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Chapter 38. Digestive Tract Disorders. Learning Objectives. Identify the nursing responsibilities in the care of patients undergoing diagnostic tests and procedures for disorders of the digestive tract. List the data to be included in the nursing assessment of

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Chapter 38

Chapter 38

Digestive Tract Disorders


Learning objectives

Learning Objectives

  • Identify the nursing responsibilities in the care of patients

    undergoing diagnostic tests and procedures for disorders of the digestive tract.

  • List the data to be included in the nursing assessment of

    the patient with a digestive disorder.

  • Describe the nursing care of patients with gastrointestinal

    intubation and decompression, tube feedings, total

    parenteral nutrition, digestive tract surgery, and drug

    therapy for digestive disorders.

  • Describe the pathophysiology, signs and symptoms,

    complications, and medical treatment of selected digestive

    disorders.

  • Assist in developing nursing care plans for patients receiving

    treatment for digestive disorders.


Anatomy and physiology of the digestive tract

Anatomy and Physiology of the Digestive Tract

Mouth

Where teeth, tongue, and salivary glands begin food digestion

Pharynx

Muscular structure shared by the digestive and respiratory tracts

It joins the mouth and nasal passages to the esophagus

Esophagus

Long muscular tube that passes through the diaphragm into the stomach

Stomach

Churns and mixes food with gastric secretions until a semiliquid mass called chyme


Anatomy and physiology of the digestive tract1

Anatomy and Physiology of the Digestive Tract

Small intestine

Chemical digestion and absorption of nutrients take place

Approximately 20 feet long and consists of three sections: the duodenum, the jejunum, and the ileum

Liver and pancreatic secretions enter the digestive tract in the duodenum


Anatomy and physiology of the digestive tract2

Anatomy and Physiology of the Digestive Tract

Large intestine and anus

The first section of the large intestine is the cecum

Ascending colongoes up right side of the abdomen

Transverse colon crosses abdomen just below waist

Descending colon goes down left side of abdomen

The last 6 to 8 inches of the large intestine is the rectum, which ends at the anus, where wastes leave the body


Chapter 38

Figure 38-1


Age related changes

Age-Related Changes

Teeth are mechanically worn down with age

The jaw may be affected by osteoarthritis

A significant loss of taste buds with age

Xerostomia (dry mouth) is common

Walls of esophagus and stomach thin with aging, and secretions lessen

Production of hydrochloric acid and digestive enzymes decreases

Gastric motor activity slows

Movement of contents through the colon is slower

Anal sphincter tone and strength decrease


Health history

Health History

Chief complaint and history of present illness

A detailed description of the present illness

Complaints include weight changes, problems with food ingestion, symptoms of digestive disturbances, or changes in bowel elimination


Health history1

Health History

Past medical history

Recent surgery, trauma, burns, or infections

Serious illnesses, such as diabetes, hepatitis, anemia, peptic ulcers, gallbladder disease, and cancer

Alternative methods of feeding or fecal diversion

Prescription and over-the-counter medications

Food allergy or intolerance


Health history2

Health History

Review of systems

Description of the patient’s general health state

Changes in skin: dryness, bruising, and pruritus

Whether the patient has any mouth problems

Document if the patient has dentures, partial plates, or natural teeth, and record the last dental examination

Problems with chewing or swallowing

Changes in appetite, food intake, and weight

Nausea, vomiting, dyspepsia, heartburn, flatus, abdominal distention, or pain

Assessment of elimination


Health history3

Health History

Functional assessment

Information about general dietary habits should include the daily pattern of food intake

Attitudes and beliefs about food, and changes in dietary habits related to health problems

Effects of chief complaint on usual functioning

Note whether the patient is able to obtain and prepare food, and eat independently


Physical examination

Physical Examination

Head and neck

Inspect the mouth

Abdomen

Inspection

Auscultation

Percussion

Palpation

Rectum and anus

Palpate for lumps and tenderness in the rectum


Chapter 38

Figure 38-2


Diagnostic tests and procedures

Diagnostic Tests and Procedures

Radiographic studies

Upper gastrointestinal (UGI or GI) series

Small bowel series

Barium enema examination


Diagnostic tests and procedures1

Diagnostic Tests and Procedures

Endoscopic examinations

Upper GI

Esophagoscopy, gastroscopy, gastroduodenoscopy, esophagogastroduodenoscopy, endoscopic retrograde cholangiography

Lower GI

Colonoscopy, proctoscopy, and sigmoidoscopy


Diagnostic tests and procedures2

Diagnostic Tests and Procedures

Laboratory studies

Gastric analysis

Occult blood test

Stool examination


Chapter 38

Figure 38-3


Chapter 38

Figure 38-4


Therapeutic measures

Therapeutic Measures


Gastrointestinal intubation

Gastrointestinal Intubation

Tube feedings

Delivered by gravity flow or by infusion pump

Gastrointestinal decompression

For the relief or prevention of distention

Levin and gastric sump tubes


Total parenteral nutrition

Total Parenteral Nutrition

Bypasses digestive tract by delivering nutrients directly to the bloodstream


Chapter 38

Figure 38-5


Chapter 38

Figure 38-6


Chapter 38

Figure 38-7


Chapter 38

Figure 38-9


Gastrointestinal surgery

Gastrointestinal Surgery

Preoperative nursing care

The digestive tract is usually cleansed

Magnesium citrate or large-volume cathartic (laxative) solutions; enemas

Diet limited to liquids 24 hours before surgery

Intravenous fluids

Oral antibiotics

Nasogastric tube inserted and attached to suction


Gastrointestinal surgery1

Gastrointestinal Surgery

Postoperative nursing care

Be sure gastrointestinal suction is draining

Inspect, describe, and measure the drainage

Abdomen for distention and bowel sounds

Administer intravenous fluids

Keep strict intake and output records

Drug therapy

Emetics, antiemetics, laxatives, cathartics, antidiarrheals, antacids, anticholinergics, mucosal barriers, histamine-2 (H2)-receptor blockers, prostaglandins, and antibiotics


Disorders of the digestive tract

Disorders of the Digestive Tract


Anorexia

Anorexia

Causes

Nausea, decreased sense of taste or smell, mouth disorders, and medications

Emotional problems such as anxiety, depression, or disturbing thoughts


Anorexia1

Anorexia

Medical diagnosis

Physician assesses for malnutrition

Weight may be monitored over several weeks

Complete history and physical examination

Serum hemoglobin, iron, total iron-binding capacity, transferrin, calcium, folate, B12, zinc

Thyroid function tests


Anorexia2

Anorexia

Medical treatment

Correctable causes of anorexia are treated, but sometimes no physical cause is found

Nutritional supplements


Anorexia3

Anorexia

Assessment

Record chronic and recent illnesses, hospitalizations, medications, and allergies

Female patient’s obstetric history

Symptoms: pain, nausea, dyspnea, extreme fatigue

The functional assessment reveals patterns of activity and rest, usual dietary patterns, current stressors, and coping strategies—all can affect appetite


Anorexia4

Anorexia

Interventions

Assist with oral hygiene before and after meals

Teach proper oral hygiene; refer for dental care

Relieve nausea before presenting a meal tray

Before serving meal tray, remove bedpans/emesis basins from sight, conceal drains and drainage collection devices, deodorize room if necessary

Socialization during mealtime

Respect food likes and dislikes

Position patient comfortably with easy access to food


Feeding problems

Feeding Problems

Patients with paralysis, arthritis, neuromuscular disorders, confusion, weakness, or visual impairment are likely to need assistance

Medical diagnosis and treatment

Identifying problems, prescribing treatment

Patients often referred to physical therapy and occupational therapy


Feeding problems1

Feeding Problems

Assessment

Assess each patient’s ability to feed self

Determine nature of patient’s difficulty and identify remaining abilities

Assess visual acuity, range of motion and muscle strength in both arms, and range of motion and grip strength in both hands; ability to follow instructions


Feeding problems2

Feeding Problems

Interventions

Proper positioning and arrangement of the meal tray

Provide assistive devices

Open milk cartons, cut meat, butter bread, and season food


Stomatitis

Stomatitis

A general term for inflammation of the oral mucosa

Medical treatment is directed toward determining the cause and eliminating it; a soft, bland diet may be ordered


Vincent s infection

Vincent’s Infection

Bacterial infection that causes a metallic taste and bleeding ulcers in the mouth, foul breath, and increased salivation

Topical antibiotics and mouthwashes to treat infection; rest, a nutritious diet, and good oral hygiene


Herpes simplex

Herpes Simplex

Caused by the herpes simplex virus, type 1

Ulcers and vesicles in mouth and on lips

Occur with upper respiratory tract infections, excessive sun exposure, or stress

Spirits of camphor, topical steroids, and antiviral agents as treatment


Aphthous stomatitis canker sore

Aphthous Stomatitis (“Canker Sore”)

May be caused by a virus

Characterized by ulcers of the lips and mouth that recur at intervals

Topical or systemic steroids may be used


Candida albicans

Candida albicans

Yeastlike fungus causes the oral condition known as thrush or candidiasis

Bluish white lesions on the mucous membranes

Patients at high risk include those on steroid or long-term antibiotic therapy

Treated with oral or topical antifungal agents; vaginal nystatin tablets can be used like lozenges and allowed to dissolve in the mouth


Nursing care

Nursing Care

Assessment

Pain location, onset, and precipitating factors

Record any known illnesses and treatments, including drugs and radiation therapy

Describe habits, including diet, oral care practices, alcohol intake, and use of tobacco

Assess patient’s stress level

Inspect lips and oral cavity for redness, swelling, and lesions


Nursing care1

Nursing Care

Interventions

Gentle oral hygiene, prescribed mouthwashes

The teeth and tongue can be cleansed with a soft-bristle toothbrush, sponge, or cotton-tipped applicator

Medications must be given as ordered


Dental caries

Dental Caries

A destructive process of tooth decay

The only treatment for dental caries is removal of the decayed part of the tooth, followed by filling the cavity with a restorative material


Periodontal disease

Periodontal Disease

Begins with gingivitis; progresses to involve the other structures that support the teeth

Gums red, swollen, painful, and bleed easily

Primarily from inadequate oral hygiene

Treatment in early stage: dental care for teeth cleaning and correction of contributing problems

Untreated, abscesses develop around the roots, the teeth loosen, and extraction is necessary


Chapter 38

Figure 38-10


Nursing care2

Nursing Care

Assessment

Observe condition of teeth and gums

Document missing or broken teeth, caries, redness or lesions of the gums, and gum recession


Nursing care3

Nursing Care

Interventions

Most patients are treated for dental and gum conditions in dentists’ offices

Interventions directed at minimizing pain until the problem can be corrected by a dentist

Provide oral care for patients who cannot do it themselves


Oral cancer

Oral Cancer

Squamous cell carcinoma and basal cell carcinoma

Risk factors

Cancer of the lip related to prolonged exposure to irritants, including sun, wind, and pipe smoking

Factors that increase the risk of cancers inside the mouth include tobacco and alcohol use, poor nutritional status, and chronic irritation


Oral cancer1

Oral Cancer

Signs and symptoms

Tongue irritation, loose teeth, and pain in the tongue or ear

Malignant lesions may appear as ulcerations, thickened or rough areas, or sore spots

Leukoplakia: hard, white patches in the mouth; premalignant


Oral cancer2

Oral Cancer

Medical diagnosis and treatment

A biopsy of suspicious lesions

Treatment includes surgery, radiation, or chemotherapy, or a combination of these


Oral cancer3

Oral Cancer

Assessment

History of prolonged sun exposure, tobacco use, or alcohol consumption

Assess for difficulty swallowing or chewing, decreased appetite, weight loss, change in fit of dentures, and hemoptysis

The physical examination should focus on examination of the mouth for lesions

Assess the neck for limitation of movement and enlarged lymph nodes


Chapter 38

Figure 38-11


Oral cancer4

Oral Cancer

Interventions

Impaired Oral Mucous Membrane

Ineffective Breathing Pattern

Pain

Imbalanced Nutrition: Less Than Body Requirements

Impaired Verbal Communication

Disturbed Body Image

Risk for Infection

Ineffective Tissue Perfusion


Parotitis

Parotitis

Inflammation of the parotid glands

Causes painful swelling of the salivary glands below the ear next to the lower jaw; pain increases during eating

Treated with antibiotics, mouthwashes, and warm compresses; surgical drainage or removal may be necessary


Achalasia

Achalasia

Progressively worsening dysphagia

Failure of the lower esophageal muscles and sphincter to relax during swallowing

Thought to be a neuromuscular defect affecting the esophageal muscles

Treatment includes drug therapy, dilation, and surgical measures


Esophageal cancer

Esophageal Cancer

Pathophysiology

No known cause, but predisposing factors are cigarette smoking, excessive alcohol intake, chronic trauma, poor oral hygiene, and eating spicy foods

Signs and symptoms

Progressive dysphagia


Esophageal cancer1

Esophageal Cancer

Medical diagnosis

Barium swallow, computed tomography, esophagoscopy, and endoscopic ultrasonography

Medical and surgical treatment

Surgery, radiation, chemotherapy, or various combinations


Chapter 38

Figure 38-12


Esophageal cancer2

Esophageal Cancer

Assessment

Dysphagia, pain, and choking

Hoarseness, cough, anorexia, weight loss, and regurgitation

The functional assessment documents the use of alcohol and tobacco and dietary practices


Esophageal cancer3

Esophageal Cancer

Interventions

Pain

Imbalanced Nutrition: Less Than Body Requirements

Anxiety

Risk for Injury

Impaired Gas Exchange

Deficient Knowledge


Nausea and vomiting

Nausea and Vomiting

Nausea: sometimes referred to as queasiness

Vomiting: forceful expulsion of stomach contents through the mouth

Complications

Significant losses of fluids and electrolytes

Aspiration

Medical treatment

Antiemetics

Intravenous fluids

Oral fluids may be limited to clear liquids or withheld

Nasogastric tube


Nausea and vomiting1

Nausea and Vomiting

Assessment

Onset, frequency, and duration of present illness

Conditions under which nausea and vomiting occur

Amount, color, odor, and contents of the vomitus

Surgeries, chronic illnesses, allergies, and medications

General appearance; record vital signs, height/weight

Assess pulse and blood pressure, tissue turgor, mental status, and muscle tone

Inspect, auscultate, and palpate the abdomen for distention, bowel sounds, and tenderness


Nausea and vomiting2

Nausea and Vomiting

Interventions

Imbalanced Nutrition and Deficient Fluid Volume

Risk for Aspiration


Hiatal hernia

Hiatal Hernia

Pathophysiology

Protrusion of lower esophagus and stomach up through the diaphragm and into the chest

Causes

Weakness of diaphragm muscles where esophagus and stomach join, but exact cause is not known

Factors are excessive intra-abdominal pressure, trauma, and long-term bed rest in a reclining position


Hiatal hernia1

Hiatal Hernia

Signs and symptoms

Many people have no symptoms at all; others report feelings of fullness, dysphagia, eructation, regurgitation, and heartburn


Chapter 38

Figure 38-13


Hiatal hernia2

Hiatal Hernia

Medical diagnosis

Barium swallow examination with fluoroscopy

Esophagoscopy

Esophageal manometry

Medical treatment

Drug therapy, diet, and measures to avoid increased intra-abdominal pressure

Surgery: fundoplication and placement of the synthetic Angelchik prosthesis


Chapter 38

Figure 38-14


Chapter 38

Figure 38-15


Hiatal hernia3

Hiatal Hernia

Assessment

Document symptoms

Record factors that trigger symptoms as well as measures that aggravate or relieve them

Patient’s dietary habits, use of alcohol and tobacco, and medication history

Interventions

Chronic Pain

Risk for Aspiration

Imbalanced Nutrition: Less Than Body Requirements


Hiatal hernia4

Hiatal Hernia

Postoperative care

Turning, coughing, and deep breathing

Patient might have nasogastric tube in place and connected to suction for a day or two

Until bowel function returns, the patient is given only intravenous fluids

Tell the patient to expect mild dysphagia for several weeks


Chapter 38

GERD

Backward flow of gastric contents from the stomach into the esophagus

Pathophysiology

Abnormalities around the LES, gastric or duodenal ulcer, gastric or esophageal surgery, prolonged vomiting, and prolonged gastric intubation

Eventually causes esophagitis

Signs and symptoms

Painful burning sensation that moves up and down, commonly occurs after meals, and is relieved by antacids


Chapter 38

GERD

Medical diagnosis

Suggested by the signs and symptoms

Endoscopy, biopsy, gastric analysis, esophageal manometry, 24-hour monitoring of esophageal pH, and acid perfusion tests

Medical treatment and nursing care

Like those described earlier for hiatal hernia

Drug therapy may include H2-receptor blockers, prokinetic agents, and proton pump inhibitors

If medical care unsuccessful, surgical fundoplication


Gastritis

Gastritis

Pathophysiology

Inflammation of the lining of the stomach

Mucosal barrier that normally protects the stomach from autodigestion breaks down

Hydrochloric acid, histamine, and pepsin cause tissue edema, increased capillary permeability, possible hemorrhage

Helicobacter pylori thought to be prime culprit

Signs and symptoms

Nausea, vomiting, anorexia, a feeling of fullness, and pain in the stomach area


Gastritis1

Gastritis

Medical diagnosis

Gastroscopy

Laboratory studies to detect occult blood in the feces, low blood hemoglobin and hematocrit, and low serum gastrin levels; H. pylori can be confirmed by breath, urine, stool, or serum tests, or by gastric tissue biopsy


Gastritis2

Gastritis

Medical treatment

Oral fluids and foods withheld until the acute symptoms subside; IV fluids administered

Medications to reduce gastric acidity and relieve nausea

Analgesics for pain relief and antibiotics for H. pylori

Surgical intervention may be needed


Gastritis3

Gastritis

Assessment

Patient’s present illness

Pain, indigestion, nausea, and vomiting

Determine the onset, duration, and location of pain

Note factors that trigger or relieve the symptoms

Diet, use of alcohol and tobacco, activity/rest patterns

Patient’s general appearance for signs of distress

Compare vital signs, height, weight to previous readings

Note the skin color and check turgor

Inspect abdomen for distention; palpate for tenderness

Auscultate abdomen for increased bowel sounds


Gastritis4

Gastritis

Interventions

Pain

Imbalanced Nutrition: Less Than Body Requirements

Deficient Fluid Volume

Ineffective Coping


Peptic ulcer

Peptic Ulcer

Pathophysiology

Loss of tissue from lining of the digestive tract

Classified as gastric or duodenal

Causes

Contributing factors: drugs, infection, stress

Most ulcers are caused by the microorganism H. pylori


Peptic ulcer1

Peptic Ulcer

Signs and symptoms

Burning pain

Nausea, anorexia, weight loss

Complications

Hemorrhage, perforation, or pyloric obstruction


Peptic ulcer2

Peptic Ulcer

Medical diagnosis

Barium swallow examination, gastroscopy, and esophagogastroduodenoscopy

H. pylori can be detected by antibodies in the blood or stool, and by a breath test

Medical treatment

Drug therapy

Diet therapy

Managing complications


Peptic ulcer3

Peptic Ulcer

Care of the patient managed medically

Assessment

Pain, including location, aggravating factors, and measures that bring relief; relationship between pain and food intake

Recent serious illnesses, previous peptic ulcer disease, and a medication history

Functional assessment: patient’s usual diet, use of alcohol and tobacco, activities, sleep patterns, and stressors

Vital signs; height and weight; skin and mucous membranes for turgor and moisture

Inspect abdomen for distention and palpate for tenderness

Auscultate for bowel sounds


Peptic ulcer4

Peptic Ulcer

Care of the patient managed medically

Interventions

Pain

Imbalanced Nutrition: Less Than Body Requirements

Risk for Injury

Ineffective Coping


Peptic ulcer5

Peptic Ulcer

Care of the patient managed surgically

Assessment

Pain, nausea, and vomiting

Measure vital signs at frequent intervals

Note the amount and type of IV fluids, and check the infusion site for swelling or redness

Document patency of the nasogastric tube as well as the color and amount of drainage

Breath sounds; inspect the wound dressing for bleeding

Inspect abdomen for distention and auscultate for bowel sounds

Monitor urine output and palpate for bladder distention


Peptic ulcer6

Peptic Ulcer

Care of the patient managed surgically

Interventions

Risk for Injury

Imbalanced Nutrition: Less Than Body Requirements

Decreased Cardiac Output


Stomach cancer

Stomach Cancer

Pathophysiology

Begins in the mucous membranes, invades the gastric wall, and spreads to the regional lymphatics, liver, pancreas, and colon

No specific signs or symptoms in the early stages

Late signs and symptoms are vomiting, ascites, liver enlargement, and an abdominal mass


Stomach cancer1

Stomach Cancer

Risk factors

H. pylori infection, pernicious anemia, chronic atrophic gastritis, and achlorhydria, type A blood, and a family history

Cigarette smoking, alcohol abuse, and a diet high in starch, salt, pickled foods, salted meats, and nitrates


Stomach cancer2

Stomach Cancer

Medical diagnosis

Gastroscopy, endoscopic ultrasound, upper GI series, CT, PET scan, MRI, laparoscopy

Laboratory studies include hemoglobin and hematocrit, serum albumin, liver function tests, and carcinoembryonic antigen

Medical treatment

Surgery, chemotherapy, and radiation therapy


Chapter 38

Figure 38-16


Stomach cancer3

Stomach Cancer

Preoperative care of the patient with stomach cancer

Inform about the nasogastric tube and IV fluids; teach coughing, deep breathing, and leg exercises

Identify/support patient’s coping methods

Include sources of support, such as family members or a spiritual counselor, in the preoperative care


Stomach cancer4

Stomach Cancer

Postoperative care of the patient with stomach cancer

Assessment

Comfort, appetite, and nausea and vomiting

Monitor weight changes and determine dietary preferences

Identify the patient’s support system and coping strategies

Interventions

Pain

Imbalanced Nutrition: Less Than Body Requirements

Ineffective Coping


Obesity

Obesity

Increased weight caused by excessive body fat

Causes

Heredity, body build/metabolism, psychosocial factors

Basic problem: caloric intake exceeds metabolic demands

Complications

Cardiovascular and respiratory problems, polycythemia, diabetes mellitus, cholelithiasis (gallstones), infertility, endometrial cancer, and fatty liver infiltration


Obesity1

Obesity

Medical diagnosis

Standard weight tables

Measuring skinfold thickness

Endocrine function tests

Medical and surgical treatment

Weight reduction diet accompanied by a planned exercise program

Drug therapy

Bariatric surgery


Obesity2

Obesity

Assessment

Identify factors that contribute to obesity

Ask about usual dietary practices

Identify factors that trigger overeating and reactions to overeating

Collect data about previous efforts to lose weight and current interest in losing weight


Obesity3

Obesity

Interventions for the obese patient managed nonsurgically

Imbalanced Nutrition: More Than Body Requirements

Ineffective Tissue Perfusion

Ineffective Breathing Pattern

Disturbed Body Image


Obesity4

Obesity

Interventions after bariatric surgery

Impaired Gas Exchange

Impaired Tissue Perfusion

Impaired Skin Integrity

Imbalanced Nutrition: Less Than Body Requirements


Malabsorption

Malabsorption

One or more nutrients are not digested or absorbed

Many causes: bacteria, deficiencies of bile salts or digestive enzymes, alterations in the intestinal mucosa, and absence of all or part of the stomach or intestines


Malabsorption1

Malabsorption

Signs and symptoms

Steatorrhea

Weight loss, fatigue, decreased libido, easy bruising, edema, anemia, and bone pain

Bloating, cramping, abdominal cramps, and diarrhea are symptoms of lactase deficiency


Malabsorption2

Malabsorption

Medical diagnosis

Sprue: based on laboratory studies, endoscopy with biopsy, and radiologic imaging studies

Lactase deficiency: based on the health history, the lactose tolerance test, a breath test for abnormal hydrogen levels, and if necessary, biopsy of the intestinal


Malabsorption3

Malabsorption

Medical treatment

Sprue: diet and drug therapy; foods that aggravate symptoms eliminated from the diet

Celiac disease: avoid products that contain gluten

Tropical sprue: antibiotics, oral folate, and vitamin B12 injections

Lactase deficiency: eliminate milk and milk products


Malabsorption4

Malabsorption

Nursing care

Document the patient’s symptoms

Note stool characteristics

In the case of celiac sprue, teach the patient how to eliminate gluten from the diet

Give antibiotics as ordered for tropical sprue

If folic acid therapy continued, instruct patient in self-medication

The effect of therapy is evaluated by the return of normal stool consistency

Advise the patient with lactase deficiency of dietary restrictions and alternative products


Diarrhea

Diarrhea

The passage of loose, liquid stools with increased frequency

May have cramps, abdominal pain, and a feeling of urgency before bowel movements


Diarrhea1

Diarrhea

Causes

Spoiled foods, allergies, infections, diverticulosis, malabsorption, cancer, stress, fecal impactions, and tube feedings

Adverse effect of some medications

Complications

Dehydration, electrolyte imbalances, and metabolic acidosis

Malnutrition and anemia


Diarrhea2

Diarrhea

Medical treatment

Acute diarrhea usually treated by resting the digestive tract and giving antidiarrheal drugs

Severe, persistent diarrhea may require TPN


Diarrhea3

Diarrhea

Assessment

Diarrhea and onset, severity, precipitating factors, and measures that bring relief

Ask about stool characteristics, including amount, color, odor, and unusual contents, such as blood, mucus, or undigested food

Functional assessment focuses on usual diet, dietary changes, recent and current medications, recent travel to a foreign country


Diarrhea4

Diarrhea

Interventions

Deficient Fluid Volume and Imbalanced Nutrition: Less Than Body Requirements

Impaired Skin Integrity

Pain

Self-Care Deficit


Constipation

Constipation

Hard, dry, infrequent stools that are passed with difficulty


Constipation1

Constipation

Causes

Frequently ignoring the urge to defecate

Frequent use of laxatives or enemas

Inactivity

Inadequate water intake

Diet low in fiber and high in cheese, lean meat, pasta

Drugs that slow intestinal motility/increase urine output

Diseases of the colon or rectum, as well as brain or spinal cord injury; abdominal surgery


Constipation2

Constipation

Complications

Valsalva maneuver

The rapid changes in blood flow can be fatal to a patient with heart disease

Hemorrhoids

Fecal impaction

Medical treatment

Laxatives, suppositories, enemas, or combination for prompt results

Stool softeners


Constipation3

Constipation

Assessment

Usual pattern of bowel elimination, including frequency, amount, color, unusual contents, and pain associated with defecation

Information about diet, exercise, and drug therapy

Any aids to elimination; type and frequency of use

Examine abdomen for distention or visible peristalsis

Auscultate for bowel sounds in all four quadrants of the abdomen


Constipation4

Constipation

Interventions

Maintained with diet, fluids, exercise, and regular toilet habits

Megacolon

Regular enemas for bowel cleansing

Fecal impaction

Assess for impaction by inserting a gloved, lubricated finger into the rectum

Remove impaction following agency protocol or specific physician’s orders


Intestinal obstruction

Intestinal Obstruction

Causes

Strangulated hernia, tumor, paralytic ileus, stricture, volvulus (twisting of the bowel), intussusception (telescoping of the bowel into itself), and postoperative adhesions

Signs and symptoms

Vomiting (possibly projectile), abdominal pain, and constipation

Blood or purulent drainage passed rectally

Abdominal distention, especially with colon obstruction


Intestinal obstruction1

Intestinal Obstruction

Complications

Fluid and electrolyte imbalances and metabolic alkalosis

Gangrene and perforation of the bowel


Chapter 38

Figure 38-17


Intestinal obstruction2

Intestinal Obstruction

Medical diagnosis

History, physical examination, and laboratory studies; confirmed by radiologic studies

Medical treatment

Gastrointestinal decompression; intravenous fluids; and surgical intervention


Intestinal obstruction3

Intestinal Obstruction

Assessment

Symptoms, including pain and nausea

Onset and progression of symptoms

Hernia, cancer of the digestive tract, and abdominal surgeries

Ask when the patient’s last bowel movement was and if the characteristics were normal


Intestinal obstruction4

Intestinal Obstruction

Interventions

Acute Pain

Deficient Fluid Volume

Risk for Infection

Ineffective Breathing Pattern

Anxiety


Appendicitis

Appendicitis

Pathophysiology

Inflammation of the appendix

A ruptured appendix allows digestive contents to enter the abdominal cavity, causing peritonitis


Appendicitis1

Appendicitis

Signs and symptoms

Pain at McBurney’s point, midway between the umbilicus and the iliac crest

Temperature elevation, nausea, and vomiting

Elevated WBC count (10,000-15,000/mm3 )

Peritonitis: absence of bowel sounds, severe abdominal distention, increased pulse and temperature, nausea/vomiting; rigid abdomen


Chapter 38

Figure 38-18


Appendicitis2

Appendicitis

Medical treatment

Nothing by mouth

A cold pack to the abdomen may be ordered

Laxatives and heat applications should never be used for undiagnosed abdominal pain

Immediate surgical treatment indicated

Ruptured appendix: surgery may be delayed 6-8 hours while antibiotics and IV fluids given


Appendicitis3

Appendicitis

Assessment

Location, severity, onset, duration, precipitating factors, and alleviating measures in relation to the pain

Previous abdominal distress, chronic illnesses, surgeries; record allergies and medications

Temperature; abdominal pain, distention, and tenderness; presence and characteristics of bowel sounds


Appendicitis4

Appendicitis

Preoperative interventions

Semi-Fowler or side-lying position with the hips flexed

Until physician determines the diagnosis, analgesics may be withheld

If rupture suspected, elevate patient’s head to localize the infection


Appendicitis5

Appendicitis

Postoperative interventions

Administer antibiotics, intravenous fluids, and possibly gastrointestinal decompression

Assist the patient in turning, coughing, and deep breathing; incentive spirometry

Splint the incision during deep breathing

Early ambulation

Assess abdominal wound for redness, swelling, and foul drainage

Wound care as ordered or according to agency policy


Peritonitis

Peritonitis

Pathophysiology

Inflammation of peritoneum caused by chemical or bacterial contamination of the peritoneal cavity

Signs and symptoms

Pain over affected area, rebound tenderness, abdominal rigidity and distention, fever, tachycardia, tachypnea, nausea, and vomiting


Peritonitis1

Peritonitis

Medical diagnosis

History and physical

Complete blood cell count, serum electrolyte measurements, abdominal radiography, computed tomography, and ultrasound

Paracentesis


Peritonitis2

Peritonitis

Medical treatment

Gastrointestinal decompression, intravenous fluids, antibiotics, and analgesics

Surgery to close a ruptured structure and remove foreign material and fluid from the peritoneal cavity


Peritonitis3

Peritonitis

Assessment

Onset, location, and severity of the pain and any related symptoms

Record a history of abdominal trauma, including surgery

Take and record vital signs

Inspect abdomen for distention and auscultate for the presence of bowel sounds


Peritonitis4

Peritonitis

Interventions

Acute Pain

Decreased Cardiac Output

Imbalanced Nutrition: Less Than Body Requirements

Anxiety


Abdominal hernia

Abdominal Hernia

Pathophysiology

Weakness in the abdominal wall that allows a portion of the large intestine to push through

Weak locations include the umbilicus and the lower inguinal areas of the abdomen; may also develop at the site of a surgical incision

Classified as reducible or irreducible


Abdominal hernia1

Abdominal Hernia

Signs and symptoms

A smooth lump on the abdomen

With incarceration, the patient has severe abdominal pain and distention, vomiting, and cramps


Chapter 38

Figure 38-19


Abdominal hernia2

Abdominal Hernia

Medical diagnosis

Health history and physical examination

Medical treatment

Surgical repair

Herniorrhaphy

Hernioplasty


Abdominal hernia3

Abdominal Hernia

Assessment

Chief complaint

Ask about pain and vomiting

Inspect for abnormalities, and listen for bowel sounds in all four abdominal quadrants


Abdominal hernia4

Abdominal Hernia

Preoperative interventions

Risk for Injury

Impaired Skin Integrity

Postoperative interventions

Impaired Urinary Elimination

Constipation

Acute Pain

Risk for Injury


Inflammatory bowel disease

Inflammatory Bowel Disease

Pathophysiology

Ulcerative colitis and Crohn’s disease

Inflammation and ulceration of intestinal tract lining

Exact cause is unknown

Possible causes: infectious agents, autoimmune reactions, allergies, heredity, and foreign substances


Inflammatory bowel disease1

Inflammatory Bowel Disease

Signs and symptoms

Ulcerative colitis

Diarrhea with frequent bloody stools, abdominal cramping

Crohn’s disease

If the stomach and duodenum are involved, symptoms include nausea, vomiting, and epigastric pain

Involvement of the small intestine produces pain and abdominal tenderness and cramping

An inflamed colon typically causes abdominal pain, cramping, rectal bleeding, and diarrhea

Systemic signs and symptoms include fever, night sweats, malaise, and joint pain


Inflammatory bowel disease2

Inflammatory Bowel Disease

Complications

Hemorrhage, obstruction, perforation (rupture), abscesses in the anus or rectum, fistulas, and megacolon


Inflammatory bowel disease3

Inflammatory Bowel Disease

Medical diagnosis

History and physical examination

Abdominal radiography

Barium enema examination with air contrast; colonoscopy with biopsy, ultrasonography, CT, and cell studies

Video capsule

Medical treatment

Drug therapy, diet, and rest


Inflammatory bowel disease4

Inflammatory Bowel Disease

Assessment

Onset, location, severity, and duration of pain

Note factors that contribute to the onset of pain

Onset and duration of diarrhea; presence of blood

Vital signs, height and weight, measures of hydration

Inspect perianal area for irritation or ulceration

Maintain accurate intake and output records

Measure diarrhea stools if possible and count as output


Inflammatory bowel disease5

Inflammatory Bowel Disease

Interventions

Acute Pain

Diarrhea

Deficient Fluid Volume

Imbalanced Nutrition: Less Than Body Requirements

Ineffective Coping

Risk for Injury


Diverticulosis

Diverticulosis

Pathophysiology

Small saclike pouches in intestinal wall: diverticula

Weak areas of the intestinal wall allow segments of the mucous membrane to herniate outward

Risk factors

Lack of dietary residue

Age, constipation, obesity, emotional tension


Diverticulosis1

Diverticulosis

Signs and symptoms

Often asymptomatic, but many people report constipation, diarrhea, or periodic bouts of each

Rectal bleeding, pain in left lower abdomen, nausea and vomiting, and urinary problems


Chapter 38

Figure 38-20


Diverticulosis2

Diverticulosis

Complications

Diverticulitis

Bleeding, obstruction, perforation (rupture), peritonitis, and fistula formation

Medical diagnosis

Symptoms

Abdominal CT and barium enema examination


Diverticulosis3

Diverticulosis

Medical treatment

High-residue diet without spicy foods

Stool softeners or bulk-forming laxatives; antidiarrheals; broad-spectrum antibiotics; anticholinergics

Surgical intervention may be necessary


Diverticulosis4

Diverticulosis

Assessment

Assess patient’s comfort and stool characteristics; note nausea and vomiting

Monitor patient’s temperature

Assess abdomen for distention and tenderness


Diverticulosis5

Diverticulosis

Interventions

Fluids as permitted; monitor intake and output

Antiemetics, analgesics, anticholinergics as ordered

Be alert for signs of perforation

Teach patient about diverticulosis, including the pathophysiology, treatment, and symptoms of inflammation


Colorectal cancer

Colorectal Cancer

Pathophysiology

Cancer of the large intestine

People at greater risk for colorectal cancer are those with histories of inflammatory bowel disease, or family histories of colorectal cancer or multiple intestinal polyps

High-fat, low-fiber diet and inadequate intake of fruits and vegetables also contribute to development

Can develop anywhere in the large intestine

Three fourths of all colorectal cancers are located in the rectum or lower sigmoid colon


Chapter 38

Figure 38-21


Colorectal cancer1

Colorectal Cancer

Signs and symptoms

Right side of the abdomen

Vague cramping until the disease is advanced

Unexplained anemia, weakness, and fatigue related to blood loss may be the only early symptoms

Left side or in the rectum

Diarrhea or constipation and may notice blood in the stool

Stools may become very narrow, causing them to be described as pencil-like

Feeling of fullness or pressure in the abdomen or rectum


Colorectal cancer2

Colorectal Cancer

Medical and surgical treatment

Usually treated surgically

Combination chemotherapy postoperatively if tumor extends through the bowel wall or if lymph nodes involved

Early stage rectal cancer sometimes treated with radiation and surgery


Colorectal cancer3

Colorectal Cancer

Assessment

Vital signs, intake and output, breath sounds, bowel sounds, and pain

Appearance of wounds and wound drainage

If there is a colostomy, measure and describe the fecal drainage


Colorectal cancer4

Colorectal Cancer

Interventions

Risk for Injury

Ineffective Tissue Perfusion

Acute Pain

Sexual Dysfunction

Ineffective Coping


Polyps

Polyps

Small growths in the intestine

Most benign but can become malignant

Inherited syndromes: familial polyposis and Gardner’s syndrome

Usually asymptomatic; found on routine testing

Complications are bleeding and obstruction

Diagnosed by barium enema or endoscopic exam

Colectomy for familial polyposis or Gardner’s syndrome because of the high risk of malignancy


Hemorrhoids

Hemorrhoids

Internal or external dilated veins in the rectum

Thrombosed

Blood clots form in external hemorrhoids; become inflamed and very painful

Risk factors

Constipation, pregnancy, prolonged sitting or standing

Signs and symptoms

Rectal pain and itching

Bleeding with defecation

External hemorrhoids easy to see; appear red/bluish


Chapter 38

Figure 38-22


Hemorrhoids1

Hemorrhoids

Medical diagnosis and treatment

Diagnosed by visual inspection

Nonsurgical treatment

Topical creams, lotions, or suppositories soothe and shrink inflamed tissue

Sitz baths often comforting

The physician may order heat or cold applications

Outpatient procedures: ligation, sclerotherapy. Thermocoagulation/electrocoagulation, laser surgery

Hemorrhoidectomy

The surgical excision (removal) of hemorrhoids


Hemorrhoids2

Hemorrhoids

Assessment

After hemorrhoidectomy, monitor vital signs, intake and output, and breath sounds. Assess the perianal area for bleeding and drainage

Interventions

Acute Pain

Impaired Skin Integrity

Constipation


Anorectal abscess

Anorectal Abscess

An infection in the tissue around the rectum

Signs and symptoms are rectal pain, swelling, redness, and tenderness

Treated with antibiotics followed by incision and drainage

Preoperatively, pain is treated with ice packs, sitz baths, and topical agents as ordered


Anorectal abscess1

Anorectal Abscess

Postoperatively, pain treated with opioid analgesics

Patient teaching emphasizes importance of thorough cleansing after each bowel movement

Advise patient to consume adequate fluids and a high-fiber diet to promote soft stools


Anal fissure

Anal Fissure

Laceration between the anal canal and the perianal skin

May be related to constipation, diarrhea, Crohn’s disease, tuberculosis, leukemia, trauma, or childbirth

Signs and symptoms include pain before and after defecation and bleeding on the stool or tissue

If fissure chronic, the patient may experience pruritus, urinary frequency or retention, and dysuria

Usually heal spontaneously, but can become chronic

Conservative treatment: sitz baths, stool softeners, and analgesics

Surgical excision may be necessary


Anal fistula

Anal Fistula

Abnormal opening between anal canal and perianal skin

Develops from anorectal abscesses or related to inflammatory bowel disease or tuberculosis

Patient typically complains of pruritus and discharge

Sitz baths provide some comfort

Surgical treatment is excision of fistula and surrounding tissue

Sometimes a temporary colostomy to allow the surgical site to heal

Postoperative care: analgesics and sitz baths for pain


Pilonidal cyst

Pilonidal Cyst

Located in the sacrococcygeal area

Results from an infolding of skin, causing a sinus that is easily infected because of its closeness to the anus

Once infected, it is painful and swollen and may form an abscess

Surgical excision usually recommended

Care is similar to that for the patient having a hemorrhoidectomy


Patient education to promote normal bowel function

Patient Education to Promote Normal Bowel Function

Good hand washing and proper food handling

People who recognize that stress affects their gastrointestinal function may benefit from relaxation techniques and stress management training

Signs and symptoms of digestive problems should be reported for prompt diagnosis and treatment if indicated

Teaching patients what is normal, how to promote normal function, and how to detect problems can help to avoid serious gastrointestinal dysfunction


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