Major Disorders of the Gastro-Intestinal Tract

Major Disorders of the Gastro-Intestinal Tract

• Fracture of the jaw

• Cancer of the oral cavity

• Cancer of the esophagus

• Hiatal hernia

• Peptic ulcer disease

• Cancer of the stomach

• Appendicitis

• Inflammatory bowel diseases

• Intestinal obstruction

• Diverticular disease

• Cancer of the small intestine, colon and rectum

• Peritonitis

• Hemorrhoids

• Hernias

Fracture of the Jaw

Fracture of the Jaw

Overview:

• Generally the result of trauma such as motor vehicle accidents or physical combat

Fracture of the Jaw

Clinical Findings:

• History of trauma to the face; pain in the face and jaw

• Bloody discharge from the mouth; swelling of the face on the affected side; difficulty opening or closing the mouth

Fracture of the Jaw

Therapeutic Interventions:

• Separated fragments of the broken bone are reunited and immobilized by wires and rubber bands; usually placed without surgical incision

• Open reduction of the jaw is indicated for the severely fractured or displaced bones; interosseous wiring is done

Fracture of the Jaw

Nursing Care:

Assessment:

• Respiratory status for presence of distress

• Presence of nausea and potential for vomiting

• Structures of the face and neck for signs of edema

Fracture of the Jaw

Nursing Care:

Nursing Diagnoses:

• Risk for aspiration related to presence of oral wires

• Altered nutrition: less than body requirements related to inability to consume regular diet

Fracture of the Jaw

Nursing Care:

Planning/Implementation:

• Postoperatively control vomiting and reduce the chance of aspiration pneumonia by positioning client on abdomen or side

• Keep wire cutters at the bedside to release the wires and rubber bands if emesis occurs and aspiration can not be prevented by suctioning

Fracture of the Jaw

Nursing Care:

Planning/Implementation:

• Explain diet to the client and family; no solid foods are permitted; encourage high-protein liquids or blenderized soft foods

• Stress the importance of regular oral hygiene and institute it early in the postoperative period

Fracture of the Jaw

Nursing Care:

Evaluation/Outcomes:

• Adheres to nutritionally balanced safe diet

• Demonstrates oral hygiene techniques

• Describes technique for releasing wires and rubber bands if emesis occurs

Cancer of the Oral Cavity

Cancer of the Oral Cavity

Overview:

• Primarily in clients who smoke and drink alcohol in large quantities

• Cancer of the lip, easily diagnosed; prognosis is good; incidence highest in pipe smokers

• Cancer of the tongue usually occurs with cancer of the floor of the mouth

• Cancer of the submaxillary glands; highly malignant and grows rapidly

Cancer of the Oral Cavity

Clinical Findings:

• Pain (not an early symptom); alterations of taste

• Leukoplakia (white patches on mucosa), which is precancerous; ulcerated, bleeding areas in the involved structure

Cancer of the Oral Cavity

Therapeutic Interventions:

• Reconstructive surgery if indicated

• Radiation or implantation of radioactive material may arrest growth of tumor

• Total parenteral nutrition, enteral tube feedings

Cancer of the Oral Cavity

Nursing Care:

Assessment:

• History of hemoptysis and pain

• Baseline nutritional data including weight, dietary intake, and ability to chew

• Characteristics of lesions in oral cavity

Cancer of the Oral Cavity

Nursing Care:

Nursing Diagnoses:

• Ineffective airway clearance related to tissue trauma from iatrogenic stresses

• Alteration in oral mucous membranes related to oral lesions

• Alteration in nutrition: less than body requirements related to decreased taste, dysphagia and pain

Cancer of the Oral Cavity

Nursing Care:

Planning/Implementation:

• Maintain a patent airway , keep a tracheostomy set at the bedside

• Maintain fluid, electrolyte, and nutritional balance; administer TPN, enteral tube feedings as ordered

• If radiation therapy is indicated, relieve dryness of the mouth by frequent saline mouthwashes and ample fluids

Cancer of the Oral Cavity

Nursing Care:

Planning/Implementation:

• Consider time and distance in relation to the radioactive material when giving nursing care

Cancer of the Oral Cavity

Nursing Care:

Evaluation/Outcomes:

• Maintains airway patency

• Maintains nutrition status

Cancer of the Esophagus

Cancer of the Esophagus

Overview:

• Occurs predominantly in persons with a history of alcohol abuse or chronic esophageal reflux

• Tumor may develop anywhere in the esophagus, but most commonly in the middle and lower third

Cancer of the Esophagus

Clinical Findings:

• Dysphagia, substernal burning pain, particularly after hot fluids

• Regurgitation; esophago-gastro-duodenoscopy (EGD) with biopsy and brushings reveals malignant cells

Cancer of the Esophagus

Therapeutic Interventions:

• Surgical removal of the esophagus is the treatment of choice

(a) esophagogastrostomy: resection of a portion of the esophagus; a portion of the bowel may be grafted between the esophagus and stomach, or the stomach may be brought up to the proximal end of the esophagus

Cancer of the Esophagus

Therapeutic Interventions:

(b) esophagectomy: removal of part or all of the esophagus, which is replaced by a Dacron graft

(c) Gastrostomy: opening directly into the stomach in which a feeding tube is usually inserted to bypass the esophagus

Cancer of the Esophagus

Therapeutic Interventions:

• Radiation and/or chemotherapy may be used before or instead of surgery as a palliative measure

• Total parenteral nutrition (TPN), enteral tube feedings

Cancer of the Esophagus

Nursing Care:

Assessment:

• History of nutritional status and weight loss

• Presence of pain and dysphagia

• History of foul breath, eructation, nausea, and vomiting

Cancer of the Esophagus

Nursing Care:

Nursing Diagnoses:

• Ineffective airway clearance related to tumor

• Altered nutrition: less than body requirements related to dysphagia

Cancer of the Esophagus

Nursing Care:

Planning/Implementation:

• Observe for respiratory distress caused by pressure of tumor on the trachea; place in a semi-Fowler’s or high-Fowler’s position to facilitate respirations

• Monitor vital signs, especially respirations

• Provide oral care because dysphagia may result in increased accumulation of saliva in mouth

Cancer of the Esophagus

Nursing Care:

Planning/Implementation:

• Maintain nutritional status by providing TPN, tube feedings, high-protein liquids, and vitamin and mineral replacements as ordered

Cancer of the Esophagus

Nursing Care:

Evaluation/Outcomes:

• Maintains airway

• Maintains nutritional status

Hiatal Hernia

Hiatal hernia

Overview:

• Portion of the stomach protruding through a hiatus (opening) in the diaphragm into the thoracic cavity

• May result from a congenital weakness of the diaphragm or from injury, pregnancy, or obesity

• Function of the cardiac sphincter is lost, gastric juices enter the esophagus causing inflammation

Hiatal hernia

Clinical Findings:

• Substernal burning pain or fullness after eating; dyspepsia in the recumbent position; nocturnal dyspnea

• GI series and endoscopy show protrusion of the stomach through the diaphragm; regurgitation

Hiatal hernia

Therapeutic Interventions:

• Small, frequent, bland feedings

• Pharmacologic management: antacids, anti-secretory agents, anti-emetics, especially those that promote gastric emptying

• Surgical repair (done infrequently)

Hiatal hernia

Nursing Care:

Assessment:

• History of heartburn, pain, and reflux

• Relationship of body position and time of episodes to presence of symptoms

Hiatal hernia

Nursing Care:

Nursing Diagnoses:

• Pain related to reflux of gastric contents

• Risk for aspiration related to reflux of gastric contents

Hiatal hernia

Nursing Care:

Planning/Implementation:

• Teach the client and family about the dietary regimen

• Encourage attempts at weight loss

• Avoid constricting clothing and heavy lifting

• Encourage the client to sit up for at least 1 hour after eating

• Encourage the client to eat slowly and avoid drinking fluids with meals to limit the volume in the stomach

Hiatal hernia

Nursing Care:

Evaluation/Outcomes:

• States symptoms of reflux are absent or greatly reduced

• Demonstrates weight loss

Peptic Ulcer Disease

Peptic Ulcer Disease

Overview:

• Ulcerations of the gastrointestinal mucosa and underlying tissues caused by gastric secretions that have a low pH (acid)

• Causes include conditions that increase the secretion of hydrochloric acid by the gastric mucosa or that decrease the tissue’s resistance to the acid

(a) Infection of the gastric and/or duodenal mucosa by campylobacter pylori or helicobacter pylori

Peptic Ulcer Disease

Overview:

(b) Zollinger-Ellison syndrome: tumors secreting gastrin, which will stimulate the production of excessive hydrochloric acid

(c) certain drugs such as aspirin, steroids, and indomethacin will decrease tissue resistance

(d) smoking

Peptic Ulcer Disease

Overview:

• Peptic ulcers may be present in the esophagus, stomach, or duodenum (the most common site)

• Complications include pyloric or duodenal obstruction, hemorrhage, and perforation

Peptic Ulcer Disease

Clinical Findings:

• Gnawing or burning epigastric pain that occurs 1 to 2 hours after eating (gastric) or 2-4 hours after eating (duodenal); nausea; heartburn (pyrosis); relieved by food or antacids (duodenal)

• History of gastritis

• If bleeding occurs: signs of anemia; passage of tarry stools (melena); vomitus that is coffee ground to port-wine color

Peptic Ulcer Disease

Therapeutic Interventions:

• Bland foods, and restriction of irritating substances such as nicotine, caffeine, alcohol, spices, and gas producing foods

• Antibiotic therapy if microorganism is identified; tetracycline, metronidazole, and bismuth

• Histamine H2 receptor antagonists or proton pump inhibitors (PPIs) to limit gastric acid secretion; antacids to reduce acidity

Peptic Ulcer Disease

Therapeutic Interventions:

• Sedatives, tranquilizers, anti-cholinergics, and analgesics for pain and restlessness

• Anti-emetics for nausea and vomiting

• Type and cross-match so blood will be available if gastric hemorrhage occurs

• A nasogastric tube for decompression, instillation of vasoconstrictors, and/or saline lavages when hemorrhage occurs

Peptic Ulcer Disease

Therapeutic Interventions:

• Surgical Intervention:

• vagotomy: cutting the vagus nerve, which innervates the stomach, to decrease the secretion of hydrochloric acid

• Billroth I: removal of the lower portion of the stomach and the attachment of the remaining portion to the duodenum

• Billroth II: removal of the antrum and the distal portion of the stomach and subsequent anastomosis of the remaining section to the jejunum

Peptic Ulcer Disease

Therapeutic Interventions:

• Surgical Intervention:

(d) Antrectomy: removal of the antral portion of the stomach

(e) Gastrectomy: removal of 60% to 80% of the stomach

Peptic Ulcer Disease

Therapeutic Interventions:

• Surgical Intervention:

(f) Common complications of partial or total gastric resection:

• Dumping syndrome: involves the rapid passage of food from the stomach to the jejunum; the food, being hypertonic (especially if high in carbohydrates), will draw fluid from the circulating blood into the jejunum causing diaphoresis, faintness, and palpitations

• Hemorrhage, pneumonia, pernicious anemia

Peptic Ulcer Disease

Nursing Care:

Assessment:

• Characteristics of pain and relationship to types of food ingested and time food is consumed

• Abdomen for epigastric tenderness, guarding and bowel sounds

• History of dietary patterns, foods ingested, and alcohol consumption

Peptic Ulcer Disease

Nursing Care:

Nursing Diagnoses:

• Pain related to gastric secretion

• Fluid volume deficit related to hemorrhage or dumping syndrome

Peptic Ulcer Disease

Nursing Care:

Planning/Implementation:

• Allow ample time for the client to express feelings and concerns

• Administer and assess effects of sedatives, antacids, anti-cholinergics, H2 receptor antagonists, antibiotics, and dietary modifications

• Encourage hydration to reduce anti-cholinergic side effects and dilute the hydrochloric acid in the stomach

Peptic Ulcer Disease

Nursing Care:

Planning/Implementation:

• Instruct client to:

• Eat small to medium-sized meals because this helps prevent gastric distention; encourage between-meal snacks to achieve adequate calories when necessary

• Avoid foods that increase gastric acid secretion or irritate gastric mucosa, such as alcohol, caffeine containing foods and beverages, decaffeinated coffee, red or black pepper; replace with decaffeinated softdrinks and teas; use seasonings like thyme, basil, sage, etc. to replace pepper

Peptic Ulcer Disease

Nursing Care:

Planning/Implementation:

(c) Avoid foods that cause distress; varies for individuals but common offenders are the gas producers (legumes, carbonated beverages, the cruciferous vegetables)

(d) Eat meals in pleasant, relaxing surroundings to reduce acid secretion

(e) Administer calcium and iron supplements as ordered if client’s medication increases gastric pH

Peptic Ulcer Disease

Nursing Care:

Planning/Implementation:

• Refrain from administering drugs such as salicylates, NSAIDs, steroids, and ACTH

• Observe for complications such as gastric hemorrhage, perforation, and drug toxicity

Peptic Ulcer Disease

Nursing Care:

Planning/Implementation:

• Provide postoperative care after gastric resection:

• Monitor vital signs; assess the dressing for drainage

• Maintain a patent nasogastric tube to suction to prevent stress on the suture line

• Observe the color and amount of nasogastric drainage; excessive bleeding or the presence of bright red blood after 12 hours should be reported immediately

Peptic Ulcer Disease

Nursing Care:

Planning/Implementation:

(d) Have the client cough, deep breathe, and change position frequently to prevent the occurrence of pulmonary complications

(e) Monitor intake and output

(f) Apply anti-embolism stockings; have the client ambulate early to prevent vascular complications

Peptic Ulcer Disease

Nursing Care:

Planning/Implementation:

• To prevent dumping syndrome, instruct the client to:

• Eat smaller meals at more frequent intervals

• Avoid high carbohydrate intake and concentrated sweets

• Consume liquids only between meals

• Lie down or rest after eating

Peptic Ulcer Disease

Nursing Care:

Evaluation/Outcomes:

• States pain is reduced or relieved

• Identifies signs of complications and the need for immediate medical care

• Follows a nutritionally sound diet

Cancer of the Stomach

Cancer of the Stomach

Overview:

• Often not diagnosed until metastasis occurs; the stomach is able to accommodate to the growth of a tumor, and pain occurs late in the disease

• May metastasize by direct extension, lymphatics, or blood to the esophagus, spleen, pancreas, liver, or bone

Cancer of the Stomach

Overview:

• Heredity apparently a factor in the development of carcinoma of the stomach, as in the presence of precursors such as ulcerative disease and pernicious anemia

• Incidence higher in men more than 40 years of age; Japan has 4 times greater rate of cancer of the stomach than does the United States

Cancer of the Stomach

Clinical Findings:

• Anorexia (lack of interest in food); nausea; belching (eructation); heartburn

• Weight loss; stools positive for occult blood; anemia; achlorhydria (absence of hydrochloric acid); pale skin and acanthosis nigricans, symmetrically distributed hard and soft papillary growths with hyperpigmentation and hyperkeratosis

Cancer of the Stomach

Therapeutic Interventions:

• Subtotal or total gastrectomy

• Radiation

• Chemotherapy (fluorouracil is often used)

Cancer of the Stomach

Nursing Care:

Assessment:

• History of causative factors, presence of pain, and weight loss

• Axillary lymph nodes and left supraclavicular nodes for hard nodes, indicative of metastasis

• Skin for color and presence of lesions associated with cancer of the GI tract

Cancer of the Stomach

Nursing Care:

Nursing Diagnoses:

• Pain related to pathologic processes

• Altered nutrition: less than body requirements related to anorexia, increased metabolic rate, and interruption in digestion

• Hopelessness related to diagnosis of cancer

Cancer of the Stomach

Nursing Care:

Planning/Implementation:

• Offer the client every opportunity to verbalize fears (e.g., cancer, death, family problems, self image)

• Provide care after a gastric resection (see Peptic Ulcer for nursing care); in addition, if a total gastrectomy is performed, the chest cavity is usually entered, so the client will have chest tubes (see Pneumothorax for nursing care)

Cancer of the Stomach

Nursing Care:

Planning/Implementation:

• Modify diet to include smaller, more frequent meals (see Peptic Ulcer for more dietary information)

• If total gastrectomy has been performed, the client will have a vitamin B12 deficiency (see Pernicious Anemia)

• Client may require gavage feedings via nasogastric tube (see procedure for gavage)

Cancer of the Stomach

Nursing Care:

Evaluation/Outcomes:

• States relief from discomfort and pain

• Maintains adequate nutritional status

• Verbalizes feelings

Appendicitis

Appendicitis

Overview:

• Compromised circulation and the inflammation of the vermiform appendix; inflammation may be followed by edema, necrosis, and rupture

• Causes include obstruction by a fecalith, foreign body, or kinking

Appendicitis

Clinical Findings:

• Anorexia; nausea; right lower quadrant pain (McBurney’s point); rebound tenderness

• Vomiting; fever; leukocytosis; abdominal distention and paralytic ileus if appendix has ruptured

Appendicitis

Therapeutic Interventions:

• Surgical removal of the appendix without delay to decrease the chance of rupture and the risk of peritonitis

• Prophylactic use of antibiotics

• Fluid and electrolyte maintenance

• Analgesics for pain

Appendicitis

Nursing Care:

Assessment:

• History of characteristics of pain and presence of nausea and vomiting

• Presence of anorexia or the urge to pass flatus

• Presence of rebound tenderness when palpating abdomen

• Presence of tenderness/rigidity when palpating McBurney’s point

• Temperature for baseline data

• Presence and extent of bowel sounds

Appendicitis

Nursing Care:

Nursing Diagnoses:

• Pain related to inflammatory process

• Risk for infection related to rupture of appendix

Appendicitis

Nursing Care:

Planning/Implementation:

• Provide emotional support because this condition is unanticipated and the individual needs to ventilate any fear of surgery

• Monitor fluid and electrolyte balance

• Assess client for signs of infection; maintain a semi-Fowler’s position to help localize infection if the appendix ruptures

• Assess the client’s return of bowel function (bowel sounds, flatus, bowel movement); encourage ambulation

Appendicitis

Nursing Care:

Evaluation/Outcomes:

• States pain is alleviated

• Remains free from infection

Inflammatory Bowel Disease (Crohn’s disease)

Inflammatory Bowel Disease (Crohn’s disease)

Overview:

• There are various theories involving genetic predisposition, autoimmune reaction, or environmental causes

• Cobblestone ulcerations along the mucosal wall of the terminal ileum, cecum, and ascending colon form scar tissue and inhibit food and water absorption

• Ulceration of the intestinal submucosa accompanied by congestion, thickening of the small bowel, and fissure formations

• Enlargement of regional lymph nodes

Inflammatory Bowel Disease (Crohn’s disease)

Clinical Findings:

• Nausea; severe abdominal pain, cramping, and spasms; exacerbations related to emotional upsets or dietary indiscretions with milk, milk products, and fried foods

Inflammatory Bowel Disease (Crohn’s disease)

Clinical Findings:

• Weight loss; fever; elevated WBCs; diarrhea with mucus, electrolyte disturbances; presence of blood, fat, protein, parasites, or ova in stools

• Fecal fat test determines fat content, an abnormal amount of which is significant in malabsorptive disorders or hypermotility

• Erythema nodosum, conjunctivitis, and arthritis

• D-xylose tolerance test determines absorptive ability of upper intestinal tract

• CT scan show bowel wall thickening and fistulas

Inflammatory Bowel Disease (Crohn’s disease)

Therapeutic Interventions:

• Nothing by mouth and TPN when inflammatory episodes are severe

• Clear fluid diet progressing to bland, low residue, low fat, but increased calories, carbohydrates, proteins, and vitamins especially K and B12 (when a large portion of the ileum is involved)

Inflammatory Bowel Disease (Crohn’s disease)

Therapeutic Interventions:

• Pharmacologic management: anti-cholinergics, analgesics, antibiotics, immunosuppressants, anti-inflammatories, vitamins, and minerals

• Surgery when fistulas or intestinal obstruction occurs; anastomosis or ostomy as indicated

Inflammatory Bowel Disease (Crohn’s disease)

Nursing Care:

Assessment:

• Weight, temperature, and intake and output

• Feces for color, consistency and steatorrhea

• Tenderness and guarding of abdomen, especially right lower quadrant

• Presence and extent of bowel sounds

Inflammatory Bowel Disease (Crohn’s disease)

Nursing Care:

Nursing Diagnoses:

• Altered nutrition related to hypermotility and malabsorption

• Pain related to abdominal cramping

• Diarrhea related to hypermotility

• Fluid volume deficit related to diarrhea

Inflammatory Bowel Disease (Crohn’s disease)

Nursing Care:

Planning/Implementation:

• Encourage verbalization of feelings; encourage client and family to participate in the Crohn’s and Colitis foundation of America

• Instruct client regarding dietary restrictions and modifications (see Ulcerative Colitis)

• Observe for signs of fluid and electrolyte imbalances; monitor intake and output

• Observe for signs of complications such as elevated temperature, increasing nausea and vomiting, abdominal rigidity

Inflammatory Bowel Disease (Crohn’s disease)

Nursing Care:

Planning/Implementation:

• Assist with total parenteral nutrition (TPN) if ordered (see procedure)

• Teach the client:

• To avoid taking laxatives and salicylates that irritate the intestinal mucosa

• How to take anti-diarrheals and mucilloid drugs effectively

• Skin care if the perianal area is irritated

• The importance of seeking help early when exacerbations occur

Inflammatory Bowel Disease (Crohn’s disease)

Nursing Care:

Evaluation/Outcomes:

• Reports a reduction in pain

• Has a decrease in the number of bowel movements

• Maintains nutritional status

• Maintains fluid and electrolyte balance

Inflammatory Bowel Disease (Ulcerative Colitis)

Inflammatory Bowel Disease (Ulcerative Colitis)

Overview:

• May be caused by emotional stress, an autoimmune response, or a genetic predisposition

• Edema of mucous membrane of colon leads to bleeding a shallow ulcerations

• Abscess formation occurs, the bowel wall shortens, and becomes thin and fragile

• Associated with increased risk of colon cancer

Inflammatory Bowel Disease (Ulcerative Colitis)

Clinical Findings:

• Weakness; debilitation; anorexia; nausea

• Dehydration with tenting of skin; passage of bloody, purulent, mucoid, watery stools; anemia; hypocalcemia; low grade fever

Inflammatory Bowel Disease (Ulcerative Colitis)

Therapeutic Interventions:

• Dietary management:

• During acute episode, low-residue diet progressing to a regular diet; raw bran may be effective in controlling bouts of diarrhea and constipation

• Unrestricted fluid intake if tolerated; high protein, high calorie diet; avoidance of food allergens, especially milk

Inflammatory Bowel Disease (Ulcerative Colitis)

Therapeutic Interventions:

• Pharmacologic management: anti-emetics, anti-cholinergics, corticosteroids, antibiotics, sedatives, analgesics, tranquilizers, and anti-diarrheals

• Replacement of fluids and electrolytes that are lost because of diarrhea

Inflammatory Bowel Disease (Ulcerative Colitis)

Therapeutic Interventions:

• Surgical intervention: temporary ileostomy, a partial colectomy, or a total colectomy with a permanent ileostomy may be performed when:

• No response to medical treatment is evident

• Course of the disease is downhill

• Massive hemorrhage or colonic obstruction occurs

• Cancer is suspected

Inflammatory Bowel Disease (Ulcerative Colitis)

Nursing Care:

Assessment:

• Localized areas of tenderness found over diseased bowel on palpation

• History of patterns and characteristics of bowel elimination

• Feces for color, consistency, and characteristics

• Temperature and weight for baseline data

• Presence and extent of bowel sounds

Inflammatory Bowel Disease (Ulcerative Colitis)

Nursing Care:

Nursing Diagnoses:

• Diarrhea related to hypermotility

• Altered nutrition: less than body requirements related to hypermotility and malabsorption

• Fluid volume deficit related to diarrhea

Inflammatory Bowel Disease (Ulcerative Colitis)

Nursing Care:

Planning/Implementation:

• Instruct client to adhere to the following dietary program:

• Eat small, frequent feedings of high-protein, high calorie foods; low fat helps decrease steatorrhea; if steatorrhea is present, vitamins A and E may be required as supplements

• Avoid irritating foods and spices

Inflammatory Bowel Disease (Ulcerative Colitis)

Nursing Care:

Planning/Implementation:

(c) Replace iron, calcium, and zinc losses with supplements; if there is ileal involvement, intramuscular injections of vitamin B12 may be prescribed monthly to reduce anemia

(d) Avoid all food allergens, especially milk; milk may be reintroduced when client is relatively asymptomatic; however, lactose intolerance is common and dairy restrictions may be permanent; lactase enzymes are available that can be added to milk products to hydrolyze lactose

Inflammatory Bowel Disease (Ulcerative Colitis)

Nursing Care:

Planning/Implementation:

• Involve client in dietary selection; recognize preferences as much as possible

• Initiate administration and recording of fluid, electrolyte, or blood replacements

• Provide gentle, thorough perineal care as required

• Observe for complications such as rectal hemorrhage, fever, dehydration

Inflammatory Bowel Disease (Ulcerative Colitis)

Nursing Care:

Planning/Implementation:

• Allow the client and family time to verbalize feelings and participate in care; encourage participation in the Crohn’s and Colitis Foundation of America

• When colostomy or ileostomy is performed:

• Help the client accept the changes in body image and function

• Provide ostomy care

• Teach that usual activities can be resumed except for contact sports

• Anticipate that stress can precipitate peristalsis

Inflammatory Bowel Disease (Ulcerative Colitis)

Nursing Care:

Evaluation/Outcomes:

• Maintains or regains weight

• Adheres to dietary regimen

• Establish an acceptable pattern of soft, formed bowel movements

• Client or family member demonstrates ability to perform ostomy care

Intestinal Obstruction

Intestinal Obstruction

Overview:

• Interference with normal peristaltic movement of intestinal contents because of neurologic or mechanical impairments

• Causes:

• Carcinoma of the bowel

• Hernias

• Fecal impaction

• Adhesions (scar tissue that forms abnormal connections after surgery or inflammation)

Intestinal Obstruction

• Causes:

(e) Intussuception (telescoping of the bowel on itself)

(f) Volvulus (twisting of the intestines)

(g) Paralytic ileus (interference with neural innervation of the intestines resulting in a decrease in or absence of peristalsis; may be caused by surgical manipulation, electrolyte imbalance, or infection)

Intestinal Obstruction

Clinical Findings:

• Colicky abdominal pain; constipation that may be accompanied by urge to defecate without results and seepage of fecal liquid

• Abdominal distention; vomiting that may contain fecal matter; decreased or absent bowel sounds; signs of dehydration and electrolyte imbalance; obstipation; flat plate of the abdomen shows the bowel distended with air

Intestinal Obstruction

Therapeutic Interventions:

• Restriction of oral intake; administration of parenteral fluids and electrolytes

• Surgical intervention: correction of cause (e.g., hernias, adhesions); colostomy, cecostomy, or ileostomy

• Drugs such as neostigmine (Prostigmin) to stimulate the passage of flatus

• Decompression of GI tract by means of a nasogastric or intestinal tube

Intestinal Obstruction

Nursing Care:

Assessment:

• Detailed history to determine risk and causative factors

• Abdomen for peristaltic waves, distention

• Presence and characteristics of bowel sounds

• Patterns and characteristics of bowel elimination

Intestinal Obstruction

Nursing Care:

Nursing Diagnoses:

• Constipation related to mechanical or functional obstruction

• Fluid volume deficit related to fluid shift into intestinal lumen and GI decompression

Intestinal Obstruction

Nursing Care:

Planning/Implementation:

• Assess for dehydration and electrolyte imbalance; monitor intake and output

• Auscultate for bowel sounds; note the passage of flatus

• Administer oral hygiene frequently

Intestinal Obstruction

Nursing Care:

Planning/Implementation:

• Provide special care for the client with an intestinal tube:

(a) Once the tube reaches the stomach position the client on the right side to facilitate the passage of tube through the pylorus; then in a semi-Fowler’s position to continue the gradual advance into the intestines

(b) Coil and loosely attach extra tubing to the client’s gown to avoid tension against peristaltic action

Intestinal Obstruction

Nursing Care:

Planning/Implementation:

• Instill or irrigate as ordered to maintain patency

• Assess placement of the tube; record the level of advancement; advance as ordered

• When the tube is discontinued, remove gradually because it is being pulled against peristalsis

Intestinal Obstruction

Nursing Care:

Evaluation/Outcomes:

• Establishes a regular pattern of bowel elimination

• Maintains fluid and electrolyte balance

Diverticular Disease

Diverticular Disease

Overview:

• Diverticulosis: multiple pouchlike herniations of intestinal mucosa, as a result of weakness and increased intra-abdominal pressure; may be asymptomatic

• Diverticulitis: inflammation caused by food or feces trapped in a diverticulum; may lead to bleeding, perforation, peritonitis, and bowel obstruction

• Most commonly occurs in the sigmoid colon, but could occur anywhere along the GI tract

• Incidence increases with age; inadequate dietary fiber, history of constipation with straining at stool, and genetic predisposition are risk factors

Diverticular Disease

Clinical Findings:

• Cramping, colicky pain in left lower quadrant; nausea; malaise

• Altered bowel elimination: diarrhea or constipation; frank blood in stool; abdominal distention; fever; leukocytosis

• Diagnostic tests: CT scan, abdominal x-ray, and colonoscopy provide direct evidence of the disease

Diverticular Disease

Therapeutic Interventions:

• Prevention through high-fiber diet

• Nothing by mouth or clear liquids during acute diverticulitis

• Pharmacologic management: analgesics (morphine sulfate is avoided because it can increase intracolonic pressure), antibiotics, antispasmodics, and bulk-forming laxatives and stool softeners

• Fluid and electrolyte replacement

• Surgery: hemicolectomy, temporary loop colostomy

Diverticular Disease

Nursing Care:

Assessment:

• History of constipation and/or diarrhea with progression of symptoms

• Stool for consistency and presence of blood

• Abdomen for distention

• Presence and extent of bowel sounds

Diverticular Disease

Nursing Care:

Nursing Diagnoses:

• Constipation related to narrowed, inflamed intestine

• Pain related to inflammation

• Risk for fluid volume deficit related to gastric decompression

Diverticular Disease

Nursing Care:

Planning/Implementation:

• Teach importance of high-fiber and high-fluid intake to prevent diverticulitis

• Administer bulk laxatives and stool softeners as prescribed

• Maintain NPO and gastric decompression if ordered during acute episode

• Monitor for signs of peritonitis: pain, hypotension, abdominal rigidity, abdominal distention, and leukocytosis

Diverticular Disease

Nursing Care:

Planning/Implementation:

• Administer fluid and electrolyte replacement

• Teach client the importance of completing antibiotic regimen

• Provide care related to bowel surgery (see Nursing Care of Clients with Cancer of the Small Intestine, Colon, and Rectum)

Diverticular Disease

Nursing Care:

Evaluation/Outcomes:

• Exhibits normal pattern of soft, formed bowel movements

• Increases intake of high-fiber foods

• Reports relief from pain

• Maintains fluid and electrolyte balance

Cancer of the Small IntestineColon & Rectum

Cancer of the Small Intestine, Colon and Rectum

Overview:

• Tumor causes narrowing of lumen of bowel, ulcerations, necrosis or perforation

• Predisposing factors include familial polyps, chronic ulcerative colitis, and bowel stasis, ingestion of food additives, and high-fat, low-fiber diet

• Cancer of the colon is more common in males, and incidence increases after 50 years of age

• Cancer of the small intestine is rare; adenocarcinoma of the large intestine is relatively common

Cancer of the Small Intestine, Colon and Rectum

Clinical Findings:

• Abdominal discomfort or pain; weakness and fatigue

• Alterations in usual bowel function (constipation or diarrhea or alternating constipation and diarrhea); pencil or ribbon-shaped stool

• Abdominal distention

• Weight loss

• Frank or occult blood in stool; secondary anemia

• Digital examination detects any palpable masses

Cancer of the Small Intestine, Colon and Rectum

Clinical Findings:

• Proctosigmoidoscopy visualizes the bowel directly and determines the presence of abnormalities; permits biopsy

• Cytologic examination of tissue from GI tract detects malignant cells

• Elevated alkaline phosphatase and aspartate aminotransferase levels detect metastasis to the liver

• Elevated serum carcinoembryonic antigen (CEA) may indicate carcinoma of the colon

Cancer of the Small Intestine, Colon and Rectum

Therapeutic Interventions:

• Surgical intervention to remove the mass and restore bowel function (e.g., hemicolectomy, abdominal perineal resection)

• Radiation in nonsurgical situations may be used to limit symptoms; may be used preoperatively to reduce size of tumor or postoperatively to limit metastases

• Chemotherapy to reduce the lesion and limit metastases

Cancer of the Small Intestine, Colon and Rectum

Therapeutic Interventions:

• Preparation for surgery:

(a) Antibiotics (e.g., neomycin or sulfonamides) to reduce bacteria in the bowel

(b) Type and cross-match of blood for transfusions to correct anemia

(c) Vitamin supplements to improve the nutritional status

(d) Gastric or intestinal decompression

(e) Bowel preparation

Cancer of the Small Intestine, Colon and Rectum

Nursing Care:

Assessment:

• Detailed history of symptoms and risk factors

• Stool for frequency, color, consistency, and shape

• Weight for baseline data

• Areas of abdominal discomfort on palpation

• Presence and extent of bowel sounds

Cancer of the Small Intestine, Colon and Rectum

Nursing Care:

Nursing Diagnoses:

• Pain related to trauma of surgery and pathologic processes

• Anxiety related to treatments and prognosis

• Body image disturbance related to alteration in GI structure and function

• Fluid volume deficit related to losses through ostomy

• Altered nutrition: less than body requirements related to malabsorption

• Risk for impaired skin integrity related to fecal irritation

Cancer of the Small Intestine, Colon and Rectum

Nursing Care:

Planning/Implementation:

• Observe vital signs, increasing abdominal pain, nausea, and vomiting to detect early signs of complications

• Monitor patency of gastric or intestinal tube; instill or irrigate with normal saline as ordered; note the amount and character of drainage

• Implement mechanical cleansing and intestinal antisepsis preoperatively

• Administer chemotherapeutic drugs if ordered; observe for significant side effects such as stomatitis, dehydration, nausea, and vomiting, diarrhea, leukopenia

Cancer of the Small Intestine, Colon and Rectum

Nursing Care:

Planning/Implementation:

• Administer electrolyte and parenteral fluid replacement as ordered in situations of bleeding, vomiting, and/or obstruction

• Administer progressive diet as ordered; assess tolerance; teach dietary modifications to client and family, including non gas-forming foods, avoidance of stimulants, adequate fluid intake; diet should be as close to the client’s normal as possible

Cancer of the Small Intestine, Colon and Rectum

Nursing Care:

Planning/Implementation:

• Teach the importance of diet in supporting the body’s natural defenses; emphasize high nutrient density foods from the fruit, vegetable, cereal grain, and legume groups with some lean meat, fish, and poultry; encourage client to eat as great a variety of foods as can be tolerated; vitamin and mineral supplements can be encouraged, especially the immune-stimulating factors

Cancer of the Small Intestine, Colon and Rectum

Nursing Care:

Planning/Implementation:

• Assess the client’s reaction to the colostomy, recognizing that it will depend on how the client sees it affecting life-style, physical and emotional status, social and cultural background, and place and role in the family; client may demonstrate the stages of grieving

• Provide colostomy care (see procedure); encourage involvement in colostomy care as soon as physical and emotional status permits

Cancer of the Small Intestine, Colon and Rectum

Nursing Care:

Planning/Implementation:

• Recognize that the client with a cecostomy or colostomy is especially sensitive to gestures, odors, and facial expressions

• Teach the client and family care of the colostomy, measures to facilitate acceptance and adjustment, resumption of activities including sexual, and the need for regular medical supervision

Cancer of the Small Intestine, Colon and Rectum

Nursing Care:

Planning/Implementation:

• Teach the client that colostomy drainage begins in 3-4 days and can be controlled by following a regular irrigation schedule and dietary modifications; adequate uninterrupted time for procedure is necessary

• Arrange for follow-up care with community agencies as required (e.g., public health, home care programs, Cancer Society, ostomy resource person)

Cancer of the Small Intestine, Colon and Rectum

Nursing Care:

Evaluation/Outcomes:

• Maintains adequate fluid and electrolyte balance

• Resumes a regular pattern of bowel elimination

• Client or family member demonstrates ability to perform ostomy care

• Discusses feelings concerning diagnosis, prognosis, and ostomy

• Maintains nutritional status

Peritonitis

Peritonitis

Overview:

• Inflammation of the peritoneum

• Generally caused by infection from perforation of GI tract or chemical stress

Peritonitis

Clinical Findings:

• Abdominal pain, rebound tenderness; malaise; nausea

• Abdominal muscle rigidity; vomiting; elevated temperature and WBCs

Peritonitis

Therapeutic Interventions:

• Bed rest in a semi-Fowler’s position to localize drainage to the dependent portion of the abdominal cavity

• Nasogastric decompression until the client passes flatus

• Fluids and electrolytes replaced parenterally; TPN

• Antibiotic therapy

• Surgery to correct the cause of peritonitis (e.g., appendectomy, incision and drainage of abscesses, closure of perforation

Peritonitis

Nursing Care:

Assessment:

• Temperature for baseline data

• Guarded movements and/or self-splinting

• Reduction or absence of bowel sounds

• Presence and characteristics of abdominal pain

Peritonitis

Nursing Care:

Nursing Diagnoses:

• Pain related to inflamed peritoneal membrane

• Fluid volume deficit related to gastric decompression and fluid shifts

Peritonitis

Nursing Care:

Planning/Implementation:

• Maintain the semi-Fowler’s position

• Assess pain and vital signs, especially temperature

• Monitor IV therapy and GI decompression, monitor intake and output

• Auscultate for bowel sounds; note the passage of flatus

• Administer antibiotics

Peritonitis

Nursing Care:

Evaluation/Outcomes:

• Reports absence of pain

• Maintains fluid and electrolyte balance

• Reestablishes regular pattern of bowel elimination

Hemorrhoids

Hemorrhoids

Overview:

• Varicosities of the rectum that can be internal or external

• Precipitated by constipation, prolonged sitting or standing, straining at defecation, and pregnancy

Hemorrhoids

Clinical Findings:

• Anal pain; pruritus

• Protrusion of varicosities around the anus; rectal bleeding and mucus discharge

Hemorrhoids

Therapeutic Interventions:

• High fiber diet (especially pectin containing fruits and vegetables during acute exacerbations

• Laxative and stool softeners to regulate bowel

• Analgesic suppositories and ointments; sitz baths or ice compresses for discomfort

• Internal hemorrhoids ligated with rubber bands; as necrosis occurs, tissue sloughs off

• Hemorrhoidectomy: surgical removal of hemorrhoids

Hemorrhoids

Nursing Care:

Assessment:

• History of causative factors

• Presence and characteristics of pain

• Presence of hemorrhoids in perianal area

Hemorrhoids

Nursing Care:

Nursing Diagnoses:

• Constipation related to fear of pain on defecation

• Pain related to inflammation

Hemorrhoids

Nursing Care:

Planning/Implementation:

• Help relieve pain by sitz baths, ice compresses, local analgesics

• Provide privacy and sufficient time for defecation, especially after meals

• Encourage generous daily intake of high-fiber foods; promote intake of at least 8 glasses of fluid per day

• Discourage routine use of laxatives, which results in dependency; bulking agents such as Metamucil may be prescribed

Hemorrhoids

Nursing Care:

Planning/Implementation:

• Provide care for the client having a hemorrhoidectomy

• Administer cleansing enemas preoperatively

• Observe for rectal hemorrhage and urinary retention postoperatively; explain that some bleeding with a bowel movement is expected

• administer a retention enema on the 2nd or 3rd postoperative day if ordered to stimulate defecation and soften the stool

Hemorrhoids

Nursing Care:

Evaluation/Outcomes:

• Report increased comfort, particularly on defecation

• Complies with treatment regimen

• Establishes a pattern of regular bowel movements

Hernias

Hernias

Overview:

• Protrusion of an organ or structure through a weakening in the abdominal wall; may result from a congenital or acquired defect

• If the protruding structure can be manipulated back in place, the hernia is said to be reducible; if it cannot, it is considered incarcerated

• Strangulation occurs when blood supply to the tissues within the hernia is disrupted; this is an emergency situation, since gangrene occurs

• Hernias are named by location: incisional, umbilical, femoral, inguinal

Hernias

Clinical Findings:

• History of appearance of swelling after lifting, coughing, or exercise; pain caused by irritation or strangulation; nausea can accompany strangulation

• Swelling (lump) in the groin or umbilicus, or near an old surgical incision that may subside when the client is in a recumbent position; vomiting and abdominal distention when strangulation occurs

Hernias

Therapeutic Interventions:

• Manual reduction by gently pushing the mass back into the abdominal cavity

• When the client is a poor surgical risk, a truss (pad worn next to the skin held in place under pressure by a belt) may be ordered

• Herniorrhaphy: repair of the defect in the abdominal musculature or fascia

• Hernioplasty: insertion of wire, mesh, or plastic to strengthen abdominal wall

Hernias

Nursing Care:

Assessment:

• History of potential causative factors

• Presence or absence of bowel sounds on auscultation

• Abdomen with client in standing and lying positions to determine if hernia reduces with positional change

Hernias

Nursing Care:

Nursing Diagnoses:

• Pain related to pathologic processes

• Risk for injury related to strangulation

Hernias

Nursing Care:

Planning/Implementation:

• Avoid abdominal palpation if hernia is strangulated

• Provide care following surgery:

• Instruct client to avoid coughing if possible; use deep breathing and incentive spirometry to prevent respiratory complications; encourage self-splinting

• Administer mild cathartics as ordered to prevent straining and increased intra-abdominal pressure

• Apply an ice bag and scrotal support if the scrotum is edematous postoperatively to reduce the edema and pain

Hernias

Nursing Care:

Planning/Implementation:

(d) Administer medication for pain as ordered

(e) Instruct the client to avoid lifting or strenuous exercise on discharge until permitted by the surgeon

Hernias

Nursing Care:

Evaluation/Outcomes:

• Reports decreased pain

• Restates discharge instructions

Related GI Procedures

• Colostomy Irrigation and Care

• Endoscopy

• Enemas

• Gastro-Intestinal Series

• Gavage (Tube Feeding)

• Parenteral Replacement Therapy

Colostomy Irrigation and Care

Endoscopy

Enemas

Gastro-Intestinal Series

(GI Series)

Gavage (Tube Feeding)

Parenteral Replacement Therapy