Gastrointestinal system.pptx

CHAPT II:
MEDICAL SURGICAL NURSING OF
GASTROINTESTINAL SYSTEM
BY : Jean Bosco NDAYAMBAJE RN BSN MPH
Phone number:0783811480
email:[email protected]

5/29/16

Tut A Jean bosco RN MPH

1

GASTROINTESTINAL SYSTEM
OBJECTIVES:
After this unit the student will be able to indicate the different
conditions affecting gastrointestinal system
To assist in different surgical intervention for gastrointestinal
management
To collaborate with other health providers in management of
the different conditions affecting gastrointestinal system
To provide an accurate education for client and family with
gastrointestinal conditions
To use nursing process in providing nursing intervention for a
client suffering (GIC)
To perform different nursing skills aimed to help a client
with(GIC)
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Jean bosco RN BSN

GENERAL CONDITIONS
The gastro intestinal system is mainly affected by :
DISORDERS OF ORAL BUCCO CAVITY( stomatitis, pa
rotitis,CANDIDOSIS,DENTAL ABCESS,PULPITIS)
TEMPOMENDIBULO DISORDERS
DISORDERS OF ESOPHAGUS (gastroesophageal
reflex ,motility disorder
GASTRIC AND DUODENAL (gastritis, peptic ulcer,Hiatal
hernia
INTESTINAL AND RECTAL(intestinal obstruction,
peritonitis ,Anal fistula, hemorrhoids)
DISORDER OF FECAL ELIMINATION (Constipation
and Diarrhea, Fecal incontinence)
CANCERS AND MALNUTRITION
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Jean bosco RN BSN

GENERAL MANAGEMENT
Surgical intervention:
 Laparotomy
 Gastrectomy
 Intestinal resection
 Vagotomy
 Sclerotherapy
 Hemorroidectomy
 Apicectomy
 Incision and drainage
 Ileostomy
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Jean bosco RN BSN

Medical management
Spasmolytic

agents
Oral and IV antibiotic
Antifungal
Antacids
Antisecretory Drugs
Antidiarrheal
anti-inflammatory

Stool

softener
Antimotility
Peristaltic Stimulant
Antiemetic drugs
Anticholinergics
Cytoprotectives
Vitamin supplements

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Jean bosco RN BSN

General nursing interventions
Oral bucco care
2. Medication administration(
Full assessment :( Physicalantibiotics,
examination,
spasmolytics,antiparasite,a
History taking ,Laboratory ntitoxin,analgesics
exam and other
3. Give fluid replacement by
diagnostic studies)
perfusion or IV line taking
Analysis of findings
4.
assist in Surgical
intervention
Formulate the accurate nursing
diagnosis
5. Education providing
Plan the appropriate intervention:
6. Vital signs monitoring
7. Perform enema, gastric and
Drug administration
intestinal lavage
8. Physical activity and
Positioning
exercise are encouraged
1.

1.

2.
3.
4.
5.
6.
7.

Nasogastric insertion, feeding
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Jean bosco RN BSN

GENERAL INVESTIGATION
Other Clinical
Laboratory exam
investigations
Stool examination ( parasite
,appearance of the
Colonoscopy
stool, gravity of the stool and
Endoscopy
Full blood count ( rule out infection or
Ultrasound
inflammation
Laparoscopy
Hemoglobin levels (usually
decreased)
Biopsy
Electrolyte studies
CT scan
Albumin and protein measurement

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Jean bosco RN BSN

GI Focused Assessment
Physical
Vital

Signs
Height and Weight
Lab and diagnostic test results
Emesis ,amount, color, consistency
Stool , amount, color, consistency, odor.
Oral Assessment
Abdominal Assessment
Rectal Assessment
Anthropometric
BMI
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Jean bosco RN BSN

General clinical (signs and symptoms)
Abdominal

Pain
Indigestion
 Intestinal

gas
Nausea and vomiting
Hematemesis
Changes in bowel habits
Stool characteristics
Dyspepsia
Heartburn
Regurgitation
Water brash
Nausea, vomiting

pain, cramps,

headache,
 Myalgias, altered sensorium
Thirst, tachycardia,
orthostatic, decreased
urination,
Lethargy, decreased skin
turgor
Watery, bloody, mucous,
purulent, greasy stool
fever, tenesmus, blood and/or
pus in the stool)
 weight gain and weigth loss
Some patients are woken at
night by choking as refluxed
fluid irritates the larynx

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Jean bosco RN BSN

CONT’CLINICAL FEATURES
Hypo or hyper pigmentation
(difficulty swallowing)
Desquamation
Odynophagia (pain on swallowing)
Ulceration
Anemia
Pain with burning sensation
Chest pain
 Redness and bleeding
sometimes
Signs of complication like dehydration
or shock
Bad odor
Severe palmar pallor
Swelling
Eye signs of vitamin A deficiency
Xerostomia mouth dryness
Pus
Localizing signs of infection
Sores
Fever or hypothermia
Hypersyarrhea or salivary
Mouth ulcers
gland decreased
Skin changes of kwashiorkor:

Dysphagia

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Jean bosco RN BSN

Related information
BY THIS WE NEED THE INFORMATION
ABOUT:
Previous GI disease
Past and current medication use.
Nutritional status and eating patterns or unexplained
weight gain or loss over the past year
 Questioning about the use of tobacco and alcohol
The nurse records all abnormal findings and reports
them to the physician
 Psychosocial, spiritual, or cultural factors that may
be affecting the patient
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Disorders of the Oral Cavity
This group combine the conditions that affect :( mouth,
lips glands, teeth oral mucus membrane or gums)
Tooth conditions infection or inflammation:
(pulpitis,gingivitis,dental abscess and dental decay)
Salivary Gland Disorders, both infectious or non
Oral mucus membrane affection: candidiasis or stomatitis
Disorders of the mouth and lips(Herpes Simplex Type I,
cold sores, fever blisters)
Cancer of the Oral Cavity, e.g. squamous cell carcinoma
Congenital defects, e.g. cleft palate

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Jean bosco RN BSN

Cause or risk factors
The most cause are infection due to bacterial, fungus, virus,
medications, product abuse
The risk factors are as follow :
Poor oral hygiene
Sugar consumption
Low immunity immune suppressed
Injury of mucus membrane
Tobacco use and alcohol consumption
The children and elder people are at more risk
People with chronic condition
People with malnutrition
Lack of phosphate and calcium
Other condition like otitis media
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Jean bosco RN BSN

Dental conditions
Dental abscess ,pulpitis ,gingivitis ,periodontitis
The most cause are inflammation that lead to
infection
Pulpitis( pus-producing inflammation of the
dental pulp) that arises from an infection
extending from dental caries
Gingivitis Painful, inflamed, swollen gums;
usually the gums bleed in response to light
contact

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Jean bosco RN BSN

Clinical manifestations

 Pain

with burning sensation
 Redness and bleeding sometimes
 Bad odor
 Swelling
 Xerostomia mouth dryness
 Pus
 Sores
 Hypersyarrorhea or salivary gland decreased
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Acute apical abscess

Acute apical abscess

Incision and drainage

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Dental abscess
Definition
Causes(food

and bacterial deposit, dental decay,

acute pulpitis
complications
Clinical manifestations
Medical management
Nursing management

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Dental abscess
This

infection of the soft tissue surrounding a
tooth or gum
This condition start with pulpitis ,The bacterial
invade the tissue after colonizing the area by
capturing the food content especially sugar then
they make tart after a long period the make
invasion of the tissue may be : staphylococcus
areus

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Jean bosco RN BSN

Cont’
Predisposing Risk FactorsClinical manifestations
Localized, constant, deep,
Dental caries
throbbing pain
Poor dental hygiene
Pain worsens with
mastication or exposure to
Dental trauma

extreme temperatures
Tooth may be mobile
Gingival or facial swelling
and tenderness (or both) may
be present
 inability to open the mouth.
Fever (rare but possible

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Jean bosco RN BSN

MANAGEMENT AND INTERVENTIONS

Medical management
Analgesics for mild to moderate pain:
(Acetaminophen, Ibuprofen
Oral antibiotic therapy: penicillin v or
amoxicillin for 60mg/kg/day in 7 days
 For a client having allergic to
penicillin the Clindamycin

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Jean bosco RN BSN

Nursing management:
Nursing assessment (history taking,
physical examination)
History taking
 Localized, constant, deep, throbbing pain
 Pain worsens with mastication or
exposure to extreme temperatures
 Tooth may be mobile
 Gingival or facial swelling and
tenderness (or both) may be present
 Fever (rare but possible)
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Jean bosco RN BSN

Physical Assessment
Facial swelling may be present
 Carious tooth
 Gingival edema and erythema
Tooth may be loose
Anterior cervical nodes enlarged and
tender


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Jean bosco RN BSN

Assess
ment

Nursing Goal/Ex
diagnosi pected
s
outcom
es

Assessm
ent:
Subjectiv
e data
Objective
data

Pain due
to
disease
process
as
manifest
ed by
facial
expressio
n
depresse
d,
inability
to talk,
inability

interven rational
tions
e

Patient
1. admin
will be
istrati
free from
on
pain in
analg
4hrs
esic
As
(aceta
evidence
minop
d bay
hen
normal
2. Oral
verbal
hygie
communi
ne
cation
with
,normal
Warm
facial
saline
expressio 5/29/16rinses
Jean bosco RN BSN

evaluati
on

Potential Complications

Cellulitis
Recurrent

abscess formation
Systemic infection
Osteomyelitis

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Surgical management
for acute Needle aspiration by a dentist surgeon
for relieving pain and for pus drainage
 for chronic ,After using x-ray to discover the
blind dental abscess
extraction or root canal therapy may be used
( apicectomy )excision of the apex of the tooth
root for dentoalveolar abscess or blind dental
abscess


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Jean bosco RN BSN

Oral candidiasis
Fungal

infection, it is characterized by creamywhite patches in the oral cavity.
Untreated, oral candidiasis progresses to involve
the esophagus and stomach. oral candidiasis can
be disseminated to other body systems

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Jean bosco RN BSN

Clinical manifestations
Burning

Ulcerating oral lesions
sensation
Altered sense of taste
Plaques on or
pharyngeal
tissues or
Persistent (chronic), white papules
or plaques
bleeding for hyperplasiticcandidiasis
Erythematous plaques
Thick whitish/ yellowish Retrosternal pain
Focal erythema
 Difficult and painful
swallowing

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Jean bosco RN BSN

Etiology AND RISK
Local factors
factors
Xerostomia
Physiological factors
 radiotherapy, medications
infancy, old age
Medications
Endocrine disorders
broad spectrum antibiotics,
corticosteroids
diabetes mellitus, hypothyroidism
High-carbohydrate diet
Nutritional factors
Dentures
iron, folate, or vitamin B12 deficiency
changes in environmental
Blood dyscrasias and malignancies
conditions, trauma,
overnight denture wearing,
acute leukemia, agranulocytosis
denture hygiene
Immune defects, immunosuppression
Smoking
AIDS, thymic aplasia

Systemic

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Cont’

Erythematous candidiasis before
and after

Candida-associated denture
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Jean bosco RN BSN
stomatitis.

Medical management
Oral

nystatin (mycostatin), amphotericin B,
clotrimazole,or ketoconazole ( in pill form or
but for suspension, instruct the patient to swish
vigorously for at least 1 minute and then swallow
Another therapy is application of 1% aqueous
gentian violet three times a day
 Flucytosine and griseofulvin

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Jean bosco RN BSN

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Jean bosco RN BSN

DIAGNOSIS
After

assessment we have to analyze the data (cues) to
obtain nursing diagnosis as the priorities
For a client with oral candidiasis ,the nursing diagnosis :
Pain due to sores, and impaired of oral mucus as
manifested by ,inability to swallow, burning
sensations, scratching ,and depressed mood
Risk for systematic infection related to mucus sores,
decreased of mucus integrity,
Risk for imbalanced electrolyte and fluid imbalance
due to inability to take fluid or food by oral route
secondary to impaired of oral mucus integrity
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Jean bosco RN BSN

• ASSESSM
ENT d

• NURSING
DIAGNOSI
S

• GOAL/EXP
ECTED
OUTCOME
S

• INTERVENTIONS

• Subjec • Impair • The
• Assess client
tive
ed
client
for and
data
oral
will
report signs
• Object
mucus
have
and
ive
integri
a
symptoms of
data
ty
health
altered oral
• sores,
relate
y oral
mucous
white
d to
cavity
membrane
papul
diseas
in
• Reinforce
es,
e
7days
importance
erythe
proces
as
of and assist
matou
s as
evide
client with
s ,and
manif
nced
oral hygiene
edem
ested
by:
after meals
atous
by
absen • Avoid use of
•
sores,
ce of
products that
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Jean bosco RN BSN
cream
white
oral
contain

• RATION
AL

• EVALU
ATION

GORD (gastroesophageal reflex diseases)
Gastric or duodenal contents flow back into the esophagus.
It causes undesirable symptoms:
Dyspepsia
Heartburn
Regurgitation
Waterbrash
 A history of weight gain
Some patients are woken at night by choking as refluxed fluid
irritates the larynx
Dysphagia (difficulty swallowing)
Odynophagia (pain on swallowing)
Anemia
Chest pain
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Jean bosco RN BSN

Medical management
Antacids,

which are said to produce a protective
H2 receptor antagonist drugs, which reduce
gastric acid secretion,
Proton pump inhibitors are the treatment of
choice for severe symptoms and for complicated
reflux disease
Anti-reflux surgery.

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Jean bosco RN BSN

Collaborative management
Weight

loss
 Avoidance of tight-fitting garments
Avoidance of dietary items which the patient
finds worsens symptoms
 Elevation of the bed-head in those who
experience nocturnal symptoms
 Avoidance of late meals
Cessation of smoking

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Jean bosco RN BSN

Hiatal hernia
A part

of the stomach protrudes through the diaphragm muscle
into the chest. When the hernia is in this position, stomach
acid and food do not drain out of it quickly. Over time, this
can result in tissue damage to the esophagus, lungs and mouth
Causes and risk factors
Ascites
pregnancy
Obesity
Constrictive clothes
Bending, straining,
Coughing
peptic ulcer
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Jean bosco RN BSN

Manifestations
Occur

in 30% of the population over the age of
50 years.
Often asymptomatic.
Heartburn and regurgitation can occur.
Gastric volumes may complicate large hernias

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Jean bosco RN BSN

TYPES
1.

Type I sliding hiatal hernias, where the gastroesophageal
junction migrates above the diaphragm6. The stomach remains
in its usual
2. Type II pure paraesophageal hernias, the gastroesophageal
junction remains in its normal anatomic position but a portion
of the fundus herniates through the diaphragmatic hiatus
adjacent to the esophagus.
3. Type III combination of Types I and II, with both the
gastroesophagea junction and the fundus herniating through the
hiatus. The fundus lies above the gastroesophageal junction.
4. Type IV the presence of a structure other than stomach, such
as the omentum, colon or small bowel within the hernia sac
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Jean bosco RN BSN

Types

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Jean bosco RN BSN

Management
Drink

1 to2 l of water within 5-10 minutes. Then
carefully jump down from a one to two foot step
but not in all condition(any health concerns)

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Jean bosco RN BSN

SURGICAL MANAGEMENT
All

symptomatic paraesophageal hiatal hernias
should be repaired
reduction of the stomach
Hernia sac excision

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Jean bosco RN BSN

Peptic ulcer
A peptic

ulcer is an quarry (hollowed-out area)
that forms in the mucosal wall of the stomach, in
the pylorus (opening between stomach and
duodenum), in the duodenum (first part of
small intestine), or in the esophagus.

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Jean bosco RN BSN

CAUSES AND RISK FACTORS
OLD

New

Idiopathic
Stress
 Smoking
Spicy food

Helicobacter Pylori
 NSAID
Crohn’s disease
Gastronoma
Hyperparthyroidism



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Jean bosco RN BSN

Clinical manifestation
30% asymptomatic
 Dyspepsia
 Anaemia
 Haematemesis / melaena
A dull pain or a burning sensation in the
midepigastrium or in the back.
 Sharply localized Tenderness
pyrosis (heartburn),
vomiting, constipation
 diarrhea and and bleeding
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Jean bosco RN BSN

complications
Bleeding:

anaemia, melaena, haematemesis
Pyloric Obstruction: vomiting, dysphagia,
weight loss, epigastric fullness
Perforation and Penetration: pain, peritonitis
Carcinoma in chronic gastric ulcer

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Jean bosco RN BSN

Management
The management is based on these following
steps
Treatment (Drugs)
 Lifestyle and dietary modification
Operation

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Jean bosco RN BSN

Lifestyle change
Less

stress
 Regular diet
 Avoid NSAID
 Quit smoking

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Jean bosco RN BSN

Drugs
Eradication

of HP
 Gastric acid neutrolizers – Antacids
Antisecretory
 Cytoprotectives
Eradication of HP
First line treatment
Triple therapy- 2 antibiotics and 1 PPI for 1 week
Clarithromycin 500mg BD
Amoxicillin 1g BD
Nexium 20mg BD
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Jean bosco RN BSN

Second line therapy
One week quadruple therapy
 Bismuth 120mg Tetracycline 500mg
Metronidazole 400mg QID, Nexium 20mg BD
Antisecretory Drugs
H2 antagonists(Inhibit the action of histamine at the H2
receptors of parietal cells)
Cimetidine (800mg), Famotidine (40mg),
Ranitidine(300mg) Once daily dose at bedtime 6-8 weeks
 Proton pump inhibitors
Block the final step in gastric acid secretion ( Omeprazole
(20mg),Once daily dose at bedtime 4-6 weeks
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Jean bosco RN BSN

Cytoprotectives
Sucalfate (aluminum hydroxide + sucrose) Form a
paste to protect gastrointestinal mucosa 1 g QID

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Jean bosco RN BSN

Surgical interventions
Indications
 Refractory ulcer
 Complications
Bleeding
Perforation
Pyloric stenosis
Acid reduction surgery
Vagotomy
Gastrectomy
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Jean bosco RN BSN

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Jean bosco RN BSN

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Jean bosco RN BSN

Post-op Care
Nasogastric Gastric tube management
patency, position (co2, pH paper)
Bright
& stability observe, record and
report output
red/24
Dark red/ PO Day
Fluid replacement
1
IV fluids
Red/green PO Day
2
blood products
Bile color PO Day
Pain management
3
Cough, Deep Breathe, Ambulate

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Jean bosco RN BSN

Assessm Nursin
ent
g
diagno
sis

Goal
/expec
ted
outco
mes

Subjecti
ve and
objectiv
e data
• Dyspep
sia
• signs
of
Anaemi
a
• Haema
temesi
s/
melaen

Patient
will
gain
the
normal
nutritio
n
status
as
evidenc
ed by
normal

Imbalan
ced
nutritio
n less
than
body
require
ment
related
to
changes
in diet
intake
As

Nursi Ration
ng
ale
interv
ention
s

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Jean bosco RN BSN

evaluation

Diagnosis
Analysis of cues or data as obtained from history and
physical examination
To obtain the priority nursing diagnosis
Epigastric pain
Electrolyte and fluid imbalance
Planning(care Plan)
Acute pain related to the effect of gastric acid secretion on
damaged tissue
Anxiety related to coping with an acute disease
Imbalanced nutrition related to changes in diet
 Deficient knowledge about prevention of symptoms and
management of the condition
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Jean bosco RN BSN

GASTRITIS
Inflammation of the gastric or stomach mucosa) is a common GI
problem it may be acute or chronic
Causes and risk factors
Exposure to irritating agents
Hypochlorhydria(absence or low levels of hydrochloric acid [hcl]) or
with hyperchlorhydria(high levels of hcl)
Excessive alcohol intake
Bile reflux and radiation therapy
Acute systemic infection
Ingestion of strong acid or alkali
NB: chronic
Autoimmune diseases such as pernicious anemia;
Dietary factors ( caffeine; the use of medications nsaids; alcohol;
smoking; or reflux of intestinal contents)
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Jean bosco RN BSN

Type of chronic gastritis
Type A (autoimmune)

it involve autoimmune
activity against parietal cells
 Type B (bacterial infection) :it provokes an
acute inflammatory response
Type C (reflux gastritis): the regurgitation of
duodenal contents into the stomach through the
pylorus

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Jean bosco RN BSN

COLLABORATIVE MANAGEMENT
Treatment

consists of diluting and neutralizing the
offending agent
To neutralize acids, common antacids (eg, aluminum
hydroxide)
 to neutralize an alkali, diluted lemon juice or diluted
vinegar
If corrosion is extensive or severe, emetics and lavage
are avoided because of the danger of perforation and
damage
Nasogastric (NG) intubation, analgesic agents and
sedatives, antacids, and intravenous (IV) fluids.
Nothing by oral to stimulate mucosal healing
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Jean bosco RN BSN

Assess
ment

Nursing Goal/ex
diagnosi pected
s
outcom
es

Subjectiv
e
objective
data
abdomin
al
discomfo
rt
headach
e
Lassitude
nausea
anorexia
vomiting

Anxiety
related
to coping
with an
acute
disease

Nursing rational
interven e
tions
1. Asses
s
what
patien
t
wants
to
know
about
the
diseas
e,
and e
valuat
e Jean bosco RN BSN
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Evaluati
on

Peritonitis
Peritonitis

is an inflammation of the peritoneum
that lines the abdominal cavity and covers the
surfaces of abdominal organs and is marked by
exudations into the peritoneum of serum, fibrin,
cells and pus

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Jean bosco RN BSN

Causes
 Primary

causes: the spread of an infection from the
blood and lymph nodes to the peritoneum and
accounts for less than 1% of all cases.
Secondary peritonitis is the commonest type and
occurs when bacteria enter the peritoneum from the
gut or biliary tract
Manifestations:
Vomiting, swelling of the abdomen
Severe abdominal pain and tenderness,
 Weight loss, constipation
Moderate fever
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Jean bosco RN BSN

Why and when?
Perforations

of GIT wall
ruptured appendix
 perforations the stomach( ulcers) and gallbladder
 Pelvic inflammatory disease in sexually active women
 after surgery
Peritoneal dialysis
Diagnostic studies
using X-rays or a CT scan (the presence of fluid,
accumulation of pus or infected organs in the abdomen.
 samples of blood or abdominal fluid (causative
microorganism)
5/29/16

Jean bosco RN BSN

Collaborative Management
Fluid and Electrolyte
Replace

Fluids & Electrolytes
Replace lost Proteins- albumin

Elimination

NG

Protection

or long intestinal tube to decompress
stomach & prevent aspiration

Incision

& Drainage
Wound Care w/ irrigations
 wound drainage
Antibiotic Therapy
5/29/16

Jean bosco RN BSN

Medical management
Antibiotic

administration(ampicilline)
Analgesic (morphine)
Immediate surgery to wash the pertonial cavity

5/29/16

Jean bosco RN BSN

General management of Peritonitis
ABC
Oxygen
Fluid

resuscitation (large bore cannule,
bloods, IVF, catheter)
IV antibiotics (Augmentin and metronidazole)
Analgesia
Surgery (with or without preceeding CT
depending on availability and stability of
patients)

5/29/16

Jean bosco RN BSN

Nursing Priorities
Assessment

◦ Pain
◦ Bowel sounds
◦ Wound Care
Post-op
◦ ARDS
◦ Sepsis  Septic Shock
◦ IV fluids & antibiotic therapy
◦ Teaching – Wound Care
5/29/16

Jean bosco RN BSN

Inflammatory Bowel Disease
Incidence◦ 2 peaks
 15-25 years
 55-65 years
◦ Male = female
◦ White, urban,  Jewish
◦ Familial (10 x )
◦ ? Autoimmune

5/29/16

Jean bosco RN BSN

Etiology: Not Clear
Current

Research: strong genetic component;
also autoimmune response
◦ Caused by an inappropriate immune response
to an environmental trigger
◦ Both intestinal and extra-intestinal CM’s
Other causes
◦ Bacterial trigger
◦ Allergic response
◦  destructive enzymes
◦  protective substances
5/29/16

Jean bosco RN BSN

Comparison

Crohn’s Disease

Ulcerative Colitis

5/29/16

Jean bosco RN BSN

Crohn’s

Ulcerative
Colitis

Distributio
n
Inflammati
on

Anywhere – common Rectum & Distal
at terminal ileum
colon

Common
CM’s

Abdominal Cramping Diarrhea
Pain & Diarrhea
Rectal Bleeding
Weight loss, esp. if
Cramps & Pain
terminal ileum is
involved

Blood in
stool

Visible w/colon
involved

Carcinogene

Mild  Risk

Discontinuous
Transmural

5/29/16

Continuous
Mucosa & submucosa

Usually visible
 Risk after 10

Jean bosco RN BSN

Management in acute phase

Hemodynamic

stability
Restore/maintain fluid & electrolyte balance
Nutritional support
◦ Parenteral Nutrition (PN) – bowel rest
◦ Elemental or low residue diet
Decrease immune response
◦ Immuno-suppressants : Azathioprine (Imuran)

5/29/16

Jean bosco RN BSN

Medical management


Diarrhea if severe(npo
Antidiarrheal(lomotil, imodium)
Aminosalicylates (anti-inflam.  Prostaglandin
synthesis)
Corticosteroids
Immunosuppressives
◦ Remicade – blocks action of TNF
Anticholinergics
Anti-infectives
◦ Sulfonamides
◦ Flagyl
◦ Cipro
5/29/16

Jean bosco RN BSN

Nursing Interventions
Diarrhea

◦ Bowel rest
◦ Help patient determine causative foods (caffeine, spicy)
Skin integrity
◦ Encourage protein intake
◦ Cleanse well, Sitz bath, moisturizer & barrier creams
Acute Pain r/t inflamed bowel mucosa
◦ Assess, alert to complications
◦ Use narcotics as needed (PRN)
Teach cancer screening (ulcerative colitis)
Ineffective coping
◦ Identify ineffective coping behaviors
◦ Include family, other staff in plan
◦ Encourage expression of feelings
◦ Stress reduction techniques
◦ Referrals as necessary
 Counseling, dietician
5/29/16

Jean bosco RN BSN

Surgical Management
Crohn’s Disease
Surgery not usually indicated except for
complications
◦ Perforation
◦ Hemorrhage
◦ Obstruction
Ulcerative colitis
25-40% eventually will need surgery.
◦ Permanent ileostomy
Continent ileostomy
5/29/16

Jean bosco RN BSN

Intestinal obstruction
A blockage

of the intestine typically resulting in
symptoms such as abdominal pain and vomiting. This
condition prevents the normal flow of intestinal
contents through the intestinal tract
TYPES:
Mechanical obstruction: An intraluminal obstruction or
a mural obstruction from pressure on the intestinal walls
occurs. neoplasms, or abscesses.
Functional obstruction: The intestinal musculature
cannot propel the contents along the bowel (Parkinson’s
disease)
 it can be partial or complete.
5/29/16

Jean bosco RN BSN

Mechanical cause of intestinal obstruction

5/29/16

Jean bosco RN BSN

Clinical Manifestations
High

Low
◦ Gradual onset
◦ Vomitus – orange brown & foul smelling
d/t overgrowth of bacteria
◦ Distention
◦ Metabolic Acidosis
◦ No fecal nor flatus that pass only blood
and mucus
◦ Signs of shock

◦ Rapid onset
◦ Projectile vomitus of bile
◦ Vomiting relieves pain
◦ Distention minimal or absent
Large Bowel
◦ Metabolic alkalosis
Bowel Sounds
◦ Vomiting may be absent with ileocecal
valve competent or fecal vomiting signs
of constipation
 high pitched
◦ Lower abdominal clumpy pain
 over area of obstruction ◦ Incompetent valve – vomits fecal material
◦ Loop of large intestine may be seen on
the outline of the abdominal wall
 audible
5/29/16

Jean bosco RN BSN

Collaborative Management











Decompression(
NG tubes- Intestinal tubes – (controversial)
Sigmoid tubes – to reduce volvulus
Correct & maintain fluid balance
(IV normal saline w/ K+
TPN to correct nutritional deficiencies
Relief or removal of obstruction
(surgery
colonoscopy then cecostomy

5/29/16

Jean bosco RN BSN

Hemorrhoids
condition in which the portion of the anal became
dilated including the vascular tissue(veins) ,this
can occur on the internal or external sphincter and
it can result the sliding of the whole anal wall
including the vascular tissue in the(lumen) of anal
cavity
TYPES:
the hemorrhoid can be categorized into 2 mains
types: internal hemorrhoid (internal sphincter) anal
and external hemorrhoid(external sphincter) depend
on the location where the veins were dilated
5/29/16

Jean bosco RN BSN

5/29/16

Jean bosco RN BSN

5/29/16

Jean bosco RN BSN

Clinical manifestations
Itch

or bleed from the anus
 Feel a mild burning.
 Have swelling and pain during bowel movements.
 Feel painful lumps around the anus
Discomfort during defection
 bright red bleeding with defecation
Hemorrhoid seen outside for external hemorrhoid(Rectal
Prolapsed)
NB: for external hemorrhoid( severe pain from the inflammation and
edema caused by thrombosis ( clotting of blood within the
hemorrhoid)
Internal hemorrhoids are not usually painful until they
Bleed or prolapsed when they become enlarged
5/29/16

Jean bosco RN BSN

Causes
 Constipation.
Hold

back or wait a long time before you have a bowel movement.
Diarrhea
◦ Heavy lifting
 Sit for a long time on the toilet
Risk factors :
 pregnant women or give birth.
 overweight or obese people.
 Cough or sneeze a lot.
Sitting for a long time.
 liver disease
 Drink too much alcohol.
Anal sex
5/29/16

Jean bosco RN BSN

Complications
Ischemia
Hemorrhage
Anal

stenosis
Thrombos
Rectal obstruction
constipation
impactation

5/29/16

Jean bosco RN BSN

Nursing Management
Good

personal hygiene
Sitting for few minutes warm water a few times
a day may help(sitz baths)
Avoiding excessive strain during defecation.
Consume diet that contains fruit
Avoid intraobdomonial pressure
Increase fluid intake
Warm compresses
Bed rest allow the engorgement to subside..
5/29/16

Jean bosco RN BSN

Pharmacological interventions
Corticosteroid

creams
Nitroglycerin ointment
Analgesic ointment( Nupercainal)
Calcium dobisilate
The addition of hydrophilic agents psyllium
and mucilloid
Analgesic ointments or suppositories,
Astringents (eg, witch hazel),
Injecting sclerosing solutions
Stool softener
5/29/16

Jean bosco RN BSN

Surgical management
With

the anoscope hemorrhoid is visualized
Involves freezing the hemorrhoid to cause necrosis.
Internal hemorrhoids can be treated by banding
Hemorrhoidectomy, or surgical excision(the rectal sphincter
is usually dilated digitally and the hemorrhoids are removed
with a clamping and cauterization or are ligated and the
excised)
Large external or internal hemorrhoids by cutting out
surgically and then closing with absorbable sutures (stitches)
 Sclerotherapy by inserting a special material to shrink and
stop bleeding
 Burning and coagulating with special instruments such as
lasers or infrared emitting probe
5/29/16

Jean bosco RN BSN

Diarrhea
Frequent

passage of feces that are larger in
volume and more fluid than normal. It is not a
disease but a symptom of some other underlying
conditions that result in abrupt increases in
intestinal movement
Osmotic balance between GIT contents and ECF
in the intestinal tissue.(Secretory stimuli, NA/K
Atapase
Diarrhea may result from one of two principal
mechanisms, secretion and osmotic imbalance.
5/29/16

Jean bosco RN BSN

Types

how?

Osmotic

diarrhea
Secretory diarrhea
Infectious diarrhea
The aim of management :
To correct dehydration and electrolyte deficits.
By fluids replacement orally or intravenously

5/29/16

Jean bosco RN BSN

Risk factors
 Consumption

of unsafe foods (e.G., Raw meats,
eggs, or fish; unpasteurized milk )
 visiting a farm or petting zoo
 knowledge of other ill persons (such as in a
dormitory or office or a social function);
 Medications (antibiotics, antacids, antimotility
agents);
 Underlying medical conditions predisposing to
infectious diarrhea (AIDS)
 receptive anal intercourse or oral-anal sexual contact
 Occupation as a food-handler or caregiver
5/29/16

Jean bosco RN BSN

Main features from diarrhea

5/29/16

Jean bosco RN BSN

General manifestations
Nausea,

vomiting
Abdominal pain, cramps, headache,
 Myalgias, altered sensorium
Thirst, tachycardia, orthostatic, decreased
urination,
Lethargy, decreased skin turgor
Watery, bloody, mucous, purulent, greasy stool
Signs of dysentery(fever, tenesmus, blood and/or
pus in the stool)

5/29/16

Jean bosco RN BSN

MANAGEMENT
The

management depend on the cause and the
person
For infectious diarrhea or
immunocomprimised(AIDS) people
(antibiotic or additional of TMP-SMZ,
RECOMMENDATION
INITIAL REHYDRATION( IV for severe or unable
to take something by oral route, Oral rehydration
solutions for mild)
CLIENT EVALUATION
FECAL TEST
5/29/16

Jean bosco RN BSN

5/29/16

Jean bosco RN BSN

What to assess
 When

and how the illness began (e.G., Abrupt or gradual onset and
duration of symptoms);
 Stool characteristics (watery, bloody, mucous, purulent, greasy, etc.);
 Frequency of bowel movements and relative quantity of stool
produced;
 Presence of dysenteric symptoms (fever, tenesmus, blood and/or pus
in the stool);
 Symptoms of volume depletion (thirst, tachycardia, or thostasis,
decreased urination, lethargy, decreased skin turgor); and
 associated symptoms and their frequency and intensity (nausea,
vomiting, abdominal pain, cramps, headache, myalgias, altered
sensorium).
Risk factors
Observe for abnormal vital signs or other signs of volume depletion
5/29/16

Jean bosco RN BSN

Constipation
The difficult or unduly infrequent passage of
faeces or abnormal infrequency or irregularity
of defecation.
Abnormal hardening of stools ( difficult and
sometimes painful, a decrease in stool volume, or
retention of stool in the rectum for a prolonged
period)

5/29/16

Jean bosco RN BSN

Causes
Rectal

or anal disorders (e.g., hemorrhoids)
 Obstruction (e.g., cancer of the bowel)
 Metabolic, neurologic, and neuromuscular conditions ( diabetes
mellitus, Parkinson's disease)
endocrine disorders (e.g., hypothyroidism)
 Lead poisoning
 reduced food (including fiber) and fluid intake
 reduced motility
 reduced abdominal and pelvic muscle power
 constipating drugs (e.g. opioids, drugs with anticholinergic
action)
reduced rectal/anal tone and sensation (neurological impairment

5/29/16

Jean bosco RN BSN

Complication

Abdominal

distension/pain;
 Anorexia, nausea and/or vomiting
 Faecal ‘overflow’ incontinence
 Hemorrhoids/anal fissure
Urinary retention/infection
Faecal impaction (that can lead to bowel
obstruction)
 Agitated delirium.
5/29/16

Jean bosco RN BSN

Management
Goals

of Management
 The main goal is to prevent the consequences of
constipation, or treat them if they have occurred.
 Identify and treat any reversible causes if appropriate.
 Proactive management with prophylactic laxatives in
patients at high risk of constipation (e.g. commencing
opioid).
Education of patient and carers about the importance of
close vigilance of bowel pattern, early intervention and
ongoing management of constipation.
 Aggressive intervention to reverse severe
constipation/faecal impaction and to prevent recurrence.
5/29/16

Jean bosco RN BSN

Medical management
First

line laxative treatment
(Stool softener
I.
Coloxyl 1-2 x 120mg tablets po
II. Macrogol (Movicol)
 Peristaltic Stimulant
I. Bisacodyl 1 - 2 x 5mg tablets
II. Senna 1 - 2 x 7.5mg tablets
Metoclopramide has a prokinetic effect for
treatment if nausea &/or vomiting are present as
addition
5/29/16

Jean bosco RN BSN

Second line
When

there is no bowel action for three days
consider a rectal examination
Rectum empty(please exclude obstruction)
There is impactation
Propulsive stimulant: bisacodyl (Durolax)
suppositories 1 - 2 PR; repeat twice daily until
good result
Movicol 8 sachets dissolved in 1 litre of water
orally, taken over 2 - 4 hours
If resolved give oral laxatative avoid recurence
5/29/16

Jean bosco RN BSN

Rectum full-hard stool
Glycerin

suppositories 1 - 2 PR to soften stools
(placed into substance of stool) +/- bisacodyl
(Durolax) suppositories 1 PR to stimulate
rectum/bowel from above (placed in contact with
rectal mucosa).
Once resolved resume oral laxatives at
appropriate dose
NB: Rarely manual evacuation under
sedative(lorazepam 1mg S/L) may be used

5/29/16

Jean bosco RN BSN

Rectum Full – Soft Faeces

Senna 2 x 7.5mg tablets , increasing to 15mg bd
Bisacodyl – propulsive stimulant 2 x 5mg tablets
PO increasing to 10mg bd (10-12 hour delay to
onset)
 Bisacodyl suppositories 1-2 PR until resolved
NB: If the patient is having difficulty expelling
soft stool then add (or increase dose of)
propulsive agent (senna or bisacodyl


5/29/16

Jean bosco RN BSN

USEFUL QWESTION TO ASSESS
CONSTIPATION
ONSET
When/how did it begin?
What was your usual bowel pattern?
 How much and how often? Before? Now?
Provoking/relieving
 What medication are you on?
 How is your appetite/food and fluid intake?
What treatments/laxatives have you tried previously?
 What are you taking now?
 How effective are these?
 Do you get any side effects from these
treatments/laxatives?
5/29/16

Jean bosco RN BSN

CONT’
Quality
What does it feel like?
Is using your bowels painful?
 Is there a feeling of incomplete evacuation?
What do the stools look like?
Where do you most feel it? (abdomen? ano-rectal area?)
Severity
How bad is the constipation (on a scale of 0 to 10 with 0 being none
and 10 being
worst possible)? Right now? At best? At worst? On average?
How bothered are you by it?
Are there any other symptoms that accompany the constipation e.g.
anorexia,nausea, vomiting, abdominal pain, pain on defecation,
bloating
5/29/16

Jean bosco RN BSN

Colaborative management
The

record of bowel elimination, character of
stool, food and fluid intake,
level of activity, bowel sounds, medications, and
other assessment data are reviewed to develop the
plan of care.
Multiple approaches may be used to prevent
constipation
The diet should be well balanced and should
include adequate intake of high-fiber foods
(vegetables, fruits, bran) to prevent hard stools and
to stimulate peristalsis]
5/29/16

Jean bosco RN BSN

Cont’
Fluid intake should be between 2 and 3 L/day unless
contraindicated. Prune juice or fig juice (120 mL)
taken 30 minutes before a meal once daily is helpful to
some cases
when constipation is a problem. Physical activity and
exercise are encouraged, as is self-care in toileting.
 The patient is encouraged to respond to the natural urge
to defecate.
Privacy during toileting is provided.
Stool softeners, bulk-forming agents, mild stimulants and
suppositories may be prescribed to stimulate defecation
and to prevent constipation.
5/29/16

Jean bosco RN BSN

CANCER AND MALNUTRITION
Conditions
Causes

and risk factors
complications
Medical management
Nursing management

5/29/16

Jean bosco RN BSN

Malnutrition
a condition in which a client show poor nutrition due to
insufficient or excessive or imbalanced diet or from inability to
absorb foods.
RISK FACTORS OF MALNUTRITION
Elderly people
Hospitalized people for long time
Poor people (People with low income)
People with chronic eating disorder
People convalescing after serious illness such as measles,
pneumonia and diarrhea
Medication’s side effects can reduce dietary intake (proton
pump inhibitor)
Dysphagia
5/29/16

Jean bosco RN BSN

Types of malnutrition
Acute

malnutrition
◦ Marasmus (wasting)
◦ Kwashiorkor (oedematous)
Chronic malnutrition
◦ Stunting
Growth faltering (underweight)
◦ Composite of acute & chronic malnutrition
Specific nutrient deficiency
◦ Anaemia, Iodine etc
Malnutrition secondary to disease
◦ HIV / TB
◦ Any illness
5/29/16

Jean bosco RN BSN

Forms of acute malnutrition
Kwashiorkor

Frequent infections, Electrolyte imbalance,
Frequent association with dehydration (often ,masked by
oedema) Generally apathetic, lethargic, miserable, and
irritable. They show no signs of hunger, and it is difficult to
persuade them to eat.
Marasmus(Extremely emaciated (fat & muscle tissue
grossly ,reduced).Thin flaccid skin, hanging in loose folds;
“baggy pants”,
“old man‟s appearance”, Normal hair, Frequent infections with
minimal signs,Electrolyte imbalance (no oedema),Frequent
association with dehydration, Alert & irritable
Marasmic-kwashorkor(signs of marasm but with edema)
5/29/16

Jean bosco RN BSN

Management
It start with initial assessment
History taking that include :
 Recent intake of food and fluids
 Diet
 Duration and frequency of diarrhea and vomiting
 history of diarrhea
 Family circumstances
 Chronic cough
 Contact with TB
 Known or suspected HIV infection
5/29/16

Jean bosco RN BSN

On physical Examination
Assessment

of Anthropometry:
(Age,Sex,Weight,Height,Bilateral edema,MUAC) Mid Upper
Arm Circumference ,BMI
 Signs of complication like dehydration or shock
 Severe palmar pallor
 Eye signs of vitamin A deficiency
 Localizing signs of infection
 Fever or hypothermia
 Mouth ulcers
 Skin changes of kwashiorkor:
 Hypo or hyper pigmentation
 Desquamation
 Ulceration
5/29/16

Jean bosco RN BSN

Management of complications

Hypoglycemia:







All severely malnourished are at risk of hypoglycemia.
Where blood glucose results can be obtained quickly (eg with
Dextrostix), this should be measured quickly.
Hypoglycemia is present when blood glucose is <3 mmol/l (<54 mg/dl)
Give 50mls of 10% glucose.
Give 2 hourly feeds, day and night at least for the first day.
If the child is unconscious. Treat with IV glucose.

Hypothermia(<35C):



Is associated with increased mortality in severely malnourished children.
Feeding the child, ensuring adequate clothing and appropriate antibiotics
forms the management.

5/29/16

Jean bosco RN BSN

Electrolyte imbalance:
Extra potassium should be added to the feeds during
their preparation.
 All severely malnourished children have deficiencies of
potassium and magnesium which may take 2 weeks or
more to correct.
Infection:
 In severe malnutrition, the usual signs of infection such
as fever are often absent, yet multiple infections are
common.
Therefore, assume all malnourished children have an
infection on their arrival at the hospital and treat with
broad spectrum antibiotics straight away


5/29/16

Jean bosco RN BSN

Micronutrient deficiencies:










All severely malnourished children have vitamin and
mineral deficiencies. Although anemia is not common, do
not give iron initially but wait until the child has good
appetite and starts gaining weight(usually in the 2 nd
week), because iron can make the infection worse.
Give daily (for at least 2 weeks)
Multivitamin supplement
Folic acid (5mg on day 1, then 1mg/day)
Zinc (2mg Zn/kg/day)
Copper (0.3mg Cu/kg/day)
Once gaining weight, ferrous sulphate (3mgFe/kg/day
5/29/16

Jean bosco RN BSN

CONT’
Eye

problems:
If the child has eye signs of vitamin A deficiency (dry
conjunctiva or cornea, corneal ulceration, keratomalacia):
 Give vitamin A orally on day 1,2 and 14 (aged <6
months5, 0000 IU; aged 6-12 months, 100000 IU; older
children, 200000 IU)
 If the eyes shows signs of inflammation or ulceration
 Instill Chloramphenicol or tetracycline eye drops, 3
hourly for 7-10 days.
 Instill atropine eye drop.
 Cover with saline-soaked eye pads.

5/29/16

Jean bosco RN BSN

Daily diet
 Frequent

small feeds of low osmolality and low in lactose.
 Oral or nasogastric feeds.
 100kcal/kg/day.
 Protein: 1-1.5 g/kg/day.
 Liquid: 130 ml/kg/day.
Monitor and record
 Amount of food offered and left
 Vomiting
 Stool frequency
 Daily body weight.
Catch up growth;
Give a milk based formula.
5/29/16

Jean bosco RN BSN

1.

2.

3.

4.

Using nursing process indicate how will you
manage a client with diarrhea PLEASE other
collaborative measures
Using nursing process indicate how will you
manage a client with vomiting please indicate
other collaborative measures
Indicate the collaborative measure and also
use nursing process manage a client with
malnutrition
Indicate the collaborative measure and also
use the nursing to manage a client with
hemorrhoids
5/29/16

Jean bosco RN BSN