Disorders Of The Digestive And Gastrointestinal Systems PDF

 DISORDERS OF THE DIGESTIVE AND GASTROINTESTINAL SYSTEMS A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 1. Disturbances in Ingestion GERD (Gastroesophageal Reflux Disease)- common disorder marked by backflow of gastric and duodenal contents into the esophagus t...

 DISORDERS OF THE DIGESTIVE AND GASTROINTESTINAL SYSTEMS A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 1. Disturbances in Ingestion GERD (Gastroesophageal Reflux Disease)- common disorder marked by backflow of gastric and duodenal contents into the esophagus that causes troublesome symptoms and/or mucosal injury to the esophagus. A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 1. Disturbances in Ingestion GERD Predisposing Factors Precipitating Factors Incompetent gastro- Coffee drinking esophageal sphincter Alcohol Previous surgeries Chronic coughing Idiopathic factors Large Meals Peptic Strictures Delayed gastric emptying  Increased secretions of the stomach content Increased pressure in the abdomen Regurgitation of the gastric acid into the esophagus Irritation and erosion of the mucosal lining Increased secretions of the stomach content Esophagitis GERD Signs and Symptoms of GERD 1. Heartburn- sharp, painful burning in the upper abdomen or middle of the chest, behind the breastbone that can rise up from the lower tip of the breastbone toward your throat 2. Regurgitation- backflow of stomach contents through your esophagus and into your mouth or throat. This may cause you to taste food or stomach acid. 3. Difficulty swallowing- stomach acid may irritate and eventually damage the larynx as it travels through the esophagus and into the throat. 4. Sour or bitter taste in the mouth- because of the digestive acids and enzymes. 5. Odynophagia- pain in swallowing due to esophagitis. MEDICAL MANAGEMENT: 1. Antacids 2. Proton pump inhibitors 3. Avoid CASH diet Caffeine Alcohol Spicy food/smoking Hot food or high in fats 4. H2 receptor blocker ex. Ranitidine NURSING DIAGNOSES: 1. Alteration in Comfort: Pain related to swallowing; difficulty secondary to inflammation of the esophagus. 2. Alteration in Nutrition: Less than body requirements related to difficulty in swallowing secondary to frequent episodes of gastric reflux 3. Knowledge deficit: Lack of health awareness on lifestyle modification secondary to lack of information on the current health status. 4. Alteration in safety: Physical injury related to risk for aspiration secondary to regurgitation. NURSING INTERVENTIONS: Encourage adequate nutritional intake. 1. Eat slowly and chew all the food thoroughly so that it can pass easily into the stomach. 2. Small frequent feeding of non-irritating food is recommended to promote digestion and to prevent tissue irritation. 3. Sometimes liquid swallowed with food helps the food pass through the esophagus, but usually liquids should be consumed between meals. Decreasing risk of aspiration 1. Keep the patient in semi-fowlers position 2. Use of oral suction to decrease the risk of aspiration 3. Post meal position: Upright or high fowlers position.  Relieving Pain 1. Small frequent feedings because large quantities of food overload the stomach and promote gastric reflux 2. Eating before bedtime is discouraged 3. Excessive use of over-the-counter antacids can cause rebound acidity 4. H2 antagonists and PPIs are given as prescribed to decrease gastric acid irritation. Providing Patient Education 1. Prepare the patient physically and psychologically for diagnostic tests, treatments and possible surgery. 2. Reassure the patient and explain the procedure and purpose. 3. Treatment interventions must be evaluated continually, and the patient is given sufficient information to participate in care and diagnostic tests.  Promoting Home, Community bases, and Transitional Care 1. Educating about self care and follow-up care 2. Educating about nutritional requirements and how to measure the adequacy of nutrition is important 3. Debilitated patients in particular often need assistance and education about ways they can adjust to their limitations and resume activities that are important to them. 4. Patients with chronic esophageal conditions require an individualized approach to their management at home. 5. Food may be prepared in a special way (blenderized food, soft food) and the patient may need to eat frequently. A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 1. Disturbances in Ingestion Hiatal Hernia- the opening in the diaphragm through which the esophagus passes becomes enlarged, and part of the upper stomach moves up into the lower portion of the thorax. A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 2 types 1. Sliding hiatal hernia- upper stomach and the gastroesophageal junction are displaced upward and slide in and out of the thorax. Between 90% and 95% of patients with esophageal hiatal hernia have sliding hernia. 2. Paraesophageal hernia- occurs when all or part of the stomach pushes through the diaphragm beside the esophagus. Type 1: Sliding hiatal hernia Type 2: Paraesophageal means beside the esophagus. The upper part of your stomach pushes up through the hiatus alongside your esophagus, forming a bulge next to it. This is also called a rolling hiatal hernia. Type 3: Both GEJ and the upper portion of stomach migrate into thoracic cavity Type 4: Stomach as well as other parts of the GI tract (small intestine and spleen) protrude into chest. A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 1. Disturbances in Ingestion HIATAL HERNIA Predisposing Factors Precipitating Factors Age- ligaments Smoking Obesity weaken with age Chronic cough Genetic predisposition COPD Chronic constipation Congenital Liver disease- ascites diaphragmatic hernia Pregnancy Prolonged intra-abdominal pressure and lax diaphragmatic esophageal hiatus  Protrusion of abdominal structures into the thorax through diaphragmatic Esophageal hiatus GEJ and the gastric cardia slide up into the posterior mediastinum Type 1 Hiatal Hernia Signs and symptoms Hiatal Hernia 1. Heartburn- inappropriate opening of the lower esophageal sphincter 2. Waterbrash- excessive salivation, acidic taste and bad taste in the mouth. 3. Belching- due to inappropriate lower esophageal opening. 4. Epigastric pain- due to irritation and inflammation. 5. Fullness-very full after eating 6. Regurgitation 7. Dysphagia 8. Feeling of getting “food stuck” 9. Nausea/vomiting and food intolerance especially in large hiatal hernias 10. Non-productive coughing 11. Hoarseness- difficulty talking/harsh, rough Diagnostic Findings: 1. Xray 2. Barium swallow 3. Esophagogastroduodenoscopy which is the passage of fiberoptic tube through the mouth and throat into the digestive tract for visualization of the esophagus, stomach, and small intestine. Medical Management: 1. Antacids 2. H2 receptor blockers 3. Proton pump inhibitors 1. Nissen Fundoplication- surgeon will make small incisions in the abdomen and use a thin, flexible tube equipped with a camera (laparoscope) to perform the surgery. During the procedure, the surgeon will wrap the upper part of the stomach around the lower esophagus to tighten the lower esophageal sphincter (LES) thus preventing stomach acid from backing up into the esophagus. 2. Collis-Nissen Gastroplasty- surgery that lengthens the esophagus and tightens the lower esophageal sphincter (LES). The surgeon makes several incisions in the abdomen and inserts a laparoscope equipped with surgical tools and a camera. The surgeon divides the stomach lengthwise, create a tube from the upper portion of the stomach, and wrap around the LES before securing it into place using surgical staples. Nursing Diagnoses 1. Alteration in Comfort: Acute epigastric pain related to irritation of the gastroesophageal lining secondary to acid reflux. 2. Alteration in Nutrition: Less than body requirements related to bad taste in mouth and acidic taste secondary to acid regurgitation 3. Alteration in circulation: Risk for anemia secondary to hematochezia. 4. Coping: Ineffective coping response on the nursing management secondary to inability to accept current health status. Medical Management Laparoscopic approach (Toupet or Nissen fundoplication) procedure with an open transabdominal or transthoracic approach reserved for patients with complications such as bleeding, dense adhesions or injury to the spleen Nursing Management: 1. Frequent small feedings 2. Advise patient not to recline for 1hour after eating, to prevent reflux or movement of the hernia and to elevate the head of the bed 4-8inches block to prevent the hernia from sliding upward 3. Post-operative, up to 50% of patients experience dysphagia. Advance the diet slowly from liquids to solids, while managing nausea and vomiting. 4. Monitor post operative belching, vomiting and gagging, abdominal distention and epigastric chest pain which may indicate the need for surgical revision. A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 1. Disturbances in Ingestion ACHALASIA- Absence of ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 1. Disturbances in Ingestion ACHALASIA Predisposing Factors Predisposing Factors Unknown Viral infection (herpes, varicella Genetics (Autoimmunity) zoster) Impairment of the vagus nerve GERD Age Impairment of the myenteric plexus Progressive degeneration of the ganglion cells in the myenteric plexus in the esophageal wall  Inflammation Loss of esophageal peristalsis Insufficient relaxation of the lower esophageal sphincter (LES) ACHALASIA Signs and Symptoms of Achalasia 1. Dysphagia- difficulty with solid food 2. Sensation of food sticking in the lower portion of the esophagus 3. Regurgitation of food either intentionally or spontaneously by the patient to relieve the discomfort produced by prolonged distention of the esophagus by food that will not pass in the stomach. 4. Noncardiac chest or epigastric pain 5. Pyrosis that may or may not be associated with eating. 6. Weight loss Diagnostic Findings: 1. Xray- esophageal dilation above the narrowing at the lower esophageal sphincter, which is called a bird’s beak deformity. 2. Barium Swallow 3. CT scan of the chest 4. Endoscopy 5. High resolution manometry- a process in which peristalsis, contraction amplitudes, and esophageal pressure is measured by a radiologist of gastroenterologist, confirms the diagnosis. Nursing Diagnoses: 1. Alteration in Nutrition: Less than body requirements related to difficulty in swallowing solid food secondary to dysphagia 2. Ineffective coping secondary to limited understanding of the condition. 3. Risk for aspiration secondary to spontaneous food regurgitation. Medical Management: 1. Injection of Botulinum Toxin- injection into the quadrants of the esophagus via endoscopy has been helpful because it inhibits the contraction of smooth muscle. However, because the benefits fade over time, and there is a risk of submucosal fibrosis, botulinum toxin is only used in patients who cannot receive other definitive treatments. 2. Pneumatic Dilation- conservative treatment to stretch the narrowed area of the esophagus. This has a high success rate; however, typically two dilations are required, and the long-term results are variable. Although perforation is a potential complication, its incidence is low. The procedure can be painful, therefore moderate sedation in the form of an analgesic or tranquilizer, or both is given for treatment. Esophagomyotomy or Heller Myotomy- involves cutting the esophageal muscle fibers. Nursing Management: 1. Instruct patient to eat slowly and to drink fluids with meals. 2. Include the family of the patient in the health teaching and lifestyle modification. 2.1. Swallowing 2.2. Dysphagia 2.3. Response to stress and anxiety 3. Provide emotional support A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 1. Disturbances in Ingestion ESOPHAGEAL DIVERTICULA- outpouching of mucosa and submucosa that protrudes through a weak portion of the musculature of the esophagus. Diverticula may occur in one of the three areas of the esophagus- pharyngoesophageal, midesophageal or epinephric. Most common is Zenker Diverticulum (ZD), located in the pharyngoesophageal area. A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 1. Disturbances in Ingestion ESOPHAGEAL DIVERTICULA Predisposing Factors Precipitating Factors Achalasia Unknown Elderly Men Progressive degeneration of the ganglion cells in the myenteric plexus in the esophageal wall Inadequate relaxation of either the upper or lower esophageal sphincter  Increased intraluminal pressure Subsequent herniation of the esophageal wall Weakened muscle fibers Bulging formation Zenker Diverticulum Signs and Symptoms of Esophageal Diverticulum 1. Dysphagia 2. Fullness in the neck 3. Regurgitation 4. Tracheal irritation 5. Coughing/ belching Collaborative Management 1. Blenderized food 2. Antacids as ordered 3. Small frequent feedings 4. Backrest for several hours after eating 5. Avoid irritating foods A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 2. Disturbances in Digestion Nausea and Vomiting Nausea- uncomfortable feeling in the back of your throat or an uneasiness in your stomach. You may feel dizzy, lightheaded or have difficulty swallowing. Often goes along with the urge to vomit but doesn’t always lead to vomiting. Vomiting- is the forcible emptying of stomach contents through your mouth. When you vomit, your stomach muscles squeeze together, propelling your stomach’s contents up through your esophagus and out your mouth. Types of Vomiting: 1. Acute- caused by infection, medical treatment and 1. A. Gastroenteritis- viral e.g. norovirus, rotavirus; bacteria e.g. salmonella, shigella B. Food poisoning- caused by staphylococcus aureus. Vomiting can start soon after eating contaminated food. C. Poisoning- household items swallowed accidentally. D. Motion sickness- usually accompanied by cold sweats Types of Vomiting: 2. Chronic- vomiting continues longer than a few days. A. Medicines including chemotherapy drugs B. Radiation treatments- side effects include nausea and vomiting. C. Vitamins D. Pregnancy E. Migraine F. Food allergies G. GERD H. Gastroparesis- delayed emptying of the stomach due to nerve damage I. Kidney stones- nausea and vomiting are symptoms of kidney stones along with gripping pain in your back Nursing Diagnoses: 1. Alteration in Nutrition: less than body requirements related to vomiting, chronic secondary to radiation treatments 2. Alteration in Comfort: Physical related to nausea secondary to radiation treatments 3. Fluid Volume Deficit: Risk for electrolyte imbalance related to projectile vomiting secondary to head injury Nursing Management: 1. Assess the possible causes of nausea and vomiting. 2. Assess the patient’s hydration status. Volume per volume replacement or administer fluids intravenously as indicated. 3. Encourage patient to eat small frequent meals if not contraindicated, NPO as ordered 4. Encourage patient to avoid spicy and greasy food 5. Administer anti emetics as ordered. 6. Encourage small sips of fluids or ice chips if not contraindicated. Nursing Diagnoses: 1. Alteration in Nutrition: less than body requirements related to vomiting, chronic secondary to radiation treatments 2. Alteration in Comfort: Physical related to nausea secondary to radiation treatments 3. Fluid Volume Deficit: Risk for electrolyte imbalance related to projectile vomiting secondary to head injury  A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 2. Disturbances in Digestion Gastro-intestinal Bleeding -also known as gastrointestinal hemorrhage. A symptom of many digestive system disorders including reflux, ulcers and cancer. Bleeding can be acute or ongoing and life threatening. 1. Upper GI bleeding- bleeding in the esophagus, stomach and initial part of the small intestine (duodenum). 2. Lower GI bleeding- bleeding in the lower intestine, large intestine, rectum, and anus Types of GI bleeding: 1. Acute: sudden, severe bleeding 2. Chronic: bleeding that comes over a long time 3. Occult: Bleeding that is not visible, but you can see signs of GI loss such as low blood counts on laboratory testing. 4. Overt- visible signs of GI bleed including abnormal colors or substances in your feces. You may also vomit blood. 5. Obscure: When standard endoscopy testing does not reveal a source of bleeding. Types of GI bleeding: GI bleed symptoms depend on the source and how severe it is. 1. Abdominal cramping 2. Dark colored feces or presence of blood 3. Pallor 4. Dyspnea 5. Tiredness 6. Hematemesis Acute GI bleed symptom: 1. Syncope 2. Difficult micturition 3. Tachycardia 4. Hypotension Diagnostic Tests for GI bleeding: 1. CBC- anemia 2. Fecal Occult blood test 3. CT scan 4. GI Xrays 5. Upper Endoscop 6. Colonoscopy 7. Capsule endoscopY 8. Laparoscopy Nursing Diagnoses: 1. Alteration in cardiac output: Decreased, related to hypovolemia secondary to blood loss as evidenced by tachycardia and hypotension. 2. Alteration in Tissue perfusion: Ineffective, related to gastrointestinal bleeding secondary to a disease process. Nursing Interventions: 1. Review Health history including medications taken, 2. Assess for GI bleeding CNS: decreased mentation, decreased level of consciousness, lightheadedness, fainting (syncope), dizziness HEENT: pale eyes, mucosa, and lips Respiratory: decreased oxygen saturation, shortness of breath Cardiovascular: chest pain, tachycardia, hypotension Gastrointestinal: abdominal pain, abdominal cramping, presence of anal fissures, hemorrhoids, masses, bright red or coffee-ground blood in the vomitus (hematemesis), black, tarry stools (melena) Hematologic: anemia Integumentary: skin pallor Nursing Interventions: 3. Perform an abdominal examination - Inspect for abdominal distension, prominent veins, or skin discoloration. Hyperactive bowel sounds upon auscultation are present in GI bleeding. Palpate for any abdominal tenderness or pain may indicate a possible perforation or ischem 4. Monitor the vital signs. Vital signs can show indicators of GI bleeding complications (such as shock or hypovolemia). Watch out for tachycardia, tachypnea, and hypotension. Nursing Interventions: 5. Monitor for symptoms of shock. The patient can experience shock if the bleeding is severe. Shock symptoms include:l Severely low blood pressure Orthostatic hypotension Supine hypotension Resting tachycardia Palpitations Rapid, bounding pulses Low (oliguria) or absent (anuria) urine output Decreased level of consciousness Syncope Nursing Interventions: 6. Review serum lab values. The following blood tests can indicate GI bleeding: Complete blood count reveals low hemoglobin and hematocrit, indicating blood loss. Coagulation profile reflects abnormal blood clotting. Increased international normalized ratio (INR), prolonged prothrombin time, and activated partial thromboplastin time are expected in GI bleeding. Lactate levels are elevated in GI bleeding. Liver function enzymes may be abnormal. An impaired liver cannot produce enough clotting factors, increasing the risk of bleeding. Nursing Interventions: 7. Obtain a sample for a stool exam. Stool samples may have obvious bright red bleeding. Dark, black stools signal old bleeding or bleeding of the upper digestive tract. A fecal occult blood test can be completed at the bedside to assess for hidden blood in the stool. 8. Assist with endoscopy. A tube with a tiny camera at the end is put into the mouth (upper GI endoscopy) or the rectum (lower GI endoscopy). It allows visualization of the gastrointestinal tract and inspection for any bleeding. These procedures can also offer treatment with injection, thermal coagulation, or hemostatic clips/bands. Nursing Interventions: 9. Consider other imaging scans. 9.1. Capsule endoscopy uses a capsule the size of a vitamin that contains a tiny camera to visualize the small intestine. You swallow the capsule, and a recorder receives images as the capsule passes through the digestive system. 9.2. Flexible sigmoidoscopy utilizes a tube with a light and camera. It is inserted through the rectum to visualize any bleeding. 9.3. Balloon-assisted enteroscopy allows for the management or treatment of the bleeding source. It uses a specialized scope that can view the small intestine in places where other tests utilizing an endoscope cannot. Nursing Interventions: 9. Consider other imaging scans. 9.4. Angiography detects and treats active bleeding vessels. A contrast dye is introduced into an artery, and X-rays are taken. Bleeding is managed by embolization or intra-arterial vasopressin. 9. 5. CT angiography (CTA) shows active bleeding blood vessels. 9.6. Enteroscopy visualizes the small bowel for bleeding. 9.7. Nuclear scintigraphy is the most sensitive test for detecting active lower GI bleeding.  A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 2. Disturbances in Digestion Gastritis- inflammation of the gastric and stomach mucosa a. Acute gastritis- lasts for several hours to a few days. Classification: 1. Erosive- caused by local irritants such as aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) eg. Ibuprofen, corticosteroids, excessive amounts of alcohol consumption, tea, mustard, paprika, cloves and pepper and food with rough texture or those eaten at extremely high temperature. 2. Nonerosive- caused by infection with a spiral-shaped gram-negative bacterium, Helicobacter pylori (H. Pylori) 3. Severe form- ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur and can result in pyloric stenosis (narrowing or tightening) or obstruction 4. Stress related gastritis- gastritis that develops into an illness especially when the patient has had major traumatic injuries, burns, severe infection, lack of perfusion to the stomach lining or major surgery. a. Chronic Gastritis- often classified according to the underlying causative mechanism, which most often includes an infection with H. pylori. 1. Chronic H. pylori gastritis- implicated in the development of peptic ulcers and gastric adenocarcinoma 2. Chemical gastric injury- result of long-term drug therapy or reflux of duodenal contents into thr stomach 3. Autoimmune disorders e.g Addison’s disease, Hashimoto thyroiditis, Graves disease. Signs and Symptoms for Acute Gastritis a. Epigastric discomfort b. Abdominal tenderness c. Cramping d. Belching e. Reflux f. Severe nausea and vomiting g. Hematemesis h. Diarrhea i. Melena j. Hematochezia Signs and Symptoms for Chronic Gastritis 1. Anorexia 2. Feeling of fullness 3. Dyspepsia 4. Belching 5. Vague epigastric pain Diagnostic: 1. CBC to assess anemia (pernicious). Patients with chronic gastritis may not be able to absorb vitamin B12 because of diminished production of Intrinsic factor. 2. PTT, Platelet count, fibrinogen 3. Endoscopy 4. Histologic examination of a tissue obtained by biopsy. Medical Management: 1. Intravenous fluids esp if bleeding is present 2. Nasogastric intubation 3. Antacids 4. Histamine2 receptor antagonists 5. Proton pump inhibitors 6. Gastrojenunoscopy- anastomosis of jejunum to stomach to detour around the pylorus to treat gastric outlet obstruction (also called pyloric obstruction Nursing Diagnoses: 1. Imbalanced Nutrition: less than body requirements related to insufficient absorption of nutrients secondary to swelling of the gastric mucosa 2. Risk for Fluid Volume Deficit: Risk factors: Dehydration related to vomiting secondary to the inflammation of the gastric lining. Nursing Management: 1. Instruct patient to refrain from alcohol until the symptoms subside. 2. Supportive therapy to the patient and the family during treatment especially if the patient has ingested acids or alkalis 3. Promote optimal nutrition, NPO for a few days until acute symptoms subside, allowing gastric mucosa to heal 4. I and O monitoring 5. Monitor episodes of gastritis symptoms as soon as food is introduced. 6. No caffeinated beverages and alcohol 7. Discourage smoking 8. Monitor for signs of gastric hemorrhage, hematemesis, tachycardia, hypotension 9. Examine stools for bleeding 10. Discharge instructions. A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 2. Disturbances in Digestion Peptic Ulcer Disease- is an excavation (hollowed-out area) that forms in the mucosa of the stomach, in the pylorus (the opening between the stomach and duodenum) or in the esophagus. Erosion of a circumscribed of mucosa is the cause. The cause of Peptic ulcer is Helicobacter pylori infection. o Hemorrhage is the most life-threatening complication. Blood loss of 20% 1000ml is fatal. This leads to hypovolemic shock Medical Management: 1. Antacids- to neutralize HCl 2. H2 receptor antagonists to suppress the secretion of gastric acid 3. Cytoprotective drug to coat the ulcers e.g. sucralfate 4. Prostaglandin Analogue- replaces gastric prostaglandin. Suppresses the secretion of gastric acid e,g, Misoprostol (Cytotec) 5. Proton pump inhibitors- suppress gastric acid secretion 6. Antocholinergics- reduce gastric motility 7. H. Pylori treatment - Amoxicillin - Metronidazole - Tetracycline- contraindicated in pregnancy. Teratogenic - Clarithromycin Nursing Diagnoses: A. Impaired Comfort: Pain, Acute related to hypersecretion of HCL secondary to prolonged stress B. Knowledge Deficit: Health management related to inability to understand the emergency situation C. Coping: Impaired related to lifestyle modification secondary to lack of family support Nursing Management: Pain medication as prescribed Monitor for signs of hemorrhage - When the hemorrhage is large (2L-3L) most of the blood is vomited - When the hemorrhage is small, much or all of the blood is passed in the stools which appear tarry - Management is based on the amount of blood lost and the rate of the bleeding - Assess for faintness or dizziness and nausea which may precede or accompany bleeding. - Evaluate for tachycardia, hypotension and tachypnea - Monitor for hemoglobin and hematocrit A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 2. Disturbances in Digestion Food Poisoning: Sudden illness that occurs after ingestion of contaminated food and drink. Botulism- serious paralytic caused by a nerve toxin that is produced by bacterium clostridium botulinum (a client can die within 24hours). Kinds of Botulism 1. Foodborne botulism- eating foods contaminated with botulinum toxin. Common sources are improperly canned foods, preserved or fermented. 2. Wound botulism- spores get into a wound and make a toxin. People who inject illicit drugs have a greater chance of getting wound botulism such as motorcycle crash. 3. Infant botulism- when the spores get into their intestines, grow and produce a toxin. 4. Iatrogenic botulism- too much botulinum is injected for cosmetic reasons as for wrinkles. 5. Adult intestinal toxemia- is also known as adult intestinal colonization. This is very rare. It can happen if the spores of the bacteria get into an adult’s intestines, grow and produce the toxin. The key to treatment is determining the source and type of food poisoning. If possible, the suspected food should be brought to the medical facility and a history obtained from the patient or family. It cannot be spread from person to person. Clinical manifestations: abdominal cramps, diarrhea, nausea and vomiting, double vision, blurred vision, drooping eyelids, difficulty swallowing or speaking, dry mouth and muscle weakness. It can progress to paralysis of the arms, legs, trunk or respiratory muscles. Medical management: 1. Antitoxin 2. Induction of vomiting 3. Enemas 4. Penicillin Nursing Management: Assess for fluid and electrolyte status because large volumes of electrolytes and water are lost by vomiting and diarrhea e.g. lethargy, rapid pulse rate, fever, oliguria, anuria, hypotension and delirium Obtain baseline weight and serum electrolyte levels for future comparisons. Airway management including mechanical ventilation when necessary Administration of antitoxin  A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 2. Disturbances in Digestion Diarrhea: Abnormal increase in the frequency and liquidity of the stool.  Classification: 1. Acute- self-limiting, lasting 1-2 days 2. Persistent- lasts between 2-4 weeks 3. Chronic diarrhea- persists for more than 4 weeks and may return sporadically Etiology: 1. Viral infection 2. Some drugs 3. Chemotherapy 4. Parasitic infections  Clinical Manifestations: 1. Increased frequency and fluid content of stools 2. Abdominal cramps 3. Distention 4, Borborygmus- rumbling noise caused by the movement of gas through the intestines 5. Anorexia 6. Thirst 7. Tenesmus Diagnostic findings: 1. CBC 2. Urinalysis 3. Stool examinations 4. Endoscopy and barium enema  Fecal analysis (occult blood, ova and parasite, quantitative fecal fat studies, fecal leukocytes, stool electrolyte tests) 1. Occult blood- Bleeding that is not visible, but you can see signs of GI loss such as low blood counts on laboratory testing. 2. Stool exam for ova and parasite Protozoa- parasites that replicate in the intestines of the infected hosts and are excreted in the feces. Enteric protozoa are the leading cause of water-borne infections Giardiasis- common protozoal cause of diarrhea, feco-oral transmission. Assessment: Diarrhea, nausea and vomiting, abdominal cramps, excessive foul flatulence, foul-smelling, greasy stools, malabsorption which results in weight loss Implementation: Metronidazole, Furazolidone,and handwashing Cryptosporidium- water-borne and food-borne outbreaks in nursing homes and day care centers. Spread by drinking contaminated water or swimming pools. It is characterized by the inflammation of the intestinal epithelium and watery diarrhea. Amebiasis- caused by the protozoan, Entamoeba histolytica. Manifested by rectal inflammation as well as blood, pus amoeba in the stool. Metronidazole is the drug of choice. b. Helminths- Contracted through the skin or from ingested contaminated food or water. May cause UTI or pruritus ani. Infecting the intestinal tract are: Ascaris-round worms Enterobius- pinworms Trichinella spiralis -trichinosis Various species of Cestoda- tapeworms Treatment of all household members may reduce. infections. Treatment are as follows: Mebendazole Pyrantel pamoate Piperazine  Schistosomiasis- cause by a blood fluke (parasitic flatworm). The cercariae (larvae) of the parasite penetrate the skin, migrate to the liver via the lungs and remain in the intrahepatic portal venule until the worm matures. Treatment are as follows: Oxamniquine Metrifonate Praziquantel Niridazole Quantitative fecal fat studies- measures the amount of fat in stools for a period of 3 days. Patient is to eat 100mg of fat each day for a period of 3 days before taking the fecal test. Fecal leukocytes- immune system cells that can show up in stools if you have inflammatory diarrhea Stool electrolyte test- measures the electrolytes’ concentration in a stool sample to determine the cause of watery stools. Some common electrolytes are Na, K, Cl Medical Management: 1, Antibiotics 2. Anti-inflammatory agents 3. Anti diarrheal agents Nursing Management: 1. Assess the pattern of diarrhea 2. Assess for health history, medical therapy, surgical history and diatary patterns and intake 3, Record recent travel and geographic area 4 Determine hydration status 5. Fluid therapy  A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 3. Disturbances in Absorption and Elimination Constipation: Fewer than 3 bowel movements weekly or bowel movements that are hard, dry, small or difficult to pass. Causes: 1. Medications 2. Weakness, immobility, debility, fatigue 3. Patients with spinal injury 4. Ignoring the urge to defecate 5. Dietary habits Classes: 1. Functional- The type that can be successfully treated by increasing intake of fiber and fluids 2. Slow-transit- inherent disorders of the motor function of the colon characterized by infrequent bowel movements e.g. hirschprung disease- a birth defect characterized by missing nerves from part of the intestine. 3. Defecatory disorders- dysfunctional motor coordination between the pelvic floor and anal sphincter. Anismus is a term used to describe the pelvic floor dysfunction and constipation 4. Opioid-induced constipation- new or worsening symptoms that occur with opioid therapy Clinical Manifestations: 1. Fewer than 3 bowel movements per week 2. Abdominal distention 3. Abdominal pain 4. Bloating 5. Tenesmus 6. Incomplete evacuation 7. Small volume, lumpy, hard, dry stools Diagnostic Findings: 1. Physical examination 2. Barium enema 3. Sigmoidoscopy 4. Stool testing for occult blood 5. Anorectal manometry to assess malfunction of the sphicter 6. Defecography 7. Xray 8. Colonoscopy 9. Lower GI endoscopy Complications: 1. Increased intracranial pressure- During active straining, the flow of blood venous blood in the chestis temporarily impeded because of increased intrathoracic pressure. This pressure tends to collapse the large veins in the chest, the atria and the ventricles receive less blood and consequently, less blood is ejected in the left ventricle. Cardiac output is decreased, and there is a transient drop in the arterial pressure which may cause orthostasis, dizziness and syncope. 2. Hemorrhoids 3. Rectal prolapse 4. Anal fissures 5. Fecal impaction Medical Management: 1. Education 2. Exercise 3. Bowel habit training 4. Increased fiber and fluid intake 5. Laxatives Nursing Management: 1. Assess for onset and duration of constipation, current and past elimination patterns, lifestyle information, fluid intake and stress level 2. Note for past surgeries, current medications 3. Ensure adequate intake if not contraindicated 4. Give enema as prescribed 5. Administer laxatives as prescribed  A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 3. Disturbances in Absorption and Elimination Irritable Bowel Syndrome (IBS): A chronic functional disorder characterized by recurrent abdominal pain associated with disordered bowel movements, which may include diarrhea, constipation or both, without an identifiable cause. Global prevalence is estimated at 11%. Typically diagnosed in adults younger than 45yrs old. Clinical Manifestations: 1. Diarrhea (IBS-D) 2. Constipation (IBS-C) 3. Mixed; Combination of 1 and 3 (IBS-M) 4. Unclassified (IBS-U) 5. Pain 6. Bloating 7. Abdominal distention 8. Abdominal pain often precipitated by eating and is frequently relieved by defecation. Assessment and Diagnostic findings: 1. Bristol Stool Form Scale: Assessment and Diagnostic findings: 2. CBC 3. C-reactive Protein 4. Fecal Calprotectin 5. Colonoscopy Medical Management: The goals of treatment are to relieve abdominal pain and control diarrhea or constipation. Lifestyle modification, including stress reduction, ensuring sleep, instituting exercise regimen. 1. Soluble fiber diet. Restriction and then gradual reintroduction of foods that are possibly irritating may help determine what type of foods are acting as irritants Low FODMAP diets Fermentable Oligosaccharides (wheat, rye, asparagus, legumes, garlic, onions Disaccharides (lactose-containing foods such as milk, yogurt) Monosaccharides (fructose-containing foods such as honey, agave nectar, figs, mangoes And Polyols (blackberries, lychee, low-calorie sweeteners 2. Antidiarrheal for IBS-D 3. Alosetron for severe IBS-D which slows colonic motility 4. Lubiprostone, a chloride channel regulator in the gut can be prescribed for patients with IBS-C. 5. Antispasmodics for abdominal pain 6. Peppermint oil for abdominal discomfort 7. Probiotics to decrease abdominal bloating and gas Nursing Management: 1. Provide patient and family education and encourage self- care activities like use of bowel habit diary, good sleep habits and good dietary habits 2. Advise patient to keep a 1-2-week food diary and correlate symptoms with food intake. 3. They should understand that although adequate food intake is necessary, fluids should not be taken with meals because this results in abdominal distention 4. Alcohol and cigarette smoking are discouraged 5. Stress management  A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 3. Disturbances in Absorption and Elimination Fecal Incontinence: Inadvertent bowel leakage; describes the recurrent involuntary passage of stool from the rectum for at least 3 months Factors: 1. Ability of the rectum to sense and accommodate stool. 2. Integrity of the anal sphincters and musculature 3. Rectal motility Causes: 1. Anal sphincter weakness 2. Traumatic (after surgical procedures) 3. Non-traumatic (scleroderma) 4. Disorders of the pelvic floor 5. CNS disorders (dementia, stroke, spinal cord injury, multiple sclerosis 6. Loss of anal or rectal muscle tone Clinical Manifestations: 1. Minor soiling 2. Occasional urgency 3. Loss of control 4. Complete incontinence 5. Poor control of flatus, diarrhea, constipation 6. Urge to defecate but cannot reach the toilet in time Assessment and diagnostic findings: 1. Flexible sigmoidoscopy to rule out tumors, inflammation, fissures, or impaction. 2. Endosonography 3. MRI Medical Management: 1. Correcting the underlying cause e.g. diarrhea, medications, and other disorders 2. Psyllium- fiber supplement 3. Loperamide 30 minutes before meals 4. Transanal irrigation and bowel training programs including techniques like valsalva maneuver and digital rectal examination. 5. Surgical procedures include surgical reconstruction or repair of anal sphincter, artificial sphincter implantation, fecal diversion. Nursing Management: 1. Gather information about previous surgical procedures, chronic illnesses, dietary patterns, bowel habits and problems and current medication regimen. 2. Bowel diary 3. Bristol stool form 4. Bowel training program 5. Maintain skin integrity 6. Incontinence pads 7. Toilet assistance for patients with dementia  A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 3. Disturbances in Absorption and Elimination Celiac Disease: a disorder of malabsorption caused by an autoimmune response to consumption of products that contain the protein gluten. Gluten is most commonly found in wheat, barley, rye and other grains, malt, dextrin and brewer’s yeast. Clinical Manifestations: 1. Diarrhea 2. Steatorrhea 3. Abdominal Pain 4. Abdominal Distention 5. Flatulence 6. Weight loss 7. Dermatitis herpetiformis- clusters of erythematous macules that develop into itchy papules and vesicles on the forearms, elbows, knees, face and buttocks. Assessment and Diagnostic Findings: 1. Immunoglobulin A (IgA)- anti tissue transglutaminase (tTG). 90% sensitive and 95% specific to celiac disease. 2. Findings are confirmed with upper endoscopy with biopsies of the proximal small intestine. Medical Management: 1. No drugs that induce remission 2. Refrain from exposure to gluten products 3. Consultation with dietician Nursing Management: 1. Patient and family education 2. Avoid gluten products 3. Read labels of food products 4. Caution the patient that it will take time before the signs and symptoms will resolve.  A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 3. Disturbances in Absorption and Elimination Abdominal Hernia: A protrusion of an organ or structure through a weakened abdominal muscle. It may be congenital or acquired defect. Common Sites of Abdominal Hernia Causes: 1. Congenital or acquired muscle weakness 2. Increased abdominal pressure due to: heavy lifting obesity pregnancy Chronic constipation Types: 1. Reducible hernia: It can be returned by manipulation. It may appear as a lump in the groin or in the abdominal area. 2. Irreducible hernia: requires surgery 3. Inguinal hernia: Common among males Two types: 1. Indirect inguinal hernia- protrusion of bowel through the inguinal ring, follows the course of the spermatic cord and moves down into the scrotum. 2. Direct inguinal hernia- protrusion through inguinal wall at the point of muscle weakness. Types: 4. Umbilical hernia- Common among infants. Protrusion is through congenital defect muscle. Types: 5. Femoral Hernia- Common among females. Protrusion is through femoral canal Types: 6. Incisional Hernia- Common after surgery. Protrusion is through inadequately healed surgical repair. Types: 7. Incarcerated Hernia- Characterized by bowel obstruction. 8. Strangulated hernia- compromised blood flow to the trapped segment of bowel. Intestinal obstruction occurs, and gangrene of the viscera can develop rapidly. Clinical Manifestations: 1. Lump in the groin, around umbilicus, or from an old surgical incision. The lump disappears when lying down, reappears with standing, coughing, straining or lifting. 2. Sedation of heaviness in the area with vague discomfort. 3. Nausea, vomiting, distention and pain indicate strangulated hernia Collaborative Management: 1. Surgery: Herniorrhaphy (hernioplasty) Pre-operative care: Assess for presence of respiratory tract infection, sneezing or coughing post-op may weaken the repair. Post-op care: 1. Encourage the patient to deep breathe, but not coughing exercises. Coughing exercises may weaken the repair. 2. Increase fluid intake to prevent constipation. Straining at stool may weaken the repair. 3. Monitor for bladder distention. This is a common post-op complication in hernia repair. 4. Elevate the scrotum with rolled small towel, apply ice bag over the scrotum. To prevent edema of the scrotum and minimize discomfort during ambulation. Collaborative Management: 5. Discharge patient teachings include the following: 1. Avoid heavy lifting, pushing, pulling for about 2 weeks 2. Avoid climbing stairs for 2 weeks 3. Stool softeners or bulk laxatives as prescribed to prevent straining during defecation 4. Monitor incision for signs of infection, like redness, swelling, warmth, pain and exudates. Notify the physician for these signs and symptoms. 5. Sexual activity may be resumed once healing is complete and comfort is assured. Usually 3 weeks after discharge.  A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 3. Disturbances in Absorption and Elimination Intestinal Obstruction: blockage prevents the normal flow of the intestinal contents through the intestinal tract. Types: 1. Mechanical Obstruction: Extrinsic lesions from outside the intestine or Intrinsic lesions within the intestine can obstruct flow. 2. Functional or paralytic obstruction: The intestinal musculature cannot propel the contents along the bowel either due to interruption of innervation or vascular supply to the bowel. Mechanical causes of Intestinal Obstruction: 1. Adhesions: Loops of intestine become adherent to areas that heal slowly or scar after abdominal surgery, after surgery adhesions produce a kinking of an intestinal loop. There is formation of fibrous bands that cause sticking of loops of colon. The impaired peristalsis causes accumulation of gas and feces. Adhesiolysis (surgical removal of adhesions) is done to resolve the condition. 2. Intussusception: One part of the intestine slips into another part located below it(like a telescope shortening), occurs commonly in infants than adults. The intestinal lumen becomes narrowed, and blood supply becomes strangulated. Volvulus: Bowel twists and turns on itself and occludes the blood supply. Intestinal lumen becomes obstructed. Gas and fluid accumulate in the trapped bowel. Surgery is required to remove the affected end-to-end anastamosis is done. Tumor: exists within the wall of the intestine, extends into the intestinal lumen, or a tumor outside the intestine causes pressure on the wall of the intestine. Intestinal lumen becomes partially obstructed; if the tumor is not removed, complete obstruction results. Surgery- small bowel resection. Mechanical causes of Intestinal Obstruction: Clinical Manifestations: 1. Currant jelly stools (stools containing blood and mucus) 2. Colicky abdominal pain that causes the patient to draw knees to the abdomen 3. Vomiting of gastric content 4. Bile-stained fecal emesis 5. Hypoactive and hyperactive bowel sounds 6 Tender, distended abdomen with palpable sausage-shaped mass in the right upper quadrant Clinical Manifestations: 7. Crampy pain that is wavelike and colicky due to persistent peristalsis both and above the blockage. 8. The patient may pass blood and mucus but no fecal matter and no flatus. 9. Vigorous peristaltic waves for complete obstruction, initially. Eventually assume a reverse direction, with the intestinal contents propelled toward the mouth instead of toward the rectum. Collaborative Management: 1. Monitor signs of perforation and shock e.g. fever, increased heart rate, change in level of consciousness and blood pressure and respiratory distress. 2. Antibiotics 3. Iv fluids 4. Decompression via NGT 5. Monitor for the passage of normal, brown stool. This indicates resolution of intussusception. Notify physician. There will be no more need for surgery. 6. Monitor for return of bowel sounds 7. Administer clear fluids and advance diet gradually 8. Surgery-Laparoscopic surgery Assessment and Diagnostic Findings: The approach to small bowel bowel obstruction focuses on confirming the diagnosis, identifying the etiology, and determining the likelihood of strangulation. 1. Hyperactive and high-pitched bowel sounds at first then eventually becomes hypoactive 2. Abdominal Xray 3. CT scan findings include abnormal quantities of gas, fluid or both Large Bowel Obstruction: results in an accumulation of intestinal contents, fluid and gas proximal to the obstruction. Clinical Manifestations: 1. 2. 1. Constipation may be the only symptom that last for weeks 3. 2. Altered shape of stool as it passes the obstruction that is gradually increasing in size 4. 3. Weakness, weight loss and anorexia 5. 4. Distended abdomen 6. 5. Crampy abdominal pain 7. Assessment and Diagnostic Findings 1. Abdominal Xray 2. Abdominal CT 3. MRI Medical management: 1. NG Aspiration and decompression 2. Surgical resection to remove obstructing lesion 3. Ileoanal anastamosis maybe perfomed if removal of the entire large bowel is necessary. 4. Surgery- temporary or permanent colostomy may be necessary Nursing Management: 1. Monitor for symptoms indicating that the intestinal obstruction is worsening or resolving and to provide emotional support and comfort 2. IV fluids and electrolytes as prescribed 3. Colostomy care  A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 3. Disturbances in Absorption and Elimination Diverticulitis: Acute inflammation and infection caused by trapped fecal material and bacteria in an outpouching of the mucosal lining of the colon. Diverticulum: single outpouching of the mucosal lining in the GI tract, commonly in the colon Diverticula (Diverticulosis): multiple outpouchings of the mucosal lining of the GI tract, especially in the colon. Cause: Low fiber diet PATHOPHYSIOLOGY: Clinical Manifestations: 1. Crampy abdominal pain in the left lower quadrant that worsens with movement, coughing or straining. 2. Chronic constipation with episodes of diarrhea. 3. Low grade fever 4. Nausea and vomiting 5. Abdominal distention and tenderness 6. Occult bleeding Collaborative Management: 1. High fiber diet 2. Liberal fluid intake 2,500-3,000 mls/day 3. Avoid nuts and seeds. 4. Bulk-forming laxatives 5. During an acute episode: - bed rest -NPO -Avoid high fiber foods to prevent further irritation of the colonic mucosa - IV fluids - Antibiotics - Antispasmodics. To rest the bowels and relieve pain - NGT insertion to relieve abdominal distention  A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 3. Disturbances in Absorption and Elimination Hemorrhoids: Dilated portions of veins in the anal canal. Shearing of the mucosa during defecation results in the sliding of the structures in the wall of the anal canal. TYPES: Internal hemorrhoids- above the internal sphincter External hemorrhoids- outside the external sphincter Classification of Internal hemorrhoids: 1. First degree- do not prolapse or protrude into the anal canal 2. Second degree- prolapse outside the anal canal during defecation but reduce spontaneously 3. Third degree- prolapsed to the extent that they require manual reduction 4. Fourth degree- prolapsed to the extent that they may not be reduced and are at risk for strangulation and thrombosis. Clinical Manifestation: 1. Constipation 2. Anal pain 3. Rectal bleeding with defecation 4. Anal itchiness Interpersonal Collaborative care: 1. High fiber diet, increase fluid intake, stool softeners/ bulk laxatives 2. Cold packs to the anal area followed by warm sitz bath 3. Surgery: - hemorrhoidectomy - sclerotherapy-injection of 5% phenol in saline into the base of the hemorrhoid - rubber band ligation -tissue distal to thre rubber band becomes necrotic after several days and sloughs off. Pre-op care for Hemorrhoidectomy: 1. Low residue diet 2. Stool softeners Post-op care: 1. Analgesics as prescribed 2. Side-lying or prone position 3. Apply ice packs over the dressing as prescribed for the first the first 12hrs post-op to prevent bleeding 4. Warm sitz bath 12-24hrs post-op. To relieve pain. The best time to do the procedure is after bowel movement. 5. Administer stool softeners as prescribed. 6. Increase fluids and high fiber foods. 7. Monitor for post op complications: rectal bleeding, suppurative drainage, continued pain on defecation 8. Continued defecation  A. NUTRITIONAL-METABOLIC PATTERNS/ RESPONSES TO ALTERED NUTRITION 3. Disturbances in Absorption and Elimination Anal Fissure: An ulceration or tear in the lining of the anal canal, usually the posterior wall that occurs as a result of excessive tissue stretching and possible form passage of a hard or large stool.