gastrointestinal system - nursing ednursinged.com/pnbook/nclex-pn_chapter_13_bwfinal.pdf ·...

Gastrointestinal System

265

c. Whenthestrainisreleased,thereisanincrease invenousreturntotheheart.Thismay precipitateproblemsintheclientwithcardiac disease.F. Changesinthegastrointestinalsystemrelatedtoaging (Box13-1).

System Data CollectionA. Evaluateclient’shistory. 1. Changesinbowelhabits. 2. Evaluatedietarypatternandfluidintake,note recentchangesindietaryhabits. 3. Weightlossorgain,intentionalonnonintentional. 4. Pain;locationofpain. 5. Nauseaandvomiting. a. Associatedwithpain. b. Precipitatingfactors. 6. Presenceorproblemswithflatulence.

PHYSIOLOGY OF THE GASTROINTESTINAL (GI) SYSTEM

Organs of the Gastrointestinal System (Figure13-1)A. Mouth,pharynx,esophagus.B. Stomach. 1. Liesintheupperleftportionoftheabdominal cavity. 2. Gastroesophagealsphincter(cardiacsphincter): openingoftheesophagusintotheupperportionof thestomach. 3. Lengthoftimefoodremainsinstomachdependson typeoffood,gastricmotility,andpsychologicfac- tors;averagetimeis3to4hours. 4. Chyme(foodmixedwithgastricsecretions)moves throughthepylorusintothesmallintestine.C. Smallintestine. 1. Digestionandabsorptionoffoodoccursinthesmall intestine,wherevilliprovideabsorptivesurface area;minimalamountof nutrientsareabsorbedinthestomach. 2. Carbohydratesarebrokendownandareabsorbed throughthevilliofthesmallintestine. 3. Intrinsicfactorissecretedinthestomachandpro motesabsorptionofvitaminB

12(cobalamin)inthe

smallintestine. 4. Movementoffood(chyme)throughthesmall intestinestimulatesreleaseofbilefordigestion offats.D. Largeintestine. 1. Reabsorptionofwater;peristalsismovestheresidue towardthedescendingcolonandrectum. 2. Largeintestineabsorbswaterandelectrolytesand formsfeces.E. Rectumandanus. 1.Servesasareservoirforfecalmassuntildefecation occurs. 2.Duringdefecationtherectumandcoloncontract;the individualtakesadeepbreathandinitiatesavol untarycontractionofthediaphragmandtheabdo- minalwallwiththeglottisclosed;thisactionresults inincreasedpressureintherectum. a. Valsalvamaneuveristhevoluntarypressure exertedagainstaclosedglottisduringdefecation orstrainingatstool. b. Thisactivityincreasesintrathoracicpressure andimpedesvenousreturntotheheart.

FIGURE 13-1 Organs of the digestive system (From deWit, S, Medical surgical nursing: concepts and practices, St Louis, 2009, Saunders).

266 CHAPTER 13 Gastrointestinal System

7. Medicationhistory,includingover-the-counter (OTC)andprescriptiondrugs. 8. PrevioussurgeriesrelatedtoGIsystem.B. Assessvitalsignsinclient’soverallstatus.C. Assessforpresenceandcharacteristicsofpain.D. Assessclient’smouth. 1. Overallconditionofteeth,gums,andoralmucosa. 2. Overallconditionoftongue. 3. Presenceofgagreflex.E. Evaluatetheabdomen(clientshouldbelyingflat); sequenceofassessment:inspection,auscultation, percussion,palpation. 1. Dividetheabdomenintofourquadrants(Figure13- 2)andvisualinspectcontourandpresenceofscars, masses,andmovement(aorticpulsationmaybe visible). 2. Assessforpresenceofandcharacteristicsofbowel sounds;shouldbeaudiblewithin1minute. a. Intensityandfrequency. b. Soundsareusuallyloudestjusttotherightand belowtheumbilicus. c. Bowelsoundsareconsideredabsentifnosound isheardfor2-5minutesinanyoneofthe4 quadrants. d. Normallysoftgurglesshouldbeheardevery5to 30seconds. 3. Percusstheabdomenforareasofdistentionand air. 4. Palpatetheabdomen.Beginwithnontenderareas first. a. Softtopalpation. b. Presenceofdistention. c. Presenceofmasses.

F. Assessrectalareaforlesions,hemorrhoids,or ulcerations.G. Assessstoolspecimen. 1. Color,consistency,andodor 2. Presenceofbloodormucus.H. EvaluateeliminationpatternsandeffectsofagingonGI tract(Box13-1).

TEST ALERT: Identify factors that interfere with client’s elimination, monitor status of

client’s bowel sounds.

DISORDERS OF THE GASTROINTESTINAL SYSTEM

Nausea and VomitingNausea is an unpleasant feeling that vomiting is

imminent. Vomiting is an involuntary act in which thestomachcontractsandforcefullyexpelsgastriccontents.

A. Lossoffluidandelectrolytesistheprimaryconse- quenceofrepeatedvomiting;theveryyoungandthe elderlyaremoresusceptibletocomplicationsoffluid imbalances.B. Prolongedvomitingwillprecipitateametabolic problemwithacid-basebalance.

✽

Changes in Gastrointestinal System Related to Aging

• Decreaseinproductionofhydrochloricacidanda decreaseabsorptionofvitamins;encouragefrequent, smallwellbalancedmeals.

• Tendencytowardconstipationduetoadecreasein peristalsisanddecreaseinsensationtodefecate; encouragephysicalactivityandadiethighinfiberwith aminimumof2000mLofdailyfluidintake.

• Decreaseinenzymesforfatdigestion;increaseintake offatmaycausediarrhea.

• Decreaseinabilityoflivertoproduceenzymesto metabolizedrugs,thereforeatendency,towardaccu- mulationofmedications;instructclientsnottodouble uporwithholdanyoftheirmedications,especially cardiacmedications.

BOX 13-1 OlDER ADUlt CARE FOCUS

FIGURE 13-2 Abdominal quadrants. (From deWit, S, Medical surgical nursing: concepts and practices, St Louis, 2009, Saunders).

CHAPTER 13 Gastrointestinal System 267

withweakteaororalrehydratingsolutions(ORSs) atroomtemperature;forinfantsandchildrenbegin ORSs.F. Supportabdominalincisionsduringprolonged vomiting.v Goal:Torelievenauseaandvomiting.A. Administerantiemeticsasindicated.

NURSING PRIORITY: Determine causes of nausea and vomiting do not treat symptomatically until cause is investigated.

B. Evaluateprecipitatingcauses;relieveifpossible.C. Gastricdecompressionwithanasogastrictubemaybe indicated.v Goal:Toassessclient’sresponsetoprolongedvomit-ing.A. Correlatechangesinvitalsignswithfluidloss.B. Evaluateelectrolytelossandmonitorurinespecific gravity;assessforadequacyofhydration.C. Observeforcontinuedpresenceofgastricdistention.D. Recordintakeandoutput,correlatewithweightlossor gain.

ConstipationConstipationexistswhentheintervalbetweenbowel

movements is longer than normal for the individual andthestoolisdryandhard.

Data CollectionA. Precipitatingcauses. 1. Inadequatebulkinthediet. 2. Inadequatefluidintake. 3. Immobilization. 4. Ignoringtheurgetodefecate. 5. Diseasesofthecolonandrectum. 6. Sideeffectsofmedications.B. Clinicalmanifestations. 1. Abdominaldistention. 2. Decreaseintheamountofstool. 3. Dry,hardstool,strainingtopassstool. 4. Impaction–clientisunabletopassdryhardstool, liquidstoolmaybepassedaroundimpaction.C. Diagnostics:clinicalmanifestations.

TreatmentSeeAppendix13-2andBox13-2.

Nursing Interventionsv Goal:Toidentifyclientatriskofdevelopingproblemsandinstitutepreventivemeasures.v Goal:Toimplementtreatmentmeasures.

4

✽

Data CollectionA. Clinicalmanifestations. 1. Identifyprecipitatingcause.

TEST ALERT: Recognize and intervene to prevent complications of surgery; recognize signs and symptoms of dehydration; monitor client’s response to restore fluid and electrolyte balance.

a. Postoperativeclientsmayexperienceabdominal distentionandvomiting. b. Maybeassociatedwithmedications. c. Ifproblemisaresultoffoodintolerance,client generallyfeelsbetteraftervomiting. d. Maybeassociatedwithvirus,upperrespiratory tractinfections,andpostnasaldrainage. e. Gastritisassociatedwithfoodpoisoning. f. Vomitingmaybeassociatedwithchemotherapy andradiation. g.Vomitingmayoccurinfirsttrimesterofpreg- nancy. 2. Assessfrequencyofvomiting,amountofvomiting, andcontentsofvomitus. 3. Hematemesis:presenceofbloodinvomitus. a. Brightredbloodisindicativeofbleedinginthe stomachortheesophagus. b. Coffee-groundmaterialisindicativeofbloodre- tainedinthestomach.Thedigestiveprocesshas brokendownthehemoglobin. 4. Projectilevomiting:vomitingnotprecededbynau- sea;expelledwithexcessiveforce. 5. Presenceoffecalodorinvomitusindicatesaback flowofintestinalcontentsintostomach.B. Diagnostics:clinicalmanifestations.

TreatmentA. Eliminatetheprecipitatingcause.B. Antiemetics(seeAppendix13-2).C. Parenteralreplacementoffluidiflossisexcessive.

Nursing Interventionsv Goal:Topreventrecurrenceofnauseaandvomiting,andensuingcomplications.A. Administerprophylacticantiemeticsforclientswitha tendencytowardvomiting(e.g.,chemotherapyclients, postoperativeclients).B. Providepromptremovalofunpleasantodors,including theusedemesisbasin,usedequipment,andsoiled linens.C. Encouragegoodoralhygiene.D. Positionconsciousclientonhissideorinsemi-Fowler’s position;positionunconsciousclientonsidewithhead ofbedslightlyelevated.E. WithholdPOfoodandfluidinitiallyaftervomiting; beginoralintakeslowlywithclearliquids.;begin


DiarrheaDiarrhea occurs when there is a signifi cant increase

inthenumberofstoolsandstoolsaremoreliquid.

A. Infantsandolderadultsaremostsusceptibletocompli- cationsofdehydrationandhypovolemia.B. Acutediarrheaismostoftencausedbyaninfectionand isself-limitingwhenallcausativeagentsorirritants havebeenevacuated.

Data CollectionA. Precipitatingcauses. 1. Bacteria,parasitesandvirusesoftheintestinal tract. 2. Foodanddrugintolerance,foodpoisoning. 3. Boweldisorders,malabsorptionproblems.B. Clinicalmanifestations. 1. Frequent,liquidbowelmovements. 2. Stoolsmaycontainundigestedfood,mucus,pus,or blood. 3. Frequentlyfoul-smelling. 4. Abdominalcramping,distention,andvomitingfre- quentlyoccurwithdiarrhea. 5. Weightloss. 6. Hyperactivebowelsounds. 7. Mayprecipitatedehydration,hypovolemia,electro- lyteimbalance;canprogresstohypovolemiaand shock.

✽

8. Infantsandelderlyaremostsusceptibletocompli- cationsofdiarrhea. 9. Rotavirusisthemostcommonpathogeninyoung childrenhospitalizedfordiarrhea. a. Affectsallagegroups;children6monthsto24 monthsaremostsusceptible;ismostcommonin coolweather. b. Incubationperiodis1to3days. c. Importantsourceofhospitalacquiredinfections. d. Isfrequentlyassociatedwithanupperrespira- torytractinfection.C. Diagnostics. 1. Clinicalmanifestations. 2. Stoolculture.D. Complicationsofseverediarrhea. 1. Dehydrationresultinginhypovolemia. 2. Acid-baseimbalances.

TreatmentA. Treattheunderlyingproblem.B. DecreaseactivityandirritationoftheGItractbyde- creasingintake.C. Increaseclearliquids(ORSs)astolerated.D. Parenteralreplacementoffluidsandelectrolytesif diarrheaissevere.E. Antidiarrhealmedications(seeAppendix13-2).F. Antidiarrhealmedicationsmaynotbeadministeredif causativeagentisbacterialorparasitic.Antidiarrheals preventclientfrompurgingthebacteriaorparasiteand trapsthecausativeorganism(s)intheintestinesand prolongstheproblem.G. Viralinfectionsmaybetreatedwithmedicationorleft toruntheircourse,dependingontheseverityandtype ofvirus.

Nursing Interventionsv Goal:Todecreasediarrheaandpreventcomplications.A. Identifyprecipitatingcausesandeliminateifpossible.B. Decreasefoodintake;offersoft,nonirritatingfood, clearliquidsorORSs.C. Maintaingoodhygieneintherectalareatopreventskin excoriation.D. Decreaseactivity.

NURSING PRIORITY: With nausea, vomiting and diarrhea, do not offer high carbohydrate or carbonated fl uids initially; offer small amounts of clear liquids (ORSs) at room temperature.

v Goal:Toevaluateclient’sresponsetodiarrhea.A. Evaluatechangesinvitalsignscorrelatingwithfluid loss.B. Evaluateelectrolytechanges,urinespecificgravityand overallhydrationstatus(Chapter5).

4

Preventing Fecal Impaction

• Increaseintakeofhigh-fiberfoodstoincreasebulkof stool:rawvegetables,whole-grainbreadsandcereals, freshfruits.

• Increasefluidintake,minimumintakeshouldbeatleast 2000mLdaily.

• Encouragedailyphysicalactivity:walking,swimming, orbiking.Ifconfinedtowheelchair,changeposition frequently,performlegraisesandabdominalmuscle contractions.

• Discourageuseoflaxativesandenemas:clientcan easilybecomedependentonthem.Ifabsolutelyneces- sary,warmmineraloilenemasmaysoftenandlubricate stool.

• Encourageuseofbulk-formingproductstoprovide increasedfiber(methylcellulose,psyllium).

• Encouragebowelmovementatsametimeeachday.

• Trytopositionclientonbedsidecommoderatherthan onabedpan.

• Ifclientisexperiencingdiarrhea,checktoseeifstoolis oozingaroundanimpaction.

BOX 13-2 OlDER ADUlt CARE FOCUS


C. Monitorintakeandoutputaswellasdailyweightif diarrheaisprogressive.D. Assesschangesinabdominaldistentionandcramping.E. Provideongoingevaluationofcharacteristicsof diarrhea.v Goal:Topreventspreadofdiarrhea.A. Promotegoodhandhygiene:teachfamilyimportance ofhandhygiene.B. Institutecontactprecautionsifdiarrheaisofinfectious origin(Appendix5-9).C. Maintaincleananddirtyareasintheclient’sroom- disposeofdiapersandsoiledlinens;keepsoiledobjects awayfromcleanareainroom.

TEST ALERT: Identify client risk factors for infection, apply principles of infection control

– standard plus contact precautions for client with diarrhea.

Oral CancerA. Mayoccurinanyareaofthemouth;frequentlycurable ifdiscoveredearly.B. Sitesoforalcancer. 1. Lips. 2. Tongue. 3. Salivaryglands. 4. Floorofthemouth.

Data CollectionA. Riskfactors/etiology. 1. Smoking. 2. Continuousoralirritationduetopoordental hygiene. 3. Chewingtobacco.B. Clinicalmanifestations. 1. Leukoplakia:whitishpatchonoralmucosaor tongue. 2. Painlessorallesionsthatarefixedandhardwith raisededges. 3. Advancedsymptomsincludedysphagia,difficulty chewingorspeaking,andenlargedlymphnodes.C. Diagnostics:biopsyofsuspectedlesion.

TreatmentA. Surgery. 1. Surgicalresection. 2. Reconstructivesurgery.B. Radiation.C. Chemotherapy.

Nursing Interventionsv Goal:Toprepareclientforsurgery.A. Followgeneralpreoperativecareguidelines(see Chapter3).

B. Discuss with RN/surgeon the anticipated extent of surgery; reiterate and reinforce information with client.C. Emphasizegoodoralhygiene.

TEST ALERT: Monitor and provide support to client with unexpected changes in body image;

identify family and client’s coping mechanism.

v Goal:Tomaintainpatentairwaypostoperatively.A. Intheimmediatepostoperativeperiod,elevateheadof bedslightlytopromotevenousandlymphaticdrainage, andtopromoteairwaymaintenance.B. Immediately report any swelling at incision site.C. Evaluateabilityofclienttohandleoralsecretions; preventionofaspirationisapriority.D. Frequentrespiratoryassessmenttoidentifyproblems ofairwaycompromise.E. Theclientmayhaveatracheostomy;dependsonthe extentofsurgery(seeAppendix10-5).F. Encouragegoodpulmonaryhygiene.G. Inclientswithoutatracheotomy,aspirationisaprimary concern.

NURSING PRIORITY: Airway maintenance and respiratory distress are potential problems with any operative procedure that involves the face and neck.

v Goal:Tomaintainoralhygieneandpreventinjuryandinfectionpostoperatively.A. Typeoforalhygieneisindicatedbytheextentofthe procedure. 1. Soothingmouthrinsesofnormalsalineoraweak bicarbonatesolutions. 2. Avoidantisepticorcommercialmouthwashes. 3. Ifdenturesarepresent,cleanmouthwellbefore replacing. 4. OralhygienebeforeandafterPOintake.v Goal:Tomaintainnutritionpostoperatively.B. Tubefeedingsmaybeindicatedinitially.C. Maybenecessarytomaintainnutritionbytotalparen- teralnutritionorbytubefeedings(seeAppendix13-9).D. Monitororalintake;assessclient’sabilitytoswallow andcontrolfluids. 1. Liquid,soft,nonirritatingfoods. 2. Noextremesintemperatureoffood. 3. Small,frequentfeedings. 4. Provideprivacyanddonotrushduringmeals.

Home CareA. Assistclienttoidentifycommunityresourcesforindi- vidualproblemsinrehabilitation-speechtherapist, dietitian,counseling.B. Avoidupperrespiratorytractinfections.C. Instructclientregardingoralhygiene,dressingcare, andmedications.

4


D. Teachclientsymptomsofcomplicationsandtonotify primarycareprovider(PCP)ifanyofthefollowing occur:infection,suturelinebleedingordisruption, airwayproblems,swallowingproblems,increasedpain.

TEST ALERT: Monitor a client’s ability to eat, determine impact of disease on nutritional status.

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease is caused by a reflux of gastric contents into the esophagus (esophageal reflux). When reflux occurs, the esophagus is exposed to gastric acid.A. ProlongedGERDisanincreasedriskfordevelopment ofcancer.B. Gastricacidbreaksdowntheesophagealmucosaand initiatesaninflammatoryresponse.C. Hiatalherniaistheherniationofaportionofthestom- achintotheesophagus;itpresentswithsamesymptoms asGERDandthemanagementisthesame.D. Notuncommoninclientswithchronicrespiratory problems.

Data CollectionA. Clinicalmanifestations 1. Refluxesophagitis(heartburn,dyspepsia). 2. Maybeassociatedwithnicotine,orintakeofhigh- fatfoods,andcaffeine. 3. Painaftermeals;mayberelievedwithantacids. 4. Regurgitation(effortlessreturnofstomachcontents intothemouth),notassociatedwithbelchingor nausea. 5. Discomfortoccurswithincreaseinabdominal pressure(e.g.,lifting,straining).B. Diagnostics:esophagoscopy,24-hourmonitoringof esophagealpH.

TreatmentA. Medications(seeAppendix13-3).B. Surgicalcorrectionifhiatalherniaispresent.

Nursing Interventionsv Goal:Todecreasesymptomsofesophagealreflux.A. Administerantacids.B. Modifydiet. 1. Decreaseintakeofhighlyseasonedfoodsand tomatoproducts. 2. Eatfrequent,smallmeals(4to6daily)toprevent gastricdilation. 3. Avoidcarbonatedbeveragesandalcohol. 4. Avoidanyfoodthatprecipitatesdiscomfort(e.g., fats,caffeine,chocolate;nicotinewilldecrease esophagealsphinctertone).

✽

5. Donotliedownaftereating;avoideating2to3 hoursbeforebedtime.C. Decreaseorstopsmoking.D. Elevateheadofbedon6-to8-inchblocks.E. Loseweighttodecreaseabdominalpressure.F. Avoidactivitiesthatincreaseintraabdominalpressure (e.g.,bending,weight-lifting,workinginbent-over position).G. AvoidNSAIDsandsalicylates.

OLDER ADULT PRIORITY: GERD is often under-reported in the older client; clients who awaken from coughing should be evaluated for GERD; clients are also at increased risk for aspiration.

ObesityAnimbalancebetweenenergyexpenditureandcaloricintakethatresultsinanabnormalincreaseinfatcells.A. AccordingtotheCDC,65%ofpeopleintheUnited Statesoverage20areobese.B. Childrenareconsideredoverweightiftheirweightisin the95thpercentileorhigherfortheirage,gender,and heightonthegrowthchart.

AssessmentA. Riskfactors. 1. Geneticpredisposition. 2. Sedentarylifestyle:energyintake(food)exceeds energyexpenditure. 3. Obesityputsclientatincreasedriskforcardiovas- cular,respiratory,andmusculoskeletalproblems,as wellasincreasedriskfordevelopmentofdiabetes.B. Clinicalmanifestations. 1. Arecommendedbodymassindexis18.5to24.9, aBMIof25to29.9kg/m2isconsideredover weight,andaBMIofover30kg/m2isconsidered obese. 2. ABMIiscalculatedbymultiplyingtheweight inpoundsby705anddividingthisfigurebysquare oftheheightininches.

TreatmentA. Lifestylechangesandmodificationofdietaryintake.B. Bariatricsurgery. 1. Laproscopicadjustable-bandedgastroplasty (LABG)involvesplacinganadjustablebandaround thefundusofthestomach. 2. Malabsorptive:Roux-en-Ybypass(REG)orgastric bypassinvolvesbypassingsegmentsofsmall intestinesolessfoodisabsorbed.

4


Nursing Interventionsv Goal:Toprepareclientforsurgery(Chapter3).A. Discusstheimportanceofearlyambulationtoreduce complications.B. Lengthoftimeinhospitaldependsonprocedure.C. Dietarychanges.v Goal:Tomaintainhomeostasispostoperatively(Chap-ter3).A. Immediatelypostoperativeairwaymaybeaproblem; maintaingoodpulmonaryhygiene;positiveend expiratorypressure(PEEP)andorventilatorsupport maybenecessary.B. Increasedrisksforthromboembolicproblems:sequen- tialcompressionstockings,encourageearlyambulation andthromboprophylaxiswithlow-molecular-weight heparin.C. DonotadjustanNGtube,anddonotinsertNGtube evenifthereisprotocoltodosofornauseaandvomit- ing;notifyRNorsurgeon.D. Observeclientfordevelopmentofanastomoticleaks: increasingback,shoulderandorabdominalpain,unex- plainedtachycardiaordecreaseurineoutput;notify surgeonofthesefindings.E. Mayuseabdominalbindertoprotectincision.F. Preventskinexcoriation–monitorareasinskinfolds; keepareadry,mayrequireuseofpadding.F. Inclientwithdiabetes,assessforfluctuationsinserum bloodglucose;mayrequirelessantihypoglycemics.G. Clientwithmalabsorptionsurgerymayexperience dumpingsyndrome(Box13-3).

Home Care A. Diet. 1. Eatatleast3smallmealsaday;chewfoodcom- pletely. 2. Drinkfluidsthroughouttheday,butdonotdrink fluidswithmeals. 3. Avoidhigh-calorie,high-sugar,andhigh-fatfoods. 4. Stopeatingwhenyoufeelfull. 5. Trytoget50to60gofproteindaily;mayneedto takeaproteinsupplement. 6. Learnhowtoavoiddumpingsyndrome(seeBox 13-3).B. Takeachewableorliquidmultivitaminwithiron.C. Canexpecttolose50%to70%ofexcessbodyweight over5years.D. Forwomen,donottrytogetpregnantforabout18 monthsaftersurgery.

Peptic Ulcer Disease (PUD)PUDistheulcerationorerosionofthegastricmucosa

asaresultofthedigestiveactionofhydrochloricacidandpepsin. The condition may be classifi ed as acute or chronic. Duodenalulceristhemostcommontype.

✽

Data CollectionA. Characteristics 1. Factorscontributingtothedevelopment. a. PresenceofHelicobacter pyloribacteriainthe stomach. b. Frequentlyassociatedwithincreasedacidpro- duction. c. Increasedstressinlifestyle. d. Smokingandalcohol. e. Increaseinphysicalstress(e.g.,surgery,trauma). f. Associatedwithmedications(e.g.,NSAIDsand steroids). 2. Clinicalmanifestations. a. Burning,cramping,midepigastricpain. b. Duodenalulcers:painmayoccur1to3hours aftereating;mayberelievedbyeating. c. Dyspepsiasyndromeoccurswithbothduodenal andgastriculcers:fullness,epigastric discomfort,distention,anorexia,andweight loss.

Conditionoccurswhenalargebolusoffoodthathasmixedwithgastricfluids(chyme)andhypertonicfluidentertheintestine.Mayoccurinclientsafteragastricresectionfortreatmentofaperforatedpepticulcer,cancerorbariatricsurgery.

ASSESSMENt• Symptomsoftenoccurswithin15to30minutesafter eating.

• Initialsymptomsfrequentlyinclude:weakness,dizziness,tachycardia,anddiaphoresisfrequentlyoccur.

• Epigastricfullness,abdominalcramping,hyperactive bowelsoundsmayalsooccur.

• Usuallyself-limitingandresolvesinabout6to12 months.

PREVENtING DUMPING SyNDROME.• Eat5-6smallmealsdaily;decreaseamountoffood eatenatonemeal.

• Decreaseintakeofsimplecarbohydrateandsalt.

• Increaseproteinsandhigh-fiberfoodsastolerated.

• Donotdrinkfluidswithmealsorfor1hourfollowing orbeforeameal.Drinkfluidsbetweenmealsonly.

• Positionclientinsemi-recumbentpositionduring meals;clientmayliedownontheleftsidefor20to30 minutesaftermealstodelaystomachemptying.

• Hypoglycemiamayoccur2to3hoursaftereating, causedbyrapidentryofcarbohydratesintojejunum.

BOX 13-3 DUMPING SyNDROME

TEST ALERT: Assist with teaching client about dietary modifi cations.


B. Diagnostics 1. Clinicalmanifestations. 2. Gastricanalysiswithpossiblebiopsy. 3. Endoscopy:gastroscopywithtestforH. pylori.

TreatmentA. Medical(seeAppendix13-3). 1. Antacids. 2. Histaminereceptorantagonistsandantisecretory agentstodecreaseacidproduction. 3. MedicationregimentotreatH. pylori. 4. Dietarymodifications:highlyindividual;foodspre- cipitatingpainaretobeavoided. 5. AvoiduseofNSAID’sandotheranti-inflammatory medications.B. Surgicalinterventions:gastricresection.

NURSING PRIORITY: Carefully evaluate the cli-ent’s blood pressure, observe for orthostatic hypotension – decrease in blood pressure when standing may be an early sign of hypovolemia.

ComplicationsA. Hemorrhagewhenulcererodesthroughavesselinthe gastricmusosa. 1. Pain,nauseaandvomiting. 2. Hematemesisormelena,orboth. 3. Hypovolemicshock(seeChapter11).B. Perforationofulcerintotheperitonealcavity. 1. Sudden,severe,diffuse,upperabdominalpain. 2. Abdominalmusclescontractasabdomenbecomes rigid. 3. Hyperactivebowelsoundsprogressingtoabsent. 4. Respirationsbecomeshallowandrapid. 5. Severityoftheperitonitisisproportionaltosizeof perforationandamountofgastricspillage.

Nursing Interventionsv Goal:TopromotehealthinclientswithPUD.A. Assistclienttounderstanddiseaseprocess.B. Assistclienttoidentifyfactorsthatprecipitatepainand discomfort.C. Provideinformationregardingdietaryimplications.D. Useacetaminopheninsteadofaspirinproducts.v Goal:Torelievepainandpromotehealing.A. Modifydiet. 1. Encouragesmall,frequentmeals. 2. Nonstimulatingblandfoodsaregenerallytolerated betterduringhealingofacuteepisodes. 3. Assistclienttoidentifyspecificdietaryhabitsthat accelerateorprecipitatepain. 4. Promotegoodnutritionalhabits.B. Decreaseand/orchangeactivityasindicatedbydis- comfort.

4

v Goal:Toassessforcomplicationsofhemorrhage,per-foration,andperitonitis,andtoinitiatenursingactionsac-cordingly.

TEST ALERT: Implement interventions to man-age potential client circulatory complications;

monitor client for bleeding.

A. Assessstoolsandnasogastricdrainageforpresenceof blood.B. Assessfordistention,increaseinpain,andtenderness.C. Monitorvitalsignsandevaluatechanges.D. MaintainclientNPO.E. Elevateheadofbedunlessvitalsignsareunstable. 1. Decreaseriskofaspirationifvomiting. 2. Preventchemicalirritationofthediaphragm.F. Prepareclientforimmediatesurgery.v Goal:Toassistclienttoreturntohomeostasispostop-erativegastricresection.A. Followgeneralpostoperativecareasindicated(see Chapter3).B. Assessforthebowelsoundsthatindicatereturnof peristalsis.C. Maintainnasogastricsuctionuntilperistalsisreturns: assesscolorandconsistencyofdrainage,donotadjust nasogastrictube.D. Afterremovalofnasogastrictube,assessfor: 1. Increasingabdominaldistention. 2. Nausea,vomiting. 3. Changesinbowelsounds.E. KeepclientNPOuntilremovalofnasogastrictube.F. BeginPOfluidsslowly:clearliquids;thenprogressto blandsoftdiet.G. Encourageambulationtopromoteperistalsis.

NURSING PRIORITY: carefully monitor drainage from the nasogastric tube, distention and vomiting will occur if tube is not draining properly.

v Goal:Toidentifycomplicationofdumpingsyndromeandinitiatepreventivenursingmeasurespostoperativegas-tricresection.A. Assessforsymptomsofthiscondition.B. Preventdumpingsyndrome(Box13-3).v Goal:Toinitiatemeasurestopreventthedevelopmentofperniciousanemiapostoperativetotalgastricresection(seeChapter9).v Goal:Toassistclienttounderstandimplicationsofthediseaseandmeasuresnecessarytomaintainhealthpostop-erativetotalgastricresection.A. Encouragemodificationofdietaryhabits.B. Stopsmoking.C. Clientshouldunderstandimportanceofmonthly vitaminB

12injections.

D. Continuemedicalfollow-up.

4


E. Identifyfactorsinlifestylethatprecipitatestressandif necessaryobtaincounselingtodecreasestressin lifestyle.

NURSING PRIORITY: Clients with PUD should check with their health care provider prior to taking any over-the-counter medications – especially aspirin or NSAIDs.

Pyloric StenosisTheobstructionofthepyloricsphincterbyhypertro-

phyandhyperplasiaofthecircularmuscleofthepylorus.Mostoftenoccursininfantsbetween3and6weeksold.

Data CollectionA. Onsetofvomitingmaybegradual,ormaydevelop forceful,projectilevomiting.B. Vomitingoccursshortlyafterfeeding.C. Vomitusdoesnotcontainbile.D. Infantishungryandnurseswell.E. Infantdoesnotappeartobeinpainoracutedistress.F. Failuretogainweight.G. Stoolsdecreaseinnumberandinsize.H. Evidenceofdehydrationasconditionprogresses.I. Upperabdomenisdistendedandan“olive-shaped” massmaybepalpatedintherightepigastricarea.

TreatmentSurgicalreleaseofthepyloricmuscle(pyloromyotomy).

TEST ALERT: Monitor infant’s ability to eat and maintain fluid and nutritional status; posi-

tion infant to prevent complications.

Nursing Interventionsv Goal:Torestoreandmaintainhydrationandelectro-lytebalance;toinitiateappropriatepreoperativenursingactivities.A. Monitorvitalsignsandcorrelatewithproblemsofde hydration.B. Monitorelectrolytebalance.C. Ifinfantisdehydrated,maybeplacedNPOwith continuousIVinfusion.D. Maintainaccurateintakeandoutputrecords:complete descriptionofallvomitusandstools.E. Gastricdecompressionandsuctionmaybeusedpre operatively;maintainpatencyoftubeandaccurate recordofdrainage.F. Providepreoperativeteachingforparents.G. Infantshouldhaveoptimalhydrationandelectrolyte balancepreoperatively.v Goal:Tomaintainadequatehydrationandpromotehealingpostoperativepyloromyotomy.

4

✽

A. Postoperativevomitinginthefirst24to48hoursisnot uncommon.B. Assessinfant’sresponsetosurgery.C. Continuetomonitorinfant’shydrationstatusinthe samemannerasinthepreoperativeperiod.D. Feedingsareinitiatedearly,beginningwithclear liquidsincludingoralrehydratingsolutionsandglucose. 1. Offersmallfeedingsatfrequentintervals. 2. Feedinfantslowlyinuprightpositionand“bubble” frequently. 3. Decreaseactivitywithminimalhandlingafter feeding.E. Monitorinfant’sresponsetofeedings.v Goal:Toassistparentstoprovideappropriatehomecarepostoperativepyloromyotomy.A. Generally,therearenoresidualproblemsaftersurgery.B. Modificationsoffeedingsshouldbecontinuedathome.

AppendicitisAppendicitis is characterized by an inflammation of

theappendixandisthemostcommonreasonforabdominalsurgeryduringchildhood.A. Obstructionoftheblindsacoftheappendixprecipitates inflammation,ulceration,andnecrosis.B. Problemsarisewhenthenecroticarearuptures,spilling intestinalcontentsintotheperitonealcavity,causing peritonitis.

Data Collection (Figure 13-3)

A. Morecommoninolderchildrenbetween10and12 yearsold.B. Childmaycomplainofsevereabdominalpainandmay notbeabletostandupright;painmayincreasewith coughing.C. Painbecomesmorepersistentandconsistent;more intenseatMcBurney’spoint(rightlowerquadrant).D. Painmaybecharacterizedasreboundpainortender- ness;mayhavereferredpainaroundtheperimeterof theabdomennearumbilicus.E. Anorexia,nauseaandvomiting,diarrhea.F. Low-gradefever.G. Clientassumesacharacteristicpositionofside-lying withthekneesflexed.H. Suddenrelieffrompainmaybeindicativeofruptured appendix.I. ElevatedWBCcount.J. Nospecific,definitivediagnostics.K. Complications:peritonitis.

TreatmentA. Appendectomytoremoveappendixifinflammatory conditionislocalized.B. Moreextensiveabdominalsurgerymustbedoneif appendixhasruptured(abdominallaparotomy).

✽


Nursing Interventionsv Goal:Toassistinevaluatingchildforclinicalmanifes-tationsandtopreparethechildforsurgeryasindicated.A. Performacarefulnursingassessmentforclinicalmani- festations.B. MaintainchildNPOuntilotherwiseindicated.C. Maintainbedrestinpositionofcomfort.D. Donotapplyheattotheabdomen;coldapplications mayprovidesomerelieforcomfort.E. Donotadministerenemas.F. Avoidunnecessarypalpationofabdomen.G. Immediately report changes in pain or sudden decrease in pain.H. Diagnosiscannotbeconfirmeduntilsurgery;protocol forundiagnosedabdominalpainshouldbefollowed (Box13-4).

NURSING PRIORITY: Pain medication should not be used indiscriminately in the client with abdominal pain. It may mask the symptoms of complications.

v Goal:Tomaintainhomeostasisandhealingpostopera-tiveappendectomy(seeChapter3).v Goal:Topreventabdominaldistentionandpromotebowelfunctionpostoperativeabdominallaparotomy(rup-turedappendix).A. MaintainNPO.B. Providegastricdecompressionbynasogastrictube; maintainpatencyandsuction.C. Monitorabdomenfordistentionandincreasedpain.D. Assessforreturnofperistalticactivity.

4

E. Evaluateandrecordcharacterofbowelmovements.F. Encourageambulationassoonasindicated.v Goal:Todecreaseinfectionandpromotehealingpost-operativeabdominallaparotomy.A. Positionclientinsemi-Fowler’stolocalizeinfection andtopreventspreadofinfectionanddevelopmentof abdominalabscess.B. AntibioticsareusuallyadministeredviaIVinfusion, thenasoralpreparations;monitorresponsetoantibiot- icsaswellasstatusofIVinfusionsite.C. Providewoundcare;evaluatedrainagefromabdominal Penrosedrainsandincisionalarea.D. Assessabdomenforincreaseindistentionand/orten- derness,andforpresenceofbowelsounds.E. Monitorvitalsignsfrequentlyandassessforpresence ofinfection.v Goal:Tomaintainadequatehydrationandnutritionandtopromotecomfortpostoperativeabdominallaparotomy.A. MaintainadequatehydrationviaIVinfusion.B. EvaluatetolerancetoPOliquidswhennasogastrictube isremoved.C. BeginclearliquidsPOwhenperistalsisreturns.D. Progressdietastolerated.E. Administeranalgesicsasindicated.

Acute Abdomen Anacuteabdomencoversabroadspectrumofurgent

conditionsthatrequireimmedicatesurgicalintervention.Mayalsobereferredtoasperitonitiswhichischaracterizedby a generalized infl ammation of the peritoneal cavity.

TEST ALERT: Identify the client at risk for infection and signs and symptoms of infection.

A. Intestinalmotilityisdecreasedandfluidaccumulatesas aresultoftheinabilityoftheintestinetoreabsorbfluid.

✽

FIGURE 13-3 Appendicitis. (From Zerwekh J, Claborn J, Miller CJ: Memory Notebook of nursing, ed 2, vol 2, Ingram, Tx 2007, Nursing Education Consultants.)

DO NOT• Giveanythingbymouth.• Putanyheatontheabdomen.• Giveanenema.• Givestrongnarcotics.• Givealaxative.

DO• Maintainbedrest.• Placeinapositionofcomfort.• Assesshydration.• Assessabdominalstatus:distention,bowelsounds, passageofstoolorflatus,generalizedorlocalpain.• MaintainclientNPOuntilnotifiedotherwise.

BOX 13-4 UNDIAGNOSED ABDOMINAl PAIN


B. Fluidwillleakintotheperitonealcavity,precipitating fluid,electrolyte,andproteinlossaswellasfluid depletion.

Data CollectionA. Riskfactors/etiology:primarysourceofproblemis ruptureofanareaofthegastrointestinaltract.

NURSING PRIORITY: Monitor the status of the postoperative client. Peritonitis is a potential complication whenever the abdomen is entered – either from trauma or from surgery.

B. Clinicalmanifestations(Figure13-4) 1. Presenceofprecipitatingcause(ulcerperforation, rupturedappendix,trauma,ruptureddiverticuli). 2. Painoverinvolvedarea;reboundtenderness. 3. Abdominaldistention. 4. Abdominalmusclerigidity(“board-like”abdomen) and“guarding.” 5. Fever. 6. Anorexia,nausea,vomiting. 7. Increasedpulserate,decreasedbloodpressure, shallowrespirations. 8. Decreasedorabsentbowelsounds. 9. Dehydrationleadingtohypovolemia.C. Diagnostics. 1. Increasedwhitecellcount. 2. X-rayofabdomen. 3. Peritoneallavage(aspiration)toevaluatepresence andcharacteristicsofintra-abdominalfluid. 4. Clinicalmanifestations.

TreatmentA. Identifyandtreatprecipitatingcause(mayrequire surgicalintervention).B. Antibiotics.C. IVfluids.D. Decreaseabdominaldistentionwithnasogastrictube andsuction.

Nursing Interventionsv Goal:Toprovideadequatepaincontrolandwoundcare.v Goal:Tomaintainfluidandelectrolytebalanceandreducegastricdistention(Chapter3).A. Maintainnasogastricsuction.B. MonitorIVfluidreplacementandhydrationstatus.C. Evaluateperistalsisandreturnofbowelfunction.D. Maintainintakeandoutputrecords.E. Assessforproblemsofdehydration.F. Encourageambulationassoonaspossible.tofacilitate returnofbowelfunction.v Goal:Toreduceinfectiousprocess.

4

A. Assessclient’stoleranceofantibioticsandstatusof infusionsite.B. Evaluatevitalsignsandcorrelatewithprogressof infectiousprocess.C. Maintainsemi-Fowler’spositiontoenhancerespirations aswellastodecreaseirritationofdiaphragm.v Goal:Topreventcomplicationsassociatedwithim-mobility(seeChapter3).v Goal:Toprovidepostoperativecareasindicated(seeChapter3).

TEST ALERT: Identify factors that may inter-fere with wound healing. Monitor the client

for infections and provide emergency care of wound disruption.

Intestinal ObstructionInterferencewithnormalperistalsisandimpairment

of forward flow of intestinal contents is known as an intestinalobstruction.A. Regardlessoftheprecipitatingcause,theensuing problemsarearesultoftheobstructiveprocess.B. Thehighertheobstructionintheintestine,themore severethesymptoms.

✽

Figure 13-4 Peritonitis. (From Zerwekh J, Claborn J, Miller CJ: Memory Notebook of nursing, ed 3, vol 2, Ingram, Tx 2007, Nursing Education Consultants.)


C. Thelocationoftheobstructiondeterminestheextentof fluidandelectrolyteimbalanceandacid-baseimbalance. 1. Dehydrationandelectrolyteimbalancedonotoccur rapidlyifobstructionisinthelargeintestine. 2. Ifobstructionislocatedhighintheintestine,dehy- drationoccursrapidlyduetotheinabilityofthein- testinetoreabsorbfluids.D. Fluid,gas,andintestinalcontentsaccumulateproximal totheobstruction.Thiscausesdistentionproximalto theobstructionandbowelcollapsedistaltothe obstruction.E. Asfluidaccumulationincreases,sodoespressure againstthebowel.Thisprecipitatesextravasation offluidsandelectrolytesintotheperitonealcavity. Increasedpressuremaycausetheboweltorupture.F. Increasedpressurecausesanincreaseincapillaryper- meabilityandleakageoffluidsandelectrolytesinto peritonealfluid;thisleadstoaseverereductionin circulatingvolume.G. Typesofobstruction(Figure13-5) 1. Mechanicalobstruction. a.Strangulatedhernia. b. Intussusception:thetelescopingofoneportion oftheintestineintoanother(occursmostoften ininfantsandsmallchildren). c. Volvulus:twistingofthebowel. d. Tumors:cancer(mostfrequentcauseofobstruc- tioninolderadults). e. Adhesions. 2. Neurogenic:interferencewithnervesupplyinthe intestine.

a.Paralyticileusoradynamicileusoccurringasa resultofabdominalsurgeryorinflammatory process. b.Potentialcomplicationfromspinalcordinjury. 3. Vascularobstruction:interferencewiththeblood supplytothebowel. a. Infarctionofsuperiormesentericartery. b.Bowelobstructionsrelatedtointestinal ischemiamayoccurveryrapidlyandmaybe life-threatening.

Data CollectionA. Clinicalmanifestations. 1. Vomitingoccursearlyandissevereifobstructionis high. 2. Vomitingmaybecausedbylowerobstructions occursmoreslowlyandmybefoulsmellingdueto presenceofbacteria. 3. Abdominaldistention. 4. Bowelsoundsinitiallymaybehyperactiveproximal totheobstructionanddecreasedorabsentdistalto theobstruction;eventuallyallbowelsoundswillbe absent.

TEST ALERT: Determine characteristics of bowel sounds. This is important in the diagnosis, treat-

ment, and nursing care of client with an obstructed bowel.

5. Colicky-typeabdominalpain. 6. Intussusception a.Suddenoccurrenceofacuteabdominalpain. b. Childmaypassbloodymucousstooldescribed as“currentjelly”. c. A“sausageshaped”massmaybepalpatedinthe abdomen.B. Diagnostics. 1. X-rayoftheabdomentoassistindifferentiating obstructionfromperforation. 2. Evaluationofhistoryofabdominalproblems.

TreatmentA. Mechanicalandvascularintestinalobstructionsare generallytreatedsurgically;ileostomyorcolostomy maybenecessary.B. Treatmentofneurogenicobstruction(paralyticileus) mayconsistofintestinalintubationanddecompression.C. Maintainfluidandelectrolytereplacement.

ComplicationsA. Infection/septicemia.B. Gangreneofthebowel.C. Perforationofthebowel.D. Fluidandelectrolyteimbalance.

Figure 13-5 Bowel obstructions. A, Adhesions. B, Strangulated inguinal hernia. C, lleocecal intussusception. D, Intussusception from polyps. E, Mesenteric occlusion. F, Neoplasm. G, Volvulus of the sigmoid colon. (From Lewis Sl, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby).


Nursing Interventionsv Goal:Toprepareclientfordiagnosticevaluationandtomaintainongoingnursingassessmentforpertinentdata(seeAppendix13-1).A. Monitorallstools,passageofnormalstoolmayindicate theobstructionisresolved.B. Classicsymptomsofintussussceptionmaynotbe present-observechildfordiarrhea,anorexia,vomiting andacuteepisodicabdominalpain.v Goal:Todecreasegastricdistentionandtomaintainhydrationandelectrolytebalance.A. MaintainNPO.B. Maintainnasogastricsuction(Appendix13-5).C. MonitorIVfluidreplacement.D. Evaluateperistalsisandreturnofbowelfunction.E. Maintainaccurateintakeandoutputrecords.F. Assessforproblemsofdehydrationandhypovolemia.G. Measureabdominalgirthtodetermineifdistentionis increasing.H. Encourageactivitiestofacilitatereturnofbowel function. 1. Encourageactivity,ambulateclientasoftenas possible. 2. Mayattempttodecreasepainmedicationtofacili- tatereturnofbowelfunction. 3. Maintaingoodhydration.v Goal:Toprovideappropriatepreoperativepreparationwhensurgeryisindicated(seeChapter3).v Goal:Tomaintainhomeostasisandpromotehealingpostoperativeabdominallaparotomy(seeChapter3).v Goal:Tomaintainfluidandelectrolytebalanceandpreventgastricdistentionpostoperativeabdominallaparoto-my(seepreoperativegoal).v Goal:Todecreaseinfectionandpromotehealingpost-operativeabdominallaparotomy.A. AntibioticsareusuallyadministeredviaIVinfusion. Monitorclient’sresponsetoantibioticsaswellasstatus ofIVinfusionsite.B. Monitorvitalsignsfrequentlyandevaluateforpresence ofinfectiousprocess.C. Providewoundcare;evaluatedrainagefromabdominal Penrosedrainsaswellasfromabdominalincisional area(Appendix3-2).

TEST ALERT: Empty and reestablish negative pressure of portable wound suction devices

(Hemovac, Jackson Pratt drains).

v Goal:Toreestablishnormalnutritionandtopromotecomfortpostoperativeabdominallaparotomy.A. Evaluatetoleranceofliquidswhennasogastrictubeis removed.B. Beginclearliquidsinitiallyandevaluatepresenceof peristalsis.C. Progressdietastolerated.D. Administeranalgesicsasindicated.

Diverticular DiseaseThe condition in which an individual has multiple

diverticulaisknownasdiverticulosis.A. Diverticulum:dilatationoroutpouchingofaweakened areaintheintestinalwall.B. Diverticulitis:circulationtothediverticulumiscom- promised,allowingforbacterialinvasionandan inflammatoryreaction.C. Meckel’sdiverticulumisadiverticulaintheileumin children;mostcommoncongenitalanomalyofthe GItractinchildren.

Data CollectionA. Riskfactors/etiology. 1. Increasedincidenceinclientsover45yearsofage. 2. Low-fiberdietandchronicconstipation. 3. Mostfrequentlyoccursinthesigmoidcolon. 4. Indigestiblefibers(seeds,corn,etc)mayprecipitate diverticulitis,butdonotcontributetothedevelop- mentofthediverticula.B. Clinicalmanifestations. 1. Diverticulumisusuallyasymptomatic;symptoms varywithdegreeofinflammation. 2. Intermittentleftquadranttenderness,abdominal cramping. 3. Constipationoralternatingconstipationand diarrhea. 4. Occultbloodand/ormucusinthestool. 5. Inflammatorychangesmayprecipitateperforation orabscessformation. 6. Diverticulitisoccurswhenundigestedfoodand bacteriaaretrappedinthediverticula. a. Fever. b. Leftlowerquadrantpain,usuallyaccompanied bynauseaandvomiting. c. Abdominaldistention. d. Frequentlyconstipated. e. Mayprogresstointestinalobstruction,abscess, orperforation.C. Diagnostics. 1. Stoolexamination. 2. Bariumenema. 3. Colonoscopy.

TreatmentA. Medicalmanagementofuncomplicateddiverticulum. 1. High-fiberdiet(restrictindigestiblefibersuchas corn,popcorn,andsesameseeds). 2. Decreaseintakeoffatandredmeat. 3. Preventchronicconstipation:usebulklaxativesand stoolsofteners. 4. Increasephysicalactivity.B. Treatmentforacutediverticulitis. 1. Antibiotics.

✽


2. MaybeNPOoronalow-residuediet. 3. IVfluidsifdehydrated. 4. Possiblesurgeryandcolonresectionifabscess, obstruction,bleeding,orperforationoccurs.

Nursing Interventionsv Goal:Toassistclienttounderstanddietaryimplica-tionsandmaintainprescribedtherapytopreventexacerba-tions.A. Understandhigh-fiberdiet.B. Avoidindigestibleroughagesuchasnuts,popcorn, smallfruitseeds.C. Maintainhigh-fluidintake.D. Avoidlargemeals.E. Avoidalcohol.F. Weightreductionifindicated.G. Avoidactivitiesthatincreaseintra-abdominalpressure (strainingwhiledefecating,bending,lifting,wearing tightrestrictiveclothing).

TEST ALERT: Use measures to improve client’s nutrition – clients with diverticulitis need specific

dietary instructions.

HerniasAherniaisaprotrusionoftheintestinethroughan

abnormal opening or weakened area of the abdominalwall.A. Types. 1. Inguinal:aweaknessinwhichthespermaticcord inmenandtheroundligamentinwomenpasses throughtheabdominalwallintothegroinarea; morecommoninmen. 2. Femoral:protrusionoftheintestinethroughthe femoralring;morecommoninwomen. 3. Umbilical:occursmostofteninchildrenwhenthe umbilicalopeningfailstocloseadequately;occurs inadultswhentheabdominalmuscleisweak. 4. Incisional:weaknessintheabdominalwallduetoa previousincision. 5. Classification. a. Reducible:Herniamaybereplacedintothe abdominalcavitybymanualmanipulation. b. Incarcerated:Herniamaynotbereplacedback intotheabdominalcavity. c. Strangulated:Bloodsupplyandintestinalflow totheherniatedareaareobstructed;a strangulatedhernialeadstointestinal obstruction.

Data CollectionA. Clinicalmanifestations. 1. Herniaprotrudesovertheinvolvedareawhenthe clientstandsorstrains.

✽

2. Severepainoccursifherniabecomesstrangulated orbloodsupplyiscompromised. 3. Strangulatedherniawillcausesymptomsassociated withintestinalobstruction.B. Diagnostics(Appendix13-1).

TreatmentA. Preferablyelectivesurgery(herniorrhaphy)toprevent complicationsofstrangulationB. Strangulatedherniainvolvesanemergencysurgeryfor resectionoftheinvolvedbowel.

Nursing Interventionsv Goal:Toprepareclientforsurgeryifindicated(seeChapter3).v Goal:Tomaintainhomeostasisandpromotehealingpostoperativeherniorrhaphy.A. Followgeneralpostoperativenursingcare (seeChapter3).B. Assessmaleclientsfordevelopmentofscrotaledema (inguinalhernia).C. Discouragecoughing,butencouragedeepbreathing andturning.D. Whencoughingoccurs,teachclienthowtosplintthe incision.E. Refrainfromheavyliftingforapproximately6to8 weekspostoperatively.F. Woundcare 1. Keepwoundcleananddry,mayuseadressingor leaveincisionopentoair. 2. Oninfants,changediapersfrequentlyandprevent irritationandcontaminationoftheincisionalarea.

Inflammatory Bowel DiseaseCrohn’s disease is a chronic, nonspecific, inflamma-

tory disease that extends through all layers of the bowelwallandoccursinpatchesthroughoutthedistalileumandcolon.

Ulcerative colitis is inflammation and ulceration of the mucosal layer of the colon and rectum; area ofinflammation is diffuse and involves mucosa and submucosa of the intestinal wall. It frequently begins in the rectum, andspreadsinacontinuousmannerupthecolon;seldomisthesmallintestineinvolved.

Data CollectionA. Riskfactors/etiology. 1. Maybegininadolescence;peakincidenceoccurs betweenages20and30years,secondpeakofoc currenceoccursinclient60yearsandolder. 2. Clientswithlong-standingulcerativecolitishave significantincreaseincancerofthecolon. 3. Clientswithulcerativecolitismayhavehistoryof difficultyinhandlingstress.

✽

✽


B. Clinicalmanifestations. 1. Abdominalpain. 2. Diarrhea;moresevereincolitisclients. 3. Steatorrheaduetopoorlyabsorbedfats. 4. Nauseaandvomiting. 5. Abdominaldistentionandtenderness. 6. Stoolmaycontainoccultbloodorbrightredblood. 7. Weightloss,nutritionaldeficiency,impaired absorptionofvitaminB12.C. Diagnostics(Appendix13-1). 1. Stoolanalysistoruleoutbacterialorparasiticinfec- tion. 2. Eventhoughthetwoconditionshavedistinctive criteriafordiagnosis,frequentlyacleardifferentia- tioncannotbemadebetweenthem.

TreatmentA. Dietarymodifications:low-residueandlow-fiberdiet; increasedcalorieintake;increasedproteinintake; increasedvitaminandironsupplementation.B. Medications. 1. Corticosteroidstoreducetheinflammation (seeAppendix5-7). 2. Antidiarrhealmedications(seeAppendix13-2). 3. Antibiotics(seeAppendix5-10).C. Surgicalinterventioniffistulas,perforation,bleeding, orintestinalobstructionoccurs;anileostomymaybe necessaryinclientswithwidespreaddisease.

Nursing Interventionsv Goal:(acute):Tomonitorinflammatoryresponseandpromotehealing.A. Observenumberandcharacterofstool.B. Evaluatefluidstatus;recorddailyintakeandoutputand bodyweight.C. Performgoodskinhygienearoundanalareatoprevent excoriationduetodiarrhea.D. Evaluatecharacterofbowelsounds.E. Monitorlabvaluesforanemiaandelectrolyteimbal- ance.F. Assessfordevelopmentofanemiaduetolackof absorptionofvitaminB

12,mayrequirereplacement

vitaminB12

.G. Assistclienttoidentifyfoodthatprecipitatediscomfort anddiarrhea.H. Promotecomfortbyassistingclienttokeepanalarea cleanandkeepingroomfreeofoffensiveodors.

TEST ALERT: Monitor client’s nutritional status. Use measures to improve nutritional intake;

identify signs and symptoms of fluid imbalance.

Home CareA. Modifydiet:encouragelow-residue,blandfoodsthat arehighincaloriesandprotein.Dietmayprogressas inflammationsubsides.B. Understandmedicationregimen.C. Identifysymptomsindicatingreoccurrenceofthe problem,aswellaswhentocallthephysician. 1. Bleedingfromthecolon,orvomitingblood. 2. Significantincreaseinabdominalpain. 3. Increaseinstoolswithdecreaseinbodyweight. 4. Chills,fever,increasedlethargy.D. Avoidsmokingandalcohol.

Gastritis and GastroenteritisGastritis is an inflammatory process involving the

mucosaofthestomach.Gastroenteritisinvolvesthesmallbowelaswellasthe

stomach.

NURSING PRIORITY: Problem is usually self-limiting; fluid balance is of increased concern in the older adult and in the infant.

Data CollectionA. Riskfactors. 1. Ingestionofcontaminatedfood(Salmonella and Staphylococcusbacteria). 2. Alcohol. 3. NSAIDs,aspirin. 4. Radiationtherapy.B. Clinicalmanifestations. 1. Epigastrictendernesswithabdominalcramping. 2. Nausea,vomiting,anddiarrhea.C. Diagnostics:identifyprecipitatingcause.

TreatmentAppropriatemedicationforcausativeagents.

Nursing Interventionsv Goal:Toevaluateandmaintainhydrationandelectro-lytebalance,andtopreventspreadofdisease.A. NPOuntilvomitingceases.B. Beginclearliquids(ORSs)graduallyaftervomiting ceases.C. Followcontactprecautionsuntilorganismisidentified; thenfollowappropriateprecautionsasindicated.v Goal:Toprovidesymptomaticnursingcarefordiar-rhea,nausea,andvomiting.A. Seegeneralintestinaldisorders.

✽

✽

4


Hirschsprung’s Disease (Congenital Aganglionic Megacolon)

Thisdiseaseischaracterizedbycongenitalabsenceofinnervationinasegmentofthecolonwall.

A. Precipitatesaneurogenicbowelobstruction.B. Mostcommonsiteistherectosigmoidcolon;colon proximaltotheareadilates(i.e.,megacolon).

Data CollectionA. Clinicalmanifestations. 1. Variesaccordingtoageandamountofcolon involved. 2. Newborn(first24to48hours). a. Failuretopassmeconium. b. Bile-stainedvomitus. c. Abdominaldistention. 3. Olderinfant. a. Failuretothrive. b. Abdominaldistention. c. Chronicconstipationandoverflowdiarrhea. d. Passageof“ribbon-like”stool.B. Diagnostics-rectalbiopsy.

TreatmentA. Surgery:usuallydoneintwostages:firstatemporary colostomy,thenlatermorecompleterepair.

Nursing Interventionsv Goal:Topromotenormalattachmentandpreparein-fantandparentsforsurgery.A. Allowparentstoventfeelingsregardingcongenital defectofinfant.B. Fosterinfant-parentattachment.C. Followgeneralpreoperativepreparationoftheinfant.D. Provideaexplanationofcolostomytoparents,provide opportunityforparentstoparticipateincareofinfant’s colostomy.v Goal:Toassistparentstounderstandandprovideap-propriatehomecareforthechildpostoperativecolostomy.A. Colostomyisgenerallytemporary.B. Parentsshouldbeactivelyinvolvedincolostomycare beforedischarge(seeAppendix13-8).

Cancer of the Colon and RectumColorectalcanceristhethirdmostcommoncancerin

theUnitedStates.

Data CollectionA. Riskfactors/etiology. 1. Significantincreaseinclientsoverage50years. 2. Historyofinflammatoryboweldisease. 3. Familyhistoryofcoloncancer.

✽

✽

4. Majorityofmalignanttumorsarefoundintherectal area.B. Clinicalmanifestations. 1. Symptomsarevagueearlyindiseasestate,and conditionmaytakeyearstobeidentified. 2. Changeinbowelhabits:constipationanddiarrhea. 3. Rectalbleeding,bloodystools,melena(darktarry) stools. 4. Changeinshapeofstool(pencil-shapedorribbon- shapedfromsigmoidorrectalcancer). 5. Weaknessandfatiguefromanemiaandchronic bloodloss. 6. Constipationanddistention,abdominalcramping. 7. Tenesmus:ineffective,painfulstrainingatstool. 8. Painisalatesymptom. 9. Bowelobstructionwithperforationmayoccur.C. Diagnostics:sigmoidoscopyandcolonoscopywith biopsies.

TreatmentA. Surgicalresectionoftumor:atemporaryorpermanent colostomymaybeperformed.B. Radiationtherapy.C. Chemotherapy.

OLDER ADULT PRIORITY: Abdominal pain, obstruction, and rectal bleeding are common symptoms in the older adult; older adults are at higher risk for complications.

Nursing Interventionsv Goal:Provideinformationtohighriskclients.A. Increasedfiberindiet,withdecreaseinfatandred meat.B. Digitalrectalexamsyearlyafterage40.C. Annualfecaloccultbloodtestingafterage50.D. Flexiablesigmoidoscopy/colonoscopyafterage50, subsequentexamsdependonfindingsandriskfactors.v Goal:Toprovidepreoperativecareasindicatedforabdominallaparotomyandcolostomy(seeAppendix13-8).A. Clientmustusuallyundergoextensivepreoperative bowelpreparation(seeAppendix13-2).B. Determineextentofsurgerytobeperformed,discuss implicationsandplacementofostomyifindicated.v Goal:Toprovideappropriatewoundcarepostoperativeabdominal-perinealresection.A. Forrectalcancer,clientwillfrequentlyhavethree incisionalareas. 1. Abdominalincision. 2. Leftabdominalincisionforcolostomy. 3. Perinealincision.

TEST ALERT: Identify factors interfering with wound healing and or symptoms of infections.

4


B. PerinealwoundmaybeclosedwithaPenrosedrain inserted,ormaybeleftopentohealbysecondary intention. 1. Drainagefromwoundshouldbeserosanguineous. 2. Drainsareleftinplaceuntilthereisminimal(50mL orless)drainage. 3. Ifwoundisleftopenandpacked,theremaybe profusedrainageinitiallyaftersurgery.Check frequently,reinforceandorchangedressingas necessary. 4. Generallyirrigatetheperinealwoundwithsaline. 5. Useawarmsitzbathfor10-20minutestopromote debridement,toincreasecirculationtotheperineal area,andtopromotecomfort.C. Abdominalwoundmayneedfrequentdressingchanges duetoprofuseserosanguineousdrainageimmediately postoperative.D. Usuallythepositionofcomfortisontheside,toprevent pressureonrectalareaandtorelaxabdominalmuscles.E. Keeproomfreeofoffensiveodors,clientmayfeelvery selfconsciousaboutopenwoundandcolostomy.

v Goal:Topreventcomplicationsofimmobilitypostop-erativeabdominal-perinealresection(seeChapter3).v Goal:Tomaintainhomeostasisandpromotewoundhealingpostoperativeabdominal-perinealresection(seeChapter3).A. Provideopportunityforclienttoparticipateincolos- tomycareearlyinrecovery.B. Infections,hemorrhage,wounddisruptionandstoma problemsarenotuncommoninpostoperativeperiod.

Home CareA. Frequentlyfortheolderadultclient,recoveryperiod maybelong;assistclientandfamilytoidentify communityresources.B. Provideinstructionsincareofperinealwoundifitis nothealed. 1. Sitzbaths–therapeuticbath,notacleansingbath, alwayschecktemperatureofwater. 2. Presenceofcontinuousdrainagecouldindicatea fistula.B. Assistclientandfamilytoperformcolostomycare(see Appendix13-8).C. Discussimportantanceofreturningformedicalcheck ups.D. Understandsymptomstoreporttophysician. 1. Increasedpain. 2. Changeinstoolorbleeding. 3. Weightloss. 4. Sustainedvomitinganddiarrhea.

Celiac Disease (Malabsorption Syndrome)

Celiac disease is also known as sprue, gluten enteropathy, and malabsorption syndrome. Conditionresults from an immune reaction to rye, wheat, barley, and oat grains. An inflammatory response causes damage tothemucosaofthesmallintestinesandresultingintheinability to absorb nutrients (malabsorption).

A. Previouslyconsideredadiseaseofchildhoodwith symptomsbeginningbetweentheagesof1yearand 5years;celiacdiseaseisnowcommonlyseenatallages withmeanageofdiagnosisbeing40years.B. Symptomsfrequentlybegininearlychildhood,but conditionmaynotbediagnoseduntilclientisanadult.C. Developmentofceliacdiseaseisdependentongenetic predisposition,ingestionofgluten,andimmune- mediatedresponse.

AssessmentA. Cause:congenitaldefectoranautoimmuneresponsein glutenmetabolism.B. Clinicalmanifestations. 1. Symptomsmaybeginwhenchildhasincreased intakeoffoodscontaininggluten:cereals,crackers, breads,cookies,pastas,etc. 2. Foul-smellingdiarrheawithabdominaldistention andanorexiaininfantsandtoddlers. 3. Poorweightgaininchildren,failuretothrive. 4. Constipation,vomiting,andabdominalpainmaybe theinitialpresentingsymptomsinadults. 5. Vitamindeficiencyleadstocentralnervoussystem impairmentandbonemalformation.C. Diagnostics:biopsyofduodenumandsmallintestine.

TreatmentPrimarilydietarymanagement:gluten-freediet.

Nursing Interventionsv Goal:Tohelpclientandfamilyunderstanddiettherapyandpromoteoptimalnutritionintake.A. Writteninformationregardingagluten-freediet;corn, rice,potato,andsoyproductsmaybesubstitutedfor wheatindiet.B. Dietshouldbewellbalancedandhighinprotein.C. Teachclientand/orfamilyhowtoreadfoodlabelsfor glutencontent;thickenings,soups,instantfoodsmay containhiddensourcesofgluten.D. Importanttodiscussthenecessityofmaintaininga lifelonggluten-restricteddiet;problemsmayoccurin clientswhorelaxtheirdietandexperienceanexacerba- tionofthediseasestate.E. Lackofadherencetodietaryrestrictionsmayprecipi- tategrowthretardation,anemia,andbonedeformities.

✽


B. Stoolsofteners,increasedfiberindiet.C. Sitzbath,ointmentsforcomfort.D. Removalofthehemorrhoidbyligation,infraredcoagu- lationofhemorrhoids,orsurgicalremoval.

Nursing Interventionsv Goal:Toprovideappropriateinformationtoassistcli-enttomanageproblemathome.A. Avoidprolongedstandingorsitting.B. Enouragesitzbathstodecreasediscomfort.C. Applyover-the-counterointmentstodecreasediscom- fort.D. Useanicepackfollowedbyawarmsitzbathifsevere discomfortoccurs.E. Avoidconstipationandstrainingatstool.F. Modifydiettopreventconstipation(e.g.,bulklaxa- tives).v Goal:Tomaintainhomeostasisandpromotehealingpostoperativehemorrhoidectomy.A. Rectalpainmaybequitesevere.B. Assessforurinaryretention.C. Encouragetakingasitzbath2to3timesadayafter surgery;thispromotescleanliness,decreasespain,and increaseshealing.D. Promotepassageofnormalstool. 1. Encouragestoolsoftenersandbulk-forminglaxa- tivespriortosurgerytopreventconstipation(see Appendix13-3). 2. Teachclientnottoresisturgetodefecate. 3. Encourageactivitytopromoteperistalsis.

TEST ALERT: Reinforce client teaching for prevention of constipation.

TEST ALERT: Adapt the diet to meet client’s specific needs.

HemorrhoidsHemorrhoidsaredilatedveinsof theanusandrec-

tum; may be external (outside the external sphincter) or internal (above the internal sphincter).

Data CollectionA. Riskfactors/etiology. 1. Byage50,approximately50%ofpeoplehavethem. 2. Mayappearperiodicallydependingonamountof anorectalpressure. 3. Causedbyconditionsthatincreaseanorectal pressure. a. Pregnancy. b. Prolongedconstipation,obesity. c. Prolongedstandingorsitting. d. Heavyliftingorstraining. e. Portalhypertension.B. Clinicalmanifestations. 1. Externalhemorrhoidsappearasreddishprotrusions attheanus. 2. Internalhemorrhoidsmaybecomeconstrictedand painful,maybleedduringdefecation. 3. Rectalbleeding.C. Diagnostics:rectalexamination.

TreatmentA. Ointmentsandtopicalanestheticstoshrinkmucous membranes.

✽

Study Questions: Gastrointestinal System

1. Aclienthashadextensiveoralsurgeryforcancerofthe mouth.Whatisanimportantnursingmeasurewhen providingoralcareforthisclient? 1 Gentlycleansethemouthwithalemonandglycerin swab. 2 Assisttheclienttorinsehismouthwithaweakbi- carbonatesolution 3 Providefrequentoralcarewithabactericidal mouthwash. 4 Offeronlycoldfoodsthatarenonirritating.2. AclientisplacedonNPOstatusduetoabowelob- struction.Anasogastrictubeisinserted.Whatis thepurposeofthistube? 1 Decreasegastricdistention. 2 Eliminatenauseaandvomiting. 3 Reducepainpostoperatively. 4 Providearoutefortubefeeding.3. Whattypeofstoolcanthenurseexpectfromaclient whohasacolostomyofthelowerdescendingcolon?

1 Liquid. 2 Bloody. 3 Black. 4 Formed.4. Aclienthasjusthadhisnasogastrictuberemoved. Whatwouldbethebestimmediatenursinginterven- tion? 1 Checkforthepresenceofbowelsounds. 2 Assistclientwithoralhygiene. 3 Offertheclientsomeicecream. 4 Palpatetheabdomenfordistention.5. Anurseischangingtheileostomybagonaclientthe dayaftersurgery.Whatisanormalcharacteristicofthe stoma? 1 Pittingedemaaroundbase. 2 Duskygraycolor. 3 Redwithsomeedema. 4 Tissuesloughinginthearea.


6. Whatisimportantforthenursetoassessanddocument inclientswhohavedigestivetractproblems? 1 Peripheraledemaandurinaryoutput. 2 Changesinbowelactivityandweightfluctuation. 3 Decreaseinappetitewithbloodglucoselevelof110 mg/100ml. 4 Alterationinappetitewithachangeindaily activities.7. Whenattemptingtoauscultatebowelsoundsthatare decreasedornoteasilyheard,howlongshouldthe nurselistentoeachquadrant? 1 2minutes. 2 5minutes. 3 30seconds. 4 1minute.8. Whilebeingpreparedforgastroscopy,theclientcom- plainsofexcessivefatigueandsayshedoesnotwant thisproceduredone.Whatisthebestnursingmanage- ment? 1 Wait5minutes;thenreturntopreparetheclient. 2 Explaintotheclienttheimportanceoftheproce- dure. 3 Stopthepreparationandnotifythechargenurse. 4 Callthenurse’sstationandaskforassistance.9. Thenurseiscaringforaclientwhoisbeingprepared forsurgeryforappendicitis.Whatisthepreoperative preparation? 1 Ambulatetodecreaseproblemswithdistention. 2 Administermeperidine(Demerol)forpain. 3 Allowpositionofcomfort;maintainNPO. 4 Putawarmpadonabdomen;offerclearliquids.10. Aclienthasjustreturnedtothenursingunitfollowing agastrectomy.Anasogastrictubeisinplaceand theclientbeginstocomplainofnausea.Whatisthe prioritynursingaction? 1 Gentlyirrigatethenasogastrictubewithnormal saline. 2 Clampthetubefor30minutesandreassessthe client. 3 Measuregastricoutputtodetermineexcessiveacid production. 4 Determineifthenasogastrictubeispatentand draining.11. Aclientisreceivingtubefeedingsviahisnasogastric tube3daysaftersurgery.Whatmethodofadministra- tionofthetubefeedingwouldcausetheclientto experiencetheleastproblemswithtoleranceand absorptionofthefeeding? 1 Diluteformulainfusedviaacontinuousdrip. 2 Fullstrengthformulagivenat50ml/hourviacon- tinuousdrip. 3 250mLofdiluteformulagivenasabolusvia gravityflow. 4 Bolusof300mlfull-strengthformulagivenvia gravityflow.12. Whatwouldbeappropriateteachingforaclientwhois experiencinggastroesophagealrefluxdisease(GERD)?

1 Takeanantacidaftereating. 2 Laydownonyourrightsideaftereating. 3 Increaseintakeoffluidsaftereating. 4 Avoideatingwithin3hoursofbedtime.13. Aclientwithnauseaandvomitingwouldbeplacedin whatpositiontopreventaspiration? 1 Supinewithheadturnedtotheright. 2 Pronewithheadofbedelevated45degrees. 3 Side-lying. 4 Trendelenburg.14. Whatisthedesiredactionofranitidine(Zantac)inthe treatmentofaclientwithagastriculcer? 1 Increasegastricacidproduction. 2 Increaseproductionofbile. 3 Neutralizehydrochloricacidproduction. 4 Decreaseproductionofhydrochloricacid.15. Ontheseconddayaftergastricsurgery,theclient’sna- sogastrictubeisdrainingafluidthatappearstocontain coffeegrounds.Whatisthenurse’sinterpretationof thisdrainage? 1 Thefluidcontainsmucusandstomachcontents. 2 Thedrainageprobablycontainsoldbloodasaresult ofthesurgery. 3 Theclientisactivelybleedingandthetubeshould beirrigated. 4 Thereisanexcessiveamountofbileinthedrainage.16. Thenurseisassessingaclientwhois4-dayspostopera- tiveforanexploratorysurgerysecondarytoaruptured appendix.Whatassessmentfindingwouldsuggest theclientisdevelopingperitonitis? 1 Abdominalpainintheareaoftheincision;painin- creaseswithcoughing. 2 Temperatureincreaseto102˚F;clienthasarigid abdomenanddecreasedorabsentbowelsounds. 3 Purulentdrainagefromthesurgicalwound;nausea andvomitingafterclearliquidintake. 4 Absentbowelsounds,decreasedwhitebloodcell count,low-gradefever.17. Thenurseiscaringforaclientwhoisreceivingtube feedingsviaagastrostomytube.Theorderisfor1⁄2 strengthformulaatacontinuousrateof55mLperhour, in250-mLcans.Howmanycanswouldthenurseanti- cipateusingoveran8-hourperiodoftime? Answer:_______can(s)18. Dietarymodificationshavenotbeensuccessfulinpre- ventingconstipationinanolderclient.Whatover-the- counterpreparationswouldthenurserecommendto assisttheclientinthepreventionofconstipation? 1 Uselaxativesthatstimulateperistalsisandpromote dailybowelmovements. 2 Takeabulklaxativethatcontainspsylliumwitha fullglassofwatereverymorning. 3 Increaseintakeofrawfruitsandvegetables. 4 Administeratapwaterenemaeveryotherday.

Answers and rationales to these questions are in the section at the end of the book titled Chapter Study Questions: An-swers and Rationales.


Appendix 13-1 GAStROINtEStINAl SyStEM DIGNOStICS

X-RayUpper Gastrointestinal Series or Barium SwallowX-rayexaminationusingbariumasacontrastmaterial;usedtodiagnosestructuralabnormalitiesandproblemsoftheesophagusandstomach.

Nursing Implications1. Explainproceduretoclient(usuallynotdoneonclientwithundiagnosedabdominalpainuntilthepainisdiagnosedandthepossibility ofperforationhasbeenruledout).2. Maintainclient’snothingbymouth(NPO)statusatleast6hoursbeforeprocedure.3. Afterexamination,administeralaxativeandencourageincreasedfluidintaketopreventconstipationandtopromoteevacuation ofbarium.5. Stoolshouldreturntonormalcolorwithin72hours.

Lower Gastrointestinal Series or Barium EnemaX-rayexaminationofthecoloninwhichbariumisusedasacontrastmedium;bariumisadministeredrectally.

Nursing Implications1. Clientmayhaveclearliquidstheeveningbeforethetest;maintainclient’sNPOstatusfor8hoursbeforetest.2. Colonmustbefreeofstool;bowelevacuantsareadministeredthedaypriortothetest,enemasmaybeadministeredthedayof thetest.(Appendix13-2)3. Explaintoclientthatheorshemayexperiencecrampingandfeeltheurgetodefecateduringtheprocedure.4. Aftertheprocedure,increasefluidsandadministeralaxativetoassistinexpellingthebarium.

EndoscopyGastroscopy, Esophagogastroduodenoscopy (EGD), Colonoscopy, SigmoidoscopyEndoscopyisthedirectvisualizationoftheesophagus,stomachandduodenumthroughaflexible,lightedscope.Inflammation,ulcerations,tumorsandesophagealvaricesmaybeidentified.Biopsyspecimensmaybeobtainedandbenignpolypsmayberemoved.

Nursing Implications Before Procedure1. UpperGI:NPOforupto12hoursbeforeprocedure.2. LowerGI:bowelprep—bowelevacuantsand/orenemas,clearliquiddietfor24hourspriortotest.3. Clientshouldavoidaspirin,NSAIDs,ironsupplements,andgelatincontainingredcoloringforseveraldayspriortoprocedure.4. Maygivepreoperativemedicationforrelaxationandtodecreasesecretions.5. ForupperGIstudies,atopicalanesthesiawillbeusedtoanesthetizethethroatbeforeinsertionofthescope.6. UpperGIstudies:assessclient’smouthfordenturesandremovablebridges.7. LowerGIstudies:helpclientintotheleftside-lyingposition,encouragetheclienttotakeadeepbreathduringtheinsertionofthescope; clientmayfeelurgetodefecateasscopeispassed.8. ConscioussedationfrequentlyusedforlowerGIstudiesorcolonoscopy.

Nursing Implications Before Procedure1. Immediatelypriortoprocedure,verifyinformedconsentandclientidentification.2. ConfirmNPOstatusforpast8hours;forlowerGIstudies,confirmbowelpreparation.3. Maintainsafety:airwayprecautionsduringsedation;positioning,monitorlevelofsedation(Chapter3).

Nursing Implications Before Procedure1. UpperGI:maintainclient’sNPOstatusuntilthegagreflexreturns;positionclientonhisorhersidetopreventaspirationuntilgagor coughreflexreturns;usethroatlozengesorwarmsalinesolutiongarglesforreliefofsorethroat.2. MonitorvitalsignsandO2saturationduringrecovery.3. Observeforsignsofperforation:upperGIbleeding—dysphagia,substernalorepigastricpain;lowerGIbleeding—rectalbleeding, increasingabdominaldistention.4. Assistclienttouprightposition:observefororthostatichypotension.5. Warmsitzbathforanyanaldiscomfort.

Continued


Appendix 13-1 GAStROINtEStINAl SyStEM DIGNOStICS—cont’d.

ANALYSIS OF SPECIMENSParacentesis; Diagnostic Peritoneal LavageProcedure:Acatheterisinsertedintotheperitonealcavity,mostoftenjustbelowtheumbilicus.

Purpose1. Todetermineintra-abdominalbleeding.2. Toassessforpresenceandordrainageofascites.3. Toidentifycauseofacuteabdominalproblems(e.g.,perforation,hemorrhage).

Nursing Implications1. Anasogastrictubemaybeusedtomaintaingastricdecompressionduringprocedure.2. Havetheclientvoidbeforetheprocedure,ifclienthasafullbladderatthetimeofinsertionofthecatheter,riskforbladderperforation andperitonitisisincreased.3. Inclientswithchronicliverproblems,assesscoagulationlabvaluesbeforeprocedure.4. Placeclientinsemi-Fowler’sposition.5. Maintainsterilefieldforpuncture.6. Inclientswithascites,usuallydonotdrainmorethan1L.

Complications1. Perforationofbowel:peritonitis.2. Introductionofairintoabdominalcavity;clientmaycomplainofrightreferredshoulderpain(causedbyairunderthediaphragm).3. Contraindicatedinpregnancyandinclientswithcoagulationdefectsorpossiblebowelobstruction.

STOOL EXAMINATIONStoolisexaminedforformandconsistencyandtodeterminewhetheritcontainsmucus,blood,pus,parasites,orfat.Stoolwillbeexaminedforpresenceofoccultblood.

Nursing Implications1. Collectstoolinsterilecontainerifexaminingforpathologicorganisms.2. Afresh,warmstoolisrequiredforevaluationofparasitesorpathogenicorganisms.3. Collectthesamplefromvariousareasofthestool.4. Theresultoftheguaiactestforoccultbloodispositivewhenthepaperturnsblue.5. Documentmedicationsandover-the-counterdrugsclientistakingwhensampleisobtained.

NURSING PROCEDURE: STOOL SPECIMEN

4 KEY POINTS: Collecting the Specimen• Alwayswearglovesduringprocedure.

• Usecleanbedpanorbedsidecommodetocollectstool;donotusestoolthathasbeenincontactwithtoiletbowlwaterorurine.

• Collectstoolspecimeninaclean,drycontainer.Ifstoolistobeevaluatedfororganisms,useasterilecontainer.Useatonguebladeto

obtainspecimensfromseveralareasofthestoolandplaceinthestoolcollectioncontainer.

• Theclientcollectingastoolspecimenforanoccultbloodtestneedstofollowdirectionsregardingdietrestrictions(noredmeat,beets,or

foodsthatmaycausethestooltoturnredorleadtoafalse-positiveresult).

• Stoolspecimenshouldbeapproximatelysizeofawalnut.Ifstoolisliquid,approximately30mLisneeded.

• Takethespecimentothelaboratory.Donotallowittoremaininunit.

TEST ALERT: Obtain specimen from client for laboratory tests.


Appendix 13-2 GAStROINtEStINAl MEDICAtIONS

ANTIEMETICS

Medications Side Effects Nursing Implications

DopamineAntagonistsDepressorblocksdopaminereceptorschemoreceptortriggerzoneofthebrain.

Phenothiazines—suppressemesisChlorpromazinehydrochloride(Thorazine):PO,suppository,IMPromethazine(Phenergan):PO,IM,suppositoryProchlorperazine(Compazine):PO,suppository,IMThiethylperazinemaleate(Torecan):PO,suppository,IM

Prokinetics—stimulatemotilityMetoclopramide(Reglan):PO,IM,IV

Centralnervoussystemdepression,drowsiness,dizziness,blurredvision,hypotension,photosensitivity

Restlessness,drowsiness,fatigue,anxiety,headache

1. Subcutaneousinjectionorintravenousadministrationmaycausetissueirritationandnecrosis.2. Usewithcautioninchildren–causeofnauseaneedstobeinvestigated.3. Thorazineshouldbeusedonlyinsituationsofseverenauseaorvomiting.Canalsobeusedforintractablehiccups.4. Torecan:usedwithcautioninclientswithliverandkidneydiseases.

1. Usedtodecreaseproblemswithesophagealrefluxandnauseaandvomitingassociatedwithchemotherapy.2.Usewithcautioninclientswithundiagnosedabdominalpain;couldprecipitateaperforation.

AntihistaminesDepressthechemoreceptortriggerzone,blockhistaminereceptors.

Hydroxyzine(Atarax, Vistaril):PO,IMDimenhydrinate(Dramamine, Marmine):PO,suppository,IM

Sedation;anticholinergiceffects—blurredvision,drymouth,difficultyinurinationandconstipation;paradoxicalexcitationmayoccurinchildren

1. Cautionclientregardingsedation:shouldavoidactivitiesthatrequirementalalertness.2. Administerearlytopreventvomiting.3. Usewithcautioninclientswithglaucomaandasthma.4. Subcutaneousinjectionmaycausetissueirritationandnecrosis;useZ-trackinjectiontechnique.

LAXATIVES

General Nursing Implications— Laxatives should be avoided in clients who have nausea, vomiting, undiagnosed abdominal pain and cramping, and/or any indications of appendicitis.— Dietary fiber should be taken for prevention of, and as first-line treatment for, constipation.— Encourage increase in daily fluid intake. — Increasing activity will increase peristalsis and decrease constipation.— Narcotic analgesics and anticholinergics will increase problem with constipation.— A laxative should be used only briefly and in the smallest amount necessary.— Use laxatives with caution during pregnancy.

Continued


Appendix 13-2 GAStROINtEStINAl MEDICAtIONS—cont’d.


Bulk laxatives—stimulateperistalsisandpassageofsoftstoolMethylcellulose(CITRUCEL)Psyllium(Metamucil, Perdiem)FiberconBranSurfactants—decreasesurfacetension,allowingwatertopenetratefeces.Docusate(Colace, Surfak)

Stimulants—stimulateandirritatethelargeintestinetopromoteperistalsisanddefecationBisacodyl(Dulcolax):suppository,POSennaconcentrate(Senokot, Ex-Lax):PO,suppository

Bowel evacuants—nonabsorbableosmoticagentsthatpullfluidintothebowelPolyethyleneglycol(GoLYTELY, Colyte):PO,NGMagnesiumcitrate:PO

Esophagealirritation,impaction,ab-dominalfullness,flatulenceOccasionalmildabdominalcramping

Diarrhea,abdominalcramping

Nausea,bloating,abdominalfullness.

1. Notimmediatelyeffective;12to24hoursbeforeeffectsareapparent.2. Usewithcautioninclientswithdifficultyswallowing.3. Administerwithfullglassoffluidtopreventproblemswithirritationandimpaction.

1.Donotuseconcurrentlywithmineraloil.2. Notrecommendedforchildrenlessthan6yearsold.

1.Useforshortperiodoftime.2.DonotuseinpresenceofundiagnosedabdominalpainorGIbleeding.

1. Primaryuseisinpreparingforbowelforexamination.2. Clearliquidsonly(noredgelatin,orreddrinks)afteradministration.3. GoLYTELYrequirestheclienttodrinkalargeamountoffluid(4L);provide8to10ozchilledatatimetoincreaseclientconsumptionandenhancetaste.4. Bestifconsumedover3to4hours.5. Evacuantscausefrequentbowelmovements;adviseclienttoplanaccordingly.

ANTIEMETICS


Anhydrousmorphine(Paregoric): PO

DiphenoxylateHClAtropine(Lomotil):POLoperamideHCl(Imodium, KaopectateIIcaplets):POBismuthsubsalicylate(Kaopectate, Pepto-Bismol):PO

Lightheadedness,dizziness,seda-tion,nausea,vomiting,paralyticileus,abdominalcramping

Mayprecipitateconstipationandanimpaction

1.Opioidderivatives,suppressperistalsis.2. Notrecommendedduringpregnancyorbreastfeeding.3.Canproducedependenceandmildwithdrawalsymptoms.4. Encourageincreasedfluids.5. Avoidactivitiesthatrequirementalalertness.

1.Mayinterferewithabsorptionoforalmedications.2.Causeofdiarrheashouldbeidentifiedpriortoadministeringmedications.3. Shouldnotbegiventoclientswithfevergreaterthan101°.4. Donotgiveinpresenceofbloodydiarrhea.

Continued


Appendix 13-2 GAStROINtEStINAl MEDICAtIONS—cont’d.

INTESTINAL ANTIBIOTICS AND ANTIINFLAMMATORY MEDICATIONS


IntestinalAntibioticsDecreasebacteriaintheGItract;usedtosterilizebowelbeforesurgery.

Kanamycinsulfate(Kantrex):PONeomycinsulfate(Mycifradinsulfate):PO

Paromomycin(Humatin):PO

Suprainfectionofthebowel

Vomitinganddiarrhea

1.Donothavesideeffectsofparenterallyadministeredaminoglycosides.

1. Administerwithmeals.2. Administerwithcautioninclientswithulcerativeboweldisease.

5 Aminosalicylates (5 ASA)Antiinflammatoryeffectinsmallbowelandcolon,usedtotreatclientwithinflammatoryboweldisease(IBD).

Sulfasalazine(Azulfidine):PO

Mesalamine(Asacol):PO,(Pentasa)POentericcoatedtablet(Rowsa)Suppositoryorenema

Balsalazide(Colazal)PO

Nausea,feverrash,arthalgia

GIsymptoms,headache

Abdominalpain,headache,

1. Assessclientforallergytosulfur.2. Shouldnotbeusedwiththiazidediuretics.3.MonitorCBC,encouragefluidstomaintainhydration.4Maycontinueonmedicationtomaintainremission.

1. Suppositoryorenemahasminimalsystemiceffects.2. Rectaladministrationisusuallyatnight.

GI,Gastrointestinal;IM,intramuscular;IV,intravenous;NSAID,nonsteroidalantiinflammatorydrug;PO,bymouth(orally);PUD,pepticulcerdisease.


Appendix 13-3 ANtIUlCER AGENtS


AntacidAnalkalinesubstancethatwillneutralizegastricacidsecretions;nonsystemic.Somecombinationantacidsalsorelievegas,andsomeworkaslaxatives.SeveralantacidsformaprotectivecoatingonthestomachandupperGItract.

Aluminumhydroxide(Amphojel)

Aluminumhydroxideandmagnesiumsaltcombinations(Gelusil, Maalox, Gaviscon)SodiumpreparationsSodiumbicarbonate(Rolaids, Tums):PO

Sodium preparationsSodiumbicarbonate(Rolaids, Tums):PO

Constipation,phosphorusdepletionwithlong-termuse

Constipationordiarrhea,hypercal-cemia,renalcalculi

Reboundacidproduction,alkalosis

1. Avoidadministrationwithin1to2hoursofotheroralmedications;shouldbetakenfrequently—beforeandaftermealsandatbedtime.2. Instructclientstotakemedicationeveniftheydonotexperiencediscomfort.3. Clientsonlow-sodiumdietsshouldevaluatesodiumcontentofvariousantacids.4. Administerwithcautiontotheclientwithcardiacdisease,becauseindigestionmaybecharacteristicofanginalpainandcardiacischemia.

1. Discourageuseofsodiumbicarbonatebecauseofoccurrenceofmetabolicalkalosisandreboundacidproduction.

HistamineH2ReceptorAntagonistsReducevolumeandconcentrationofgastricacidsecretion.

Cimetidine(Tagamet):PO,IV,IM

Ranitidine(Zantac):PO,IM,IV

Nizatidine(Axid):POFamotidine(Pepcid):PO,IV

Rash,confusion,lethargy,diarrhea,dysrhythmias

Headache,GIdiscomfort,jaundice,hepatitis

Anemia,dizzinessHeadache,dizziness,constipation,diarrhea

1. Take30minutesbeforeoraftermeals.2. MaybeusedprophylacticallyorfortreatmentofPUD.3. Donottakewithoralantacids.

1. Usewithcautioninclientswithliverandrenaldisorders.2. Donottakewithaspirinproducts.3. Wait1hourafteradministrationofantacids.

1. Usewithcautioninclientswithrenalorhepaticproblems.2. Dosingmaybedonewithwithoutregardtofoodortomealtime.3. CautionclientstoavoidaspirinandotherNSAIDs.

ProtonPumpInhibitorsInhibittheenzymethatproducesgastricacid.

Omeprazole(Prilosec):POLansoprazole(Prevacid):PO

Headache,diarrhea,dizziness 1. Administerbeforemeals.2. Donotcrushorchew;donotopencapsules3. SprinklegranulesofPrevacidoverfood;donotchewgranules.4. Thecombinationofomeprazole(Prilosec)withclarithromycin(Biaxin)effectivelytreatsclientswithHelicobacterpyloriinfectioninduodenalulcer.

CytoprotectiveAgentsBindtodiseasedtissueprovidesaprotectivebarriertoacid.

Sucralfate(Carafate):PO Constipation,GIdiscomfort 1. Avoidantacids.2. Usedforpreventionandtreatmentofstressulcers,gastriculceration,andPUD.3. Mayimpedetheabsorptionofmedicationsthatrequireanacidmedium.

ProstaglandinAnaloguesSuppressesgastricacidsecretion;increasesprotectivemucusandmucosalbloodflow.

Misoprostol(Cytotec) GIproblems,headache 1. Contraindicatedinpregnancy.2. IndicatedforpreventionofNSAID-inducedulcers.

GI,Gastrointestinal;IM,intramuscular; IV,intravenous;NSAID,nonsteroidalantiinflammatorydrug;PO,bymouth(orally);PUD,pepticulcerdisease.


ANursing Implications1. Parenteralnutritionsolutioniscustomizedinthehospitalpharmacyspecificallyfortheclient’smostrecentbloodanalysisfindings; nothingshouldbeaddedtosolutionafterithasbeenpreparedinthepharmacy.2. Ordersarewrittendaily,basedonthecurrentelectrolyteandproteinstatus;alwayscheckthedoctor’sorderforcorrectfluidfortheday.3. Solutionmayberefrigeratedforupto24hours,butsolutionshouldbetakenoutofrefrigeration30minutespriortoinfusion.Ifsolution hasbeenhangingfor24hours,itshouldbediscardedandanewbagofsolutionhung.4. Donotrandomlyacceleratetheinfusionto“catchup”overanhour;parenteralnutritionmustbecarefullymonitoredandadministered viaaninfusionpump.5. Monitorserumbloodglucoselevelsonaregularbasis;someinstitutionsrequireglucosetestingevery4to6hours.Maybeless frequentafterfirstweekofadministration.6. Infusionisinitiatedanddiscontinuedonagradualbasistoallowthepancreastocompensateforincreasedglucoseintake.If parenteralnutritionsolutionsistemporarilyunavailable,checkwithRNregardingfluidtohanguntilparenteralsolutionisavailable.7. Monitorintakeandoutputandcomparedailytrends.Bodyweightisanindicationoftheadequacyofhydration.Tissuehealingisan indicationofadequacyofproteinandpositivenitrogenbalance.8. Checklabelonbagofsolutionagainstorders;checksolutionforleaks,clarity,orcolorchanges.

Maintenance1. Asterileocclusivedressingshouldbeusedatthecathetersite,changesitedressingevery48-72hoursorperfacilityprotocol.2. ChangeIVtubingevery24hoursorperfacilityprotocol;3. Donotdrawbloodormeasurecentralvenouspressure(CVP)fromthePNline.4. Maintainrecordofdailyweight;desiredweightgainisapproximately2poundsperweek.

Complications1. Hyperglycemiamaybecausedbytoorapidinfusionofsolution.Bloodglucoseismonitoredevery4to6hoursduringinitialinfusion, andslidingscaleinsulinmaybeordered.3. Siteinfection:Monitorsiteandchangedressingaccordingtopolicy;importanttofollowsterileguidelinesindressingchanges.Clients maybeimmunosuppressedandsignsofinfectionmaybemasked.Ifinfectionissuspected(erythema,tenderness,exudates),theRN shouldbenotifiedimmediately.5. Airembolusorriskforpneumothorax(centralline):Increasedtendencytooccurduringinsertionofcentralcatheterlineandduring dressingchanges;placeclientinTrendelenburgpositionduringinsertionandduringdressingchanges.

TEST ALERT: Monitor and provide for client’s nutritional needs.

Appendix 13-4 PARENtERAl NUtRItION

Parenteral Nutrition (PN or TPN for total parenteral nutrition): Anintravenous(IV)deliveryofhighlyconcentratednutrientsandvitamins.

1. Goalistoprovideadequatenutritiontopromotehealingandgrowthofnewbodytissue.2. Utilizedinconditionsthatinterferewiththeprocessofnutritionorinclientswhorequireanextensiveamountofnutrientsfor healing(burnclients).Goal: Tomaintainclientinpositivenitrogenbalanceandpromotehealing.

Routes of Administration1. Peripheral:Peripheralparenteralnutrition(PPN)isadministeredviaalargeperipheralveinorperipherallyinsertedcentralcatheter (PICC)whennutritionalsupportisindicatedforashortperiod.MayuseIVfat(lipid)emulsions.2. Central:Parenteralnutrition(PNorTPN)isadministeredviaaparenteralline(PICC,Hickman,Broviac,centralline)insertedinthe antecubital,jugularorsubclavianveinandthreadedintothevenacava;usedfornutritionalsupportintheclientwhorequiresinexcess of2500caloriesperdayforanextendedperiod.Solutionsusedarehypertonicwithhighglucosecontentandrequirerapiddilution.


• Beforeinsertion,positiontheclientinhigh-Fowler’sposition,ifpossible.(Ifclientcannottoleratehigh-Fowler’s,placeinleft

lateralposition.)

• Useawater-solublelubricanttofacilitateinsertion.

• Measurethetubefromthetipoftheclient’snosetotheearlobeandfromthenosetothexiphoidprocesstodeterminetheapproximate

amountoftubetoinserttoreachthestomach.

• Insertthetubethroughthenoseintothenasopharyngealarea;flextheclient’sheadslightlyforward.

• Offertheclientsipsofwaterandasktheclienttoswallow;astheswallowoccurs,progressthetubepasttheareaofthetracheaandinto

theesophagusandstomach.Withdrawtubeimmediatelyifclientexperiencesrespiratorydistress(coughingorhoarsevoice).

• Securethetubetothenose;donotallowthetubetoexertpressureontheupperinnerportionofthenares.

• Validatingplacementoftube.

a. Aspirategastriccontents.

b. MeasurepHofaspiratedfluid(pHofgastricsecretionsisusuallylessthan4).

c. Itisno longer recommendedtodetermineplacementbyinjectingairandlisteningwithastethoscopeforsoundofairinthestomach.

d. Alwaysvalidateplacementofanasogastrictubepriortoinstillinganythingintotube.

e. Afterinitialplacement,requestvalidationbyx-ray.

• Characteristicsofnasogastricdrainage.

a. Normallyisgreenishyellow,withstrandsofmucus.

b. Coffee-grounddrainage:oldbloodthathasbeenbrokendowninthestomach.

c. Brightredblood:indicatesbleedingintheesophagus,thestomach,orthelungs.

d. Foul-smelling(fecalodor):occurswithreverseperistalsisinbowelobstruction;increaseinamountofdrainagewithobstruction.

• Ifduodenalplacementisrequired,haveclientlayinrightlateralpositionforseveralhours.Provideenoughexcessinthetubetoallowthe

tubetomigratedownintoduodenum.

Clinical Tips for Problem Solving• Abdominaldistention:Checkforpatencyandadequacyofdrainage,determinepositionoftube,assesspresenceofbowelsounds,and

assessforrespiratorycompromisefromdistention.

• Nauseaandvomitingaroundtube:Placeclientinsemi-Fowler’spositionorturntosidetopreventaspiration;suctionoralpharyngeal

area.Attempttoaspirategastriccontentsandvalidateplacementoftube.Tubemaynotbefarenoughintostomachforadequate

decompressionandsuction;tryrepositioning.Iftubepatencycannotbeestablished,tubemayneedtobereplaced.

• Inadequateorminimaldrainage:Validateplacementandpatency;tubemaybeintoofarandbepastpyloricvalveornotinfarenough

andintheupperportionofthestomach.Reassesslengthoftubeinsertionandcharacteristicsofdrainage,requestx-rayforvalidation.

TEST ALERT: Check client feeding tube placement and patency.

TEST ALERT: ALWAYS check the placement of a gastric tube before irrigating it or administering medications; placement should be checked each shift; do not adjust or irrigate the nasogastric tube on a client after a gastric resection or bariatric surgery.

Appendix 13-5 NURSING PROCEDURE: NASOGAStRIC tUBES 1. Levintube:Singlelumen. a. Suctioninggastriccontents. b. Administeringtubefeedings.2. Salemsumptube:Doublelumen(smallerbluelumenventsthetubeandpreventssuctiononthegastricmucosa;maintainsintermittent suction,regardlessofsuctionsource). a. Suctioninggastriccontentsandmaintaininggastricdecompression. b. Donotclamp,irrigate,orapplysuctiontoairventtube. c. Connecttocontinuouslowsuction.

4 KEY POINTSInsertfeeding/nasogastric

TEST ALERT: Insert nasogastric tube.


Appendix 13-6 NURSING PROCEDURE: ENtERAl FEEDING

Short-Term1. Nasogastric:Providesalternativemeansofingestingnutrientsforclients.

2. Nasointestinal:Aweightedtubeofsoftmaterialisplacedinthesmallintestinetodecreasechanceofregurgitation.Astyletorguide

wireisusedtoprogressthetubeintotheintestine.Donotremovestyletuntiltubeplacementhasbeenverifiedviax-ray.Donotattempt

toreinsertstyletwhiletubeisinplace;thiscouldresultinperforationofthetube.

Long-Term1. Percutaneous endoscopic gastrostomy (PEG):Atubeisinsertedpercutaneouslyintothestomach;localanesthesiaandsedationare

usedfortubeplacement.

2. Percutaneous endoscopic jejunostomy (PEJ):Atubeisinsertedpercutaneouslyintothejejunum.

3. Gastrostomy:Asurgicalopeningismadeintothestomach,andagastrostomytubeispositionedwithsutures.

Methods of Administering Enternal Feedings• Continuous:Controlledwithafeedingpump.Decreasesnauseaanddiarrhea.

• Intermittent:Prescribedamountoffluidinfusesviaagravitydriporfeedingpumpoverspecifictime.Forexample,350mLisgivenover

30minutes.

• Cyclic:Involvesfeedingsolutioninfusedviaapumpforapartofaday,usually12to16hours.Thismethodmaybeusedforweaning

fromfeedings.

Nursing Implications

• Theclientshouldbesittingorlyingwiththeheadelevated30to45°.Headofbedshouldremainelevatedfor30to60minutesafter

feedingifintermittentorcyclicfeedingisused.

• Iffeedingsareintermittent,tubeshouldbeirrigatedwithwaterbeforeandafterfeedings.

• Tubepositionshouldbevalidatedevery4to6hoursforfirst24hours,thenbeforeeachintermittentfeeding,andthenevery8hoursif

oncontinuousfeedings.Gastriccontentsareaspirated,andphischecked.ApHoflessthan4indicatesgastriccontents.

• Aspirategastriccontentstodetermineresidual.Ifresidualismorethan200mL,andtherearesignsofintolerance(nausea,vomiting,

distention),holdnextfeedingfor1hourandrecheckresidualor,ifresidualisgreaterthanhalfoflastfeeding,delaynextfeedingfor

1to2hours.

• Returnaspiratedcontentstostomachtopreventelectrolyteimbalance.

• Flushthetubewith30to50mLofwater:

a. Aftereachintermittentfeeding.

b. Every4to6hoursforcontinuousfeeding.

c. Beforeandaftereachmedicationadministration.

• WhenaPEGorPEJtubeisplaced,immediatelyafterinsertionmeasurethelengthofthetubefromtheinsertionsitetothedistalendand

markthetubeattheskininsertionsite.Thistubeshouldberoutinelycheckedtodeterminewhetherthetubeismigratingfromthe

originalinsertionpoint.

• Preventdiarrhea:

a. Slow,constantrateofinfusion.

b. Keepequipmentcleantopreventbacterialcontamination.

c. Checkforfecalimpaction;diarrheamaybeflowingaroundimpaction.

d.Identifymedicalconditionsthatwouldprecipitatediarrhea.

• Forcontinuousfeeding,changefeedingreservoirevery24hours.

TEST ALERT: Provide feeding and care for client with an enteral tube.

NURSING PRIORITY: If in doubt of the placement of a nasogastric tube or an enteral feeding tube, stop or hold the feeding and obtain x-ray confirmation of location.4


Appendix 13-7 NURSING PROCEDURE: ENEMAS

Types of EnemasSoapsudsenema:Castilesoapisaddedtotapwaterornormalsaline.Dilute5mLofcastilesoapin1literofwater.

Tapwaterenema:Usecautionwhenadministeringtoadultswithalteredcardiacandrenalreserveandtochildrenandinfants.Checkwith

RNregardingspecificamountoffluidtouse.

Salineenemas:thesafestenemastoadminister;safeforinfantsandchildren.

Retentionenema:Anoilbasedsolutionthatwillsoftenthestool.Shouldberetainedbyclient30to60minutes.Typically150to200mL.

Maybemineraloilorsimilaroil;ormayincludeantibioticsornutritivesolution.

Hyptertonicenema:Usedwhenonlyasmallamountoffluidistolerated(120-180mL).CommerciallypreparedFleetsenema.

Carminativeenema:AnagentusedtoexpelgasfromtheGItract.Exampleismagnesiumsulfate/glycerin/water(MGW).

Harrisflushorreturnflowenema:Mildcolonicirrigationof100to200mLoffluidintoandoutoftherectumandsigmoidcolontostimulate

peristalsis.Repeatedmultipletimesbyraisingandloweringcontaineruntilflatusisexpelledandabdominaldistentionisrelieved.

4 KEY POINTS: Administering an Enema• Fillenemacontainerwithwarmedsolution.

• Allowsolutiontorunthroughthetubingbeforeinsertingintorectumsothatairisremoved.

• PlaceclientonleftlateralSims’position.

• Generouslylubricatethetipofthetubingwithwater-solublelubricant.

• Gentlyinserttubingintoclient’srectum(3to4inchesforadults,1inchforinfants,2to3inchesforchildren),pasttheexternal

andinternalsphincters.

• Raisethesolutioncontainernomorethan12to18inchesabovetheclient.

• Allowsolutiontoflowslowly.Iftheflowisslow,theclientwillexperiencefewercramps.Theclientwillalsobeabletotolerateand

retainagreatervolumeofsolution.

Clinical Tips for Problem SolvingIfclientexpelssolutionprematurely:

• Placeclientinsupinepositionwithkneesflexed.

• Slowthewaterflowandcontinuewiththeenema.

Iftheenemareturnscontainfecalmaterialbeforesurgeryordiagnostictesting:

• Repeatenema.

• Ifafterthreeenemas,returnsstillcontainfecalmaterial,notifyhealthcareprovider.

If client complains of abdominal cramping during instillation of fluid:

• Slowtheinfusionratebyloweringthefluidbag.

TEST ALERT: Assist and intervene with client who has an alteration in elimination.


Appendix 13-8 CARE OF tHE ClIENt WItH AN OStOMy

Colostomy:Openingofthecolonthroughtheabdominalwall;stoolisgenerallysemisoftandbowelcontrolmaybeachieved.

Ileostomy:Openingoftheileumthroughtheabdominalwall;stooldrainageisliquidandexcoriating;drainageisfrequentlycontinuous;thereforeit

isdifficulttoestablishbowelcontrol.Fluidandelectrolyteimbalancesarecommoncomplications.

Kock’sileostomy:Maybereferredtoasa“continent”ileostomy;aninternalreservoirforstoolissurgicallyformed.Decreasesproblemofskincare

causedbyfrequentirritationofstomabydrainage.Complicationsmayincludeleakageatthestomasiteandperitonitis.

4 KEY POINTS: Nursing Implications—Initial Care• Selectaflatareaoftheabdomen,avoidingskincreasesandfolds;selectsitethatdoesnotinterferewithclothing.

• Postoperativelyevaluatestomaevery8hoursaftersurgery.Itshouldremainpinkandmoist;darkbluestomaindicatesischemia.

• Measurethestomaandselectanappropriatelysizedappliance.Mildtomoderateswellingiscommonforthefirst2to3weeksaftersurgery,

whichnecessitateschangesinsizeoftheappliance.

• Applianceshouldfiteasilyaroundthestomaandcoverallhealthyskin.

• Keeptheskinaroundthestomaclean,dry,andfreeofstoolandintestinalsecretions.Preventcontaminationoftheabdominalincision.

• Changetheskinapplianceonlywhenitbeginstoleakorbecomesdislodged.

• Ostomybagsshouldbechangedwhenaboutone-thirdfulltoavoidweightofbagdislodgingskinbarrier.

Figure 13-6 Types of Ostomies

Continued


Appendix 13-8 CARE OF tHE ClIENt WItH AN OStOMy —cont’d.

4 KEY POINTS: Irrigation• Donotirrigateanileostomyormaintainregularirrigationsinchildwithcolostomy.

• Irrigatecolostomyatsametimeeachdaytoassistinestablishinganormalpatternofelimination.

• Involveclientincareasearlyaspossible.

• Inadults,irrigatewith500to1000mLofwarmtapwater.

• Placetheclientinasittingpositionforirrigation,preferablyinthebathroomwiththeirrigationsleeveinthetoilet.

• Elevatethesolutioncontainerapproximately12to20inchesandallowsolutiontoflowingently.Ifcrampingoccurs,lowerfluidor

clampthetubing.

• Allow25to45minutesforreturnflow.Clientmaywanttowalkaroundbeforethereturnstarts.

• Encourageclienttoparticipateincareofhisorherowncolostomy.Haveclientperformreturndemonstrationofcolostomy

irrigationbeforeleavingthehospital.

• Assisttheclienttocontrolodors:dietandodor-controltablets.

• Kock’sileostomyisdrainedwhenclientexperiencesfullness.Anipplevalveiscreatedinsurgeryanddrainedbyinsertionofacatheter.

Clinical Tips for Problem SolvingIf water does not flow easily into colostomy stoma:

• Checkforkinksintubingfromcontainer.

• Checkheightofirrigatingcontainer.

• Encourageclienttochangepositions,relax,andtakeafewdeepbreaths.

If client experiences cramping, nausea, or dizziness during irrigation:

• Stopflowofwater,leavingirrigationconeinplace.

• Donotresumeuntilcrampinghaspassed.

• Checkwatertemperatureandheightofwaterbag;ifwateristoohotorflowstoorapidly,itcancausedizziness.

Ifclienthasnoreturnofstoolorwaterfromirrigation:

• Encourageambulation,besuretoapplydrainablepouch;solutionmaydrainasclientmovesaround.

• Haveclientincreasefluidintake.

• Repeatirrigationnextday.

Ifdiarrheaoccurs:

• Donotirrigatecolostomy.

• Checkclient’smedications;sometimestheymaycausediarrhea.

• Ifdiarrheaisexcessiveand/orprolonged,notifyRN.

NURSING PRIORITY: - Use a cone tipped ostomy irrigator; do not use an enema tube/catheter. - Do not irrigate more than once a day. - Do not irrigate in the presence of diarrhea.

4

TEST ALERT: Intervene to improve client elimination by instituting bowel management.

gastrointestinal system - nursing ednursinged.com/pnbook/nclex-pn_chapter_13_bwfinal.pdf ·...

Documents