GI

Terms to be familiar with:

  • Diarrhea; 3 or more

  • Gastritis

  • Peptic ulcer disease

  • Constipation;

  • Appendicitis

  • Peritonitis

  • Crohn’s disease

  • Ulcerative colitis

  • Bowel obstruction

  • Hernia

  • GI decompression; removing content from stomach

  • Diverticulitis;

  • Strangulated hernia;

  • Low residue diet

  •  High fiber diet

Digestive System

  • GI tract - pathway in length that extends from the mouth to esophagus, stomach, small and large intestine, and rectum to the anus.

  • Major functions: Breakdown of food particles into the molecular form for digestion.

  • Absorption into the bloodstream of small nutrient molecules produced by digestion.

  • Elimination of undigested unabsorbed food and other waste products.

Discussion

  • The nurse is obtaining a health history of a client admitted for dysfunction of the GI system. Using assessment parameters appropriate for determining the status of GI function, what key parameters should the nurse focus on in collecting the client’s GI health history and physical assessment?

    • 1. Health History

      • Symptoms: Chief complaint, onset, duration, and triggers of symptoms.

      • Appetite and Diet: Changes in appetite, dietary habits, and food intolerances.

      • Weight: Recent weight changes indicating potential GI issues.

      • Bowel Habits: Frequency, consistency, color of stools, and any changes.

      • Pain: Location, nature, and factors affecting pain or discomfort.

    • 2. Physical Assessment

      • Inspection: Abdominal shape, distention (acistes, bowel obstruction), and skin changes

      • Auscultation: Bowel sounds in all quadrants.

      • Palpation: Tenderness, masses, or abnormal findings.

      • Percussion: Detection of fluid, air, or organ enlargement.

A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education?

A. "Drinking beverages after your meal, rather than with your meal, may bring some relief."

B. "It's best to avoid dry foods, such as rice and chicken, because they're harder to swallow."

C. "Many clients obtain relief by taking over-the-counter antacids 30 minutes before eating."

D. "Instead of eating three meals a day, try eating smaller amounts more often."

Assessment

  • Health history:

    • Information about abdominal pain, dyspepsia, gas, nausea and vomiting, diarrhea, constipation, fecal incontinence, jaundice, and previous GI disease is obtained

    • Dyspepsia

      • Most common symptom of patients with GI dysfunction

    • Intestinal gas

      • Bloating, distention, or feeling “full of gas” with excessive flatulence as a symptom of food intolerance or gallbladder disease

    • Nausea and vomiting

      • Nausea is a vague, uncomfortable sensation of sickness or “queasiness” that may or may not be followed by vomiting

    • Change in bowel habits and stool characteristics

    • May signal colonic dysfunction or disease

    • Constipation, diarrhea

    • Stool characteristics - can vary greatly, normal is light to dark brown

      • Abnormal

        • Tarry/black - upper GI bleed

        • bright/dark red - lower GI bleed

        • Bulky, greasy, foamy that are foul in odor may or may not float

        • Light gray or clay colored- decreased or absence of conjugated bilirubin

          • Stool with mucus thread or pus may be visible on gross inspection of the stool

        • Small, dry rock hard masses occasional streaked with blood

        • Loose, watery stool that may or may not be streaked with blood - indicate constipation

    • Past health, family and social history

      • Oral care and  dental visits

      • Lesions in mouth

      • Discomfort with certain foods

      • Use of alcohol and tobacco

      • Dentures

      • Cancers

  • Pain:

    • Pain scale, character, duration, pattern, frequency, location, distribution of referred abdominal pain, and time of the pain vary greatly depending on the underlying cause

Physical Assessment

  • Oral cavity

    • Lips

    • Gums; inspect bleeding, breath, etc

    • Tongue; texture, color, lesion

    • Pharynx

  • Abdominal assessment; four quadrant method

    • draw invisible line to divide quads - Sounds?

    • Inspection;

    • Auscultation;

    • Percussion;

    • Palpation;

      • Palpate - determines tenderness, not so much for rebound tenderness because of pain

  • Rectal inspection

    • Rectal - inspection of hemorrhoids

  • Percussion - size, density of abdominal organs, air filled, fluid filled, solid masses, assess tympany, dullness

Quadrants in the abdomen

  • Epigastric - above the belly button

  • Umbilical - belly button area

  • Suprapubic - have you seen a suprapubic catheter? #3

    • under the belly button; surgically implanted.

Diagnostic Tests

  • Serum laboratory studies

    • CBC (WBC,RBC), CMP (ELECTROLYTE AND KIDNEY FUNCTION, PT/PTT, triglycerides, LFT’s, amylase, lipase, CEA, CA 19-9

  • Stool tests

    • FOBT

      • Bacteria, pathogens, parasites

  • Breath tests; H Pylori (bacteria in the stomach)

  • Abdominal ultrasonography - appy, gallbladder

  • Imaging studies: CT (localized inflammation; contrast, kidney function), MRI (abscesses)

  • Upper GI tract study

    • drink contrast, stomach motility, detect ulcers,

  • Lower GI tract study

  • Endoscopic procedures - EGD, colonoscopy

  • Diagnostics- r/o, stage, and diagnose various disease states including cancer

  • Preparation is important. Nursing interventions pg 1217

  • Inform the primary provider of known medical conditions or abnormal laboratory values that may affect the procedure

  • Assess for adequate hydration before, during, and immediately after the procedure, and provide education about the maintenance of hydration

  • Provide health information and procedural education to patients and significant others

  • Provide instructions about post procedure care and activity restrictions

  • Help the patient cope with discomfort and alleviate anxiety

Patients undergoing Gastroscopy

Colonoscopy and Flexible Fiber Optic Sigmoidoscopy

Oral Disorders

  • Lips

    • Actinic Cheilitis

    • Herpes Simplex 1

  • Mouth

    • Leukoplakia

    • Candidiasis

    • Karposi’s sarcoma

Gums

  • Gingivitis

  • Periodontitis

  • Herpes Simplex 1

  • Leukoplakia

  • Candidiasis

  • Karposi’s sarcoma

  • Gingivitis

  • Periodontitis

  • May see these disorders in hospitalized patients. Not necessarily why they are admitted.

Esophageal Disorders

  • Hiatal hernias

  • Gastroesophageal reflux disease (GERD)

  • Barrett esophagus

Esophageal Disorders

  • Hiatal Hernia- Define

    • Hernia- opening in the diaphragm through which the esophagus passes becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax also referred to as a sliding hernia

    • Occurs more often in women than men

    • Sliding hiatal hernia is more common

  • Clinical Manifestations - pyrosis, regurgitation, dysphagia.

  • Vague symptoms - intermittent epigastric pain or fullness after eating

  • Assessment/ Diagnostics - xray, barium swallow, EGD

  • Pts may have pyrosis, regurgitation, and dysphagia- many are asymptomatic

  • Vagus sx are intermittent epigastric pain or fullness after they eat

  • Large hiatal leads to intolerance to food, n/v, sliding hernias commonly assoc with GERD

  • Assessment/ Diagnostics - xray, barium swallow, EGD

  • Management - frequent small feedings

    • don’t recline for 1 hour after eating to prevent reflux or movement of the hernia and elevate HOB

    • surgical intervention for those that are symptomatic, done to relieve the reflux versus the repair of the hernia

Gastroesophageal Reflux Disease (GERD)

  • Common disorder marked by backflow of gastric or duodenal contents into the esophagus that causes troublesome symptoms and/or mucosal injury to the esophagus

  • Excessive reflux may occur because of an incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia, or a motility disorder

  • Incidence: increases with age; irritable bowel syndrome and obstructive airway disorders (asthma, COPD, cystic fibrosis); Barrett esophagus, peptic ulcer disease, and angina

  • Other risk factors: tobacco use, coffee drinking, alcohol consumption, gastric infection with Helicobacter pylori

  • GERD- incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia, or motility disorder

  • Incidence increases with age also seen in pts with IBS and airway obstructive disorders, BE, peptic ulcer disease, and angina

  • Association with tobacco use, ETOH, and H. pylori

  • Medications

  • Sucralfate given in clinical

  • Nissan Fundoplication - more severe cases use this surgical procedure

Management of GERD

  • Low-fat diet

  • Avoid caffeine, tobacco, beer, milk, foods containing peppermint or spearmint, and carbonated beverages

  • Avoid eating or drinking 2 hours before bedtime

  • Elevate the head of the bed by at least 30 degrees

Barret’s Esophagus

  • Lining of esophageal mucosa becomes damaged by stomach acid

  • Typically seen in conjunction with GERD, can be precursor to esophageal cancer

Gastric and Duodenal Disorders

  • Disruption of the mucosal barrier that normally protects the stomach tissue from digestive juices

  • Acute: rapid onset of symptoms usually caused by dietary indiscretion; self-limiting. Other causes include medications, alcohol, bile reflux, and radiation therapy. Ingestion of strong acid or alkali may cause serious complications

  • Chronic: prolonged inflammation, atrophy of gastric tissue, due to benign or malignant ulcers of the stomach or by Helicobacter pylori. May also be associated with some autoimmune diseases, dietary factors, medications, alcohol, smoking, or chronic reflux of pancreatic secretions or bile

  • Erosive- damage stomach lining, frequent use of ASA, NSAIDS, corticosteroids, ETOH, and gastric radiation therapy

  • Nonreosive- H. Pylori

Erosive Gastritis

  • Mucosa protects the stomach if no protection eating away in which this may cause ulcerations that may bleed and leak into the abd cavity

 Gastritis Manifestations

  • Acute: epigastric pain, dyspepsia, anorexia, hiccups, nausea, vomiting. Erosive gastritis can lead to melena, hematemesis or hematochezia

  • Chronic: fatigue, pyrosis, belching, sour taste in the mouth, halitosis, early satiety, anorexia, nausea and vomiting. May have pernicious anemia due to malabsorption of B12. Some are asymptomatic

  • Definitive diagnosis by endoscopy and biopsy specimen

 Medical Management of Gastritis

  • Acute

    • Refrain from alcohol and food until symptoms subside

    • Supportive therapy: IV fluids, nasogastric intubation, antacids, histamine-2 receptor antagonists, proton pump inhibitors

  • Chronic

    • Modify diet, promote rest, reduce stress, avoid alcohol and NSAIDs

    • Pharmacologic therapy including a variety of medications  (Table 40-2)

  • Appetite my be diminished for an additional 2-3 days

Nursing Management

  • Reduce anxiety; use calm approach and explain all procedures and treatments

  • Promote optimal nutrition; for acute gastritis, the patient should take no food or fluids by mouth. Introduce clear liquids and solid foods as prescribed. Evaluate and report symptoms. Discourage caffeinated beverages, alcohol, cigarette smoking. Refer for alcohol counseling and smoking cessation

    • Promote fluid balance; monitor I&O, for signs of dehydration, electrolyte imbalance, and hemorrhage

  • Measures to relieve pain: diet and medications

Test Your Knowledge #2

  • A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence?

    • A. Tachycardia, hypotension, and tachypnea

    • B. Tarry, foul-smelling stools

    • C. Diaphoresis and sudden onset of abdominal pain

    • D. Sudden thirst, unrelieved by oral fluid administration

  • A client was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize?

    • A. Esophageal or pyloric obstruction related to scarring

    • B. Uncontrolled proliferation of H. pylori

    • C. Gastric hyperacidity related to excessive gastrin secretion

    • D. Chronic referred pain in the lower abdomen

Peptic Ulcer Disease

  • Erosion of a mucous membrane forms an excavation in the stomach, pylorus, duodenum, or esophagus

  • Associated with infection of H. pylori, not stress, stress can aggravate

  • Risk factors include excessive secretion of stomach acid, dietary factors, chronic use of NSAIDs, alcohol, smoking, and familial tendency

  • Manifestations include a dull gnawing pain or burning in the midepigastrium; heartburn and vomiting may occur

  • Treatment includes medications (Table 40-3), lifestyle changes, and occasionally surgery (Table 40-4)

Gastric Ulcer- pain is after eating versus Duodenal Ulcer 2-3 hours later

  • History including presenting signs and symptoms

  • Dietary history and dietary associations with symptoms such as predictable time for pain

  • 72-hour diet; a diary may be helpful

  • Abdominal assessment, vital signs

  • Medications; include use of NSAIDs

  • Sign and symptoms of anemia or bleeding

Nursing Interventions for the Patient with Gastritis or Peptic Ulcer Disease

  • Relieving pain

  • Reducing anxiety

  • Maintaining optimal nutritional status

  • Monitoring and managing potential complications

  • Hemorrhage

  • Perforation and penetration

  • Gastric outlet obstruction

  • Patient education

Management of Patients with Intestinal and Rectal Disorders

Elimination Abnormalities

Constipation

  • Defined as fewer than three bowel movements weekly or bowel movements that are hard, dry, small, or difficult to pass

  • Causes include medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intra-abdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise

  • Perceived constipation: a subjective problem in which the person’s elimination pattern is not consistent with what he or she believes is normal

Manifestations of Constipation

  • Fewer than three bowel movements per week

  • Abdominal distention, pain, and bloating

  • A sensation of incomplete evacuation

  • Straining at stool

  • Elimination of small-volume, hard, dry stools

Assessment and Diagnostic Findings of Constipation

Chronic constipation is usually idiopathic

  • Further testing for severe, intractable constipation

  • Thorough history and physical examination

  • Barium enema, sigmoidoscopy, and stool testing

  • Defecography and colonic transit studies

  • MRI

Complications of Constipation

  • Decreased cardiac output (Valsalva manuever)

  • Fecal impaction

  • Hemorrhoids

  • Fissures

  • Rectal prolapse

  • Megacolon

  • Fecal impaction- digital removal/ enema

  • Megacolon- fecal mass that can obstruct the colon may lead to perforation of the colon and contents leak into the sterile peritoneal cavity (peritonitis)

Management

  • Medical Management

    • Identify underlying cause and aim to prevent recurrence

    • Medication

      • Laxatives

      • Medications that enhance colonic transit

  • Nursing Management

    • Health hx interview focusing on symptoms of constipation

    • Teaching/Education Chart 41-2 pg 1289

  • Pt needs to include education, exercise, bowel habit training, increased fiber and fluid intake and judicious use of laxatives

  • Increase fiber slowly in the diet to avoid cramping/ bloating

  • Enemas and rectal supp are generally not recommended for treating constipation unless other meds have failed

Diarrhea

  • Increased frequency of bowel movements (more than three per day) with altered consistency (i.e., increased liquidity) of stool

  • Usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors

  • May be acute, persistent, or chronic

  • Causes include infections, medications, tube feeding formulas, metabolic and endocrine disorders, and various disease processes

Manifestations of Diarrhea

  • Increased frequency and fluid content of stools

  • Abdominal cramps

  • Distention

  • Borborygmus

  • Anorexia and thirst

  • Painful spasmodic contractions of the anus

  • Tenesmus

Assessment and Diagnostic Findings of Diarrhea

  • CBC

  • Serum chemistries

  • Urinalysis

  • Stool examination

  • Endoscopy or barium enema

  • Ask patient about recent travel

  • if cause is not obvious may do CBC, metabolic profile, stool sample for infectious or parasitic organisms, bacterial toxins, blood, fat, electrolytes, and WBCs

    • Clostridium Difficile most commonly identified agent in antibiotic associated diarrhea

    • Endoscopy and Barium Enema may be used.

Complications of Diarrhea

  • Fluid and electrolyte imbalances

  • Dehydration

  • Cardiac dysrhythmias

  • Chronic diarrhea can result in skin care issues related to irritant dermatitis

Management

  • Medical

    • Directed at controlling symptoms, preventing complications, and eliminating or treating underlying disease

      • Medications used: antibiotics, anti-inflammatory agents, anti-diarrheals

  • Nursing

    • Health Hx- including any exposure to acute illness or travel outside of country

    • Assess and monitor characteristics and pattern of diarrhea

    • Abdominal Examination

    • During acute phase encourage bedrest and intake of liquids and low bulk foods, then advance to bland diet of semisolids and solid foods.

    • Anti-diarrheals (not long term)

    • Rectal tubes- bowel management system Figure 41-1

    • Use to eliminate fecal skin contact and are especially used when there is extensive excoriation or skin breakdown

    • Tube is placed in the rectum to drain stool short term use no more than 4 weeks

Patient Learning Needs for Diarrhea

  • Recognition of need for medical treatment

  • Rest

  • Diet and fluid intake

  • Avoid irritating foods, including caffeine, carbonated beverages, very hot and cold foods

  • Perianal skin care

  • Medications

  • May need to avoid milk, fat, whole grains, fresh fruit, and vegetables

  • Lactose intolerance

Irritable Bowel Syndrome

  • Chronic functional disorder characterized by recurrent abdominal pain associated with disordered bowel movements, which may include diarrhea, constipation, or both (IBS-D, IBS-C, IBS-M)

  • Triggers: chronic stress, sleep deprivation, surgery, infections, diverticulitis, and some foods

  • Manifestations: Wide variability in symptom presentation, range in intensity and duration from mild and infrequent to severe and continuous

  • Pain, bloating, and abdominal distention may be present

  • More common in women than men before age of mid 40’s,

  • Assessment/Diagnostics:  ROME IV, stool diary using the Bristol Stool Form, CBC, C-reactive protein, stool studies, and colonoscopy

Patient Learning Needs for Irritable Bowel Syndrome

  • Medication management

    • Aimed at relieving abdominal pain, controlling the diarrhea or constipation, and reducing stress

    • Try to identify foods that are irritants (food diary)

    • High Fiber Diet

    • Exercise and Stress Reduction

  • Complimentary medicine (peppermint oil)

  • Dietary changes

  • Food diary

  • Adequate fluid intake

  • Avoid alcohol and smoking

  • Relaxation techniques

  • Medications Medical

    • IBS-D- antidiarrheal agents

    • All pts- antispasmodic agents, antidepressants these both improve abd comfort   

    • probiotics- decrease and bloating/gas

  • Nursing Management

    • Provide patient and family education

    • Good dietary habits, avoidance of triggers

    • Eat at regular times, chew food slowly and thoroughly

Acute Abdomen

  • -

Appendicitis

  • Appendicitis is the most frequent cause of acute abdomen in the United States, most common reason for emergency abdominal surgery

  • Appendix becomes inflamed and edematous as a result of becoming kinked or occluded by a fecalith or lymphoid hyperplasia

  • The inflammatory process increases intraluminal pressure, causing edema and obstruction of the orifice

  • Once obstructed, the appendix becomes ischemic, bacterial overgrowth occurs, and eventually gangrene or perforation occurs

  • Clinical Manifestations

    • Epigastric or peri-umbilical pain that progresses to RLQ pain, N/V, low grade fever, loss of appetite, tenderness at

  • McBurney’s point, rebound tenderness, possible constipation

  • Diagnosis

    • Based on physical exam, labs, and imaging studies

  • Management

    • Emergent Appendectomy unless perforation has occurred

  • Labs WBC increased, Plt increased, CT scan or US go to definitive

  • Preg test, trans vaginal US may ne used to confirm diagnosis

  • NPO

  • Urinalysis- r/o UTI, kidney stones

  • Goals include:

    • Relieving pain

    • Preventing fluid volume deficit

    • Reducing anxiety

    • Preventing or treating surgical site infection

    • Preventing atelectasis

    • Maintaining skin integrit

    • Attaining optimal nutrition

Diverticular Disease

  • Diverticulum: sac-like herniation of the lining of the bowel that extends through a defect in the muscle layer

  • May occur anywhere in the intestine but most common in the sigmoid colon

  • Diverticulosis: multiple diverticula without inflammation

  • Diverticulitis: infection and inflammation of diverticula

  • Diverticular disease increases with age and is associated with a low-fiber diet

  • Diagnosis is usually by colonoscopy

Nursing Management of Diverticulitis

  • Encourage fluid intake of at least 2 L/day

  • Soft foods with increased fiber, such as cooked vegetables

  • Avoid foods such as nuts and popcorn

  • Individualized exercise program

  • Bulk laxatives (psyllium) and stool softeners

  • Medical Management

    • Inpatient treatment

    • In acute cases hospitalization can be necessary for older and immunocompromised, taking steroids, and unable to tolerate oral fluids.  Treatments would include:

      • NPO until symptoms subside, IV fluids, NGT if vomiting or distention,  antibiotics for 7-10 days, opioid analgesics, antispasmodics, low fiber diet once infection signs decrease

      • Surgery is an option

    • Outpatient treatment

      • Rest, analgesics, and anti-spasmodics

      • Clear liquid diet until inflammation subsides, then high-fiber, low fat diet

      • Antibiotics for 7-10 days

      • Bulk-forming laxatives

      • Complications

      • Peritonitis, abscess, fistulas, and bleeding

  • Manifestations

    • Diffuse pain becomes constant, localized and more intense. Movement aggravates the pain, affected areas tender and distended, and the muscle becomes rigid

    • Rebound tenderness, anorexia, n/v, peristalsis is dimished followed by paralytic ileus

    • Increased temp, hr progresses with hypotension oliguric and anuric will mirror those with sepsis and septic shock

  • Medical Management

    • Fluids, electrolyte replacement, analgesics, antiemetics, oxygen, abx, nutritional support

    • Nursing

    • Assessment, fluids, food intake

Peritonitis

  • Inflammation of the peritoneum

    • Can result from external or internal source

    • Leakage of contents from abdominal organs into abdominal cavity, bacterial proliferation occurs, leads to tissue edema and exudation of fluid.

  • Manifestations

    • Based on location and extent of inflammation

  • Diagnostics

    • X-ray, abdominal U/S, CT scan

  • Management

    • Supportive tx of symptoms, antibiotics &fluids, surgical interventions

  • Manifestations

    • Diffuse pain becomes constant, localized and more intense.

    • Movement aggravates the pain, affected areas tender and distended, and the muscle becomes rigid

    • Rebound tenderness, anorexia, n/v, peristalsis is dimished followed by paralytic ileus

    • Increased temp, hr progresses with hypotension oliguric and anuric will mirror those with sepsis and septic shock

  • Medical management

    • Fluids, electrolyte replacement, analgesics, antiemetics, oxygen, abx, nutritional support

    • Nursing

    • Assessment, fluids, food intake

Inflammatory Bowel Disease Chronic

  • Chron’s Disease

    • Regional Enteritis

    • Subacute and chronic inflammation that extends through all layers of GI tract wall

    • Most commonly occurs in distal ileum and ascending colon

    • Course is prolonged and variable, are some periods of remissions and exacerbations

    • Fistulas, Fissures, and Abscesses common

  • Ulcerative Colitis

    • Ulcerative and inflammatory disease of mucosal and submucosal layer

    • Most commonly occurs in rectum and colon

    • Periods of remissions and exacerbations

    • Fistulas and Fissures are uncommon

  • Chron’s- inflammatory process that begins with crypt inflammation & abscesses which turn into small, focal ulcers

  • Bowel wall thickens and becomes fibrotic and the intestinal wall narrows, diseased bowel loops can adhere to other loops surrounding them

  • Sx- insidious with diarrhea and prominent RLQ pain unrelieved by defecation

  • Eating can cause intestinal peristalsis, crampy pain pt tend not to eat leads to weigh loss and malnutrition and secondary anemia

  • Ulcers can leak a discharge in the colon

  • Disrupted absorption can cause chronic diarrhea and nutritional deficits---- weight loss and dehydration

  • Inflammed intestine perforates- lead to intrabdominal abscess----- fever, leukocytosis, chronnc symptoms- diarrhea, abd pain, steatorrhea, anorexia, weight loss, and nutritional deficiencies

  • CT scan, MRI, CBC, albumin and protein levels

  • Complications-intestinal obstruction or structure formation, perianal disease, fluid and electrolyte imbalances, malnutrition, fistula and abscess formation

  • Ulcerative Colitis

  • Bouts of abd cramps and bloody or purulent diarrhea, typically begin in rectum and progress through the colon

  • Bleeding occurs  because of the ulcerations, the mucosa becomes edematous and inflamed , lesions occur one after the other, bowel eventually shortens, narrows, and thickens because of the muscular hypertrophy and fate deposits

  • The inflammatory is not transmural (only the inner lining) that is why abscesses, fistulas, obstruction, and fissures

  • Sx- diarrhea, with passage of mucus, pus, blood. LLQ, pain, tenesmus

  • Bleeding can be mild or severe. May see pallor, anemia, and fatigue. Anorexia, weight loss, fever, vomiting, dehydration. Cramping and the passage of at least 6 stools per day

  • Classified as mild, severe, fulminant depending on how severe the symptoms are

  • Hypoalbuminemia, electrolyte imbalance, and anemia

  • Extraintestinal manifestaions such as skin lesions, eye lesions, and joint abnormalities, and liver disease

  • Assessment/Diagnostics

  • Abd xray, Colonoscopy. Biopsies may be taken

  •  CT scan, MRI, and US- indicate abscess

  • CBC- WBC, Hgb, HCT, electrolytes, stool for occult and parasites, C-reactive proteins

  • Complications

  • Toxic megacolon, perforation, bleeding- ulceration. Surgical intervention may be needed

  • Steroid use can lead to diminshed bone density

  • Colon cancer may develop

Management of Chron’s and UC

Nutritional Therapy

  • Oral Fluids

    • Low Residue High Protein High Calorie Diet

    • Vitamin Replacement

  • Pharmacologic Therapy

    • Corticosteroids, Immunomodulators, Aminosalicylates

  • Surgical Management

    • Stricturplasty

    • Intestinal transplant

    • Colectomy

  • See pg 1306 Table 41-5 and Nursing process pg 1310-1312

Bowel Obstruction

  • Can be mechanical or functional obstruction

  • Obstruction can be partial or complete and located in small or large bowel.

    • Most obstructions occur in the small intestine and are caused by adhesions

  • Manifestations

    • In SBO initial symptom is usually crampy pain that is wave-like and colicky.  Other symptoms can include vomiting, dehydration, abdominal distention.

    • In LBO symptoms develop and progress relatively slowly.  May experience constipation that can last for months, weakness, weight loss, anorexia.  Eventually ABD will become distended and pt will have crampy lower abdominal pain.

  • Diagnosis

    • Typically diagnosed by abdominal Xray or CT

  • Management

    • Decompression of bowel through NG tube, if unsuccessful  or if obstruction is complete surgical intervention is necessary

    • Diagnosis based on symptoms, physical findings, results of imaging

    • Bowel sounds are high-pitched and hyperactive in an attempt to pass obstruction

    • Later hypoactive, may indicate strangulation when there is a change in pattern

    • Lab studies CBC, electrolytes reveal dehydration, loss of plasma volume, and possible infection

Gastric Tubes

  • NGT (for suction or feeds)

    • Large-bore (larger than 12 Fr)

    • Small-bore (Dobhoff)

  • Gastric

    • Stomach

    • Duodenum

    • Proximal jejunum

  • Nasoduodenal and nasojejunal feedings are indicated when the esophagus and stomach needs to be bypassed or when the patient at risk for aspiration

  • Tube feedings longer than 4 weeks, gastrostomy or jejunostomy tubes are preferred admin of meds or nutrition

  • Nursing assessment Chart 39-5 pg 1246

  • Complications- dumping syndrome, aspiration, residual checks, and patency

  • Xrays should be performed before using an NGT pg. 1249-1252

  • G-tube and J-tube

  • Peds- may have a PEG “button” than a tube

Nutrition

  • Parenteral Nutrition

    • Provides nutrients to the body by IV route

    • Given through Peripheral or Central Line, depends on pt condition

    • Inability to ingest at least 50% of daily required calories

    • Timeframe when to start depend on pt

    • Length of therapy is usually 5-7 days

  • Enteral Nutrition

    • Given to meet nutritional requirements when oral intake is inadequate or not possible and the middle and lower portions of the GI tract are functionally normal.

    • Can be given through NG, ND, G-tube, J-tube

  • Parental Nutrition- mixture of providing nutrients proteins, carbs, fats, electrolytes, vit, trace minerals, sterile water

  • Table 41-6 pg 1313 Indications for Parental Nutrition

  • Start therapy slow then increase to goal

  • Give peripheral route because solution is less hypertonic, not nutritionally complete because of the low dextrose content

  • Give central route because it is very high in solute concentration of blood

Diets

  • High Fiber Diet

    • Increases bulk in stool and reduces pressure within the colon

  • Low Residue Diet

    • Residue includes any food, including fiber that remains in your intestinal tract and contributes to stool.

    • Low Residue Diet is like low-fiber

    • May be used following abdominal surgery or during a flare-up of a digestive disorder such as diverticulitis or IBD.

    • Should only be used for a short time because it cannot provide al the nutrients necessary for staying healthy.

    • Foods that can be consumed include refined breads, cereals, crackers, chips, and pasta with less than 1 gram of fiber/serving, white rice, fruit juice with no pulp, strained broth-based soups

    • Foods to avoid whole grain breads, cereals, and pastas, peanut butter, seeds and nuts, tough or coarse meats

Surgeries

  • Avoided until complications such as bowel obstruction, perforation abscess and perianal occur.

  • Bowel resection-end to end anastomosis remove diseased portion and retaining as much bowel as possible

  • Ostomy-surgical creation of an opening into the bowel, allows for drainage of fecal matter to the outside of the body.

    • Name of ostomy is based on its location

      • Colostomy is opening into large colon (formed)

      • Ileostomy is opening into the ileum or small intestine (liquid)

Nursing Care for Ostomy

  • Abd surgery post op

  • Ambulation

  • Pain meds

  • Monitor for fecal drainage 24-48 hours after ileostomy, 3-6 after colostomy

  • Monitor labs esp electrolytes, fluid replacement

  • NGT to suction may be indicated

  • Emotional support

  • Managing skin and stoma care, change appliance

  • Managing dietary and fluid needs

  • Preventing complications

  • Chart 41-9 pg 1325

Management of Patients with Intestinal and Rectal Disorders

Elimination Abnormalities

Constipation

  • Defined as fewer than three bowel movements weekly or bowel movements that are hard, dry, small, or difficult to pass

  • Causes include medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intra-abdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise

  • Perceived constipation: a subjective problem in which the person’s elimination pattern is not consistent with what he or she believes is normal

Manifestations of Constipation

  • Fewer than three bowel movements per week

  • Abdominal distention, pain, and bloating

  • A sensation of incomplete evacuation

  • Straining at stool

  • Elimination of small-volume, hard, dry stools

Assessment and Diagnostic Findings of Constipation

  • Chronic constipation is usually idiopathic

  • Further testing for severe, intractable constipation

  • Thorough history and physical examination

  • Barium enema, sigmoidoscopy, and stool testing

  • Defecography and colonic transit studies

  • X-ray, colonoscopy, lower GI endoscopy

Complications of Constipation

  • Decreased cardiac output (Valsalva manuever)

  • Fecal impaction - digital removal/ enema

  • Hemorrhoids

  • Fissures

  • Rectal prolapse

  • Megacolon - fecal mass that can obstruct the colon may lead to perforation of the colon and contents leak into the sterile peritoneal cavity (peritonitis)

Management

  • Medical Management

  • Identify underlying cause and aim to prevent recurrence

  • Medication

  • Laxatives

  • Medications that enhance colonic transit

  • Nursing Management

  • Health hx interview focusing on symptoms of constipation

  • Teaching/Education Chart 41-2 pg 1289

  • Pt needs to include education, exercise, bowel habit training, increased fiber and fluid intake and judicious use of laxatives

    Increase fiber slowly in the diet to avoid cramping/ bloating

  • Enemas and rectal supp are generally not recommended for treating constipation unless other meds have failed

Diarrhea

  • Increased frequency of bowel movements (more than three per day) with altered consistency (i.e., increased liquidity) of stool

  • Usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors

  • May be acute, persistent, or chronic

  • Causes include infections, medications, tube feeding formulas, metabolic and endocrine disorders, and various disease processes

Manifestations of Diarrhea

  • Increased frequency and fluid content of stools

  • Abdominal cramps

  • Distention

  • Borborygmus

  • Anorexia and thirst

  • Painful spasmodic contractions of the anus\

  • Tenesmus

Assessment and Diagnostic Findings of Diarrhea

  • CBC

  • Serum chemistries

  • Urinalysis

  • Stool examination

  • Endoscopy or barium enema

  • Ask patient about recent travel if cause is not obvious may do CBC, metabolic profile, stool sample for infectious or parasitic organisms, bacterial toxins, blood, fat, electrolytes, and WBCs

    • Clostridium Difficile most commonly identified agent in antibiotic associated diarrhea

    • Endoscopy and Barium Enema may be used.

Complications of Diarrhea

  • Fluid and electrolyte imbalances

  • Dehydration

  • Cardiac dysrhythmias

  • Chronic diarrhea can result in skin care issues related to irritant dermatitis

Management

  • Medical

    • Directed at controlling symptoms, preventing complications, and eliminating or treating underlying disease

      • Medications used: antibiotics, anti-inflammatory agents, anti-diarrheals

  • Nursing

    • Health Hx- including any exposure to acute illness or travel outside of country

    • Assess and monitor characteristics and pattern of diarrhea

    • Abdominal Examination

    • During acute phase encourage bedrest and intake of liquids and low bulk foods, then advance to bland diet of semisolids and solid foods.

  • Anti-diarrheals (not long term)

  • Rectal tubes- bowel management system Figure 41-1

  • Use to eliminate fecal skin contact and are especially used when there is extensive excoriation or skin breakdown

  • Tube is placed in the rectum to drain stool short term use no more than 4 weeks

Patient Learning Needs for Diarrhea

  • Recognition of need for medical treatment

  • Rest

  • Diet and fluid intake

  • Avoid irritating foods, including caffeine, carbonated beverages, very hot and cold foods

  • Perianal skin care

  • Medications

  • May need to avoid milk, fat, whole grains, fresh fruit, and vegetables

  • Manage lactose intolerance

Irritable Bowel Syndrome

  • Chronic functional disorder characterized by recurrent abdominal pain associated with disordered bowel movements, which may include diarrhea, constipation, or both (IBS-D, IBS-C, IBS-M)

  • Triggers: chronic stress, sleep deprivation, surgery, infections, diverticulitis, and some foods

  • Manifestations: Wide variability in symptom presentation, range in intensity and duration from mild and infrequent to severe and continuous

  • Pain, bloating, and abdominal distention may be present

  • More common in women than men before age of mid 40’s,

    Assessment/Diagnostics:  ROME IV, stool diary using the Bristol Stool Form, CBC, C-reactive protein, stool studies, and colonoscopy

Patient Learning Needs for Irritable Bowel Syndrome

  • Medication management

    • Aimed at relieving abdominal pain, controlling the diarrhea or constipation, and reducing stress

    • Try to identify foods that are irritants (food diary)

    • High Fiber Diet

    • Exercise and Stress Reduction

  • Complimentary medicine (peppermint oil)

  • Dietary changes

  • Food diary

  • Adequate fluid intake

  • Avoid alcohol and smoking

  • Relaxation techniques

  • Medications Medical

    • IBS-D- antidiarrheal agents

    • All pts- antispasmodic agents, antidepressants these both improve abd comfort 

    • Probiotics- decrease abd bloating/gas

  • Nursing Management

    • Provide patient and family education

      • Good dietary habits, avoidance of triggers

      • Eat at regular times, chew food slowly and thoroughly

Acute Abdomen

Appendicitis

  • Appendicitis is the most frequent cause of acute abdomen in the United States, most common reason for emergency abdominal surgery

  • Appendix becomes inflamed and edematous as a result of becoming kinked or occluded by a fecalith or lymphoid hyperplasia

  • The inflammatory process increases intraluminal pressure, causing edema and obstruction of the orifice

  • Once obstructed, the appendix becomes ischemic, bacterial overgrowth occurs, and eventually gangrene or perforation occurs

  • Clinical Manifestations

    • Epigastric or peri-umbilical pain that progresses to RLQ pain, N/V, low grade fever, loss of appetite, tenderness at McBurney’s point, rebound tenderness, possible constipation

  • Diagnosis

    • Based on physical exam, labs, and imaging studies

  • Management

    • Emergent Appendectomy unless perforation has occurred

  • Labs WBC increased, CRP, CT scan or US go to definitive

    • Preg test, trans vaginal US may ne used to confirm diagnosis

    • NPO

    • Urinalysis- r/o UTI, kidney stones

    • Goals include:

      • Relieving pain

      • Preventing fluid volume deficit

      • Reducing anxiety

      • Preventing or treating surgical site infection

      • Preventing atelectasis

      • Maintaining skin integrity

      • Attaining optimal nutrition

Peritonitis

  • Inflammation of the peritoneum

    • Can result from external or internal source

    • Leakage of contents from abdominal organs into abdominal cavity, bacterial proliferation occurs, leads to tissue edema and exudation of fluid.

  • Manifestations

    • Based on location and extent of inflammation

    • Diffuse pain becomes constant, localized and more intense.

    • Movement aggravates the pain, affected areas tender and distended, and the muscle becomes rigid

    • Rebound tenderness, anorexia, n/v, peristalsis is diminished followed by paralytic ileus

    • Increased temp, hr progresses with hypotension oliguric and anuric will mirror those with sepsis and septic shock

  • Diagnostics

    • X-ray, abdominal U/S, CT scan

  • Management

    • Supportive tx of symptoms, antibiotics &fluids, surgical interventions

    • Fluids, electrolyte replacement, analgesics, antiemetics, oxygen, abx, nutritional support

    • Nursing Assessment, fluids, food intake

Diverticular Disease

  • Diverticulum: sac-like herniation of the lining of the bowel that extends through a defect in the muscle layer

  • May occur anywhere in the intestine but most common in the sigmoid colon

  • Diverticulosis: multiple diverticula without inflammation

  • Diverticulitis: infection and inflammation of diverticula

  • Diverticular disease increases with age and is associated with a low-fiber diet

  • Diagnosis is usually by colonoscopy

Nursing Management of Diverticulitis

  • Medical Management

    • Inpatient treatment

      • In acute cases hospitalization can be necessary for older and immunocompromised, taking steroids, and unable to tolerate oral fluids.  Treatments would include:

        • NPO until symptoms subside, IV fluids, NGT if vomiting or distention,  antibiotics for 7-10 days, opioid analgesics,  low fiber diet once infection signs decrease

        • Surgery is an option

    • Outpatient treatment

      • Rest, analgesics, and selective antibiotics

      • Clear liquid diet until inflammation subsides, then high-fiber, low fat diet

      • Antibiotics for 7-10 days

      • Bulk-forming laxatives

  • Complications

    • Peritonitis, abscess, fistulas, and bleeding

Inflammatory Bowel Disease Chronic

  • Chron’s Disease

    • Regional Enteritis

    • Subacute and chronic inflammation that extends through all layers of GI tract wall

    • Most commonly occurs in distal ileum and ascending colon

    • Course is prolonged and variable, are some periods of remissions and exacerbations

    • Fistulas, Fissures, and Abscesses common

    • Chron’s- inflammatory process that begins with crypt inflammation & abscesses which turn into small, focal ulcers

    • Bowel wall thickens and becomes fibrotic and the intestinal wall narrows, diseased bowel loops can adhere to other loops surrounding them

    • Sx- insidious with diarrhea and prominent RLQ pain unrelieved by defecation

    • Eating can cause intestinal peristalsis, crampy pain pt tend not to eat leads to weigh loss and malnutrition and secondary anemia

    • Ulcers can leak a discharge in the colon

    • Disrupted absorption can cause chronic diarrhea and nutritional deficits---- weight loss and dehydration

    • Inflammed intestine perforates- lead to intrabdominal abscess----- fever, leukocytosis, chronnc symptoms- diarrhea, abd pain, steatorrhea, anorexia, weight loss, and nutritional deficiencies

    • CT scan, MRI, CBC, albumin and protein levels

    • Complications-intestinal obstruction or structure formation, perianal disease, fluid and electrolyte imbalances, malnutrition, fistula and abscess formation

  • Ulcerative Colitis

    • Ulcerative and inflammatory disease of mucuosal and submucosal layer

    • Most commonly occurs in rectum and colon

    • Periods of remissions and exacerbations

    • Fistulas and Fissures are uncommon

    • Bouts of abd cramps and bloody or purulent diarrhea, typically begin in rectum and progress through the colon

    • Bleeding occurs  because of the ulcerations, the mucosa becomes edematous and inflamed , lesions occur one after the other, bowel eventually shortens, narrows, and thickens because of the muscular hypertrophy and fate deposits

    • The inflammatory is not transmural (only the inner lining) that is why abscesses, fistulas, obstruction, and fissures

      Sx- diarrhea, with passage of mucus, pus, blood. LLQ, pain, tenesmus

    • Bleeding can be mild or severe. May see pallor, anemia, and fatigue. Anorexia, weight loss, fever, vomiting, dehydration.

    • Cramping and the passage of at least 6 stools per day

    • Classified as mild, severe, fulminant depending on how severe the symptoms are

    • Hypoalbuminemia, electrolyte imbalance, and anemia

    • Extraintestinal manifestaions such as skin lesions, eye lesions, and joint abnormalities, and liver disease

    • Assessment/Diagnostics

      • Abd xray, Colonoscopy. Biopsies may be taken

      • CT scan, MRI, and US- indicate abscess

      • CBC- WBC, Hgb, HCT, electrolytes, stool for occult and parasites,

      • C-reactive proteins

    • Complications

      • Toxic megacolon, perforation, bleeding- ulceration. Surgical intervention may be needed

      • Steroid use can lead to diminished bone density

        Colon cancer may develop

  • Nutritional Therapy

    • Oral Fluids

    • Low Residue High Protein High Calorie Diet

    • Vitamin Replacement

    • Pharmacologic Therapy

    • Corticosteroids, Immunomodulators, Aminosalicylates

    • Surgical Management

    • Stricturplasty

    • Intestinal transplant

    • Colectomy

Bowel Obstruction

  • Can be mechanical or functional obstruction

  • Obstruction can be partial or complete and located in small or large bowel.

    • Most obstructions occur in the small intestine and are caused by adhesions

  • Manifestations

    • In SBO initial symptom is usually crampy pain that is wave-like and colicky.  Other symptoms can include vomiting, dehydration, abdominal distention.

    • In LBO symptoms develop and progress relatively slowly.  May experience constipation that can last for months, weakness, weight loss, anorexia.  Eventually ABD will become distended and pt will have crampy lower abdominal pain.

  • Diagnosis

    • Typically diagnosed by abdominal Xray or CT

    • Diagnosis based on symptoms, physical findings, results of imaging

    • Bowel sounds are high-pitched and hyperactive in an attempt to pass obstruction

    • Later hypoactive, may indicate strangulation when there is a change in pattern

    • Lab studies CBC, electrolytes reveal dehydration, loss of plasma volume, and possible infection

  • Management

    • Decompression of bowel through NG tube, if unsuccessful  or if obstruction is complete surgical intervention is necessary.

Gastric Tubes

  • NGT (for suction or feeds)

    • Large-bore (larger than 12 Fr)

    • Small-bore (Dobhoff)

  • Gastric

    • Stomach

    • Duodenum

    • Proximal jejunum

  • Nasoduodenal and nasojejunal feedings are indicated when the esophagus and stomach needs to be bypassed or when the patient at risk for aspiration

  • Tube feedings longer than 4 weeks, gastrostomy or jejunostomy tubes are preferred admin of meds or nutrition

  • Complications- dumping syndrome, aspiration, residual checks, and patency

  • Xrays should be performed before using an NGT

  • G-tube and J-tube

  • Peds- may have a PEG “button” than a tube

Nutrition

  • Parenteral Nutrition

    • Provides nutrients to the body by IV route

    • Given through Peripheral or Central Line, depends on pt condition

    • Inability to ingest at least 50% of daily required calories

    • Timeframe when to start depend on pt

    • Length of therapy is usually 5-7 days

    • Parental Nutrition- mixture of providing nutrients proteins, carbs, fats, electrolytes, vit, trace minerals, sterile water

  • Enteral Nutrition

    • Given to meet nutritional requirements when oral intake is inadequate or not possible and the middle and lower portions of the GI tract are functionally normal.

      • Can be given through NG, ND, G-tube, J-tube

  • Start therapy slow then increase to goal

  • Give peripheral route because solution is less hypertonic, not nutritionally complete because of the low dextrose content

  • Give central route because it is very high in solute concentration of blood

Diets

  • High Fiber Diet

    • Increases bulk in stool and reduces pressure within the colon

  • Low Residue Diet

    • Residue includes any food, including fiber that remains in your intestinal tract and contributes to stool.

    • Low Residue Diet is like low-fiber

    • May be used following abdominal surgery or during a flare-up of a digestive disorder such as diverticulitis or IBD.

    • Should only be used for a short time because it cannot provide al the nutrients necessary for staying healthy.

    • Foods that can be consumed include refined breads, cereals, crackers, chips, and pasta with less than 1 gram of fiber/serving, white rice, fruit juice with no pulp, strained broth-based soups

    • Foods to avoid whole grain breads, cereals, and pastas, peanut butter, seeds and nuts, tough or coarse meats

Surgeries

  • Avoided until complications such as bowel obstruction, perforation abscess and perianal occur.

  • Bowel resection-end to end anastomosis remove diseased portion and retaining as much bowel as possible

  • Ostomy-surgical creation of an opening into the bowel, allows for drainage of fecal matter to the outside of the body.

  • Name of ostomy is based on its location

    • Colostomy is opening into large colon (formed) effluent

    • Ileostomy is opening into the ileum or small intestine (liquid) effluent

  • Abd surgery post op

  • Ambulation

  • Pain meds

  • Monitor for fecal drainage 24-48 hours after ileostomy, 3-6 days after colostomy

  • Monitor labs esp electrolytes, fluid replacement

  • NGT to suction may be indicated

  • Emotional support

  • Managing skin and stoma care, change appliance

  • Managing dietary and fluid needs

  • Preventing complications