Care of the Adult Patient with Disorders of Gastrointestinal (Part 2) PDF

Care of the Adult Patient with Disorders of GASTROINTESTINAL (Part 2) Presented by Mrs. K. Jones-Fraser RN, BScN, Cert. Nsg. Ed. MScN; PhD Candidate Objectives At the end of the session students should be able to: Give a review of the Gastrointestinal System describe correctly the upper gas...

Care of the Adult Patient with Disorders of GASTROINTESTINAL (Part 2) Presented by Mrs. K. Jones-Fraser RN, BScN, Cert. Nsg. Ed. MScN; PhD Candidate Objectives At the end of the session students should be able to: Give a review of the Gastrointestinal System describe correctly the upper gastro-intestinal disorders based on information in text and class discuss outline the management of the adult patient with upper gastro-intestinal disorders based on class discussion Objectives Describe correctly the lower gastro-intestinal disorders based on information in text and class discuss Outline the management of the adult patient with lower gastro-intestinal disorders based on class discussion OBJECTIVES Explain correctly the disorders of the liver, biliary tract, and pancreas based on information in text Outline the management of the adult patient with disorders of the liver, biliary tract, and pancreas based on class discussion OBJECTIVES Describe correctly the lower gastro-intestinal disorders based on information in text and class discuss Outline the management of the adult patient with lower gastro-intestinal disorders based on class discussion Recap of the Digestive System Care of the Adult Patient with Disorders of Metabolism (Recap) The digestive system is composed of the - gastrointestinal tract (GT) and the accessory digestive organs Gastrointestinal (GI) tract- digests and absorbs food It consist of – mouth, pharynx, esophagus, stomach, small intestine, and large intestine Accessory digestive organs – teeth, tongue, gallbladder, salivary glands, liver, and pancreas Digestive System (Recap) Functions of the digestive system Ingestion Secretion Mixing and Propulsion Digestion Absorption Excretion Nutritional disorder (Recap) Malnutrition The World Health Organization defines malnutrition as "the cellular imbalance between supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions. Types- 2 Disorder of the upper Intestinal tract Esophagitis - is inflammation of the esophagus Cause- gastro esophageal reflux disease (GERD)allergy, infection (candida), medication DISORDER OF UPPER GI SYSTEM Disorders of the Jaw and Salivary Glands Temporomandibular disorders: Myofascial pain Internal derangement of joint Degenerative joint disease Fractures (of bone) Parotitis Sialadenitis Sialolithiasis Neoplasms Disorders of the Teeth Dental plaque Dental caries Periapical abscess Malocclusion DISORDER OF THE TEETH Effective mouth care, including regular brushing and flossing Reduce intake of starches and sugars, and maintain good nutrition. Fluoride application or fluorinated water Refrain from smoking and alcohol. Control diabetes. Regular dental care Disorders of the Lips, Mouth, and Gums Lips Actinic cheilitis Herpes simplex 1 (“cold sore”) Chancre Mouth Leukoplakia, hairy leukoplakia, lichen planus Candidiasis Stomatitis Gums: gingivitis, periodontitis Oral Cancer Risk factors Tobacco use, including smokeless tobacco Alcohol Increased incidence in men, persons over age 40, and African-Americans Usually a squamous cell cancer May occur in any area, but lips, lateral tongue, and floor of the mouth are most frequently affected Oral Cancer Manifestations: Painless mass or sore that does not heal Any lesion that is present more than 2 weeks or that does not heal should be examined and biopsied. Later manifestations include tenderness; difficulty in chewing, swallowing, or speaking; coughing up blood-tinged sputum; and enlarged cervical lymph nodes. Oral cancer Medical management: Surgical resection Radiation therapy Chemotherapy Oral cancer Nursing Process: The Care of the Patient with Cancer of the Oral Cavity: Assessment Health history: include symptoms related to oral problems, oral hygiene and dental care, use of tobacco and alcohol, and eating and nutrition Inspect and palpate the structures of the mouth and neck. Oral cancer Nursing Process: The Care of the Patient with Cancer of the Oral Cavity: Diagnosis Impaired oral mucous membranes Imbalanced nutrition Disturbed body image Fear of pain and social isolation Pain Impaired verbal communication Risk for infection Deficient knowledge Oral cancer Impaired Oral Mucous Membranes Preventive oral care Dental care prior to surgery or radiation therapy Frequent gentle brushing and flossing, or if patient cannot tolerate brushing, use of mouthwashes and other methods of cleaning and rinsing ORAL CANCER Patient education related to oral hygiene Encourage fluid intake to reduce dry mouth Use of synthetic saliva such as Oral Balance or a saliva production stimulant such as Salagen Oral Cancer Imbalanced Nutrition Assess nutritional requirements and dietary patterns. Assess patient preferences and take into account social and cultural factors when encouraging and recommending dietary intake. A calorie count may be needed to assess if intake is meeting needs. Dietary consult Oral Cancer Other Interventions Support a positive self-image: Encourage patient to verbalize. Listen and offer acceptance and support. Referral to support group, psychiatric liaison, or spiritual advisor Pain Avoid hot, spicy, or hard foods. Oral care Viscous xylocaine or other pain medications Oral Cancer Other Interventions Promote effective communication: Assess patient’s writing ability preop. Plan communication preop. Communication board or pencil and paper Speech therapy Prevent infection: Assess for signs and symptoms of infections. Appropriate wound and skin care Patient teaching Radical Neck Dissection and Selective Radical Neck Dissection Nursing Process: The Care of the Patient with a Radical Neck Dissection: Assessment Assess knowledge. Assess for risks for potential complications. Postoperatively, the patient will need careful monitoring and assessment: Airway and breathing Pain Potential bleeding and wound drainage system Other Care of the Adult Patient with Disorders of Metabolism Lower gastro-intestinal disorders Lower Gastro-Intestinal Disorders Lower gastro-intestinal disorders Gastroenteritis Malabsorption syndrome Ulcerative colitis Crohn’s disease Appendicitis Peritonitis Diverticulosis Lower Gastro-Intestinal Disorders Lower gastro-intestinal disorders cont. Cancer of the colon, rectum Ileostomy Colostomy – transverse / sigmoid Hernias Gastroenteritis Gastroenteritis - an infection or inflammation of the digestive tract, particularly the stomach and intestines (Brunner & Suddarth, 2008) Gastroenteritis Etiology Viruses – such as rotaviruses, astroviruses and adenoviruses. Bacteria – such as the Campylobacter bacterium Parasites – such as giardia lamblia and cryptosporidium Bacterial toxins – poisonous by- products caused by bacteria can contaminate food - Some strains of staphylococcal bacteria produce toxins that can cause gastroenteritis Gastroenteritis Etiology cont. Drugs – certain drugs, such as antibiotics, can cause gastroenteritis in susceptible people and can irritate the digestive tract Gastroenteritis Clinical manifestations Loss of Appetite Bloating Nausea and Vomiting Diarrhea Abdominal Pain and Cramps Body Aches Bloody stools Pus in the stools Lethargy Gastroenteritis Diagnostic investigations History Physical examination Blood studies Stool tests Gastroenteritis Management Admission to hospital Fluid resuscitation Pharmacologic agent- Antibiotics, anti- diarrhea, antihelmic Gastroenteritis Nursing management Assessment – history and examination Problem identification Fluid Volume Deficit related to active fluid volume loss/excess loss through vomiting Acute pain related to abdominal distension Knowledge deficient related to the lack of information about the disease, prognosis and treatment Gastroenteritis Prevention Wash hands thoroughly with soap and water after going to the toilet Use disposable paper towels to dry your hands rather than cloth towels, since the bacteria can survive for some time on objects Make sure foods are thoroughly cooked Clean the toilet and bathroom regularly, especially the toilet seat, door handles and taps When travelling overseas to countries where sanitation is suspect, only drink bottled water. Crohn’s Disease Crohn’s disease is a chronic inflammatory disease of the gastrointestinal tract. It primary causes ulceration in the large and small intestines but can occur anywhere in the gastro- intestinal (GI) tract from the mouth to the anus. Crohn’s Disease Etiology - is unknown Can occur as a result of an : immune response genes Crohn’s Disease Clinical manifestations Abdominal pain and cramping Diarrhea Fever Weight Loss Bloating Anal pain or drainage Rectal abscess Fissure Crohn’s Disease Investigations Stool test Blood test - Complete blood count (CBC). Colonoscopy Computed tomography (CT ) scans Barium X-rays Crohn’s Disease Management Pharmacologic agents - anti- inflamatory -Sulfasalazine, immune suppressors -Cyclosporin, and antibiotics - Metronidazole (Flagyl) Diet Surgery Crohn’s Disease Nursing management Assessment Problem identification Ulcerative colitis Ulcerative colitis is an inflammatory bowel disease (IBD) Ulcerative colitis usually affects only the innermost lining of your large intestine (colon) and rectum. It occurs only through continuous stretches of the colon, unlike Crohn's disease, which occurs anywhere in the digestive tract and often spreads deeply into the affected tissues. Ulcerative colitis Etiology Immune response - the immune system is activated only when the body is exposed to harmful invaders. Genetic Ulcerative colitis Clinical manifestation Abdominal pain Blood in the stool Ongoing bouts of diarrhea that don't respond to over-the-counter (OTC) medications Unexplained fever lasting more than a day or two Tenesmus (rectal pain) Weight loss Ulcerative colitis Investigations Blood tests – complete blood count Stool sample – the presence of white blood cells in your stool indicates an inflammatory disease, possibly ulcerative colitis. Colonoscopy -this exam allows for the viewing of the entire colon using a thin, flexible, lighted tube with an attached camera. Ulcerative colitis Flexible sigmoidoscopy - a slender, flexible, lighted tube to examine the sigmoid, the last portion of your colon. Barium enema. X-ray. CT scan  Ulcerative colitis Management Pharmacologic agent - Antibiotics Anti-diarrheals Pain relievers Anti-inflammatory drugs -Corticosteroids. Surgery - proctocolectomy, removal of the entire colon and rectum Ulcerative colitis Nursing management History Administer medications Monitor blood values Observe stool for blood Appendicitis Appendicitis Appendicitis is an inflammation of the appendix The appendix is a small, tube-like structure in the lower right portion of the abdomen; it is attached to the first part of the colon (large intestine) Appendicitis Etiology Bacterial or viral infections in the digestive tract Traumatic injury to the abdomen Feces blocks the inside of appendix Genetics - genetic variant that predisposes a person to obstruction of the appendiceal lumen Appendicitis Appendicitis is classified into three types. 1. Acute appendicitis 2. Recurrent appendicitis 3. Chronic appendicitis Appendicitis Clinical manifestations Abdominal pain Loss of appetite Nausea and vomiting Constipation or diarrhea Inability to pass gas Low grade fever Abdominal distension Appendicitis Diagnosis History and physical examination Laboratory tests - WBC count and haemoglobin Ultrasound of the lower abdomen Abdominal computed tomography (CT scans) - may be used when symptoms are recurrent or prolonged. Appendicitis Management Surgery - Appendectomy Antibiotics are most effective when given preoperatively and they decrease post-op infections and abscess formation Appendicitis Nursing management Pre -operative – nil per os (NPO) status upon admission Administer IV fluids Semi-Fowler’s position to contain abdominal drainage in the lower abdomen Post-operative - Administer opioid analgesia (morphine sulfate) Administer intravenous (IV) antibiotics as ordered (surgical prophylaxis) Monitor naso-gastric (NG) tube drainage for perforation or abscess Monitor surgical drains. Peritonitis Peritonitis is an inflammation of the peritoneum (Brunner & Suddarth’s, 2008) Peritonitis Peritonitis can occur Spontaneous -this sort of peritonitis is the result of a liver as well as kidney malfunction Secondary- from an infection in the abdominal cavity Dialysis associated- is a chronic irritation of the peritoneum that occurs within individuals receive peritoneal dialysis. Peritonitis Types of peritonitis Primary spontaneous peritonitis - an infection that develops in the peritoneum Secondary peritonitis - which develops when an injury or infection in the abdominal cavity allow infectious organisms into the peritoneum. Peritonitis Signs and Symptoms Poor appetite Nausea Dull abdominal pain Fever Fluid in the abdomen Extreme thirst Anuric, or passing significantly less urine than usual Difficulty passing gas or having a bowel movement Vomiting Peritonitis Causes: Primary peritonitis - is usually caused by liver disease. Fluid builds up in the abdomen, creating an environment for bacteria to grow. Secondary peritonitis is caused by other conditions that allow bacteria, enzymes, or bile into the peritoneum from a hole or tear in the gastrointestinal or biliary tracts. Such tears can be caused by pancreatitis, a ruptured appendix, stomach ulcer, Crohn's disease, or diverticulitis. Peritonitis Investigations X-rays – to produce images of internal tissues, bones, and organs Laboratory tests (to identify the infectious organism) Exploratory surgery CT scans Peritonitis Management Pharmacologic agents Surgical intervention Nutrition and Dietary Supplements Diverticulitis Diverticulitis - is a small, bulging sacs or pouches of the inner lining of the intestine (diverticulosis) that become inflamed or infected. Most often, these pouches are in the large intestine (colon The cause of diverticulitis is unknown, but it is associated with a low-fiber diet, constipation, bacteria, and obesity. Diverticulitis Investigations Blood studies CT scan Ultrasound of the abdomen X-rays of the abdomen Diverticulitis Clinical manifestations Left lower quadrant pain Nausea and vomiting Constipation Diarrhea Flatulence Bloating. Diverticulitis Diagnostic investigations Blood studies- haemoglobin, white cell count, electrolytes A pregnancy test must be performed in any female of childbearing age who presents with abdominal pain to rule out ectopic pregnancy CT scans -can help assess disease severity, the presence of complications, and clinical staging. Diverticulitis Clinical manifestations cont. Abdominal x-ray Barium x-ray Diverticulitis Management Pharmacologic – antibiotics, analgesics Surgical – hartman procedure Collaborative care- dietician Diverticulitis Nursing Management Altered Comfort: Acute Pain r/t out pouching colon and stimulation of the diverticula during abdominal contraction Risk for Nutritional Imbalance: less than body requirement r/t impaired nutritional absorption secondary to disease process Interventions – administer analgesic, provide comfort, education, nutrition Stomas ostomy - surgical procedure that creates an artificial opening for the elimination of bodily wastes Types- 1. Colostomy- large intestine 2. Ileostomy – small intestine Stoma can be - temporary or permanent Diagram of a stoma Stomas Colostomy - is an artificial opening in the large intestine brought to the surface of the abdomen for the purpose of evacuating the bowel (Wells & Weller, 2004) Ileostomy- surgical procedure that creates an opening from the ileum through the abdominal wall to function as an anus Colostomy types Colostomy Reasons for Stoma formation To divert feces away from a surgical anastamosis, to allow healing Removal of or damage to sphincters which control continence To aid in symptom control where surgery is not possible Ostomies Indications Colostomy 1. Colo-rectal cancer 2. Diverticular disease fistula 3. Anal incontinence Ileostomy 1. Crohn’s disease 2. Ulcerative disease Ostomies Common problems Parastomal hernia Skin problems Constipation Diarrhoea Bleeding Prolapse Colostomy and Ileostomy apparatus Diagram of a colostomy bag Colostomy and Ileostomy Nursing management Stoma care Patient education Administer medications Hernias Hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. Causes Weakness in the wall of the muscles Repeated pregnancy Surgery Chronic constipation Weight training Hernias Clinical manifestations Weakness in the abdominal wall Pain at the site Visible or palpable lump Tenderness Nausea Vomiting Fever Hernias Types of hernias Inguinal Femoral Umbilical Incisional hernia Epigastric hernia Hernias Investigations Blood studies -Complete blood count, electrolytes, creatinine levels Urinalysis CT scan Chest x-ray - exclude free air Abdominal ultrasound Hernias Management Surgical –Herniotomy Medication therapy Disorders of Liver, Biliary Tract and Pancreas OBJECTIVES Review the Biliary System explain correctly the disorders of the liver, biliary tract, and pancreas based on information in text outline the management of the adult patient with disorders of the liver, biliary tract, and pancreas based on class discussion. Disorders of Liver, Biliary tract and Pancreas Pancreas Pancreas - dual function -produces pancreatic fluid that breaks down all categories of food Pancreatic fluid is secreted into the duodenum Endocrine function – secretes, Insulin and Glucagons Liver Liver - largest internal organ Located on the right side of the body inferior the diaphragm Produces Bile (fat emulsifier) Connected to the gall bladder via the common hepatic duct Gall bladder Gall Bladder - sac found in hollow fossa of liver Stores bile from the liver by way of the cystic duct Bile is introduced into the duodenum in the presence of fatty food Gallstones can cause blockage to the gall bladder Hepatitis Hepatitis - is an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, types A, B, C, D and E Disorders of the Liver, Biliary tract and Pancreas The disorders Hepatitis Cirrhosis Cholecystitis Cholelithiasis Pancreatitis Carcinoma of the pancreas Hepatitis Hepatitis A -this is caused by eating infected food or water. The food or water is infected with a virus called Hepatitis A Virus (HAV). Hepatitis B - this is an sexually transmitted disease (STD). It is caused by the virus HBV (Hepatitis B Virus) and is spread by contact with infected blood, semen, and some other body fluids. Hepatitis Hepatitis B cont. Using a syringe that was previously used by an infected person. Having your skin perforated with unsterilized needles, as might be the case when getting a tattoo. Hepatitis Hepatitis cont Sharing personal items, such as a toothbrush or razor, with an infected person. A baby can become infected through his mother's milk if she is infected. Hepatitis Hepatitis C - Hepatitis C is usually spread through direct contact with the blood of a person who has the disease. It is caused by the virus HCV (Hepatitis C Virus). Hepatitis D - only a person who is already infected with Hepatitis B can become infected with Hepatitis D. Hepatitis It is caused by the virus HDV (Hepatitis D Virus). Infection is through contact with infected blood, unprotected sex, perforation of the skin with infected needles. Hepatitis Hepatitis E - a person can become infected by drinking water that contains HEV (Hepatitis E Virus). Infection is also possible through anal-oral sex. Hepatitis Signs and Symptoms Diarrhea Fatigue Loss of appetite Mild fever Muscle or joint aches Nausea Slight abdominal pain Vomiting Dark urine Light colored feces Yellow skin Hepatitis Investigations History and physical examination Abdominal ultrasound Hepatitis virus serologies Liver function tests Liver biopsy to check for liver damage Paracentesis if fluid is in your abdomen Hepatitis Management - is dependent on the type Pharmacologic agents Education Cholecystitis Definition Cholecystitis is - defined as inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from gallstones. Cholecystitis Causes Gallstones - in the majority of cases acute cholecystitis is caused by gallstones or biliary sludge getting trapped at the gallbladder's opening. Injury - trauma to the abdomen, or surgery, can result in cholecystitis. Cholecystitis Infection - if the infection is located within the bile, the gallbladder can become inflamed Tumor - a tumor may stop the bile from draining out of the gallbladder properly, resulting in an accumulation of bile, which can lead to cholecystitis. Cholecystitis Clinical manifestations Pain in your upper right abdomen that radiates to back and right shoulder blade. Nausea and vomiting. Tenderness in the right abdomen. Fever Cholecystitis Investigations History Examination Computed tomography (CT) Magnetic resonance imaging (MRI) Endoscopy. Cholecystitis Management Surgery to remove the gallbladder (cholecystectomy). Cholelithiasis Definition Cholilethiasis is the presence of gallstone in the gall bladder Cholelithiasis Sign and Symptoms Pain in the right upper or middle upper abdomen: Fever Yellowing of skin and whites of the eyes (jaundice) Clay-colored stools Nausea and vomiting Cholelithiasis Investigations Abdominal ultrasound Blood studies - complete blood cell (CBC) count with differential, liver function test, amylase and lipase. Computed tomography (CT) Magnetic resonance imaging (MRI) Cholelithiasis Management Cholecystectomy Laparoscopic cholecystectomy Dietary management Medications: ursodeoxycholic acid and chenodeoxycholic acid Nonsurgical removal By instrumentation Intracorporeal or extracorporeal lithotripsy Nonsurgical Techniques for Removing Gallstones Laparoscopic Cholecystectomy Nursing Process: The Care of the Patient Undergoing Surgery for Gallbladder Disease—Assessment Patient history Knowledge and teaching needs Respiratory status and risk factors for respiratory complications postoperative Nutritional status Nursing Process: The Care of the Patient Undergoing Surgery for Gallbladder Disease—Assessment Monitor for potential bleeding Gastrointestinal symptoms: after laparoscopic surgery asses for loss of appetite, vomiting, pain, distention, fever—potential infection or disruption of GI tract Nursing Management Possible Nursing Diagnosis Acute pain Impaired gas exchange Impaired skin integrity Imbalanced nutrition Deficient knowledge Pancreatitis Definition Pancreatitis is inflammation in the pancreas Pancreatitis may be either acute (sudden and severe) or chronic. Pancreatitis Signs and Symptoms: Acute Severe abdominal pain Patient appears acutely ill Abdominal guarding Nausea and vomiting Fever, jaundice, confusion, and agitation may occur Ecchymosis in the flank or umbilical area may occur May develop respiratory distress, hypoxia, renal failure, hypovolemia, and shock Pancreatitis Chronic Recurrent attacks of severe upper abdominal and back pain accompanied by vomiting Weight loss Steatorrhea  Pancreatitis Etiology Gallstones Certain drugs, such as sulfonamides, corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and antibiotics such as tetracycline Infection with mumps, hepatitis virus, rubella, and cytomegalovirus Abnormalities in the structure of the pancreas or the pancreatic or bile ducts, including pancreatic cancer Pancreatitis Causes Surgery to the abdomen, heart, or lungs that temporarily cuts off blood supply to the pancreas, damaging tissue Hereditary diseases, such as cystic fibrosis Injury to the abdomen Chronic alcohol abuse Pancreatitis Diagnosis History, Physical exam Abdominal ultrasound CT scan Endoscopic ultrasound Pancreatitis Management Medication therapy – Antibiotics, analgesic Surgical intervention Diet-Avoid coffee and other stimulants, alcohol, and tobacco Nursing Process: The Care of the Patient With Acute Pancreatitis— Assessment Focus on abdominal pain and discomfort Fluid and electrolyte status Medications Alcohol use GI assessment and nutritional status Respiratory status Emotional and psychological status of patient and family; anxiety and coping Pancreatitis Nursing Management: Diagnosis Acute pain Ineffective breathing pattern Imbalanced nutrition Impaired skin integrity Carcinoma of the Pancreas The most common type of pancreatic cancer arises from the exocrine glands and is called adenocarcinoma of the pancreas. The endocrine glands of the pancreas can give rise to a completely different type of cancer, referred to as pancreatic neuroendocrine carcinoma or islet cell tumor Carcinoma of the Pancreas Etiology Smoking Advanced age Male sex - The male-to-female ratio of pancreatic cancer is 1.3:1. Chronic pancreatitis Diabetes mellitus Family history of pancreatic cancer Carcinoma of the Pancreas Clinical manifestations Anorexia Malaise Nausea Fatigue Mid-epigastric or back pain Weight loss Jaundice. Carcinoma of the Pancreas Investigations Management Abdominal Surgical ultrasound Radiation A CT scan therapy Chemotherapy - Fluorouracil Pancreatoduodenectomy (Whipple’s Procedure) Normal Whipple’s Procedure NURSING MANAGEMENT STUDENTS’ ACTIVITY Using following nursing diagnosis to develop a plan of care for a patient with pancreatitis Acute Pain Risk for deficient fluid balance Imbalance nutrition less than body requirement References Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H, (2008). Textbook of medical and surgical nursing. Philadelphia PA: Lippincott Williams & Wilkins. Tortora, G.J, & Grabowski, S., (2002). Principles of anatomy and physiology. USA: John Wiley & Sons. http://www.umm.edu/altmed/articles/peritonitis-00 0127.htm#ixzz29FEk04B3