blood). Preparation for many NOTE: Occult – bleeding is not visible; Guaiac – is a substance from a plant which is used for FOBT test. Fasting Laxatives Breath Test Enema and injection or injection of contrast agent Hydrogen Breath Test: or radio opaque dye (barium enema) o Help diagnose common digestive Nursing Considerations: problems such as Small Intestinal Bacterial Overgrowth (SIBO) and ✓ Diagnostic test is always depending on the Inflammatory Bowel Disease (IBD). primary care provider o Evaluates carbohydrate absorption ✓ Review and check institutional protocols for any o Determine amount of hydrogen expelled specific laboratory procedures that we may use in the breath. for the patient. o NOTE: Hydrogen is a byproduct of reaction between galactose and bacteria. 4 | JK LEI - IRIS  If bacteria is present in the small o To determine if barium solution hasn’t intestine, it will break glucose down. flushed yet – there is constipation and Urea Breath Test fecal impaction. o Detect Helicobacter Pylori (bacteria that Lower GI Fluoroscopy lives in the mucosal lining of stomach that o Done after rectal installation of barium causes peptic ulcer disease). solution (barium enema) o Patient will ingest a capsule of carbon- o Detects polyps, tumors, lesions of the labeled urea, then breath sample is LGIT. obtained after 10-20 minutes by blowing o Determine anatomic abnormalities and into a balloon. functional disorder of LGIT. o Carbon dioxide will be measured in the o Nursing Considerations: expired breath because H. Pylori ✓ Explain procedure metabolizes urea quickly – to determine ✓ Emptying and cleansing of lower H. Pylori is present. bowels is done by using enema o Nursing Considerations: solution. ✓ Avoid antibiotics or bismuth ✓ Low-residue diet 1-2 days prior subsalicylate for 1 month before ✓ Clear liquid diet and laxatives the the test. evening before test ✓ Avoid proton pump inhibitors for ✓ NPO after midnight 2 weeks prior (it can kill H. Pylori ✓ Barium enema is scheduled prior when combined with other any UGIT studies (enema is drugs) more uncomfortable because of ✓ Avoid H2 blockers for 24 hours the feeling of defecation after prior because it depresses enema) production of hydrochloric acid. ✓ Do not administer barium enema ✓ NPO for at least 4-6 hours prior if there is inflammatory disease ✓ Do not smoke for at least 2 hours of colon, intestinal obstruction, prior and signs of perforations to avoid further injuries. Radiology and Imaging Studies ✓ Increase fluid intake Upper GI Fluoroscopy ✓ Evaluate bowel movements o Done by introduction of contrast agent Abdominal Ultrasonography (barium sulfate) which is done after o Non-invasive test focuses high frequency barium swallow. sound waves to obtain an image of the o Detects anatomic or functional disorders. structure. o Aids in diagnosis of ulcers, tumors, o Detects: regional enteritis, crohn’s disorder, − Enlarged gall bladder or malabsorption syndromes, obstructions, pancreas ileitis, diverticula. − Gallstones o Multiple x-ray images are also obtained. − Enlarge ovaries o Nursing Considerations: − Ectopic pregnancies ✓ Explain procedure − Appendicitis ✓ Low-residue diet 2-3 days prior o Advantages: (white rice, potato, banana) − No ionizing radiation ✓ NPO after midnight − Less side effects ✓ Do not smoke or chew gum − Low cost during NPO (can increase − Results available immediately gastric secretion and salivation) o Nursing Considerations: ✓ Narcotics or anticholinergics are ✓ NPO for 8-12 hours withheld (it blocks the effects of ✓ Gallbladder: fat-free meal (fats acetylcholine) and tissues block the ✓ Instruct the stool will be light in technician’s view of the organ) color (due to barium sulfate) ✓ UTZ first prior barium studies ✓ Increase fluid intake after test (barium can interfere with sound ✓ Instruct to notify primary care waves) provider if barium has not ✓ Observer for level of flushed yet. consciousness, orientation and 5 | JK LEI - IRIS  ambulation if patient receives a ✓ WOF complications: Level of moderate sedation. consciousness, VS, O2 sat, pain ✓ Change position level, signs of perforation. ✓ Lozenges, saline gargle, oral Endoscopic Procedures analgesic to prevent minor throat − Use of fiberoptic endoscope to visualize the GIT. discomfort after gag reflex has returned. − For diagnostic and therapeutic ✓ Remain in bed until fully awake. − Inserted through mouth or rectum − Purpose: biopsy, removal of foreign objects or Lower GIT polyps, control of bleeding, and opening of strictures. Anoscopy, Proctoscopy, Sigmoidoscopy − Types: EGD/fibroscopy, colonoscopy, anoscopy, o Endoscopy of the LGIT (anus, rectum, proctoscopy, sigmoidoscopy, small-bowel sigmoid colon) enteroscopy, and endoscopy through an ostomy. o Evaluate chronic diarrhea, fecal incontinence, ischemic colitis, LGI Upper GIT hemorrhage. o Observe ulceration, fissures, abscesses, Fibroscopy/EGD tumors, polyps, other pathologic o It allows direct visualization of processes. esophagus, stomach, and duodenum. o Nursing Considerations: o Useful if there is suspected inflammation, ✓ Pre-op: neoplasm, infection of GIT. − Bowel preparation o It evaluates GI motility, collect secretion maybe performed until and tissue specimen. return flow is clear using Endoscopic Retrograde Cholangio- warm tap water or fleet Pancreatography (ERCP) enema. o Endoscope with x-ray − NPO not necessary o Allows to view the common bile duct, − Sedation not required pancreatic duct, hepatic duct, and gall ✓ Intra-op: bladder through ampulla of vater (duodenal papilla) − Position (left side-lying position with knees bend o Uses contrast dye o It evaluates jaundice, pancreatitis, anteriorly) tumors, common bile duct and gall − Monitor VS, skin color, bladder stones, biliary tract disease. temperature, pain, vagal o Therapeutic Indications: response (sudden drop ✓ Remove CBD and GB stones of BP and heart rate ✓ Dilate strictures suggest low of blood ✓ Control gastric bleeding flow to the brain) ✓ Treat esophageal varices ✓ Post-op: o Topical anesthesia (to keep patient − Rectal bleeding and gagging) and moderate sedation (to signs of intestinal lessen anxiety as prescribed) perforation o NOTE: ERCP may take an hour, the Fiberoptic Colonoscopy position of the patient is side-lying o Direct visualization of LGIT (anus to position. In some, patient is in prone cecum) position. o Use as diagnostic and screening device o Nursing Interventions (UGI): (cancer screening and surveillance) ✓ NPO for 8 hours prior o Used for tissue biopsies and removal of ✓ Anticipate administration of polyps midazolam (sedative to prevent o Evaluation of diarrhea of unknown cause, gag reflex and anxiety), atropine occult bleeding, anemia and IBD’s. (to reduce secretion), glucagon o Therapeutic Purposes: (relax smooth muscle). ✓ Remove all polyps using special ✓ Left lateral position during snare. procedure (to facilitate of ✓ Early detection and prevention of pulmonary secretions and colon cancer provide smooth entry). 6 | JK LEI - IRIS  ✓ Treat areas of bleeding and Laparoscopy (Peritoneoscopy) strictures o Minimal invasive procedure ✓ Bowel decompression o Allows visualization of the organs and o Potential Complications: structures within the abdomen with the ✓ Circulatory overload use of fiberoptic laparoscope. ✓ Vasovagal reactions o Purposes: ✓ Hypotension (due to sedatives) ✓ Diagnostic: It identifies ✓ Cardiac arrhythmias abnormalities and inflammatory ✓ Respiratory depressions (due to process in the GIT and evaluate medications and sedatives) peritoneal disease, chronic ✓ Death abdominal pain, masses, Gall o Nursing Interventions (LGI): bladder and liver diseases. ✓ Secure consent ✓ Therapeutic: Excision of the gall ✓ Limit fluid and low-residue diet bladder if appropriate. for 24-72 hours o Nursing Considerations: ✓ NPO post-midnight (duet to ✓ Secure consent sedatives): Opioid IV (morphine, ✓ Require stomach and bowel fentanyl, Demerol, decompression (through NGT hydromorphone) insertion or bowel preparation). ✓ Bowel preparation: laxative for 2 ✓ General anesthesia is nights prior examination and administered. fleet enema or saline enema the ✓ Pneumoperitoneum is expected morning of the test. to be performed (CO2 ✓ Oral electrolyte lavage solutions: insufflation in the abdomen Non-split dose regimen (entire because it separates intestines solution is ingested prior), split- from the pelvic organs for dose regimen (half of the dose is working space of surgeons for ingested the night prior, and the visualization). other half is ingested in the ✓ Small lateral incision to the morning prior). umbilicus (allows insertion of the ✓ Special precautions on patients fiberoptic laparoscope). with implantable defibrillators and pacemakers: consult cardiologist for device management and patient is monitored during the procedure. ✓ Not performed if there is colon perforation, coagulopathies, those receiving anticoagulants. ✓ NSAID’s, aspirin, ticlopidine must be discontinued because it promotes bleeding. ✓ Prophylactic antibiotics those with prosthetic heart valves or endocarditis due to infection in the circulation. ✓ Observe for signs of intestinal perforation (bleeding, pain). NOTE: Endoscopy procedures is usually done in OPD basis (procedure will be done in the morning, then the patient will be discharged in the afternoon); Once discharge, the patient can’t drive for several hours due to possible injury because of sedation. 7 | JK LEI - IRIS  NCMB – 316: MEDICAL SURGICAL NURSING 2 2nd SEMESTER PRELIMS 3RD YEAR NURSING WEEK 2 – Disorders of the Upper G.I. Mimic heart attack – it may complain heart attack; We need to understand the manifestation Gastroesophageal Reflux Disease (GERD) so we can deliver an appropriate management to the patient. − This is a common disorder Dental erosions, ulceration in the pharynx and − Characterized by backflow of stomach or esophagus, laryngeal damage, esophageal gastric/duodenal contents into the esophagus strictures, adenocarcinoma, pulmonary resulting esophageal mucosal injury complications such as aspiration. − Causes: Incompetent lower esophageal Diagnosis: sphincter – the junction between the esophagus and stomach the sphincter is Patient’s History open which allows the reflux. Ambulatory pH monitoring – involves the Pyloric stenosis – stenosis is a placement of trans nasal catheter, so this narrowing in the junction between the endoscopy is inserted wireless capsule and stomach and duodenum which prevents inserted inside the stomach at approximately the stomach contents from moving 24hrs, it quantifies a measure of the reflux. toward to the intestine. Gold standard Hiatal hernia – is a part of the stomach Endoscopy or barium swallow – use to that protrudes into the diaphragm. evaluate damage to the esophageal mucosal and Motility disorder – peristaltic movement also rule out esophageal strictures and hiatal is abnormal. hernia. − Other Risk Factor: Increased in aging Management: Irritable bowel syndromes Obstructive airway disorders – such as ✓ Patient education – avoid secretion can cause asthma, COPD, possible cause is esophageal irritation to decreases lower hyperinflation of the lungs. esophageal sphincter pressure. Barrett esophagus – wherein the lining ✓ Stop smoking of esophageal mucosal is altered so it ✓ Limit alcohol intake looks like the stomach rugae; Esophagus ✓ Weight loss – obesity can contribute to burn should be smooth. wherein fats puts pressure into the stomach. ✓ Maintain normal body weight Peptic Ulcer Disease (PUD) ✓ Low-fat diet, avoid caffeine, foods containing Angina (is related to chest pain which peppermint, carbonated beverages. may contribute to gas stimulation which ✓ Elevate head of bed – to prevent aspirations. results in GERD) ✓ Avoid eating or drinking 2 hours prior bedtime Irritants are; Tobacco use, coffee ✓ Avoid tight-fitting clothes drinking, alcohol consumption, H. ✓ Antacids – this neutralizes gastric acids (SE of pylori infection (wherein the stomach is antacid is including the loss of normal gastric flora exposed to the h. Pylori infection which may lead to infection of clostridium difficile). Clinical Manifestation: ✓ H2 blockers – it can contribute managing GERD by decreasing gastric acid production. Example Pyrosis (Heartburn) – wherein the patient has a of this are famotidine and cimetidine, proton feeling of burning sensation in the esophagus pump inhibitor (it can contribute managing GERD which is not cardiac in nature. by decreasing gastric acid production) Regurgitation – considered as a whole mark of ✓ Pantoprazole and omeprazole, prokinetic symptoms. agents – such as metoclopramide or plasil Dyspepsia – feeling of indigestion. (accelerate gastric emptying which is promote Dysphagia or odynophagia – difficulty of passage of stomach contents in the intestine. swallowing. Hypersalivation – excessive production of Open laparoscopic Nissen fundoplication saliva. Esophagitis – inflammation of esophageal lining. − It involves wrapping of a portion of the gastric fundus around in the sphincter area of esophagus; It will tighten the junction between 8 | JK  esophagus and stomach to prevent reflux that is tissues and organs in the mediastinum that organ the purpose of this surgery. separate the lungs. − If the medical management is unsuccessful, surgical intervention may be necessary Management: particularly Open laparoscopic Nissen fundoplication. Endoscopic Septostomy Esophageal Diverticulum − Wherein it involves dissection of the pouch. − Peroral Endoscopic Myotomy (POEM) – it − An out–pouching of mucosa and submucosa that involves dissecting only the cricopharyngeal protrudes through a weak portion of the muscles muscle leaving the pouch sac unchanged. of the esophagus − Open surgery − NOTE: May occur in 1 of 3 areas of the − Diverticulectomy – to remove pouch itself. esophagus, the 1st area is in the upper part of esophagus which is the pharyngoesophageal; Intra-op The 2nd area is in the middle part of the ✓ Extra care is given to Avoid trauma to the carotid esophagus which is the mid-esophageal. 3rd artery and internal jugular veins (because the area is in the lower part of the esophagus is surgical site in the diverticulectomy is just epiphrenic diverticula. adjacent to the major arteries). ✓ Facilitate gastric emptying to prevent. Zenker Diverticulum ✓ Postop ileus and allow feeding and medications; NGT may be inserted with imaging technique – − The most common type of diverticulum with a guide of imaging. − Located in the pharyngoesophageal area of the ✓ NOTE: The blind insertion for NGT is avoided to esophagus and located posterior to the pharynx prevent perforation middle of the neck. − Caused by a dysfunctional sphincter that fails to Postop: open (pulsion diverticulum) – this leads to an increased pressure that forces to the mucosa and ✓ Observe for the incision for evidence of leakage submucosa to protrudes herniate through the and from the esophagus and development of esophageal musculature or muscle of fistula. esophagus. ✓ Intermediate post operation, after the surgery, − Common in people older than 60 years old. nurses should request for Post-operative X-ray. To determine if there are any leakage from the Clinical Manifestation: surgical site – from the site wherein the pouch or the diverticulum has been removed. Dysphagia ✓ Food and fluids are withheld until evidence of no Fullness in the neck because of the presents of leakage (that means the patient is still under NPO food until the X-ray shows no leakage in the surgical Pouch becomes full with food or liquid site. Once the patient x-ray shows no evidence of Belching, regurgitation of undigested food leakage, the diet may begin with liquid and (particularly if the patient is recumbent position). progresses to). ✓ Diet begins with liquid then DAT (diet as Coughing (irritation of the tracheal and tolerated) aspiration). ✓ It can be treated by endoscopy (rigid or flexible) Gurgling noises after eating (occurs when air or open surgery. passes in the diverticulum). ✓ Endoscopic septostomy effectively treats ZD, Halitosis (is a foul odor which caused by with a recurrence rate of 11% to 30% of cases; decomposed food at are retain in the POEM may be a better option as it is associated diverticulum). with a decreased risk of symptom recurrence. Sour taste in the mouth (retained food in the ✓ If surgery is required, care is taken to avoid diverticulum that also decomposed). trauma to the common carotid artery and internal jugular veins. Diagnosis: ✓ In addition to a diverticulectomy, a myotomy of the cricopharyngeal muscle is often performed to Barium swallow – it can determine the exact relieve spasticity of the musculature, which measure and location of the diverticulum. seems to contribute to a continuation of Esophagoscopy is contraindicated – there’s a symptoms. possibility of perforation of diverticulum when the ✓ An NGT tube may be inserted at the time of diverticulum perforates it may result of surgery. Postoperatively, the nurse observes the mediastinitis wherein there’s an inflammation of incision for evidence of leakage from the esophagus and a developing fistula. 9 | JK LEI - IRIS  ✓ Food and fluids are withheld until x-ray studies Esophagogastroduodenoscopy (EGD) – which show no leakage at the surgical site. The diet is the passage of a fiberoptic tube through the begins with liquids and is progressed as mouth and throat into the digestive tract for tolerated. visualization of the esophagus, stomach, and ✓ Surgery is indicated for epiphrenic and mid small intestine. esophageal diverticula only if the symptoms are Esophageal manometry – measures the troublesome and becoming worse. pressure and constriction of the esophagus ✓ Treatment consists of a diverticulectomy and long during the swallowing; or chest CT scan. myotomy. Intramural diverticula usually regress after the esophageal stricture is dilated. Management: Hiatal Hernia ✓ It includes frequent, small feedings that can pass easily through the esophagus. − The opening in the diaphragm which esophagus ✓ The patient is advised not to recline for 1 hour passes becomes enlarged and part of the after eating, to prevent reflux or movement of the stomach hernias into the lower portion. hernia, and to elevate the head of the bed on 4- − 2 types: to 8- inch (10- to 20-cm) blocks to prevent the hernia from sliding upward. 1. Sliding Type 1 ✓ Surgical hernia repair is indicated in symptomatic − Upper portion to the stomachs and the patients, although the primary reason for the gastroesophageal junction is displaced upward surgery is typically to relieve GERD symptoms and slide in and out of the thorax. and not repair the hernia. − Between 90% and 95% of 3406 patients with ✓ Current guidelines recommend a laparoscopic esophageal hiatal hernia have a sliding hernia. approach (Toupet or Nissen fundoplication procedures), with an open transabdominal or 2. Paraoesophageal transthoracic approach reserved for patients with − Classified into II, III, IV complications such as bleeding, dense − All or part of the stomach pushes through the adhesions, or injury to the spleen. diaphragm ✓ Frequent, small feeding – so that food can pass − Type IV has the greatest herniation with other easily through the esophagus. intra-abdominal viscera such as the colon, ✓ Recline for 1 hour after eating – to prevent omentum, or small bowel present in the hernia reflux and movement the esophagus. sac that is displaced through the hiatus along with ✓ Elevate head of bed 4-8 inches – to prevent the stomach. hernia from sliding upward. − Other abdominal structures move up through the ✓ NOTE: A surgical repair is indicated with hiatal diaphragm. hernia, particularly with asymptomatic Clinical Manifestation: Toupet or Nissen fundoplication The patient with a sliding hernia may have pyrosis − Considered as current guidelines and that are (heart burn), regurgitation, and dysphagia, but indicated for patients with complications such as many patients are asymptomatic. bleeding, adhesions and injury to the spleen. The patient may present with vague symptoms of − Involves in creating a barrier between the intermittent epigastric pain or fullness after esophagus and the stomach. Nissen eating. fundoplication is a wrapping of a gastric fundus Large hiatal hernias may lead to intolerance to around the sphincter of the esophagus. food, nausea, and vomiting. Postop: Sliding hiatal hernias are commonly associated with GERD. ✓ Progressive liquid to solid diet Hemorrhage, obstruction, volvulus (bowel ✓ Manage N&V, nutritional intake, weight obstruction caused by a twist in the intestines and monitoring WOF belching, abdominal distention, supporting mesentery), and strangulation can epigastric pain. occur with any type of hernia but are more ✓ Up to 50% of patients may experience early common with paraoesophageal hernia. postoperative dysphagia; therefore, the nurse advances the diet slowly from liquids to solids, Diagnosis: while managing nausea and vomiting, tracking nutritional intake, and monitoring weight. Is typically confirmed by x-ray studies ✓ The nurse also monitors for postoperative (confirmatory) belching, vomiting, gagging, abdominal Barium Swallow – to determine the extent of the distention, and epigastric chest pain which may hernia. indicate the need for surgical revision; these 10 | JK LEI - IRIS  should be reported immediately to the primary ✓ Patient is instructed to eat slowly and to drink provider. fluids with meals. ✓ Surgical repair is often reserved for patients with ✓ Injection of botulinum toxin injection is injected more extreme cases that involve gastric outlet into quadrants of the esophagus via endoscopy obstruction or suspected gastric strangulation, has been helpful because it inhibits the which may result in ischemia, necrosis, or contraction of smooth muscle; However, the perforation of the stomach. benefits of these injections fade over time and there is a risk of submucosal fibrosis, botulinum Achalasia toxin is only used in patients who cannot receive other definitive treatments. − Is absent or ineffective peristalsis of the distal ✓ It can be treated conservatively by pneumatic esophagus accompanied by failure of the dilation to stretch the narrowed area of the esophageal sphincter to relax in response to esophagus. swallowing. ✓ Pneumatic dilation has a high success rate; − Narrowing of the esophagus just above the however, typically two dilations are required and stomach results in a gradually increasing dilation the long-term results are variable. Although of the esophagus in the upper chest. perforation is a potential complication, its − Is rare may progress slowly, and occurs most incidence is low). often in people between ages 20 and 40 and ages ✓ The procedure can be painful; therefore, 60 and 70 years moderate sedation in the form of an analgesic or tranquilizer, or both, is given for the treatment. Clinical Manifestation: ✓ Achalasia may be treated surgically by Esophagomyotomy, called a Heller myotomy Dysphagia (main symptoms, with hallmark being (involves cutting the esophageal muscle fibers). difficulty with solid food). ✓ A complete lower esophageal sphincter myotomy Patient has a sensation of food sticking in the is usually performed laparoscopically, with or lower portion of the esophagus. without a fundoplication (anti-reflux procedure As the condition progresses, food is commonly that minimizes the incidence of GERD). regurgitated either spontaneously or intentionally ✓ A newer technique, an endoscopic myotomy (per- by the patient (to relieve the discomfort produced oral endoscopic myotomy [POEM]) – provides an by prolonged distention of the esophagus by food alternative procedure that has been adopted by that will not pass into the stomach). many high-volume achalasia centers. The patient may also report noncardiac chest or epigastric pain (mimic myocardial infarctions) and Disturbances in Digestion pyrosis (heartburn) that may or may not be associated with eating. These symptoms mirror Gastritis those of GERD, and patients are often − Inflammation of the gastric mucosa misdiagnosed and treated for GERD. − It may be acute or chronic gastritis Diagnosis: Acute Gastritis − Erosive – caused by local irritants; particularly X-ray studies show esophageal dilation above the use of aspirin, NSAIDs, corticosteroids, alcohol narrowing at the lower gastroesophageal consumptions, undergoing gastric region therapy. sphincter, which is called a bird’s beak deformity. − Non-erosive – caused by infection (H. pylori). Barium swallow − Most severe form is ingestion of strong acid or CT scan of the chest alkali, this may cause damage to the gastric Endoscopy may be used for diagnosis; however, mucosa, the mucosa may become gangrenous or high-resolution manometry (confirmatory the mucosa may perforate. diagnosis) – a process in which peristalsis, − The inflammation present in your acute gastritis contraction amplitudes, and esophageal pressure can cause scarring which may result to pyloric is measured by a radiologist or stenosis or obstruction. gastroenterologist, confirms the diagnosis. − It may develop in patients who have/had major traumatic injuries, burns, severe infection, lack of Management: perfusion to the stomach lining, and surgical procedure can cause acute gastritis. ✓ Eat slowly and drink fluids with meals − NOTE: Acute gastritis is also referred to as your ✓ Botulinum toxin injection stress related gastritis or ulcer. ✓ Pneumatic dilation ✓ Esophagomyotomy (Heller myotomy) Chronic Gastritis ✓ POEM − Classified according to causative mechanism (H. pylori). 11 | JK LEI - IRIS  − Can lead to peptic ulcer diseases and cancer of o Belching /Burping (due to inflammation & the stomach/gastric adenocarcinoma. irritation in the stomach lining that will − Can also result to gastric mucosa associated lead to the late gastric emptying which lymphoid tissue lymphoma. result to accumulation of air) − NOTE: Chronic gastritis is being implicated in the o Sour taste in mouth (presence of acid) development of peptic ulcer diseases o Halitosis o Early satiety Other possible causes: o Anorexia, N&V o Problems Vit. B12 absorption (px may − Long-Term Drug Therapy – NSAIDs, aspirin not be able to absorb Vit. B12, there may which may lead to chemical, gastric injury or be malabsorption of the Vit. B12 because gastropathy. of diminished intrinsic factor by the − Reflux of duodenal contents into the stomach stomach due to the atrophy of the – often occurs after gastric surgery stomach - may lead to pernicious (gastroduodenostomy & gastrojejunostomy). anemia. − Autoimmune disorder – can also contribute to chronic gastric such as hashimoto thyroiditis, Diagnosis: Addison’s disease. − Hashimoto Thyroiditis – does not produce Endoscopy & Biopsy enough thyroid hormone. CBC – to assess for anemia as a result of − Addison’s Disease – has damage to adrenal hemorrhage/pernicious anemia and to determine glands. presence of H. pylori). Biopsy Pathophysiology Serologic Testing (presence of antibodies against H. Pylori. Stool Antigen Test Urea Breath Test (to determine the presence of H. Pylori). Medical Management: Acute Gastritis o Refrain from alcohol and food o Non-irritating diet (bland diet) o IV fluids if necessary o Supportive therapy (NGT, antacids H2 blockers, proton pump inhibitors - omeprazole, and IV fluids) o EMERGENCY: gastrojejunostomy (it is done in extreme and emergency situations, to treat pyloric NOTE: Gastritis is characterized by a disruption of the obstruction/gastric outlet obstructions mucosal barrier which normally protects the stomach which involves the narrowing of the lining/stomach tissues. pyloric orifice. Clinical Manifestations: Chronic Gastritis o Modify diet Acute Gastritis o Promote rest o Epigastric Pain o Reduce stress o Dyspepsia o Avoid alcohol and NSAIDs o Anorexia, N&V o Treat H. Pylori if appropriate (particularly o Hiccups with proton pump inhibitors, antibiotics, o Blood in vomitus and bismuth salts) o Melena o hematochezia Nursing Management: Chronic Gastritis ✓ Manage N&V, pyrosis o Fatigue ✓ Maintain on NPO while with symptoms o Pyrosis after eating (heartburn after ✓ Ice chips followed by clear liquids if symptoms eating) subside. ✓ Introduce solid foods ASAP ✓ Discourage intake of caffeine and alcohol 12 | JK  ✓ Discourage smoking Pathophysiology ✓ Monitor daily I&O ✓ Assess electrolytes every 24 hours ✓ WOF signs of hemorrhagic gastritis ✓ Observe stools for presence of frank bleeding or occult bleeding ✓ Avoid foods and fluids that may irritate gastric mucosa Peptic Ulcer Disease − Excavation of mucosa in an area of the GIT (hollowed-out area). − NOTE: As a role, peptic ulcer, this occur alone but NOTE: Peptic ulcer diseases commonly occurs in the they may occur in multiple as well and the gastroduodenal mucosa because those tissues around ulceration/excavation of the GIT depends on the that area cannot withstand the digestive action of the location of your peptic ulcer). gastric acid and pepsin. Ulceration depends on the location: Clinical Manifestation: − Gastric (pylorus) − Duodenal Epigastric pain or back pain − Esophageal Dull, gnawing, burning − Ulceration is caused by erosion of the Pain after eating circumscribed area or the GIT mucosa Gastric ulcer Pain 2-3 hours after eating and during night Circumscribed Area Duodenal ulcer − Limited area of the GIT mucosa due to the Pyrosis (non-specific symptoms) increase of concentration or increase activity of Vomiting (which is a rare complication but may be acid pepsin or due to the decreased resistance of due to gastric outlet obstructions and muscular the protective mucosal barrier spasm of the pylorus or may be due to mechanical obstruction from the inflammation of Predisposing Factors: the mucus membrane) Constipation or diarrhea (which may occur as a Onset between 30-60 years old result of diet and medications) H. Pylori infections Hematemesis or melena (as a result of Use of NSAIDs (major risk factor) perforation) Common in older adults because of the presence Sour eructation (sour burps) of H. Pylori infections or the use of NSAIDs can Hypotension and tachycardia lead to impairment of the protective function of the gastric mucosa and failure of the GI tract Assessment: (mucosa) which leads to the ulceration. Smoking and alcohol UGI endoscopy (preferred diagnostic procedure Familial tendency which allows direct visualization of the Wherein blood type O are more at risk than A, B, esophagus, stomach and duodenum - to and AB determine lesion, size, location) The blood type O there is an enhance binding of Serologic testing (antibodies for H. Pylori) H. Pylori to the epithelial cells of patients with Stool Ag test (determine process of H. Pylori) blood type O. Urea breath test (determine process of H. Pylori) COPD, liver cirrhosis, CKD, autoimmune Periodic CBCs disorders which may be due to the decrease Stool tests immune system Gastric secretory studies Zollinger-Ellison Syndrome (ZES) ZES Multiple Endocrine Neoplasia Type 1 (MEN-1) Achlorhydria Rare condition or benign or malignant tumors that Hypochlorhydria form in the pancreas and duodenum which Hyperchlorhydria secretes the hormone gastrin. Medical Management: Goals: ✓ Eradicate H. Pylori ✓ Manage gastric acidity 13 | JK LEI - IRIS Pharmacologic Treatment: Triple therapy ✓ Hemorrhage and gastritis ✓ 2 antibiotics and PPI ✓ Faintness, nausea and dizziness ✓ Metronidazole or Amoxicillin and Clarithromycin ✓ Perforation and penetration (involve the erosion ✓ Lansoprazole or Omeprazole or Rabeprazole of ulcers through the gastric mucosa into the parent to a peritoneal activity until it reaches Quadruple Therapy: adjacent structures - pancreas, biliary tract, ✓ 2 antibiotics (Metronidazole & Tetracycline), a omentum) PPI and bismuth salts ✓ Typically prescribed for 10-14 days Signs and Symptoms of Penetration: ✓ Advise client to adhere to drug regimen and avoid NSAIDs ✓ Back pain and epigastric pain which may not be ✓ Maintenance of H2 blockers dosages relieved by medications. (recommended for 1 year) ✓ Sudden and severe abdominal pain, and right ✓ Octreotide (usually prescribed to suppress shoulder because of irritation of the phrenic nerve gastrin levels) in the diaphragm ✓ Stop smoking (can decrease the secretions of Complications of Perforation & Penetration: bicarbonate from the pancreas into the ✓ Vomiting & collapse duodenum, this results to increase acidity of the Manifestation of Perforation & Penetration: duodenum). ✓ Extreme tenderness and rigid abdomen upon palpation or board-like abdomen upon palpation. NOTE: Your bicarbonate is alkaline which neutralizes acid Hypertension and tachycardia may indicate and smoking delays healing of peptic ulcers and to avoid shock over excretions of acids and hypermotility of the GIT. ✓ Peritonitis Dietary Modifications: NOTE: The evidence of perforation and penetration may ✓ Avoid extremes of temperature in foods and require surgical intervention based on the evidences beverages showed by the patient. Perforation & Penetration may ✓ Avoid alcohol, coffee, caffeinated beverages lead to peritonitis – Which you will expect that patient will ✓ Eat 3 regular meals a day undergo exploratory laparotomy. Surgical Management: Evaluation: ✓ Vagotomy with or without pyloroplasty ✓ Antrectomy with billroth I or II ✓ Reports freedom from pain (between day and NOTE: intractable ulcers are those that fail to heal night) after 12-16 weeks of medical treatment ✓ Maintains weight ✓ No evidence of complications (e.g., hemorrhage, Nursing Management: perforation or penetration, gastric outlet obstruction) Assessment ✓ Demonstrates knowledge of self-care activities o Describe pain and its pattern ✓ Avoids irritating foods and beverages (alcohol) o Determine how often vomiting is and medications such as NSAIDs, particularly o Note for melena aspirin o Determine usual food intake, smoking, ✓ Takes medications as prescribed ENDS, alcohol intake, use of NSAIDs, family history Diagnosis o Acute pain associated with the effect of gastric juice on damage tissue o Anxiety associated with an acute illness Planning & Goals o Relief of pain o Reduced anxiety o Maintenance of nutritional requirements o Absence of complications Nursing Interventions: ✓ Avoid NSAIDs, eat meals at regular intervals ✓ Explain meds and lab tests ✓ Adhere to medication regimen and dietary restrictions ✓ Monitor and manage potential complications 14 | JK LEI - IRIS  NCMB – 316: MEDICAL SURGICAL NURSING 2 2nd SEMESTER PRELIMS 3RD YEAR NURSING WEEK 3 – Disturbances of the Liver, Pancreas, and Large Bowel Obstruction Gallbladder − Most obstructions in the large intestines occur in Intestinal Obstruction the sigmoid colon. − Most common causes of large bowel obstruction − Intestinal obstruction exists when blockage are cancer (60%), diverticular disease (20%), and prevents the normal flow of intestinal contents volvulus (5%). through the intestinal tract. − Other causes of large bowel obstruction include − Two types of processes can impede this flow: benign tumors, strictures, and obstipation or fecal 1. Mechanical obstruction (Intrinsic & impaction. extrinsic) − Obstipation – severe constipation may result 2. Functional or paralytic obstruction fecal impaction that accumulates on the sigmoid − Obstruction can occur in the large or small colon. intestine and can be partial or complete. − Severity depends on the region of bowel affected, Clinical Manifestations: the degree to which the lumen is occluded, and especially the degree to which the vascular Initial symptom is usually crampy pain that is supply to the bowel wall is disturbed. wavelike and colicky due to persistent peristalsis both above and below the blockage. Mechanical Obstruction Small Bowel Obstruction: − Extrinsic lesions from outside the intestines. Includes adhesions, hernias, and Abdominal pain – accompanied by visible abscesses. peristalsis wave in upper and middle abdomen − Intrinsic lesions within the intestines can Upper or epigastric abdominal distention obstruct flow. Nausea and vomiting – results in loss of Includes intestinal tumors (benign and hydrogen ions and potassium from the stomach, cancerous), strictures (from prior surgery leading to reduction of chloride and potassium in or radiation), or intraluminal lesions due the blood and to metabolic alkalosis. to a defect in the bowel lumen Obstipation – result from fecal impaction (intussusception, volvulus). Severe fluid and electrolyte imbalances – signs of dehydration, intense thirst, drowsiness, oliguria, NOTE: Volvulus – twisting of the intestine; generalized malaise, aching, and a parched Intussusception – a part of the intestine folds into tongue and mucous membranes. another section of intestines, resulting in obstruction. Metabolic alkalosis – occur due to loss of hydrogen ions and vomiting Functional or Paralytic Obstruction Large Bowel Obstruction: − Non-mechanical − The intestinal musculature cannot propel the Symptoms progresses slowly contents along the bowel (decrease peristalsis Intermittent lower abdominal cramping – d/t either due to interruption of innervation or occurring loops of large bowel vascular supply to the bowel) Lower abdominal distention − Ex: are amyloidosis, muscular dystrophy, Minimal or no vomiting – if there is vomiting it may endocrine disorders (such as diabetes, or contain fecal material neurologic disorders such as Parkinson’s Obstipation, ribbon-like stools disease). No major fluid and electrolyte imbalances − Blockage can be temporary and the result of the Metabolic acidosis manipulation of the bowel during surgery. Ribbon-like stools – trying to pass the obstruction Small Bowel Obstruction Diagnosis: − Adhesions, hernia, and tumor account for 90% of Above level of obstruction obstructions in the small intestines Bowel sounds are high-pitched and hyperactive − Other causes of small bowel obstruction include in an attempt to pass the obstruction Crohn’s disease, intussusception, volvulus, and paralytic ileus. Below level of obstruction - bowel sounds will be hypoactive. 15 | JK LEI - IRIS  Changes in the pattern (constant) or increased ✓ Fowlers positions intensity of bowel sounds may also be indicative ✓ Nasal breathing – to prevent swallowing of air of strangulation or ischemic bowel ✓ Provide comfort during NGT insertion and Abdominal x-ray and CT scan findings – decompression include abnormal quantities of gas, fluid, or both ✓ Prevent complication – of hemorrhage & in the intestines and sometimes collapsed distal perforation. bowel. ✓ Measure abdominal girth daily Laboratory studies – electrolyte studies and a ✓ Assess for sign and symptoms of peritonitis CBC: reveal a picture of dehydration, loss of – result of possible perforation of the intestine plasma volume, and possible infection. ✓ Diffused abdominal pain The approach to small bowel obstruction focuses ✓ Manifestation of infection on confirming the diagnosis, identifying the ✓ Rebound tenderness etiology, and determining the likelihood of ✓ Measure first before NGT strangulation. ✓ Peritonitis – swelling/inflammation of the lining of NOTE: Bowel strangulation – entangled bowel; your belly or abdomen or in peritoneal Ischemia – loss of blood supply may result to ✓ Layers of the abdomen – skin, subcutaneous, necrosis. fascia, muscle, peritoneum. Medical/Nursing Management: Inflammatory Bowel Disease Small Bowel − Group of chronic disorders – Crohn’s disease and ulcerative colitis that result in inflammation or ✓ Administration of hypertonic water-soluble GI ulceration (or both) of the bowel. contrast media (Gastrografin) ✓ May be of benefit in stimulating peristalsis and Crohn’s Disease (Regional Enteritis) determining the probability of needing surgical intervention. − Also called regional enteritis ✓ The dye is administered via NG tube, the tube is − Skip lesions – the diffuse bowel segment is clamped for 2 to 4 hours, then an abdominal x-ray adjoined or to next to normal bowel segment is taken within 6 to 24 hours; evidence of the dye − Characterized by a subacute and chronic in the large intestine is predictive of resolution of inflammation of the GI tract wall that extends obstruction without surgical intervention. through all layers (transmural lesion) ✓ Decompression of the bowel through − Cause of crohn's disease is idiopathic insertion of an NG tube (necessary for all − Most commonly occurs in the distal ileum and the patients with small bowel obstruction) – to ascending colon promote drainage, promote decompression, to − 35% of patients have ileitis (only ileal relieve abdominal distention. involvement); 45% have ileocolitis (diseased ✓ This may be tried for up to 3 days for patients with ileum and colon); and 20% have granulomatous partial obstructions, as resting the bowel in this colitis (only colon involvement) manner can result in resolution of the obstruction. − Risk Factors: ✓ Surgery – on complete bowel obstruction with Smoking strangulation and portion of the intestine is Family history necrotic. Genetic predisposition Large Bowel Altered immune response Altered response to GIT microorganism ✓ Restore volume correct electrolytes ✓ NGT decompression Pathophysiology: ✓ Rectal tube ✓ Surgical resection Crohn’s disease begins with crypt inflammation ✓ Ileoanal anastomosis – ileum, distal portion of and abscesses the small intestine, and the anus has been It develops into small focal ulcers 3 connected. These initial lesions then deepen into longitudinal ✓ Gastric resection – is the removal entire large and transverse ulcers, separated by edematous bowel. patches, creating a characteristic cobblestone appearance in the affected bowel. Nursing Management: Fistulas, fissures, and abscesses form as the inflammation extends into the peritoneum. ✓ Assessing for fluid and electrolyte imbalance External Enterocutaneous: ✓ Keep the patient on NPO and administer iv fluids o Fistula occurs between skin and ✓ Accurate measurement of drainage from NGT or intestine. intestinal tube 16 | JK LEI - IRIS  oMost common, fistula protrudes outside Erythrocyte sedimentation rate (ESR) is usually the intestine it creates abnormal elevated due to inflammation. communication or connection between Albumin and protein levels – may be the intestine and skin. decreased, indicating malnutrition. Enteroenteric: o Occurs between two intestines. Complications: o As the disease advances, the bowel wall thickens and becomes fibrotic, and the Intestinal obstruction intestinal lumen narrows. Stricture formation o Diseased bowel loops sometimes adhere Perianal disease – inflammation at or near the to other loops surrounding them. anus, including tags, fissures, fistulae, abscesses, or stenosis. Clinical Manifestations: Fluid and electrolyte imbalances Malnutrition from malabsorption Insidious onset – gradual but harmful Fistula and abscess formation – common type Abdominal tenderness and spasm of small bowel fistula caused by Crohn’s disease Prominent right lower quadrant abdominal pain is the enterocutaneous fistula unrelieved by defecation. Colon cancer Characterized by cramping pain: o Due to Scar tissue and the formation of Ulcerative Colitis granulomas interfere with the ability of the intestine to transport products of − Chronic ulcerative and inflammatory condition of upper intestinal digestion through the affecting the mucosal lining of the colon or rectum constricted lumen. − Characterized by unpredictable periods of o Also occur after meal remissions and exacerbations (remission in your Weight loss, malnutrition, and secondary anemia cancer is the disappearance of symptoms and occur. worsening of symptoms is the exacerbations) Chronic diarrhea – due to malabsorption; − Cause is unknown disrupted absorption, ulcers in the membranous − NOTE: the inflammation of your ulcerative colitis lining of the intestine and other inflammatory begins from the rectum through the colon changes result in a weeping, edematous intestine that continually empties an irritating discharge Pathophysiology into the colon. Fever and leukocytosis – due to inflamed It affects the superficial mucosa of the colon and intestine may perforate, leading to intra- is characterized by multiple ulcerations, diffuse abdominal and anal abscesses inflammations, and desquamation or shedding of Joint disorders (arthritis), skin lesions (erythema the colonic epithelium nodosum), ocular disorders (uveitis), and oral The mucosa becomes edematous and inflamed. ulcers. The lesions are contiguous, occurring one after Intestinal lining – distal & ileum & ascending the other colon Bleeding occurs as a result of the ulcerations Anemia – malabsorption vit. B12 / iron The bowel narrows, shortens, and thickens Malnutrition – impaired nutritional intake. because of muscular hypertrophy and fat Erythema nodosum – skin lesion redness over deposits because the inflammatory process is not skin shed (tibia) (Erythema nodosum & uveitis). transmural (it affects the inner lining only), abscesses, fistulas, obstruction, and fissures are Diagnosis: uncommon in ulcerative colitis CT scan is indicated – to find bowel wall Clinical Manifestation: thickening and mesenteric edema, as well as obstructions, abscesses, and fistulas, and may Diarrhea – experien