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GASTRO INTESTINAL TRACT DISORDERS

Gastro-esophageal reflux (GERD) Backflow of gastric contents into the esophagus Usually due to incompetent lower esophageal sphincter , pyloric stenosis or motility disorder Symptoms may mimic ANGINA or MI

 

 

ASSESSMENT  Heartburn  Dyspepsia  Regurgitation  Epigastric pain  Difficulty swallowing  Ptyalism

 Diagnostic test  Endoscopy or barium  swallow  Gastric pH analysis

NURSING INTERVENTIONS 1. Instruct the patient to AVOID stimulus that increases stomach pressure and decreases GES pressure 2. Instruct to avoid spices, coffee, tobacco and carbonated drinks 3. Instruct to eat LOW-FAT, HIGH-FIBER diet 4. Avoid foods and drinks TWO hours before bedtime

NURSING INTERVENTIONS 5. Elevate the head of the bed with an approximately 8-inch block 6. Administer prescribed H2-blockers, PPI and prokinetic meds like cisapride and metochlopromide 7. Advise proper weight reduction

BARRET’S ESOPHAGUS Result from long standing untreated GERD Identified as a precancerous condition and if untreated can result in adenocarcinoma of the esophagus Common among middle aged white men, woman, and African Americans

DIGESTIVE DISORDERS Pathophysiology Untreated GERD

Barret’s esophagus

Adenocarcinoma of the esophagus

 

 

BARRET’S ESOPHAGUS Clinical Manifestation Frequent heart burn Complain symptom same as GERD, peptic ulcer or esophageal stricture Diagnostic finding Esophagogastroduodenoscopy (EGD) is performed Biopsy are taken

BARRET’S ESOPHAGUS Assessment It reveals an esophageal lining that is red rather than pink Management EGD in six to twelve months Medical management is similar that of GERD

HIATAL HERNIA

HIATAL HERNIA

 Protrusion of the stomach into the diaphragm  thru an opening  Two types­ Sliding hiatal hernia(most  common) and Axial hiatal hernia

ASSESSMENT  Heartburn  Regurgitation  Dysphagia  50%; without symptoms

 

 

DIAGNOSTIC TEST  Barium swallow and fluoroscopy.

NURSING INTERVENTIONS  Provide small frequent feedings  AVOID reclining for 1 hour after eating  Elevate the head of the head on 8 –inch block  Provide pre­op and post­op care

 

 

Hiatal hernia  

Hiatal hernia – Xray  

Sliding Hiatal Hernia  Protrusion of the esophagastric junction into the  thoracic cavity and back into the abdominal cavity  in relation to position changes.

Causes:  Muscle weakness in  the esophageal hiatus:

 

 Aging process   Congenital muscle weakness  Obesity  Trauma  Surgery  Prolonged increases in intra­abdominal pressure  

Sliding Hiatal Hernia

 

 

Paraesophageal / Rolling Hernias  The gastric junction remains below the diaphragm, but  the fundus of the stomach and the greater curvature rolls  into the thorax next to the esophagus  Cause:  anatomic defect.

 

 

Management

 Medications

 Antacids  Antiemetics  Histamine Receptor Antagonist  Gastric Acid Secretion Inhibitor

 AVOID; These drugs lowers the LES (lower  esophageal sphincter) pressure:  Anticholinergics  Xanthine derivatives  Ca­channel blockers  Diazepam

 

 

Nursing Interventions  Relieve Pain  Modify diet  High CHON diet to enhance LES pressure  Small frequent feedings (4­6)  Eat slowly and chew food properly  Avoid: fatty foods, Cola beverages, Coffee, Chocolate, Alcohol; all these  Foods and beverages decrease LES pressure  Assume upright position before and after eating (1­2hours.)  Do not eat at least 3 hours before bedtime to prevent  nighttime reflux  No evening snacks.  Promote lifestyle changes  Elevate head of bed 6­12 inches for sleep.  Avoid factors that increase the intra­abdominal pressure.  Use of constrictive clothing   Straining  Heavy lining  Bending, stooping  Coughing  

 

 

 

Surgery

 Nissen Fundoplication (gastri wrap­around)  Pre­op Care

 Teach on DBCT exercise, incentive spirometry to prevent postop respiratory  complications.  Inform on possible post –op contraptions:  Chest tube  NGT

 Postop Care

 Facilitate airway clearance  Semi­Fowler’s Position  Reinforce DBCT exercises, incentive spirometry, chest physiotheraphy.

 Facilitate swallowing          

A large NGT is inserted to prevent the fundoplication from being made too tightly. Drainage from NG tube returns to yellowish green within first 8­12 hours post­op. Oral fluids after peristalsis returns; near normal diet within 6 weeks. Small frequent meals. Maintain upright position. Avoid gas forming foods. Frequent position changes and early ambulation to clear air from the GI tract. Report for persistent Dysphagia and gas pain.  

DIGESTIVE DISORDERS GASTRITIS Inflammation of the gastric or stomach mucosa. Common GI problem

 

Signs & Symptoms A. Acute Gastritis - Abdominal discomfort - Headache - Lassitude - Nausea - Anorexia - Vomiting   - Hiccupping

DIGESTIVE DISORDERS B. Chronic Gastritis - Anorexia - Heartburn after eating - Belching - A sour taste in the mouth - Nausea and vomiting

 

 

Acute Gastritis  

Chronic Gastritis  

DIGESTIVE DISORDERS Pathophysiology

 

Gastric mucous ↓ Edematous and hyperemic ↓ Superficial erosion ↓ Secretes gastric juice ↓ Contains little acid but more mucus ↓ Superficial erosion ↓   Hemorrhage

DIGESTIVE DISORDERS Treatment 1.Naso gastric intubation 2.Analgesics agents 3.Sedatives 4.Antacids 5.Intravenous fluids 6.Fiberoptic endoscopy 7.Gastrojejunostomy or gastric resection (Pyloric obstruction) 8.Antibiotics 9.Proton Pump Inhibitors 10.Bismuth salt  

 

DIGESTIVE DISORDERS Nursing Intervention 1.Reducing anxiety 2.Promoting optimal nutrition 3.Promoting fluid balance 4.Relieving pain 5.Teaching patient self-care

 

 

Peptic Ulcer Disease These are circumscribed lesions in the mucosal membranes of the stomach and duodenum Commonly referred with respect to the location  if in the stomach, gastric ulcer and if in the duodenum, duodenal ulcer The precise cause is not known, but there are implicated factors that can lead to its development:

Duodenal vs Gastric Ulcer

DIGESTIVE DISORDERS Pathophysiology Emotional Psychogenic

Drugs

Caffeine

Alcohol

Cigarette Smoking

Genetic Factors

Imbalance between Acid secretion and mucosal barrier Autodigestion Erosion Ulceration

Painless Pain N/V

 

 

Bleeding

Gastric Ulcers Ulceration of the mucosal lining of the stomach; most commonly found in the antrum Gastric secretions and stomach emptying rate are usually normal Also characterized by reflux into the stomach of bile containing duodenal contents Occurs more often in men, in unskilled laborers, and in lower socioeconomic groups; peak age 40 – 55 years (older age group) Caused by smoking, alcohol abuse, emotional tension, and drugs (salicylates, steroids)

Assessment findings 1. Pain located in the upper left epigastrium, with possible radiation to the back; usually occurs 1 – 2 hours after meals, rarely at night. The pain is described as burning, aching, gnawing discomfort. The pain is NOT relived by eating. 2. Weight loss, vomiting, bleeding episodes, epigastric tenderness, and pyrosis. 3. Complications associate with peptic ulcer: Bleeding, Perforation, Pyloric obstruction and intractable pain. A chronic complication seen in gastric ulcer is gastric cancer.

Laboratory: Hgb and Hct decreased (if anemic) Endoscopy reveals ulceration; BIOPSY is usually done to detect H. pylori infection and to rule out MALIGNANCY! Gastric analysis: normal gastric acidity in gastric ulcer (increased in duodenal ulcer) Upper GI series: presence of ulcer confirmed

Nursing interventions 1. Administer medications as ordered. Watch out for side – effects of cimetidine like dizziness, rash, mild diarrhea, muscle pain and gynecomastia in males. 2. Provide nursing care for the client with ulcer surgery. 3. Prepare the client for diagnostic procedure for barium swallow and EGD 4. Provide client teaching and discharge planning concerning

Nursing interventions A. Medication regimen 1) Take medications at prescribed times. Antacids are taken ONE hour AFTER meals. 2) Have antacids available at all times. 3) Recognize situations that would increase the need for antacids. 4) Avoid ulcerogenic drugs (salicylates, steroids). 5) Know proper dosage, action, and side effects.

Nursing interventions B. Proper diet 1) Bland diet consisting of six small meals/ day. Small frequent meals are NOT necessary as long as the medications are taken BEFORE meals. 2) Eat meals slowly. 3) Avoid acid-producing substances (caffeine, alcohol, highly seasoned foods, milk and creams). 4) Avoid stressful situations at mealtime. 5) Plan for rest periods after meals. 6) Avoid late bedtime snacks.

Nursing interventions C. Avoidance of stress-producing situations and development of stress-reduction methods (relaxation techniques, exercises, biofeedback).

Duodenal Ulcers  Most commonly found in the first 2 cm of the duodenum  Occur more frequently than gastric ulcers  Characterized by gastric hyperacidity and a significant increased rate of gastric emptying  Occur more often in younger men; more women affected after menopause; peak age: 35 – 45 years (younger than gastric ulcer group)  Caused by smoking, alcohol abuse, psychologic stress

An acute duodenal ulcer is seen in two views on upper endoscopy in the panels below.

 

 

Assessment findings Pain located in mid – epigastrium and described as burning, cramping; usually occurs 2 – 4 hours after meals and is relieved by food. Usually not accompanied by nausea and vomiting Diagnostic tests: same as for gastric ulcer. Nursing interventions: same as for gastric ulcers. Medical management: same as for gastric ulcers

Ulcer Surgery Types Vagotomy: severing of part of the vagus nerve innervating the stomach to decrease gastric acid secretion Antrectomy: removal of the antrum of the stomach to eliminate the gastric phase of digestion Pyloroplasty: enlargement of the pyloric sphincter with acceleration of gastric emptying

Ulcer Surgery Gastroduodenostomy (Billroth I): removal of the lower portion of the stomach with anastomosis of the remaining portion of the duodenum Gastrojejunostomy (Billroth II): removal of the antrum and distal portion of the stomach and duodenum with anastomosis of the remaining portion of the stomach to the jejunum Gastrectomy: removal of 60% - 80% of the stomach Esophagojejunostomy (total gastrectomy): removal of the entire stomach with a loop of jejunum anastomosed to the esophagus

 

 

Summary of Nursing Management of the Patient undergoing Gastric Surgery  Pre – op Care  Teach deep breathing exercises  (high abdominal incision causes  respiratory complications).  Provide nutritional support  TPN  Inform about post­op measures and  tubes to anticipate Nasogastric tube TPN until peristalsis returns

Summary of Nursing Management of the Patient undergoing Gastric Surgery Post-op Care  Promote patent airway and  ventilation  Semi­Fowler’s position  Reinforce Deep Breathing and  Coughing exercise, incentive  spirometry  Administer analgesic before  activities  Splint incision before patient coughs  Encourage early ambulation

Summary of Nursing Management of the Patient undergoing Gastric Surgery Promote adequate nutrition

 NPO until peristalsis returns  Measure NG drainage accurately  (reddish for the first 12 hrs.)  Monitor for sign of leakage of  anastomosis, e.g. dyspnea, pain, fever,  when oral fluids are initiated  Small, frequent feedings  Monitor for early satiety and  regurgitation  Eat less food at a slower pace

 Monitor weight regularly

Summary of Nursing Management of the Patient undergoing Gastric Surgery  Prevent potential complications  Bleeding – first 24 hours, 4th to 7th day post-op due to non-healing  Monitor NG drainage for blood  Avoid unnecessary irrigation or repositioning of the  NGT  Monitor for signs of peritonitis:  Severe abdominal pain, rigidity fever

Dumping Syndrome

DUMPING SYNDROME A group of unpleasant vasomotor and G.I. symptoms caused by rapid emptying of gastric content into the jejunum. Abrupt emptying of stomach contents into the intestine Common complication of some types of gastric surgery

Pathophysiology

Pathophysiology

Nursing Interventions Eat in a recumbent or semi  recumbent position Lie down after a meal Small, frequent feedings Moderate fat, high protein diet.  Fats slow down gastric motility, proteins increase colloidal osmotic pressure and prevents shifting of plasma Limit carbohydrates, no simple sugars Give fluids few hours after meals or in between meals Avoid very hot and cold foods and beverages

 The client is scheduled to have an upper  gastrointestinal tract series. Which of the  following treatments should the nurse  anticipate after the examination? A. B. C. D.  

Administering a laxative. Placing the client on a clear liquid diet. Giving the client a tapwater enema. Starting an intravenous infusion.  

 The client is scheduled to have an upper  gastrointestinal tract series. Which of the  following treatments should the nurse  anticipate after the examination? A. B. C. D.  

Administering a laxative. Placing the client on a clear liquid diet. Giving the client a tapwater enema. Starting an intravenous infusion.  

A client who has been diagnosed with gastroesophageal  reflux disease (GERD) complains of heartburn. To decrease  the heartburn, the nurse should instruct the client to  eliminate which of the following items from the diet?



A. B. C. D.

 

Lean beef. Air­popped popcorn. Hot chocolate. Raw vegetables.

 

A client who has been diagnosed with gastroesophageal  reflux disease (GERD) complains of heartburn. To decrease  the heartburn, the nurse should instruct the client to  eliminate which of the following items from the diet?



A. B. C. D.

 

Lean beef. Air­popped popcorn. Hot chocolate. Raw vegetables.

 

 The client with (GERD) complains of a  chronic cough. The nurse understands that in  a client with GERD this symptom may be  indicative of which of the following  conditions? A. B. C. D.

 

Development of laryngeal cancer. Irritation of the esophagus. Esophageal scar tissue formation. Aspiration of gastric contents.  

 The client with (GERD) complains of a  chronic cough. The nurse understands that in  a client with GERD this symptom may be  indicative of which of the following  conditions? A. B. C. D.

 

Development of laryngeal cancer. Irritation of the esophagus. Esophageal scar tissue formation. Aspiration of gastric contents.  

The client attends two sessions with the dietitian to learn  about diet modifications to minimize gastroesophageal  reflux. The teaching would be considered successful if the  client says that she will decrease her intake of which of the  following food?



A. B. C. D.  

Fats. High­sodium foods. Carbohydrates. High­calcium foods.  

The client attends two sessions with the dietitian to learn  about diet modifications to minimize gastroesophageal  reflux. The teaching would be considered successful if the  client says that she will decrease her intake of which of the  following food?



A. B. C. D.  

Fats. High­sodium foods. Carbohydrates. High­calcium foods.  

 Which of the following dietary measures  would be useful in preventing esophageal  reflux? A. B. C. D.

 

Eating small, frequent meals.  Increasing fluid intake. Avoiding air swallowing with meals. Adding a bedtime snack to the dietary plan.

 

 Which of the following dietary measures  would be useful in preventing esophageal  reflux? A. B. C. D.

 

Eating small, frequent meals.  Increasing fluid intake. Avoiding air swallowing with meals. Adding a bedtime snack to the dietary plan.

 

A client with peptic ulcer disease tells the nurse that he has  black stools, which he has not reported to his physician.  Based on this information, which nursing diagnosis would  be appropriate for this client? A. Ineffective Coping related to fear of diagnosis of chronic  illness. B. Deficient Knowledge related to unfamiliarity with  significant signs and symptoms. C. Constipation related to decreased gastric motility. D. Imbalanced Nutrition: Less Than Body Requirements  related to gastric bleeding.



 

 

A client with peptic ulcer disease tells the nurse that he has  black stools, which he has not reported to his physician.  Based on this information, which nursing diagnosis would  be appropriate for this client? A. Ineffective Coping related to fear of diagnosis of chronic  illness. B. Deficient Knowledge related to unfamiliarity with  significant signs and symptoms. C. Constipation related to decreased gastric motility. D. Imbalanced Nutrition: Less Than Body Requirements  related to gastric bleeding.



 

 

 The client asks the nurse what causes a  peptic ulcer to develop. The nurse responds  that recent research indicates that many  peptic ulcers are the result of which of the  following? A. B. C. D.

 

Work­related stress. Helicobacter pylori infection. Diets high in fat. A genetic defect in the gastric mucosa.  

 The client asks the nurse what causes a  peptic ulcer to develop. The nurse responds  that recent research indicates that many  peptic ulcers are the result of which of the  following? A. B. C. D.

 

Work­related stress. Helicobacter pylori infection. Diets high in fat. A genetic defect in the gastric mucosa.  

A client with a peptic ulcer reports epigastric pain that  frequently awakens her during the night, a feeling of  fullness in the abdomen, and a feeling of anxiety about her  health. Based on this information, which nursing diagnosis  would be most appropriate?  A. Imbalanced Nutrition: Less than Body Requirements  related to anorexia. B. Disturbed Sleep Pattern related to epigastric pain. C. Ineffective Coping related to exacerbation of duodenal  ulcer. D. Activity Intolerance related to abdominal pain.



 

 

A client with a peptic ulcer reports epigastric pain that  frequently awakens her during the night, a feeling of  fullness in the abdomen, and a feeling of anxiety about her  health. Based on this information, which nursing diagnosis  would be most appropriate?  A. Imbalanced Nutrition: Less than Body Requirements  related to anorexia. B. Disturbed Sleep Pattern related to epigastric pain. C. Ineffective Coping related to exacerbation of duodenal  ulcer. D. Activity Intolerance related to abdominal pain.



 

 

The nurse is preparing to teach a client with a peptic  ulcer about the diet that should be followed after  discharge. The nurse should explain that the diet  will most likely consist of which of the following?



A. B. C. D.

 

Bland foods. High­protein foods. Any foods that are tolerated. Large amounts of milk.

 

The nurse is preparing to teach a client with a peptic  ulcer about the diet that should be followed after  discharge. The nurse should explain that the diet  will most likely consist of which of the following?



A. B. C. D.

 

Bland foods. High­protein foods. Any foods that are tolerated. Large amounts of milk.

 

The nurse finds a client who has been diagnosed  with a peptic ulcer surrounded by papers from his  briefcase and arguing on the telephone with a  coworker. The nurse’s response to observing these  actions should be based on knowledge that:



A. Involvement with his job will keep the client from  becoming bored.  B. A relaxed environment will promote ulcer healing. C. Not keeping up with his job will increase the client’s  stress level. D. Setting limits on the client’s behavior is an important  nursing responsibility.  

 

The nurse finds a client who has been diagnosed  with a peptic ulcer surrounded by papers from his  briefcase and arguing on the telephone with a  coworker. The nurse’s response to observing these  actions should be based on knowledge that:



A. Involvement with his job will keep the client from  becoming bored.  B. A relaxed environment will promote ulcer healing. C. Not keeping up with his job will increase the client’s  stress level. D. Setting limits on the client’s behavior is an important  nursing responsibility.  

 

A client with a peptic ulcer has been instructed to  avoid intense physical activity and stress. Which  activity should the client incorporate into the home  care plan?



A. Conduct physical activity in the morning so that he can  rest in the afternoon. B. Have the family agree to perform the necessary yard  work at home. C. Give up jogging and substitute a less demanding hobby. D. Incorporate periods of physical and mental rest in his  daily schedule.  

 

A client with a peptic ulcer has been instructed to  avoid intense physical activity and stress. Which  activity should the client incorporate into the home  care plan?



A. Conduct physical activity in the morning so that he can  rest in the afternoon. B. Have the family agree to perform the necessary yard  work at home. C. Give up jogging and substitute a less demanding hobby. D. Incorporate periods of physical and mental rest in his  daily schedule.  

 

A client is to take one daily dose of ranitidine, (Zantac) at  home to treat her peptic ulcer. The nurse knows that the  client understands proper drug administration of ranitidine  when she says that she will take the drug at which of the  following times?



A. B. C. D.  

Before meals. With meals. At bedtime. When pain occurs.  

A client is to take one daily dose of ranitidine, (Zantac) at  home to treat her peptic ulcer. The nurse knows that the  client understands proper drug administration of ranitidine  when she says that she will take the drug at which of the  following times?



A. B. C. D.  

Before meals. With meals. At bedtime. When pain occurs.  

A client has been taking aluminum hydroxide (Amphojel)  30 mL six times per day at home to treat his peptic ulcer. He  tells the nurse that he has been unable to have a bowel  movement for 3 days.  Based on this information, the nurse  would determine that which of the following is the most  likely cause of the client’s constipation? A. The client has not been including enough fiber in his diet. B. The client needs to increase his daily exercise. C. The client is experiencing a side effect of the aluminum  hydroxide. D. The client has developed a gastrointestinal obstruction.



 

 

A client has been taking aluminum hydroxide (Amphojel)  30 mL six times per day at home to treat his peptic ulcer. He  tells the nurse that he has been unable to have a bowel  movement for 3 days.  Based on this information, the nurse  would determine that which of the following is the most  likely cause of the client’s constipation? A. The client has not been including enough fiber in his diet. B. The client needs to increase his daily exercise. C. The client is experiencing a side effect of the aluminum  hydroxide. D. The client has developed a gastrointestinal obstruction.



 

 

 

 

Intestinal Obstruction  Mechanical intestinal obstruction:  physical 

 

blockage of the passage of intestinal contents with  subsequent distention by fluid and gas caused by:  Adhesion Hernias Volvulus Intussusceptions Inflammatory bowel disease Foreign bodies Strictures Neoplasmas Fecal impaction  

 

 

Intestinal Obstruction  Paralytic ileus (neurogenic or adynamic ileus):               interference with the nerve supply to the  intestine resulting in decreased or absent peristalsis  caused by:  abdominal surgery  peritonitis  pancreatic toxic conditions  shock  spinal cord injuries  electrolyte imbalances (especially hypokalemia)

 

 

Intestinal Obstruction  Vascular obstructions: interference with the  blood supply to the portion of the intestine,  resulting in ischemia and gangrene of the  bowel caused by:  an embolus  atherosclerosis

 

 

Assessment findings  Small intestine: non­ fecal vomiting;  colicky intermittent abdominal pain  Large intestine: cramplike abdominal pain,  occasional fecal vomitus; client will be  unable to pass stools or flatus.  Abdominal distention  Abdominal rigidity  High­ pitch bowel sounds above the level of the  obstruction  Decreased or absent bowel sound distal to  obstruction

 

 

Large Bo we l

Small Bowel  Abdominal discomfort or  pain possibly accompanied  by visible peristaltic waves  in upper and middle  abdomen  Upper or epigastric  abdominal distention  Nausea and early, profuse  vomiting  Obstipation  Severe F and E imbalances  Metabolic alkalosis  

 Intermittent lower abdominal  cramping  Lower abdominal cramping  Minimal  or no vomiting  (may contain fecal material)   Obstipation or ribbon like  stool  No major F and E imbalance  Metabolic Acidosis

 

Diagnostic tests  Flat­plate (x­ray) of the abdomen reveals the  presence of the gas and fluid (air – fluid levels)  Hct increased  Serum sodium, potassium, chloride decreased  BUN increased (from dehydration and loss of  plasma volume)

 

 

Nursing Interventions Monitor fluid and electrolyte balance,  prevent further imbalance, keep client NPO  and administer IV fluids as ordered. Accurately measure drainage from NG/  intestinal tube. Place client in fowler’s position to alleviate  pressure on diaphragm and encourage nasal  breathing to minimize swallowing of air and  further abdominal distention.

 

 

Nursing Interventions  Institute comfort measures associated with  NG intubation and intestinal decompression.  Prevent complications.  Measure abdominal girth daily to assess for  increasing abdominal distention.  Assess for signs and symptoms of peritonitis. Monitor urinary output.

 

 

The physician orders intestinal decompression with  a Cantor tube for the client. The primary purpose of  a nasoenteric tube such as a Cantor tube is to  accomplish which of the following?



A. B. C. D.

 

Remove fluid and gas from the intestine. Prevent fluid accumulation in the stomach. Break up the obstruction. Provide an alternative route for drug administration.

 

The physician orders intestinal decompression with  a Cantor tube for the client. The primary purpose of  a nasoenteric tube such as a Cantor tube is to  accomplish which of the following?



A. B. C. D.

 

Remove fluid and gas from the intestine. Prevent fluid accumulation in the stomach. Break up the obstruction. Provide an alternative route for drug administration.

 

 After insertion of a nasoenteric tube, the  nurse should place the client in which  position? A. B. C. D.

 

Supine. Right side­lying. Semi­Fowler’s. Upright in a bedside chair.

 

 After insertion of a nasoenteric tube, the  nurse should place the client in which  position? A. B. C. D.

 

Supine. Right side­lying. Semi­Fowler’s. Upright in a bedside chair.

 

 Which of the following nursing diagnoses  would be most appropriate for a client with  an intestinal obstruction? A. Impaired Swallowing related to NPO status. B. Urinary Retention related to deficient fluid  volume. C. Deficient Fluid Volume related to nausea and  vomiting. D. Chronic Pain related to abdominal distention.  

 

 Which of the following nursing diagnoses  would be most appropriate for a client with  an intestinal obstruction? A. Impaired Swallowing related to NPO status. B. Urinary Retention related to deficient fluid  volume. C. Deficient Fluid Volume related to nausea and  vomiting. D. Chronic Pain related to abdominal distention.  

 

 

 

Ulcerative Colitis Is a recurrent ulcerative and inflammatory disease of the mucosal and submucosal layer of the colon and rectum. Is a serious disease, accompanied by systemic complications and a high mortality rate. The incidence of the disease is highest in Caucasians and people of Jewish heritage.

Ulcerative Colitis Signs and Symptoms: Predominant Symptoms  diarrhea, abdominal pain, rectal bleeding Pallor; if bleeding is severe Anorexia Weight Loss Dehydration Cramping Anemia Skin Lesions Rebound tenderness in right lower quadrant Joint Abnormalities

PATHOPHYSIOLOGY ulcerations bleeding Mucosa becomes edematous and inflamed Abscesses form Infiltrates is seen in the mucosa and submucosa with clumps of neutrophils (crypt abscess) Begins in the rectum Proximally to involve the entire colon Macular Hypertrophy / fat deposits Bowel narrows, shortens and thickens

Gross appearance – UC  The

most intense inflammation begins at the lower right in the sigmoid colon and extends upward and around to the ascending colon.  At the lower left is the ileocecal valve with a portion of terminal ileum that is not involved.  Inflammation with ulcerative colitis tends to be continuous along the mucosal surface and tends to begin in the rectum.  

 

Treatment Diet and Fluid intake Oral fluids, low-residue diets; supplemental vitamin therapy; and iron replacement IV Therapy Smoking Cessation Avoiding foods that exacerbate symptoms, such as milk and cold foods Parental Nutrition (PN) may be provided as indicated

Treatment Pharmacologic therapy Sedative, antidiarrheal, and antiperistaltic medications Sulfasalazine (Azulfidine) – Which are effective for mild or moderate inflammation. Given with a glass of water to prevent stone precipitation Antibiotics for secondary infections Adrenocortico tropic hormone (ACTH) and certicosteroids (↓ bleeding) Aminosalicylates (Topical and oral) Immunomodulator agent (eg. IMURAN)

Treatment Surgical management Total colectomy with ileostomy – An opening into the ileum or small intestine (usually by means of an ileal stoma on the abdominal wall) is commonly performed after a total colectomy (i.e. Excision of the entire colon). Total Colectomy with continent ileostomy – Involves the removal of the entire colon and creation of the continent ileal reservoir (i.e. Cock pouch) Total Colectomy with ileonal anastomosis – Surgical procedures that eliminates the need for a permanent ileostomy. It establishes an ileal reservoir and anal sphincter control of elimination is retained.

The client with  ILEOSTOMY

 Provide explanation of pre­operative and post­ operative procedures  Oral antibiotics  to ↓ intestinal bacteria thus  ↓potential for peritonitis and wound infection post­op  Maintain fluid and electrolyte imbalance  Self – care activities; minimize odor formation  WOF: obstruction as evidenced by sudden decrease in  drainage or onset of severe abdominal pain, vomiting

 

 

Nursing Interventions 1. Maintaining Normal Elimination  Determine if there is a relationship between diarrhea and certain foods, activities, or emotional stress  Encourage bed rest to decrease peristalsis 2. Relieving Pain  Administer anticholinergic medications 30 mins. before a meal to decrease intestinal motility  Give Analgesic agents as prescribed

Nursing Interventions 3. Maintaining Fluid balance  Record I and 0 including wound / fistula drainage  Monitor weight daily  Assess for signs of fluids volume deficit  Encourage oral intake

Nursing Interventions 4. Promoting Nutritional measures  Use PN when symptoms are severe  Test for glucose daily  Give feeding high in protein and low in fat and reside after PN therapy  Provide small frequent, low residue feedings if oral foods are tolerated 5. Promoting rest  Recommend intermittent rest periods during the day Encourage activity within limits

Nursing Interventions 6. Reducing Anxiety  Establish report by being attentive and displaying a calm confidence manner  Tailor information about impending surgery to patients level of understanding and desire for detail 7. Promoting coping skills  Provide understanding and emotional support to patient who feels isolated helpless and out of control  Use stress-reduction measures: relaxation techniques breathing exercises and biofeedback

Crohn’s Disease 



“REGIONAL ENTERITIS”

Is an inflammatory disease of the GIT affecting usually the small intestine 

Commonly occurs in adolescents and young adults Signs and Symptoms: - Anorexia, n/v - Weight Loss - Anemia - Fever - Abdominal distention - Diarrhea (bloody) - Colicky abdominal pain

Pathophysiology Edema and thickening of the transmucosa

Ulcers begin to appear on infammed mucosa (lesions are discontinuous and separated by normal tissue) Formation of fistulas, fissures & abscesses (extends into the peritoneum)

GRANULOMAS Bowel wall thickens and become fibrotic Intestinal lumen narrows Diseased bowel loops (sometimes adhere to other loops)

Gross appearance – CD • This portion of terminal ileum

 

demonstrates the gross findings with Crohn's disease. • Though any portion of the gastrointestinal tract may be involved with Crohn's disease, the small intestine--and the terminal ileum in particular--is most likely to be involved. • The middle portion of bowel seen here has a thickened wall and the mucosa has lost the regular folds. • The serosal surface demonstrates reddish indurated adipose tissue that creeps over the surface. • Serosal inflammation leads to adhesions. • The areas of inflammation tend to be  discontinuous throughout the bowel.

Nursing Interventions  Maintain NPO during the active phase  Monitor for complications like severe bleeding , dehydration, electrolyte imbalance  Monitor bowel sounds, stool and blood studies  Restrict activities



Nursing Interventions Administer IVF, electrolytes and TPN if prescribed

 Instruct the patient to AVOID gas-forming foods,milk products and foods such as whole grains, nuts, raw fruits and vegetables, pepper, alcohol and caffeine  Diet progression  clear fluid to low residue, high protein diet  Administer drugs  anti-inflammatory, antibiotics, steroids, bulk-forming agents and vitamin/iron supplements

Crohn’s Disease

Ulcerative Colitis

Transmural

Mucous ulceration

Ileum/ascending colon

Rectum/ lower colon

Unknown

Unknown

Jewish

Familial

Environmental

Jewish Emotional stress

20-30 years 40-60 years

15-40 years

; stool with pus and mucus

Severe; stool with blood, pus and mucus

Severe

Mild

Common

Rare

20%

100%

5-6 soft stool/ day

20-30 watery stool/ day

Abdominal pain

+

+

Weight loss

+

+

Intervention

TPN Steriods Azulfidine (Sulfasalazine) Ileostomy   Colectomy

Diet TPN Steriods Azulfidine (Sulafasalazine) Ileostomy/ Proctocolectomy

Cause

Age Bleeding Perianal involvement Fistulas Rectal involvement Diarrhea

 

A client who had ulcerative colitis for the past 5 years is  admitted to the hospital with an exacerbation of the disease.  Which of the following factors was most likely of greatest  significance in causing an exacerbation of ulcerative colitis? A. A demanding and stressful job. B. Changing to a modified vegetarian diet. C. Beginning a weight­training program. D. Walking 2 miles everyday.



 

 

A client who had ulcerative colitis for the past 5 years is  admitted to the hospital with an exacerbation of the disease.  Which of the following factors was most likely of greatest  significance in causing an exacerbation of ulcerative colitis? A. A demanding and stressful job. B. Changing to a modified vegetarian diet. C. Beginning a weight­training program. D. Walking 2 miles everyday.



 

 

 Which goal for the client’s care should take  priority during the first days of  hospitalization for an exacerbation of  ulcerative colitis? A. B. C. D.  

Promoting self­care and independence. Managing   diarrhea. Maintaining adequate nutrition. Promoting rest and comfort.  

 Which goal for the client’s care should take  priority during the first days of  hospitalization for an exacerbation of  ulcerative colitis? A. B. C. D.  

Promoting self­care and independence. Managing   diarrhea. Maintaining adequate nutrition. Promoting rest and comfort.  

 The client with ulcerative colitis is following  orders for bed rest with bathroom privileges.  Which would be the primary rationale for  this activity restriction?  A. B. C. D.  

To conserve energy. To reduce intestinal peristalsis. To promote rest and comfort. To prevent injury.  

 The client with ulcerative colitis is following  orders for bed rest with bathroom privileges.  Which would be the primary rationale for  this activity restriction?  A. B. C. D.  

To conserve energy. To reduce intestinal peristalsis. To promote rest and comfort. To prevent injury.  

A client who has ulcerative colitis says to the nurse,  “I can’t take this anymore! I’m constantly in pain,  and I can’t leave my room because I need to stay by  the toilet. I don’t know how to deal with this.”  Based on these comments, an appropriate nursing  diagnosis for this client would be



A. B. C. D.  

Impaired Physical Mobility related to fatigue. Disturbed Thought Processes related to pain. Social Isolation related to chronic fatigue. Ineffective Coping related to chronic abdominal pain.  

A client who has ulcerative colitis says to the nurse,  “I can’t take this anymore! I’m constantly in pain,  and I can’t leave my room because I need to stay by  the toilet. I don’t know how to deal with this.”  Based on these comments, an appropriate nursing  diagnosis for this client would be



A. B. C. D.  

Impaired Physical Mobility related to fatigue. Disturbed Thought Processes related to pain. Social Isolation related to chronic fatigue. Ineffective Coping related to chronic abdominal pain.  

A client newly diagnosed with ulcerative colitis has been  placed on steroids. He states that he has heard that taking  steroids can be dangerous and asks the nurse why steroids  are prescribed. Which of the following statements by the  nurse provides the client with accurate information about the  use of steroid therapy in the treatment of ulcerative colitis? A. “Ulcerative colitis can be cured by the use of steroids.” B. “Steroids are used in severe flare­ups because they can  decrease the incidence of bleeding.” C. “Long­term use of steroids will prolong periods of  remission.” D. “The side effects of steroids outweigh their benefit to  clients with ulcerative colitis.”



 

 

A client newly diagnosed with ulcerative colitis has been  placed on steroids. He states that he has heard that taking  steroids can be dangerous and asks the nurse why steroids  are prescribed. Which of the following statements by the  nurse provides the client with accurate information about the  use of steroid therapy in the treatment of ulcerative colitis? A. “Ulcerative colitis can be cured by the use of steroids.” B. “Steroids are used in severe flare­ups because they can  decrease the incidence of bleeding.” C. “Long­term use of steroids will prolong periods of  remission.” D. “The side effects of steroids outweigh their benefit to  clients with ulcerative colitis.”



 

 

A client who has ulcerative colitis has persistent diarrhea.  He is thin and has lost 12 pounds since the exacerbation of  his ulcerative colitis. The nurse should anticipate that the  physician will order which of the following treatment  approaches to help the client meet his nutritional needs? A. Initiate continuous enteral feedings. B. Encourage a high­calorie, high­protein diet. C. Implement total parenteral nutrition. D. Provide six small meals a day.



 

 

A client who has ulcerative colitis has persistent diarrhea.  He is thin and has lost 12 pounds since the exacerbation of  his ulcerative colitis. The nurse should anticipate that the  physician will order which of the following treatment  approaches to help the client meet his nutritional needs? A. Initiate continuous enteral feedings. B. Encourage a high­calorie, high­protein diet. C. Implement total parenteral nutrition. D. Provide six small meals a day.



 

 

 The physician prescribes sulfasalazine  (Azulfidine) for the client with ulcerative  colitis to continue taking at home. What  instructions should the nurse give the client  about taking this medication?  A. B. C. D.

 

Avoid taking it with food. Take the total dose at bedtime. Take it with a full glass (240 mL) of water. Stop taking it if urine turns orange yellow.  

 The physician prescribes sulfasalazine  (Azulfidine) for the client with ulcerative  colitis to continue taking at home. What  instructions should the nurse give the client  about taking this medication?  A. B. C. D.

 

Avoid taking it with food. Take the total dose at bedtime. Take it with a full glass (240 mL) of water. Stop taking it if urine turns orange yellow.  

 Which of the following diets would be most  appropriate for the client with ulcerative  colitis? A. B. C. D.

 

High calorie, low protein. High protein, low residue. Low fat, high fiber. Low sodium, high carbohydrate.

 

 Which of the following diets would be most  appropriate for the client with ulcerative  colitis? A. B. C. D.

 

High calorie, low protein. High protein, low residue. Low fat, high fiber. Low sodium, high carbohydrate.

 

 Which of the following would be a priority  focus of care for a client experiencing an  exacerbation of his Crohn’s disease? A. B. C. D.

 

Encouraging regular ambulation. Promoting bowel rest. Maintaining current weight. Decreasing episodes of rectal bleeding.

 

 Which of the following would be a priority  focus of care for a client experiencing an  exacerbation of his Crohn’s disease? A. B. C. D.

 

Encouraging regular ambulation. Promoting bowel rest. Maintaining current weight. Decreasing episodes of rectal bleeding.

 

 A client ulcerative colitis symptoms have  been present for longer than 1 week. The  nurse recognizes that the client should be  assessed carefully for signs of which of the  following complications? A. B. C. D.

 

Heart failure. Deep vein thrombosis. Hypokalemia. Hypocalcemia.

 

 A client ulcerative colitis symptoms have  been present for longer than 1 week. The  nurse recognizes that the client should be  assessed carefully for signs of which of the  following complications? A. B. C. D.

 

Heart failure. Deep vein thrombosis. Hypokalemia. Hypocalcemia.

 

A client is scheduled for an ileostomy. Which of the  following interventions would be most helpful in preparing  the client psychologically for the surgery? A. Include family members in preoperative teaching  sessions. B. Encourage the client to ask questions about managing an  ileostomy. C. Provide a brief, thorough explanation of all preoperative  and postoperative procedures. D. Invite a member of the ostomy association to visit the  client.



 

 

A client is scheduled for an ileostomy. Which of the  following interventions would be most helpful in preparing  the client psychologically for the surgery? A. Include family members in preoperative teaching  sessions. B. Encourage the client to ask questions about managing an  ileostomy. C. Provide a brief, thorough explanation of all preoperative  and postoperative procedures. D. Invite a member of the ostomy association to visit the  client.



 

 

A client who is scheduled for an ileostomy has an order for  oral neomycin to be administered before surgery. The nurse  understands that the rationale for administering oral  neomycin before surgery is to  A. Prevent postoperative bladder infection. B. Reduce the number of intestinal bacteria. C. Decrease the potential for postoperative hypostatic  pneumonia. D. Increase the body’s immunologic response to the  stressors of surgery.



 

 

A client who is scheduled for an ileostomy has an order for  oral neomycin to be administered before surgery. The nurse  understands that the rationale for administering oral  neomycin before surgery is to  A. Prevent postoperative bladder infection. B. Reduce the number of intestinal bacteria. C. Decrease the potential for postoperative hypostatic  pneumonia. D. Increase the body’s immunologic response to the  stressors of surgery.



 

 

 Of the following outcomes for client care  after an ileostomy, which has the highest  priority? A. B. C. D.

 

Providing relief from constipation. Assisting the client with self­care activities. Maintaining fluid and electrolyte balance. Minimizing odor formation.

 

 Of the following outcomes for client care  after an ileostomy, which has the highest  priority? A. B. C. D.

 

Providing relief from constipation. Assisting the client with self­care activities. Maintaining fluid and electrolyte balance. Minimizing odor formation.

 

The client asks the nurse, “Is it really possible to lead a  normal life with an ileostomy?” Which action by the nurse  would be the most effective to address this question? A. Have the client talk with a member of the clergy about  these concerns. B. Tell the client to worry about those concerns after  surgery. C. Arrange for a person with an ostomy to visit the client  preoperatively. D. Notify the surgeon of the client’s question.



 

 

The client asks the nurse, “Is it really possible to lead a  normal life with an ileostomy?” Which action by the nurse  would be the most effective to address this question? A. Have the client talk with a member of the clergy about  these concerns. B. Tell the client to worry about those concerns after  surgery. C. Arrange for a person with an ostomy to visit the client  preoperatively. D. Notify the surgeon of the client’s question.



 

 

 The nurse should instruct the client with an  ileostomy to report which of the following  symptoms immediately? A. Passage of liquid stool from the stoma. B. Occasional presence of undigested food in the  effluent. C. Absence of drainage from the ileostomy for 6 or  more hours. D. Temperature of 99.8F (37.7C).  

 

 The nurse should instruct the client with an  ileostomy to report which of the following  symptoms immediately? A. Passage of liquid stool from the stoma. B. Occasional presence of undigested food in the  effluent. C. Absence of drainage from the ileostomy for 6 or  more hours. D. Temperature of 99.8F (37.7C).  

 

 

 

DIGESTIVE DISORDERS APPENDICITIS Infectious and inflammatory process of the appendix creating acute abdominal pain and nausea. Signs & Symptoms Vague epigastric or peri-umbilical pain which progress to right lower quadrant pain Low-grade fever Nausea Vomiting Loss of appetite Local tenderness when pressure is applied  

 

This is the normal appearance of the appendix against the background of the cecum.

 

 

This appendix was removed surgically. The patient presented with abdominal pain that initially was generalized, but then localized to the right lower quadrant, and physical examination disclosed 4+ rebound tenderness in the right lower quadrant. The WBC count was elevated at 11,500. Seen here is acute appendicitis with

yellow to tan exudate and hyperemia, including the periappendiceal     fat superiorly, rather than a smooth, glistening pale tan serosal surface.

DIGESTIVE DISORDERS Pain gradually becomes localized in RLQ / Mc Burney’s point (halfway between the umbilicus and the anterior spine of the ileum) • Pain is initially intermittent then become steady and severe over a short period.

 

Rebound tenderness (Blumberg sign)  Psoas sign (lateral position with right hip flexion)  Rovsing’s sign (right quadrant pain when the left is palpated)  Obturator sign (pain on external rotation of the   right thigh)

McBurney's point is located one third of the distance along a line from the front of the right pelvic bone and the belly button.

 

 

Pathophysiology

 

DIGESTIVE DISORDERS Inflammation ↓ ↑ Intraluminal pressure ↓ ∗ Lymphoid Swelling ∗ ↓ Venous drainage ∗ Thrombosis ∗ Bacterial invasion ↓ Abscess ↓ Gangrene ↓ Perforation (24-36hrs) ↓   Peritonitis

DIGESTIVE DISORDERS Treatment 1. Antibiotics 2. Analgesics given post – op 3. Appendectomy 4. General or spinal anesthetic with a low abdominal incision or by laparoscopy

 

Goals:  Bed rest • NPO • Relieve pain (cold application over the abdomen NEVER heat) • Avoid factors that increase peristalsis, thereby rupture:  Heat application over the abdomen  Laxative  Enema  

REVIEW QUESTIONS

 4 items

 

 

 In a client with acute appendicitis, the nurse  should anticipate which of the following  treatments? A. B. C. D.

 

Administration of enemas to clean bowel. Insertion of a nasogastric tube. Placement of client on NPO status. Administration of heat to the abdomen.

 

 In a client with acute appendicitis, the nurse  should anticipate which of the following  treatments? A. B. C. D.

 

Administration of enemas to clean bowel. Insertion of a nasogastric tube. Placement of client on NPO status. Administration of heat to the abdomen.

 

 A client with acute appendicitis develops a  fever, tachycardia, and hypotension. Based  on these assessment findings, the nurse  suspects which of the following  complications? A. B. C. D.

 

Deficient fluid volume. Intestinal obstruction. Bowel ischemia. Peritonitis.  

 A client with acute appendicitis develops a  fever, tachycardia, and hypotension. Based  on these assessment findings, the nurse  suspects which of the following  complications? A. B. C. D.

 

Deficient fluid volume. Intestinal obstruction. Bowel ischemia. Peritonitis.  

 Postoperative nursing care for a client after  an appendectomy would include which of the  following interventions? A. Administering sitz baths four times a day. B. Noting the first bowel movement after surgery. C. Limiting the client’s activity to bathroom  privileges. D. Measuring abdominal girth every 2 hours.  

 

 Postoperative nursing care for a client after  an appendectomy would include which of the  following interventions? A. Administering sitz baths four times a day. B. Noting the first bowel movement after surgery. C. Limiting the client’s activity to bathroom  privileges. D. Measuring abdominal girth every 2 hours.  

 

A client who had an appendectomy for a perforated  appendix returns from surgery with a drain inserted  in the incisional site. The nurse understands that the  purpose of the drain is to accomplish which of the  following?



A. B. C. D.

 

Provide access for wound irrigation. Promote drainage of wound exudates. Minimize development of scar tissue. Decrease postoperative discomfort.

 

A client who had an appendectomy for a perforated  appendix returns from surgery with a drain inserted  in the incisional site. The nurse understands that the  purpose of the drain is to accomplish which of the  following?



A. B. C. D.

 

Provide access for wound irrigation. Promote drainage of wound exudates. Minimize development of scar tissue. Decrease postoperative discomfort.

 

 

 

Peritonitis  Local or generalized inflammation of part or all  of the parietal and visceral surfaces of the  abdominal cavity.  Initial response: edema, vascular congestion,  hypermotility of the bowel and outpouring  plasma­like fluid from the extracellular, vascular  and interstitial compartments into the peritoneal  space.  Later response: abdominal distention leading to  respiratory compromise, hypovolemia results in  decreased urinary output.

 

 

Peritonitis  Intestinal motility gradually decrease and  progresses to paralytic ileus.  Caused by trauma (blunt or penetrating),  inflammation (ulcerative colitis,  diverticulitis), volvulus, interstitial  ischemia, or intestinal obstruction.

 

 

Causes Ruptured appendix Perforated peptic ulcer Diverticulitis Pelvic inflammatory disease Urinary tract infection or trauma Bowel obstruction Bacteria invasion

 

 

Inflammatio n

 

Pathophysiolo gy

Adhesio ns

Fluid shift into abdominal cavity (300500 ml.)

Abscess

 Peristalsis

Intestinal Obstructio n

Bowel distended with gas & fluid

 

Hypovolemia Electrolyte imbalance Dehydration Shock

Medical Management NPO with fluid replacement. Drug therapy: antibiotics to combat  infection Surgery

 Laparatomy: opening made through the  abdominal wall into the peritoneal cavity to  determine the cause of peritonitis.  Depending on cause, bowel resection may be  necessary.

 

 

Assessment findings Severe abdominal pain, rebound tenderness, muscle  ridigity, absent bowel sounds, abdominal distention  (particularly if large bowel obstruction). Anorexia, nausea and vomiting Swallow respirations; decreased urinary output;  weak,rapid pulse; elevated temperature. Signs of shock Tachycardia Tachypnea Oliguria Restlessness Weakness pallor Diaphoresis  

 

Assessment findings  Diagnostic tests  WBC elevated WBC (20,000/cu. mm or  higher)  Hct elevated (if hemoconcentration)

 

 

Nursing Interventions Assess respiratory status for possible distress. Assess characteristics of abdominal pain and  changes overtime. Administer medications as ordered. Perform frequent abdominal assessment. Monitor and maintain fluid and electrolyte balance;  monitor for sings of septic shock. Maintain patency of NG or intestinal tubes. Provide routine pre­and post­op care if surgery  ordered.  

 

Collaborative Management Monitor VS, I and O. NGT is inserted to relieve abdominal distention Bed rest in semi­fowler’s position Encourage deep breathing exercises Insertion of drainage tube Fluid, electrolytes and colloids replacement Antibiotics TPN solutions

 

 

DIGESTIVE DISORDERS HEMORRHOIDS Dilated blood vessels beneath the lining of the anal canal Dilated portions of veins in the anal canal

 

 

DIGESTIVE DISORDERS

 

Signs and Symptoms Constipation in an effort to prevent pain or bleeding associated with defecation Anal pain Rectal bleeding Anal itchiness Mucous secretion from the anus Sensation of incomplete evacuation of the rectum Intestinal hemorrhoids may prolapsed Bright red bleeding Edema (caused by thrombus) Ischemia of the area   Necrosis

Pathophysiology

Shearing of the mucosa during defecation ↓ ↑ P during pregnancy or straining , Sliding of the structures in the anal wall ↓ Inflammation & edema of the anus ↓ Thrombosis of the hemorrhoid ↓ Ischemia ↓ Necrosis  

 

DIGESTIVE DISORDERS

 

Treatment Surgery  Hemorrhoidectomy  Sclerotherapy (5 % phenol in oil)  Cryosurgery  Rubber band ligation Preop care Low residue diet to reduce the bulk of stool Stool softeners Postop care Promotion of comfort Analgesics as prescribed  

Excision • For the patient with small, external hemorrhoids, where there is severe pain, clot formation, and danger of infection, simple excision of the clot may be all that is necessary. • This means that after the hemorrhoidal area has been anethesized, a small incisioin is made in the skin directly over the blood clot. • The clot is then gently squeezed out with thumb and forefinger.  

 

Injection • This works best for small, internal hemorrhoids that are not prolapsed and where intermittent bleeding is the only symptom. • A special solutions is injected into the tissue surrounding the hemorrhoid. • This solution causes the blood in the swollen veins to clot; the clot eventually dissolves and pain and bleeding soon disappear.  

 

Banding • If the hemorrhoids are too large to respond satisfactorily to injection, and if they are not permanently prolapsed, the banding technique offers a safe, effective, and painless alternative to surgery. • In this procedure, rubber bands are placed around the base of the hemorrhoidal mass. • In about seven days, the hemorrhoid dries up and sloughs off.  

 

 

Hemorrhoidectomy The only method for complete cure of large, permanently protruding hemorrhoids is surgical removal. This is especially true if other measures have failed to relieve symptoms. In this operation, all of the hemorrhoidal tissue is removed from beneath the skin and mucous membrane. The incision is then closed with sutures. The patient can usually leave the hospital in six or seven days. Final healing takes three to four week  

DIGESTIVE DISORDERS Promotion of comfort Analgesics as prescribed Side lying position Hot sitz bath 12-24 hrs. Postop Promotion of elimination Stool softener as prescribed Encourage the client to defecate as soon as the urge occurs Analgesic before initial defecation Enema as prescribed, using a small-bore rectal tube  

 

DIGESTIVE DISORDERS Nursing Intervention High fiber diet Bulk laxatives Provide good personal hygiene Increase Fluid intake Warm compress, sitz bath Analgesic ointments Suppositories Patient teaching

 

 

REVIEW QUESTIONS

 4 items

 

 

 A 36­year­old female client has been  diagnosed with hemorrhoids. Which of the  following factors in the client’s history  would most likely be a primary cause of her  hemorrhoids? A. B. C. D.

 

Her age. Three vaginal delivery pregnancies. Her job as a schoolteacher. Varicosities in her legs.  

 A 36­year­old female client has been  diagnosed with hemorrhoids. Which of the  following factors in the client’s history  would most likely be a primary cause of her  hemorrhoids? A. B. C. D.

 

Her age. Three vaginal delivery pregnancies. Her job as a schoolteacher. Varicosities in her legs.  

 Which position would be ideal for the client  in the early postoperative period after a  hemorrhoidectomy? A. B. C. D.

 

High Fowler’s  Supine. Side­lying. Trendelenburg’s.

 

 Which position would be ideal for the client  in the early postoperative period after a  hemorrhoidectomy? A. B. C. D.

 

High Fowler’s  Supine. Side­lying. Trendelenburg’s.

 

 The nurse instructs the client who has had a  hemorrhoidectomy not to use sitz baths until  at least 12 hours postoperatively to avoid  inducing which of the following  complications? A. B. C. D.

 

Hemorrhage. Rectal spasm. Urinary retention. Constipation.

 

 The nurse instructs the client who has had a  hemorrhoidectomy not to use sitz baths until  at least 12 hours postoperatively to avoid  inducing which of the following  complications? A. B. C. D.

 

Hemorrhage. Rectal spasm. Urinary retention. Constipation.

 

The nurse teaches the client who has had rectal  surgery the proper timing for sitz baths. The nurse  knows that the client has understood the teaching  when the client states that it is most important to  take a sitz bath



A. B. C. D.

 

First thing each morning. As needed for discomfort. After a bowel movement. At bedtime.

 

The nurse teaches the client who has had rectal  surgery the proper timing for sitz baths. The nurse  knows that the client has understood the teaching  when the client states that it is most important to  take a sitz bath



A. B. C. D.

 

First thing each morning. As needed for discomfort. After a bowel movement. At bedtime.

 

 

 

CHOLECYSTITIS    Acute inflammation of the gall 

burn, severe trauma, surgical procedure

bladder.   An empyema of the gall bladder  can be caused by calculus, acalculus    Clinical Manifestation •         Rigidity of the upper abdomen •         N&V      Nursing Interventions •         relieve pain •         improve respiratory status •         improve nutritional status •         promote skin care & biliary  drainage •         monitoring & managing  complication             bleeding           loss of appetite 

PATHOPHYSIOLOGY Inflammation of the walls of the gallbladder Edema & thickening of gallbladder mucosa ↓ blood supply to liver/ gall bladder

ischemia

necrosis

 

CHOLELITHIASIS • Presence of calculi in the gallbladder

• Increasing prevalence after age 40 • “Silent”, usually detected incidentally during surgery or evaluation for unrelated problems • 3 F’s (Fat, Female, Forty) Clinical Manifestations

Distended gall bladder Fever Biliary colic with excruciating RUQ pain radiating to the back or right shoulder Nausea and vomiting (hours after heavy meal) ↓ bile acid synthesis, ↑ cholesterol Restlessness, Jaundice synthesis Dark brown colored urine Bile becomes supersaturated w/ Grayish/clay-colored stool PATHOPHYSIOLOGY

Precipitation of unconjugated bile pigment ↓ bile transport to duodenum = clay-colored stool

 

↑ bile absorption by blood = jaundice dark colored urine

cholesterol

Cholesterol stones form Gall stone

Inflammatory changes in gallbladder Obstruction of bile passage Congestion/distension of gall   bladder

Assessment Findings     

 

Most patients are asymptomatic When symptomatic  RUQ and epigastric pain Fever and Leukocytosis in cholecystitis CHARCOT TRIAD (fever, jaundice, RUQ pain) Intolerance to fatty foods (nausea, vomiting,  sensation of fullness)

 

 

 

Gross appearance of gallbladder after sectioning longitudinally. Notice thickness of gallbladder wall, abundant stones

 

 

• Obesity increases the risk for cholelithiasis. • Note the mix gallstones with a prominent component of yellowish cholesterol seen here in an opened gallbladder removed at surgery.

 

 

Treatment  Reduce the incidence of acute episodes of gall bladder pain and cholecyctitis by supportive and dietary management  Non surgical approaches including lithotripsy and dissolution of gall stones  Provide temporary solutions to the problems associated with gall stones.  Cholecystectomy – removal of the gall bladder

CHOLECYSTECTOMY Pre­op Care  IV fluids to replace fluid electrolyte  losses due to vomiting  Vitamin K injection, especially if the  prothrombin time is prolonged

 

 

CHOLECYSTECTOMY Post­op Care   Position: Low or Semi Fowlers to  promote lung expansion  Deep breathing and coughing exercises  to avoid atelectasis  Encourage early ambulation post­op  Diet: Low fat diet for 2 – 3 months  

 

CHOLEDOCHOSTOMY If with CBD exploration: T – tube   Purpose: to drain the bile  Drainage:

 

 Brownish red for the first 24 hours  (combination of bile and blood)  300 – 500 mL of bile drainage for the  first 24 hours  Drainage bottle should be placed in bed  at the level of incision; this is to drain the    excess bile, not all the bile

 

 

 

 

Treatment  Laparoscopic cholecystectomy  Removal of the gall bladder through a small incision through the umbilicus.  Choledochotomy  Opening of the gallbladder to remove stones  Ursodeoxycholic acid(UDCA) and Chenodeoxycholic acid (CDCA)  Dissolve small gallstones composed of cholesterol  Acts by inhibiting the synthesis and secretion of cholesterol, thereby desaturating the bile.

 

 

203

 

  macky

204

 

 

205

Nursing Interventions  Relieving pain  MEPERIDINE HCL (drug of choice)  Do not administer morphine sulfate, this may cause spasm of the sphincter

 Improving respiratory status  remind patient to expand lungs fully to prevent atelectasis, promote early ambulation  monitor elderly and obese patients

 Improving nutritional status  advise patient at time of discharge to maintain a nutritious diet and avoid excessive fats:

Nursing Interventions Promoting skin care and biliary drainage  connect tubes to drainage receptacle and secure tubing to avoid kinking  place drainage bag in patient’s pocket when ambulating  observe for indications of infections, leakage of bile or obstruction of bile drainage.  observe for jaundice  change dressing frequently, using ointment  keep careful record of intake and output  measure bile colleted every 24 hours  document

REVIEW QUESTIONS

 5 items

 

 

A client is admitted to the hospital with a diagnosis of  cholecystitis. The client is complaining of severe abdominal  pain and extreme nausea and has vomited several times.  Based on this data, which nursing diagnosis  would have the  highest priority for intervention at this time? A. Anxiety related to severe abdominal discomfort. B. Deficient Fluid Volume related to vomiting. C. Pain related to gallbladder inflammation. D. Imbalanced Nutrition: Less Than Body Requirements  related to vomiting.



 

 

A client is admitted to the hospital with a diagnosis of  cholecystitis. The client is complaining of severe abdominal  pain and extreme nausea and has vomited several times.  Based on this data, which nursing diagnosis  would have the  highest priority for intervention at this time? A. Anxiety related to severe abdominal discomfort. B. Deficient Fluid Volume related to vomiting. C. Pain related to gallbladder inflammation. D. Imbalanced Nutrition: Less Than Body Requirements  related to vomiting.



 

 

 A client with cholecystitis is complaining of  severe right upper quadrant pain. Which of  the following medications would the nurse  anticipate administering to relieve the  client’s pain? A. B. C. D.

 

Meperidine (Demerol). Acetaminophen with codeine. Promethazine (Phenergan). Morphine sulfate.  

 A client with cholecystitis is complaining of  severe right upper quadrant pain. Which of  the following medications would the nurse  anticipate administering to relieve the  client’s pain? A. B. C. D.

 

Meperidine (Demerol). Acetaminophen with codeine. Promethazine (Phenergan). Morphine sulfate.  

 If a gallstone becomes lodged in the common  bile duct, the nurse should anticipate that the  client’s stools would most likely become  what color? A. B. C. D.  

Green. Gray. Black. Brown.  

 If a gallstone becomes lodged in the common  bile duct, the nurse should anticipate that the  client’s stools would most likely become  what color? A. B. C. D.  

Green. Gray. Black. Brown.  

 Which of the following discharge  instructions would be appropriate for a client  who has had a laparoscopic  cholecystectomy? A. Avoid showering for 48 hours after surgery. B. Return to work within 1 week. C. Change the dressing daily until the incision  heals. D. Use acetaminophen (Tylenol) to control any  fever.

 

 

 Which of the following discharge  instructions would be appropriate for a client  who has had a laparoscopic  cholecystectomy? A. Avoid showering for 48 hours after surgery. B. Return to work within 1 week. C. Change the dressing daily until the incision  heals. D. Use acetaminophen (Tylenol) to control any  fever.

 

 

 How much bile would the nurse expect the  T­tube to drain during the first 24 hours after  a choledocholithotomy? A. B. C. D.

 

50 to 100 mL. 150 to 250mL. 300 to 500 mL. 550 to 700 mL.

 

 How much bile would the nurse expect the  T­tube to drain during the first 24 hours after  a choledocholithotomy? A. B. C. D.

 

50 to 100 mL. 150 to 250mL. 300 to 500 mL. 550 to 700 mL.

 

 

 

DIGESTIVE DISORDERS DIVERTICULAR DISEASE • Sac like outpouching or herniation of the lining of the bowel that protrudes through a weak portion of the muscle layer. • Commonly in the colon

 

 

 

 

diverticula

 

 

DIGESTIVE DISORDERS Signs & Symptoms

Diverticulosis Exist when multiple diverticula are present without inflammation or symptoms Common in 60 years old and above

Diverticulitis Narrowing of large bowel with fibrotic structure Chronic constipation with episodes of diarrhea Occult bleeding Weakness, fatigue and anorexia Tenderness, palpable mass, fever Abdominal pain, rigid board like abdomen (due to development of abscess or perforation)  

 

DIGESTIVE DISORDERS Pathophysiology Mucosa and submucosal layers Increase intraluminal pressure, low volume in colon, decrease muscle strength Herniated through muscular wall Diverticulum Bowel contents accumulate and decompose Inflammation and infection Obstructed and irritated colon

 

 

DIGESTIVE DISORDERS Treatment high fiber diet to prevent constipation clear liquids until inflammation subsides low fat diet antibiotics for 7-10 days laxatives antispasmodics for spastic pain, taken before meals an at bed time stool softeners, warm oil enemas surgery is necessary if perforation, peritonitis, abscess formation, hemorrhage or obstruction occurs, recurrence of diverticula is common.  

 

DIGESTIVE DISORDERS

 

Nursing Intervention maintain normal elimination pattern increase fluid intake to 2L/day soft food but high fiber content exercise program to improve abdominal muscle tone encourage daily intake of laxatives relieve pain analgesics as ordered monitor and record pain (location and duration) monitor and manage potential complications  

REVIEW QUESTIONS

 5 items

 

 

 Which of the following laboratory findings  would the nurse expect to find in a client  with diverticulitis? A. B. C. D.

 

Elevated red blood cell count. Decreased platelet count. Elevated white blood cell count. Elevated serum blood urea nitrogen  concentration.  

 Which of the following laboratory findings  would the nurse expect to find in a client  with diverticulitis? A. B. C. D.

 

Elevated red blood cell count. Decreased platelet count. Elevated white blood cell count. Elevated serum blood urea nitrogen  concentration.  

 The nurse is aware that the diagnostic test  typically ordered for acute diverticulitis do  not include a barium enema A. B. C. D.

 

Can perforate an intestinal abscess. Would greatly increase the client’s pain. Is of minimal diagnostic value in diverticulitis. Is too lengthly a procedure for the client to  tolerate.  

 The nurse is aware that the diagnostic test  typically ordered for acute diverticulitis do  not include a barium enema A. B. C. D.

 

Can perforate an intestinal abscess. Would greatly increase the client’s pain. Is of minimal diagnostic value in diverticulitis. Is too lengthly a procedure for the client to  tolerate.  

 Which of the following measures should the  client with diverticulitis be taught to  integrate into his daily routine at home? A. Using enemas to relieve constipation. B. Decreasing fluid intake to increase the formed  consistency of the stool. C. Eating a high­fiber diet when symptomatic with  diverticulitis. D. Refraining from straining and lifting activities.  

 

 Which of the following measures should the  client with diverticulitis be taught to  integrate into his daily routine at home? A. Using enemas to relieve constipation. B. Decreasing fluid intake to increase the formed  consistency of the stool. C. Eating a high­fiber diet when symptomatic with  diverticulitis. D. Refraining from straining and lifting activities.  

 

 Which of the following signs would be  indicative of peritonitis in a client with  diverticulitis? a. Hyperactive bowel sounds. b. Rigid abdominal wall. c. Explosive diarrhea. d. Excessive flatulence.  

 

 Which of the following signs would be  indicative of peritonitis in a client with  diverticulitis? a. Hyperactive bowel sounds. b. Rigid abdominal wall. c. Explosive diarrhea. d. Excessive flatulence.  

 

 Which of the following medications would  the nurse anticipate administering to a client  with diverticular disease?  A. B. C. D.

 

Psyllium hydrophilic mucilloid (Metamucil). Diphenoxylate with atropine sulfate (Lomotil). Diazepam (Valium). Aluminum hydroxide (Amphojel).

 

 Which of the following medications would  the nurse anticipate administering to a client  with diverticular disease?  A. B. C. D.

 

Psyllium hydrophilic mucilloid (Metamucil). Diphenoxylate with atropine sulfate (Lomotil). Diazepam (Valium). Aluminum hydroxide (Amphojel).

 

 

 

Acute Pancreatitis Characterized by edema and inflammation confined to the pancreas.

 

Signs & symptoms Abdominal pain LUQ; may start at the epigastrium, radiate to the back, flanks Jaundice Fever Nausea & vomiting Dehydration Mental confusion Dyspnea Tachypnea Hypotension   Absent or decrease bowel sounds

Criteria on admission to  hospital  Age > 55 years old  WBC  16,000/mm3  Serum glucose > 200mg/dL (> 11.1  mmol/L)  Serum LDH > 350 u/mL   AST > 200 u/mL  

 

Pathophysiology Damage to pancreatic cells Inflammation

Edema of the pancreas and pancreatic duct Obstruction to the flow of pancreatic enzyme

Activation of pancreatic enzymes inside the pancreas Auto digestion of the pancreas

 

Hemorrhage

Fatty necrosis

 

Ulceration

Infection

DIAGNOSTIC TEST  Serum AMYLASE and Lipase are increased  Serum Calcium is decreased  Calcium combine with fatty acid released by  lipolysis  soaps

 CT Scan

 Shows enlargement of the pancreas

 Serum Glucose

 Is increased, due to damage to Islet of Langerhans  causing inadequate insulin secretion

 

 

MEDICAL  MANAGEMENT

 Drug Therapy

Analgesics (DEMEROL) to relieve pain Smooth muscle relaxant (PAPAVERINE)to relieve pain Anticholinergics (ATROPINE) to decrease pancreatic  stimulation

 Diet modification  NPO usually for a few days to promote GIT rest  Peritoneal lavage

 

 

Nursing Interventions  Administer analgesics, antacids, anti cholinergic  as ordered  Withhold food/fluid and eliminate odor of food  from environment to ↓pancreatic stimulation  Maintain nasogastric tube and assess drainage  Institute non­pharmacologic measures to decrease  pain (knee chest, fetal position)  Small frequent feedings instead of three large  ones (↑CHO, ↑CHON, ↓Fat)  

 

Nursing Interventions  TPN to provide nutritional supplement during  acute phase when NPO is instituted  Calcium supplements to manage hypocalcemia  Vitamin D to promote calcium absorption  Insulin to manage hyperglycemia  Eliminate ALCOHOL totally!

 

 

REVIEW QUESTIONS

 8 items

 

 

 The initial diagnosis of pancreatitis is  confirmed if the client’s blood work shows a  significant elevation in which of the  following serum values? A. B. C. D.  

Amylase. Glucose. Potassium. Trypsin.  

 The initial diagnosis of pancreatitis is  confirmed if the client’s blood work shows a  significant elevation in which of the  following serum values? A. B. C. D.  

Amylase. Glucose. Potassium. Trypsin.  

The client who has been hospitalized with pancreatitis does  not drink alcohol because of her religious convictions. She  becomes upset when the physician persists in asking her  about alcohol intake. The nurse should explain that the  reason for these questions is that A. There is a strong link between alcohol use and acute  pancreatitis. B. Alcohol intake can interfere with the tests used to  diagnose pancreatitis. C. Alcoholism is a major health problem, and all clients are  questioned about alcohol intake. D. The physician must obtain the pertinent facts, regardless  of religious beliefs.



 

 

The client who has been hospitalized with pancreatitis does  not drink alcohol because of her religious convictions. She  becomes upset when the physician persists in asking her  about alcohol intake. The nurse should explain that the  reason for these questions is that A. There is a strong link between alcohol use and acute  pancreatitis. B. Alcohol intake can interfere with the tests used to  diagnose pancreatitis. C. Alcoholism is a major health problem, and all clients are  questioned about alcohol intake. D. The physician must obtain the pertinent facts, regardless  of religious beliefs.



 

 

 Which of the following signs and symptoms  would the nurse expect to see in a client with  acute pancreatitis?  A. B. C. D.

 

Diarrhea. Jaundice. Hypertension .Ascites 

 

 Which of the following signs and symptoms  would the nurse expect to see in a client with  acute pancreatitis?  A. B. C. D.

 

Diarrhea. Jaundice. Hypertension .Ascites 

 

 The nurse evaluates the client’s most recent  laboratory data. Which laboratory finding  would be consistent with a diagnosis of acute  pancreatitis? A. B. C. D.  

Hyperglycemia. Leukopenia. Thrombocytopenia.  Hyperkalemia.  

 The nurse evaluates the client’s most recent  laboratory data. Which laboratory finding  would be consistent with a diagnosis of acute  pancreatitis? A. B. C. D.  

Hyperglycemia. Leukopenia. Thrombocytopenia.  Hyperkalemia.  

 The initial treatment plan for a client with  pancreatitis most likely would focus on  which of the following as a priority? A. B. C. D.

 

Resting the gastrointestinal tract. Ensuring adequate nutrition. Maintaining fluid and electrolyte balance. Preventing the development of an infection.

 

 The initial treatment plan for a client with  pancreatitis most likely would focus on  which of the following as a priority? A. B. C. D.

 

Resting the gastrointestinal tract. Ensuring adequate nutrition. Maintaining fluid and electrolyte balance. Preventing the development of an infection.

 

The nurse notes that a client with acute pancreatitis  occasionally experiences muscle twitching and  jerking. How should the nurse interpret the  significance of these symptoms?



A. The client may be developing hypocalcemia. B. The client is experiencing a reaction to meperidine  (Demerol). C. The client has a nutritional imbalance. D. The client needs a muscle relaxant to help him rest.

 

 

The nurse notes that a client with acute pancreatitis  occasionally experiences muscle twitching and  jerking. How should the nurse interpret the  significance of these symptoms?



A. The client may be developing hypocalcemia. B. The client is experiencing a reaction to meperidine  (Demerol). C. The client has a nutritional imbalance. D. The client needs a muscle relaxant to help him rest.

 

 

 Which of the following would most likely be  a major nursing diagnosis for a client with  acute pancreatitis? A. B. C. D.

 

Ineffective Airway Clearance. Excess Fluid Volume. Impaired Swallowing. Imbalanced Nutrition: Less Than Body  Requirements.  

 Which of the following would most likely be  a major nursing diagnosis for a client with  acute pancreatitis? A. B. C. D.

 

Ineffective Airway Clearance. Excess Fluid Volume. Impaired Swallowing. Imbalanced Nutrition: Less Than Body  Requirements.  

 The client with chronic pancreatitis should  be monitored closely for the development of  which of the following disorders? A. B. C. D.

 

Cholelithiasis. Hepatitis. Irritable bowel syndrome. Diabetes mellitus.

 

 The client with chronic pancreatitis should  be monitored closely for the development of  which of the following disorders? A. B. C. D.

 

Cholelithiasis. Hepatitis. Irritable bowel syndrome. Diabetes mellitus.

 

 

 

Liver Cirrhosis     Is a chronic disease of the liver in which liver  tissue is replaced by connective tissue, resulting  in the loss of liver function.     Cirrhosis is caused by damage from toxins  (including alcohol), metabolic problems, chronic  viral hepatitis or other causes.     Cirrhosis is irreversible but treatment of the  causative disease will slow or even halt the  damage.    

 

 Types o Laennec’s cirrhosis: associated with alcohol abuse and malnutrition; characterized by an accumulation of fat in the liver cells, progressing to widespread scar formation o Postnecrotic cirrhosis: results in severe inflammation with massive necrosis as a complication of viral hepatitis. o Cardiac cirrhosis: occurs as a consequence of right-sided heat failure; manifested by hepatomegaly with some fibrosis o Biliary cirrhosis: associated with biliary obstruction, usually in the common bile duct; results in chronic impairment of bile excretion  

 

PATHOPHYSIOLOGY Alcohol abuse, malnutrition, infection, drugs, biliary, obstruction Destruction of hepatocytes Fibrosis / scarring Obstruction of blood flow, Increase pressure in the venous and sinusoidal Channel, Fatty infiltration fibrosis / scarring Portal hypertension

 

 

Assessment Findings  Anorexia, N/V, changes in bowel patterns (altered     

 

ability of the liver to metabolized CHO, CHONS,  and fats) Hepatomegaly (early/initially), atrophy of the liver  (later, as fibrosis replaces the liver parenchyma) Jaundice, pruritus, tea colored urine (due to ↑ serum  bilirubin in the blood) Fever (response to tissue injury) Bleeding tendencies (liver unable to store vitamin K)

 

Assessment Findings  Splenomegaly (due to ↑ back pressure of the blood)  Spider angioma (red spots on the upper body)  Palmar erythema  Portal obstruction and ascites (due to increasing  pressure, low level of serum albumin)  Esophageal varices  Infection

 

 

 

 

 

 

Hepatic Encephalopathy  Due to ↑increased AMMONIA levels  The liver cannot convert ammonia by  products of protein metabolism into  Urea.  This will accumulate and cause the  hepatic coma.   The initial manifestations are  BEHAVIORAL changes and MENTAL  changes.  

 

Hepatic Encephalopathy Other findings in advanced stages are:  Asterixis  flapping tremors of the hands  Constructional Apraxia  deterioration of  handwriting and inability to draw a simple  star figures   Confusion / disorientation  Delirium / hallucination  Fetor hepaticus­ disagreeable odor from the  mouth.  

 

Summary of Collaborative  Management  Rest. To reduce metabolic demands of the liver.  Diet HIGH calorie, HIGH carbohydrates, LOW  protein that is restricted to complete protein  only, moderate fats.  Skin care  Avoid trauma/injury  Prevent infection

 

 

Manage Ascites  Monitor weight, intake and output, 

abdominal girth  Restrict sodium and fluid intake  Administer diuretics as ordered  Administer albumin / IV as  ordered assist in paracentesis

 

 

Manage Esophageal varices  Avoid the following to prevent rupture  of the varices:  Shouting, yelling, screaming  Straining at stool  Bending, stooping  Hot, spicy foods.  Lifting heavy objects

 

 

 

 

 

 

 

 

If bleeding esophageal  varices occur:

 Place in semi­Fowler’s position to prevent aspiration  Suction the mouth  Administer vasopressin as ordered. This produce   vasoconstriction of splanchnic arterial bed.  Gastric lavage with tap water (room temperature  saline) as ordered.  Sclerotherapy  Balloon tamponade with the use of Sengstaken –   Blakemore tube  Variceal band ligation

 

 

Decrease Ammonia  formation

 Restrict protein in the diet  Duphalac (lactulose) to lower pH in the colon and  reduce formation of alkaline ammonia. It also  increases peristalsis so, excretion of ammonia via  feces is enhanced.  Neomycin sulfate to reduce colonic bacteria  which are responsible for ammonia formation.  Tap water or NSS enema to remove digested  blood from the colon . Blood is protein and will  produce ammonia.  

 

Summary of Collaborative  Management  Avoid sedatives and paracetamol. These  are hepatotoxic agents.  Avoid ASA. This causes bleeding.  Eliminate alcohol.

 

 

Nursing Interventions Provide sufficient rest and comfort.  Provide bed rest with bathroom privileges.  Encourage gradual, progressive, increasing activity with  planned rest periods.  Institute measures to relieve pruritus. Do not use soaps and detergents. Bath with tepid water followed by application of an  emollient lotion. Provide cool, light, nonrestrictive clothing. Keep nails short to avoid skin excoriation from  scratching. Apply cool, moist compresses to pruritic areas.  

 

Nursing Interventions Promote nutritional intake  Encourage small frequent feedings.  Promote a high calorie, low to moderate protein, high  carbohydrate, low fat diet, with supplemental vitamin  therapy (vitamins A, B­complex, C, D, K and folic acid) Prevent infection  Prevent skin breakdown by frequent turning and skin  care.  Provide reverse isolation for clients with severe  leucopenia; put special attention to hand washing­ technique.  Monitor WBC.  

 

Health teachings Provide client teaching and discharge planning concerning  Avoidance of agents that may be hepatotoxic ( sedatives,  opiates, or OTC drugs detoxified by the liver).  How to assess for weight gain and increase abdominal  girth.  Avoidance of person with upper respiratory infections.  Recognition and reporting of signs of recurring illness  (liver tenderness, increased jaundice, increased fatigue,  anorexia).  Avoidance of all alcohol.  Avoidance of straining at stool, vigorous blowing of nose  and coughing to decrease the incidence of bleeding.  

 

REVIEW QUESTIONS

 8 items

 

 

 The nurse is assessing a client who is in the  early stages of cirrhosis of the liver. Which  sign would the nurse anticipate finding? A. B. C. D.

 

Peripheral edema. Ascites. Anorexia. Jaundice.

 

 The nurse is assessing a client who is in the  early stages of cirrhosis of the liver. Which  sign would the nurse anticipate finding? A. B. C. D.

 

Peripheral edema. Ascites. Anorexia. Jaundice.

 

A client with cirrhosis begins to develop ascites.  Spironolactone (Aldactone) is prescribed to treat  the ascites. The nurse should monitor the client  closely for which of the following drug related side  effects?



A. B. C. D.

 

Constipation. Hyperkalemia. Irregular pulse. Dysuria.

 

A client with cirrhosis begins to develop ascites.  Spironolactone (Aldactone) is prescribed to treat  the ascites. The nurse should monitor the client  closely for which of the following drug related side  effects?



A. B. C. D.

 

Constipation. Hyperkalemia. Irregular pulse. Dysuria.

 

 What diet should be implemented for a client  who is in the early stages of cirrhosis? A. B. C. D.

 

High calorie, high carbohydrate. High protein, low fat. Low fat, low protein. High carbohydrate, low sodium.

 

 What diet should be implemented for a client  who is in the early stages of cirrhosis? A. B. C. D.

 

High calorie, high carbohydrate. High protein, low fat. Low fat, low protein. High carbohydrate, low sodium.

 

A client with cirrhosis complains that his skin  always feels itchy and that he “scratches himself  raw” while he sleeps. The nurse should recognize  that the itching is the result of which abnormality  associated with cirrhosis?



A. B. C. D.

 

Folic acid deficiency. Prolonged prothrombin time. Increased bilirubin levels. Hypokalemia.

 

A client with cirrhosis complains that his skin  always feels itchy and that he “scratches himself  raw” while he sleeps. The nurse should recognize  that the itching is the result of which abnormality  associated with cirrhosis?



A. B. C. D.

 

Folic acid deficiency. Prolonged prothrombin time. Increased bilirubin levels. Hypokalemia.

 

 The client with cirrhosis has developed  ascites. The nurse should recognize that the  pathologic basis for the development of  ascites in clients with cirrhosis is portal  hypertension and A. B. C. D.

 

an excess serum sodium level. an increased metabolism of aldosterone. a decreased flow of hepatic lymph. a decreased serum albumin level.  

 The client with cirrhosis has developed  ascites. The nurse should recognize that the  pathologic basis for the development of  ascites in clients with cirrhosis is portal  hypertension and A. B. C. D.

 

an excess serum sodium level. an increased metabolism of aldosterone. a decreased flow of hepatic lymph. a decreased serum albumin level.  

A client with cirrhosis vomits bright red blood and  the physician suspects bleeding esophageal varices.  The physician decides to insert a Sengstaken­Blake  more tube. The nurse should explain to the client  that the tube acts by



A. B. C. D.  

providing a large diameter for effective gastric lavage. applying direct pressure to gastric bleeding sites. blocking blood flow to the stomach and esophagus. applying direct pressure to the esophagus.  

A client with cirrhosis vomits bright red blood and  the physician suspects bleeding esophageal varices.  The physician decides to insert a Sengstaken­Blake  more tube. The nurse should explain to the client  that the tube acts by



A. B. C. D.  

providing a large diameter for effective gastric lavage. applying direct pressure to gastric bleeding sites. blocking blood flow to the stomach and esophagus. applying direct pressure to the esophagus.  

 The physician orders oral neomycin as well  as a neomycin enema for a client with  cirrhosis. The nurse understands that the  purpose of this therapy is to A. B. C. D.  

reduce abdominal pressure. prevent straining during defecation. block ammonia formation. reduce bleeding within the intestine.  

 The physician orders oral neomycin as well  as a neomycin enema for a client with  cirrhosis. The nurse understands that the  purpose of this therapy is to A. B. C. D.  

reduce abdominal pressure. prevent straining during defecation. block ammonia formation. reduce bleeding within the intestine.  

 The nurse monitors a client with cirrhosis for  the development of hepatic encephalopathy.  Which of the following would be an  indication that hepatic encephalopathyis  developing? A. B. C. D.

 

Decreased mental status. Elevated blood pressure. Decreased urinary output.  Labored respirations.  

 The nurse monitors a client with cirrhosis for  the development of hepatic encephalopathy.  Which of the following would be an  indication that hepatic encephalopathyis  developing? A. B. C. D.

 

Decreased mental status. Elevated blood pressure. Decreased urinary output.  Labored respirations.  

End