husni rousan1 function of g i system the primary digestive functions are 1.break down food particles...
Post on 21-Dec-2015
218 views
TRANSCRIPT
Husni Rousan 1
Function of G I system
The Primary Digestive Functions are
1. Break down food particles “molecular forms”
2. Absorb into the bloodstream the small molecules
3. Eliminate waste products & undigested food
Husni Rousan 2
Function of G I system
Chewing & Swallowing1. 1.5 L of saliva are secreted daily2. Ptyalin “salivary amylase” starch digestion3. Saliva lubricate food as it chewed & swallowed Gastric function1. Hydrochloric acid to destruct most ingest
bacteria ,& break down food2. Pepsin for initiation of protein digestion 3. Intrinsic factors4. The food mixed with gastric secretions is
called chyme
Husni Rousan 3
Function of G I system
Small Intestine function1. Pancreas :
-Trypsin aids in digestion of proteins -Amylase aids in digestion starch -Lipase aids in digestion of fats
2. Liver : bile aids in emulsifying ingested fats3. Intestinal Glands :secrete
mucus ,hormones ,electrolytes ,and enzymes4. Two types of contractions Segmentation contraction Intestinal peristalsis
Husni Rousan 4
Function of G I system
Colonic Function
1. Two types of colonic secretion -Mucus: protect colonic mucosa -Electrolytes: mainly “HCo3” neutralize the end products
2. Slow peristaltic to allow absorption of water & electrolytes
Husni Rousan 5
Assessment
Health history ( diet history ,appetite , weight gain & loss , stool ch.ch.,& eating pattern
Clinical Manifestations :- 1. Pain2. Indigestion3. Intestinal Gas4. Nausea & Vomiting5. Change in Bowel Habits &Stool ch.ch.
Husni Rousan 6
Assessment
Physical Assessment
1. Inspection
2. Auscultation
3. Palpation
4. Percussion
Husni Rousan 7
Assessment
Diagnostic Evaluation1. Upper GI tract study2. Lower GI tract study3. Gastric Analysis 4. Endoscopy5. Laparoscopy (Peritoneoscopy )6. Anoscopy ,proctoscopy ,&Sigmoidscopy7. Colonoscopy8. Abdominal U/S , Abd CT scan ,&Abd MRI
Husni Rousan 8
Assessment
Stool Tests -Analysis & culture -occult blood test
Hydrogen Breath Test Urea Breath Test Tagged Red Blood Cells & Leukocytes
Husni Rousan 9
Disorders of the Jaw
Abnormal conditions affecting the mandible (Jaw)& the tempomandibular joint include congenital malformation, fractures , chronic dislocation , cancer , & syndrome ch.ch pain & limited motion
Tempomandibular Disorders Are a group of conditions that cause pain &\or
dysfunction of the tempomandibular joint &/or the muscle of mastication, as well as contiguous tissue components
Husni Rousan 10
Disorders of the Jaw
Clinical Manifestations
1. Pain (from dull to throbbing )
2. Debilitating pain radiated to the ears, teeth, neck muscle & facial sinuses
3. Restricted jaw motion & clicking
4. Difficulty chewing & swallowing
5. Depression may accompany
Husni Rousan 11
Disorders of the Jaw
Management
1. Patient education in stress Management
2. Range of motion exercises
3. Pain Management (NSAID)
4. Muscle relaxant &/or mild antidepressant
Husni Rousan 12
Parotitis
Inflammation of the parotid gland is the most common inflammatory condition of the salivary gland
Mumps (epidemic Parotitis) viral seen in children
Clinical Manifestations1. Fever & red shiny skin2. The gland swells ,tense ,&tender3. Pain felt in ear 4. Swollen gland interfere with swallowing
Husni Rousan 13
Parotitis
Medical Management 1. Preventive Measures (dental care, oral
hygiene, adequate fluid& nutrition ,& D/C of medication that may diminished salivary secretion)
2. Antibiotics for infection
3. Analgesic for pain
4. Drainage of gland
5. Parotidectomy
Husni Rousan 14
Impaired Esophageal Motility Achalasia
Achalasia: characterized by impaired peristalsis of smooth muscle of esophagus and impaired relaxation of lower esophageal sphincter
Manifestations: 1. Dysphagia
2. chest pain (pyrosis)
3. Sensation of food stick in lower esophagus
4. Food regurgitation
Husni Rousan 15
Achalasia
Treatment1. Eat slowly &drink fluids with meals2. Calcium channel blockers3. Endoscopically guided injection of
botulinum toxin4. Balloon dilation of lower esophageal
sphincter or pneumatic dilation 5. Esophageal myotomy (abdominal or
thoracic approach
Husni Rousan 16
Gastroesophageal Reflux Disease (GERD)
1. Definition
1. GERD common, affecting 15 – 20% of adults
2. Because of location near other organs symptoms may mimic other illnesses including heart problems
3. Gastroesophageal reflux is the backward flow of gastric content into the esophagus.
Husni Rousan 17
Gastroesophageal Reflux Disease (GERD)
2. Pathophysiology a. Gastroesophageal reflux results from transient
relaxation or incompetence of lower esophageal sphincter, sphincter, or increased pressure within stomach
b. Factors contributing to Gastroesophageal reflux
1.Increased gastric volume (post meals) 2.Position pushing gastric contents close to
Gastroesophageal juncture (such as bending or lying down)
3.Increased gastric pressure (obesity or tight clothing)
4.Hiatal hernia
Husni Rousan 18
Gastroesophageal Reflux Disease (GERD)
Manifestations1. Heartburn after meals, while bending
over, or recumbent2. Dyspepsia or indigestion 3. May have regurgitation of sour
materials in mouth, pain with swallowing
4. Atypical chest pain5. Sore throat with hoarseness
Husni Rousan 19
Gastroesophageal Reflux Disease (GERD)
6.Diagnostic Testsa. Barium swallow (evaluation of
esophagus, stomach, small intestine)b. Upper endoscopy: direct
visualization; biopsies may be donec. 24-hour ambulatory pH monitoring
Husni Rousan 20
Gastroesophageal Reflux Disease (GERD)
7.Medications a. Antacids for mild to moderate symptoms,
e.g. Maalox, Mylanta, Gaviscon b. H2-receptor blockers: decrease acid
production; given BID or more often, e.g. cimetidine, ranitidine, famotidine, nizatidine
c. Proton-pump inhibitors: reduce gastric secretions, promote healing of esophageal erosion and relieve symptoms, e.g. omeprazole (prilosec); lansoprazole
d. Promotility agent: enhances esophageal clearance and gastric emptying
Husni Rousan 21
Gastroesophageal Reflux Disease (GERD)
Dietary and Lifestyle Management a. Elimination of acid foods (tomatoes, spicy,
citrus foods, coffee) b. Avoiding food which relax esophageal
sphincter or delay gastric emptying (fatty foods, chocolate, alcohol)
c. Maintain ideal body weight d. Eat small meals and stay upright 2 hours post
eating; no eating 3 hours prior to going to bed e. Elevate head of bed on 6 – 8 blocks to
decrease reflux f. No smoking g. Avoiding bending and wear loose fitting
clothing
Husni Rousan 22
Gastroesophageal Reflux Disease (GERD)
9.Surgery indicated for persons not improved by diet and life style changes
a. Laparoscopic procedures to tighten lower esophageal sphincter
b. Open surgical procedure: fundoplication
10. Nursing Carea. Pain usually controlled by treatmentb. Assist client to institute home plan
Husni Rousan 23
Hiatal Hernia
1. Definition Part of stomach protrudes through the
esophageal hiatus of the diaphragm into thoracic cavity
Types1. Sliding hiatal herni2. Paraesophageal hiatal hernia:( hernia can become strangulated; client
may develop gastritis with bleeding)
Husni Rousan 24
Hiatal HerniaHiatal Hernia Manifestations: Similar to GERD Diagnostic Tests1. a. Barium swallow2. b. Upper endoscopy Treatment 1. Similar to GERD: diet and lifestyle
changes, medications2. If medical treatment is not effective or
hernia becomes incarcerated, then surgery; usually
3. Fundoplication by thoracic or abdominal approach
Husni Rousan 25
Husni Rousan 26
Husni Rousan 27
Diverticulum
It is an outpouching of mucosa& submucosa that protrudes through a weak portion of the musculature
Clinical Manifestations1. Difficulty of swallowing & neck fullness2. Belching 3. Regurgitation of undigested food4. Gargling noise after eating 5. Halitosis & sour taste in the mouth6. May dysphagia & chest pain
Husni Rousan 28
Diverticulum
Management
1. Diverticulectomy &myoectomy for muscle
2. NPO until x-ray show no leakage at surgical site
3. During O.P. avoid trauma to carotid artery and jugular vein
Husni Rousan 29
Perforation
May result from stab or bullet wounds of the neck & the chest as well as from accidental puncture by surgical instrument
Clinical Manifestations1. Persistent pain followed by dysphagia
2. Infection ,fever ,& leukocytosis
3. May sign of Pnuemothorax
Husni Rousan 30
Perforation
Management
1. Broad spectrum antibiotics
2. Nasogastric tube & suctioning
3. NPO – total parenteral nutrition “gastrostomy”
4. Closed the wound &post op management
Husni Rousan 31
Gastritis
1.Definition: Inflammation of stomach lining from irritation of gastric mucosa (normally protected from gastric acid and enzymes by mucosal barrier)
2.Types a. Acute Gastritis
1.Disruption of mucosal barrier allowing hydrochloric acid and pepsin to have contact with gastric tissue: leads to irritation, inflammation, superficial erosions
2.Gastric mucosa rapidly regenerates; self-limiting disorder
Husni Rousan 32
•Gastritis
Causes of acute gastritis a. Irritants include aspirin and other NSAIDS,
corticosteroids, alcohol, caffeine b.Ingestion of corrosive substances: alkali or acid c.food contamination (microorganisms)
Manifestations headache, mild epigastric discomfort, abdominal pain, nausea anorexia, vomiting Belching, heart burn , &sour taste in mouth If perforation occurs, signs of peritonitis
Husni Rousan 33
Gastritis
Treatment As a rule the patient recover in a day NPO status to rest GI tract for 6 – 12 hours,
reintroduce clear liquids gradually and progress; intravenous fluid and electrolytes if indicated
b. antacids If gastritis from corrosive substance: immediate dilution and removal of substance by gastric lavage (washing out stomach contents via nasogastric tube),
If extreme condition Gastrojejunostomy or gastric resection
Husni Rousan 34
Gastritis
Nursing Management 1. Reducing anxiety2. Promoting optimal nutrition 3. Promoting fluid balance4. Relieving pain Chronic Gastritis Progressive disorder beginning with
superficial inflammation and leads to atrophy of gastric tissues (prolong Gastritis)
Husni Rousan 35
Peptic Ulcer Disease (PUD)
Definition and Risk factorsBreak in mucous lining of GI tract comes
into contact with gastric juice , referred to as gastric ,duodenal , or esophageal ulcer
Duodenal ulcers: most common; affect mostly males ages 30 – 55 ulcers found near pyloris
Gastric ulcers:affect older persons(ages 55 – 70)
Husni Rousan 36
Peptic Ulcer Disease (PUD)
2. Pathophysiology a. Ulcers or breaks in mucosa of GI tract occur
with 1.H. pylori infection (spread by oral to oral,
fecal-oral routes) damages gastric epithelial cells reducing effectiveness of gastric mucus
2.Use of NSAIDS: interrupts prostaglandin synthesis which maintains mucous barrier of gastric mucosa
b. Chronic with spontaneous remissions and exacerbations associated with trauma, infection, physical or psychological stress
Husni Rousan 37
Husni Rousan 38
Husni Rousan 39
Husni Rousan 40
Peptic Ulcer Disease (PUD)
Manifestations Pain is classic symptom: burning, aching
hunger like in epigastric region possibly radiating to back; occurs when stomach is empty and relieved by food (pain: food: relief pattern)
Vomiting , nausea , constipation &diarrhea Symptoms less clear in older adult; may have
poorly localized discomfort, dysphagia, weight loss; presenting symptom may be complication: GI hemorrhage or perforation of stomach or duodenum
Husni Rousan 41
Peptic Ulcer Disease (PUD)
Treatment Pharmacologic therapy1. H2 receptor antagonist2. Proton pump inhibitors3. Cytoprotective agents4. Antacid Stress Reduction & Rest Smoking Cessation Dietary Modification
Husni Rousan 42
Peptic Ulcer Disease (PUD)
Surgical Management Vagotomy1. Truncal2. Selective Pyloroplasty Antrectomy1. Gastroduodenostomy2. Gastrojejunostomy3. Subtotal gastroectomy with anastomosis
Husni Rousan 43
Gastric Surgery Gastric surgeryGastric surgery : may be performed on patient
with peptic ulcers who have life threatening hemorrhage , obstruction , perforation ,or whose condition dose not respond to medical treatment
Nursing Care1. Reducing Anxiety2. Increasing Knowledge3. Resuming enteral Intake4. Relieving pain &prevent complications5. Teaching Dietary self Management
Husni Rousan 44
Intestinal and rectal disorders Constipation
Abnormal hardening of stool that makes difficult & some time painfull,decrease in stool volume , or retention of stool on rectum for prolonged period of time
Clinical Manifestations1. Abdominal distention & intestinal rumbling
2. Pain & pressure
3. Anorexia fatigue & headache
4. Incomplete emptying & strain defecation
Husni Rousan 45
Intestinal and rectal disorders Constipation Medical Management 1. Treatment of the underlying cause 2. High Fiber Diet & increase fluid intake3. Maintain regular pattern of exercises4. Laxatives & bulk forming Agents5. Bran 6-12 tsp Complications: -hypertension - hemorrhoid & fissure - fecal impaction & megacolon
Husni Rousan 46
Intestinal and rectal disorders Diarrhea
It is an increase frequency of bowel movement more than three times /day
Causes : -1. Certain medications2. Tube feeding formula 3. Certain metabolic disease 4. Viral & bacterial infectious disease5. Ulcerative colitis .enteritis & chrons
disease
Husni Rousan 47
Intestinal and rectal disorders Diarrhea
Clinical Manifestations1. Abdominal cramps, distention, intestinal
rumbling
2. Increase frequency & fluid content of stool
3. Anorexia , thirst , & dehydration
4. Fluid electrolytes imbalance Complications:-
-cardiac arrhythmia due to fluid & K loss
-drowsiness & hypotension
Husni Rousan 48
Intestinal and rectal disorders Diarrhea
Medical Management1. Treatment of underlying cause 2. Controlling symptoms & preventing complications3. Antibiotics & antinflammatory agents4. Antidiarrheal & antispasmoic agents Nursing Managements1. Assessment the ch.ch. & pattern of diarrhea2. Bed rest & monitoring of fluid status 3. Serum electrolytes (K)4. Perenial care
Husni Rousan 49
Fecal Incontinence
The involuntary passage of stool from the rectum
Clinical Manifestations
1. Minor soiling
2. Occasional Urgency & loss of control
3. Poor Control of flatus
4. Diarrhea ,or constipation may be present
Husni Rousan 50
Fecal Incontinence
Medical Management1. Bowel training program2. Surgical reconstruction3. Sphincter repair 4. Fecal diversion Nursing Management1. Assessment & Health History2. Bowel Training program3. Maintain skin integrity4. Assist patient & family to cope with illness
Husni Rousan 51
Irritable Bowel Syndrome
Functional disorder of intestinal motility ,the change may be related to neurologic regulatory system, infection or irritation or a vascular or metabolic disturbances
The peristaltic waves are affected at specific segment
Clinical Manifestations1. Alteration in bowel pattern2. Pain , bloating , & abd distention3. Pain precipitated by eating & relieved by
defecation
Husni Rousan 52
Irritable Bowel Syndrome
Medical Management1. Controlling symptoms & reducing stress2. Anticholonergic & antidepressant agents3. Well balanced diet Nursing Management1. teaching &reinforcing good dietary habits2. Encourage eat regular time & chew slowly3. Fluids should not taken with meal4. Discourage smoking & alcohol
Husni Rousan 53
Acute Inflammatory Intestinal Disorders (Appendicitis)
Acute inflammation of appendix Clinical Manifestations1. Rt Lower Quadrant pain2. Low Grade Fever, nausea , vomiting anorexia3. Rebound & Revosing signs4. Local tenderness when pressure applied5. Increase W.B.C.s count Complications: perforation peritonitis or abdominal
abscess ,occurs after 24 hrs after onset of symptoms (pain Tenderness ,fever,& toxic appearance)
Husni Rousan 54
Acute Inflammatory Intestinal Disorders (Appendicitis) Medical Management1. Surgery is indicated if surgery diagnosed
(laprascopic or open appendectomy)2. NPO ,IVF , antibiotics3. Analgesic after diagnosis is made Nursing Management1. Relieving pain &preventing FVD2. Elimination of potential infection3. Maintaining skin integrity4. Reducing anxiety5. Pre&post care
Husni Rousan 55
Acute Inflammatory Intestinal DisordersUlcerative Colitis Recurrent ulcerative & inflammatory
disease of the mucosal layer Clinical Manifestations1. Diarrhea & abdominal pain2. Intermittent tenesmus3. Rectal bleeding4. Anorexia , weight loss , fever 5. Vomiting & dehydration
Husni Rousan 56
Acute Inflammatory Intestinal Disorders Ulcerative Colitis
Medical Management1. Nutritional therapy :
- oral fluid - low residue caloric protein diet with supplementary vit & Iron
2. Pharmacological therapy : - antibiotics& corticosteroids (enema) -sedatives , antidiarrheal ,& antiperstaltic agents -Immunosuppressive agents
3. Surgical Managements: -colectomy segmental ,subtotal - total colectomy with ilioanal anastomosis -fecal diversion
Husni Rousan 57
Ulcerative Colitis
Nursing Management1. Maintaining normal elimination pattern2. Relieving pain3. Maintaining fluid Intake4. Maintaining optimal nutrition5. Promoting rest6. Reducing anxiety7. Preventing skin breakdown8. Monitoring complications
Husni Rousan 58
INTESTINAL OBSTRUCTION
Blockage prevents the normal flow of intestinal contents through the intestinal tract A- mechanical: obstruction from pressure on
the intestinal walls occurs due to adhesion, tumor & hernias
B- functional: obstruction when intestinal musculature can’t propel the contents
Husni Rousan 59
Small Bowel ObstructionClinical manifestation
Crampy pain wave like & colicky Pass of blood & mucus without feces Vomiting ( reverse peristalsis ) Thirst & generalized malaise
Management Decompression of bowel through N/G tube IVF to replace H2O, electrolytes deplession Surgical treatment of the cause Resection & end to end anastomosis
Husni Rousan 60
Large Bowel Obstruction Clinical manifestations
Abdominal distension, Crampy lower abdomen Fecal vomiting Symptoms of shock may occur
Medical management Colonoscopy, to untwist or decompress bowel Cecostomy to relief pressure Rectal tube to decompress the lower part Surgical resection Temporary or permanent colostomy Ilio-anal anastomosis
Husni Rousan 61
Nursing management Administer IV fluids & electrolytes as prescribed Emotional support Pre & post operative care for abdominal surgery
Husni Rousan 62
ANO-RECTAL DISORDERS 1- Anal FistulaDefinition: tubular tract extends into anal
canal from an opening beside the anus, from infection, abscess, trauma & fissure
S & S Pus or stool leakage Passage of flatus or feces from vagina or
bladder depends on site of fistulaTreatment
Fistulectomy ( excision of fistulous tract )Untreated fistula causes systematic infections
Husni Rousan 63
2- Anal FissureDefinition: tear or ulceration in the lining of
anal canal results from constipation, child birth & trauma
S & S Painful defecation Burning & bleeding
Treatment Conservative treatment ( stool softener, sitz
bath, analgesics ) Anal dilatation & fissure excision
Husni Rousan 64
3- Hemorrhoids ( piles )Definition: dilated portion of veins in the
anal canalTypes
Internal: above the internal sphincter External: out side the external sphincter
S & S Itching & pain Bright red bleeding with defecation Piles come out side anus
Complications Massive bleeding results in anemia Thrombosis & infection
Husni Rousan 65
Treatment
Conservative treatment (sitz bath, laxative, high residual diet, anesthetic ointments & rest)
Injection of sclerosing solutions Rubber band ligation procedure Hemorrhoidectomy
Nursing management Pre-operative: cleansing enema, shaving &
cross match, Hb + IV fluids Post-operative: analgesia ½ hour before
defecation, sitz bath in warm saline & remove the back
Husni Rousan 66
4- Pilonidal Sinus / cystDefinition: found on the posterior surface
of the lower sacrum results from the penetration of hair into the epithelium & subcutaneous tissue lead to recurrent abscess formation
Treatment Excision & drainage, antibiotic & analgesia
Husni Rousan 67
Nursing management (Ano -Rectal condition ) Relieving constipation Reducing anxiety Relieving pain Promoting urinary elimination Monitoring & managing complications
Husni Rousan 68
Husni Rousan 69
Nursing Care of Clients with Bowel Disorders
Factors affecting bodily function of eliminationA.GI tract 1. Food intake 2. Bacterial flora in bowelB. Indirect 1. Psychologic stress 2. Voluntary postponement of defecation
C.Normal bowel elimination pattern 1. Varies with the individual 2. 2 – 3 times daily to 3 stools per week
Husni Rousan 70
Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)
Definitiona. Functional GI tract disorder without
identifiable cause characterized by abdominal pain and constipation, diarrhea, or both
b. Affects up to 20% of persons in Western civilization; more common in females
Husni Rousan 71
Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)
Pathophysiology a. Appears there is altered CNS regulation of
motor and sensory functions of bowel1.Increased bowel activity in response to food
intake, hormones, stress2.Increased sensations of chyme movement
through gut3.Hypersecretion of colonic mucus
b. Lower visceral pain threshold causing abdominal pain and bloating with normal levels of gas
c. Some linkage of depression and anxiety
Husni Rousan 72
Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)
Manifestations a. Abdominal pain relieved by defecation; may
be colicky, occurring in spasms, dull or continuous b. Altered bowel habits including frequency,
hard or watery stool, straining or urgency with stooling, incomplete evacuation, passage of mucus; abdominal bloating, excess gas
c. Nausea, vomiting, anorexia, fatigue, headache, anxiety
d. Tenderness over sigmoid colon upon palpation
4. Collaborative Care a. Management of distressing symptoms b. Elimination of precipitating factors, stress
reduction
Husni Rousan 73
Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)5. Diagnostic Tests: to find a cause for client’s abdominal pain,
changes in feces elimination a.Stool examination for occult blood, ova and parasites, culture b.CBC with differential, Erythrocyte Sedimentation Rate (ESR): to
determine if anemia, bacterial infection, or inflammatory process c.Sigmoidoscopy or colonoscopy
1.Visualize bowel mucosa, measure intraluminal pressures, obtain biopsies if indicated
2.Findings with IBS: normal appearance increased mucus, intraluminal pressures, marked spasms, possible hyperemia without lesions
d.Small bowel series (Upper GI series with small bowel-follow through) and barium enema: examination of entire GI tract; IBS: increased motility
Husni Rousan 74
Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)
Medications a. Purpose: to manage symptoms b. Bulk-forming laxatives: reduce bowel spasm,
normalize bowel movement in number and form c. Anticholinergic drugs (dicyclomine (Bentyl),
hyoscyamine) to inhibit bowel motility; given before meals
d. Antidiarrheal medications (loperamide (Imodium), diphenoxylate (Lomotil): prevent diarrhea prophylactically
e. Antidepressant medications f. Research: medications altering serotonin
receptors in GI tract
Husni Rousan 75
Irritable Bowel Syndrome (IBS) (spastic bowel, functional colitis)
Dietary Management a. Often benefit from additional dietary fiber:
adds bulk and water content to stool reducing diarrhea and constipation
b. Some benefit from elimination of lactose, fructose, sorbitol
c. Limiting intake of gas-forming foods, caffeinated beverages
8. Nursing Care a. Contact in health environments outside acute
care b. Home care focus on improving symptoms with
changes of diet, stress management, medications; seek medical attention if serious changes occur
Husni Rousan 76
Peritonitis
Definitiona. Inflammation of peritoneum, lining
that covers wall (parietal peritoneum) and organs (visceral peritoneum) of abdominal cavity
b. Enteric bacteria enter the peritoneal cavity through a break of intact GI tract (e.g. perforated ulcer, ruptured appendix)
Husni Rousan 77
Peritonitis
Pathophysiology a. Peritonitis results from contamination of
normal sterile peritoneal cavity with infections or chemical irritant
b. Release of bile or gastric juices initially causes chemical peritonitis; infection occurs when bacteria enter the space
c. Bacterial peritonitis usually caused by these bacteria (normal bowel flora): Escherichia coli, Klebsiella, Proteus, Pseudomonas
d. Inflammatory process causes fluid shift into peritoneal space (third spacing); leading to hypovolemia, then septicemia
Husni Rousan 78
Peritonitis
3.Manifestations a. Depends on severity and extent of
infection, age and health of client b. Presents with “acute abdomen”
1.Abrupt onset of diffuse, severe abdominal pain
2.Pain may localize near site of infection (may have rebound tenderness)
3.Intensifies with movement c. Entire abdomen is tender with boardlike
guarding or rigidity of abdominal muscle
Husni Rousan 79
Peritonitis
d. Decreased peristalsis leading to paralytic ileus; bowel sounds are diminished or absent with progressive abdominal distention; pooling of GI secretions lead to nausea and vomiting
e. Systemically: fever, malaise, tachycardia and tachypnea, restlessness, disorientation, oliguria with dehydration and shock
f. Older or immunosuppressed client may have1.Few of classic signs2.Increased confusion and restlessness3.Decreased urinary output4.Vague abdominal complaints5.At risk for delayed diagnosis and higher
mortality rates
Husni Rousan 80
Peritonitis
4. Complications a. May be life-threatening; mortality rate overall
40% b. Abscess c. Fibrous adhesions d. Septicemia, septic shock; fluid loss into
abdominal cavity leads to hypovolemic shock5. Collaborative Care a. Diagnosis and identifying and treating cause b. Prevention of complications
Husni Rousan 81
Peritonitis
6. Diagnostic Tests a. WBC with differential: elevated WBC to 20,000; shift to
left b. Blood cultures: identify bacteria in blood c. Liver and renal function studies, serum electrolytes:
evaluate effects of peritonitis d. Abdominal xrays: detect intestinal distension, air-fluid
levels, free air under diaphragm (sign of GI perforation) e. Diagnostic paracentesis7. Medications a. Antibiotics
1.Broad-spectrum before definitive culture results identifying specific organism(s) causing infection
2.Specific antibiotic(s) treating causative pathogens b. Analgesics
Husni Rousan 82
Peritonitis
8.Surgery a. Laparotomy to treat cause (close
perforation, removed inflamed tissue) b. Peritoneal Lavage: washing out
peritoneal cavity with copious amounts of warm isotonic fluid during surgery to dilute residual bacterial and remove gross contaminants
c. Often have drain in place and/or incision left unsutured to continue drainage
Husni Rousan 83
Peritonitis
9. Treatment a. Intravenous fluids and electrolytes to maintain
vascular volume and electrolyte balance b. Bed rest in Fowler’s position to localize
infection and promote lung ventilation c. Intestinal decompression with nasogastric
tube or intestinal tube connected to suction 1. Relieves abdominal distension secondary to
paralytic ileus 2. NPO with intravenous fluids while having
nasogastric suction
Husni Rousan 84
Peritonitis
10. Nursing Diagnoses a. Pain b. Deficient Fluid Volume: often on hourly
output; nasogastric drainage is considered when ordering intravenous fluids
c. Ineffective Protection d. Anxiety11. Home Care a. Client may have prolonged hospitalization b. Home care often includes 1. Wound care 2. Home health referral 3. Home intravenous antibiotics
Husni Rousan 85
Client with Inflammatory Bowel Client with Inflammatory Bowel DiseaseDisease
Definition a. Includes 2 separate but closely related
conditions: ulcerative colitis and Crohn’s disease; both have similar geographic distribution and genetic component
b. Etiology is unknown but runs in families; may be related to infectious agent and altered immune responses
c. Peak incidence occurs between the ages of 15 – 35; second peak 60 – 80
d. Chronic disease with recurrent exacerbations
Husni Rousan 86
Ulcerative Colitis
Pathophysiology 1. Inflammatory process usually confined
to rectum and sigmoid colon 2. Inflammation leads to mucosal
hemorrhages and abscess formation, which leads to necrosis and sloughing of bowel mucosa
3. Mucosa becomes red, friable, and ulcerated; bleeding is common
4. Chronic inflammation leads to atrophy, narrowing, and shortening of colon
Husni Rousan 87
Ulcerative Colitis
Manifestations1. Diarrhea with stool containing blood
and mucus; 5 – 10 stools per day leading to anemia, hypovolemia, malnutrition
2. Fecal urgency, tenesmus, LLQ cramping
3. Fatigue, anorexia, weakness4. Severe cases: arthritis, uveitis
Husni Rousan 88
Ulcerative Colitis
Complications 1. Hemorrhage: can be massive with severe
attacks 2. Toxic megacolon: usually involves transverse
colon which dilates and lacks peristalsis (manifestations: fever, tachycardia, hypotension, dehydration, change in stools, abdominal cramping)
3. Colon perforation: rare but leads to peritonitis and 15% mortality rate
4. Increased risk for colorectal cancer (20 – 30 times); need yearly colonoscopies
5. Sclerosing cholangitis
Husni Rousan 89
Crohn’s Disease (regional enteritis)
Pathophysiology 1. Can affect any portion of GI tract, but terminal
ileum and ascending colon are more commonly involved
2. Inflammatory aphthoid lesion (shallow ulceration) of mucosa and submuscosa develops into ulcers and fissures that involve entire bowel wall
3. Fibrotic changes occur leading to local obstruction, abscess formation and fistula formation
4. Fistulas develop between loops of bowel (enteroenteric fistulas); bowel and bladder (enterovesical fistulas); bowel and skin (enterocutaneous fistulas)
5. Absorption problem develops leading to protein loss and anemia
Husni Rousan 90
Crohn’s Disease (regional enteritis)
Manifestations1. Often continuous or episodic
diarrhea; liquid or semi-formed; abdominal pain and tenderness in RLQ relieved by defecation
2. Fever, fatigue, malaise, weight loss, anemia
3. Fissures, fistulas, abscesses
Husni Rousan 91
Crohn’s Disease (regional enteritis)
Complications 1. Intestinal obstruction: caused by repeated
inflammation and scarring causing fibrosis and stricture
2. Fistulas lead to abscess formation; recurrent urinary tract infection if bladder involved
3. Perforation of bowel may occur with peritonitis
4. Massive hemorrhage 5. Increased risk of bowel cancer (5 – 6 times)
Husni Rousan 92
Crohn’s Disease (regional enteritis)Collaborative Care a. Establish diagnosis b. Supportive treatment c. Many clients need surgeryDiagnostic Tests a. Colonoscopy, sigmoidoscopy: determine area and
pattern of involvement, tissue biopsies; small risk of perforation
b. Upper GI series with small bowel follow-through, barium enema
c. Stool examination and stool cultures to rule out infections
d. CBC: shows anemia, leukocytosis from inflammation and abscess formation
e. Serum albumin, folic acid: lower due to malabsorption f. Liver function tests may show enzyme elevations
Husni Rousan 93
Crohn’s Disease (regional enteritis)
Medications: goal is to stop acute attacks quickly and reduce incidence of relapse
a. Sulfasalazine (Azulfidine): sulfonamide antibiotic with topical effect in colon; used with ulcerative colitis
b. Corticosteroids: reduce inflammation and induce remission; with ulcerative colitis may be given as enema; intravenous steroids are given with severe exacerbations
c. Immunosuppressive agents (azathioprine (Imuran), cyclosporine) for clients who do not respond to steroid therapy
d. New therapies including immune response modifiers, anti-inflammatory cyctokines
e. Metronidazole (Flagyl) or Ciprofloxacin (Cipro) f. Anti-diarrheal medications
Husni Rousan 94
Crohn’s Disease (regional enteritis)
Dietary Management a. Individualized according to client; eliminate
irritating foods b. Dietary fiber contraindicated if client has
strictures c. With acute exacerbations, client may be made
NPO and given enteral or total parenteral nutrition (TPN)
Surgery: performed when necessitated by complications or failure of other measures
a. Crohn’s disease 1. Bowel obstruction leading cause; may have
bowel resection and repair for obstruction, perforation, fistula, abscess
2. Disease process tends to recur in area remaining after resection
Husni Rousan 95
Ulcerative Colitis
1. Total colectomy to treat disease, repair complications (toxic megacolon, perforation, hemorrhage, prophylactic for cancer risk)
2. Total colectomy with an ileal pouch-anal anastomosis (initially has temporary ileostomy)
Husni Rousan 96
Ulcerative ColitisOstomy 1. Surgically created opening between intestine
and abdominal wall that allows passage of fecal material
2. Stoma is the surface opening which has an appliance applied to retain stool and is emptied at intervals
3. Name of ostomy depends on location of stoma 4. Ileostomy: opening in ileum; may be permanent
with total proctocolectomy or temporary (loop ileostomy)
5. Ileostomies: always have liquid stool which can be corrosive to skin since contains digestive enzymes
6. Continent (or Kock’s) ileostomy: has intra-abdominal reservoir with nipple valve formation to allow catheter insertion to drain out stool
Husni Rousan 97
Ulcerative Colitis
Nursing Care: Focus is effective management of disease with avoidance of complications
Nursing Diagnoses a. Diarrhea b. Disturbed Body Image; diarrhea may control
all aspects of life; client has surgery with ostomy c. Imbalanced Nutrition: Less than body
requirement d. Risk for Impaired Tissue Integrity: Malnutrition
and healing post surgery e. Risk for sexual dysfunction, related to
diarrhea or ostomy
Husni Rousan 98
Ulcerative Colitis
Home Carea. Inflammatory bowel disease is
chronic and day-to-day care lies with clientb. Teaching to control symptoms,
adequate nutrition, if client has ostomy: care and resources for supplies, support group and home care referral
Husni Rousan 99
Client with Intestinal Obstruction
Definition a. May be partial or complete obstruction b. Failure of intestinal contents to move
through the bowel lumen; most common site is small intestine
c. With obstruction, gas and fluid accumulate proximal to and within obstructed segment causing bowel distention
d. Bowel distention, vomiting, third-spacing leads to hypovolemia, hypokalemia, renal insufficiency, shock
Husni Rousan 100
Client with Intestinal Obstruction
Pathophysiologya. Mechanical1. Problems outside intestines: adhesions (bands
of scar tissue), hernias2. Problems within intestines: tumors, IBD3. Obstruction of intestinal lumen (partial or
complete) a. Intussusception: telescoping bowel b. Volvulus: twisted bowel c. Foreign bodies d. Strictures
Husni Rousan 101
Client with Intestinal Obstruction
Functional1. Failure of peristalsis to move intestinal contents:
adynamic ileus (paralytic ileus, ileus) due to neurologic or muscular impairment
2. Accounts for most bowel obstructions3. Causes include a. Post gastrointestinal surgery b. Tissue anoxia or peritoneal irritation from
hemorrhage, peritonitis, or perforation c. Hypokalemia d. Medications: narcotics, anticholinergic
drugs, antidiarrheal medications e. Renal colic, spinal cord injuries, uremia
Husni Rousan 102
Client with Intestinal Obstruction
Manifestations Small Bowel Obstructiona. Vary depend on level of obstruction and speed of
developmentb. Cramping or colicky abdominal pain, intermittent,
intensifyingc. Vomiting 1. Proximal intestinal distention stimulates vomiting
center 2. Distal obstruction vomiting may become feculentd. Bowel sounds 1. Early in course of mechanical obstruction:
borborygmi and high-pitched tinkling, may have visible peristaltic waves
2. Later silent; with paralytic ileus, diminished or absent bowel sounds throughout
e. Signs of dehydration
Husni Rousan 103
Client with Intestinal Obstruction
Complications a. Hypovolemia and hypovolemic shock
can result in multiple organ dysfunction (acute renal failure, impaired ventilation, death)
b. Strangulated bowel can result in gangrene, perforation, peritonitis, possible septic shock
c. Delay in surgical intervention leads to higher mortality rate
Husni Rousan 104
Client with Intestinal Obstruction
Large Bowel Obstruction a. Only accounts for 15% of obstructions b. Causes include cancer of bowel,
volvulus, diverticular disease, inflammatory disorders, fecal impaction
c. Closed-loop obstruction: competent ileocecal valve causes massive colon dilation
d. Manifestations: deep, cramping pain; severe, continuous pain signals bowel ischemia and possible perforation; localized tenderness or palpable mass may be noted
Husni Rousan 105
Client with Intestinal ObstructionCollaborative Care a. Relieving pressure and obstruction b. Supportive careDiagnostic Testsa. Abdominal Xrays and CT scans with contrast media 1. Show distended loops of intestine with fluid and /or gas in
small intestine, confirm mechanical obstruction; indicates free air under diaphragm
2. If CT with contrast media meglumine diatrizoate (Gastrografin), check for allergy to iodine, need BUN and Creatinine to determine renal function
b. Laboratory testing to evaluate for presence of infection and electrolyte imbalance: WBC, Serum amylase, osmolality, electrolytes, arterial blood gases
c. Barium enema or colonoscopy/sigmoidoscopy to identify large bowel obstruction
Gastrointestinal Decompression a. Treatment with nasogastric or long intestinal tube provides
bowel rest and removal of air and fluid b. Successfully relieves many partial small bowel obstructions
Husni Rousan 106
Client with Intestinal Obstruction
Surgery a. Treatment for complete mechanical obstructions,
strangulated or incarcerated obstructions of small bowel, persistent incomplete mechanical obstructions
b. Preoperative care 1. Insertion of nasogastric tube to relieve vomiting,
abdominal distention, and to prevent aspiration of intestinal contents
2. Restore fluid and electrolyte balance; correct acid and alkaline imbalances
3. Laparotomy: inspection of intestine and removal of infarcted or gangrenous tissue
4. Removal of cause of obstruction: adhesions, tumors, foreign bodies, gangrenous portion of intestines and anastomosis or creation of colostomy depending on individual case
Husni Rousan 107
Client with Intestinal Obstruction
Nursing Care a. Prevention includes healthy diet, fluid intake b. Exercise, especially in clients with recurrent
small bowel obstructionsNursing Diagnoses a. Deficient Fluid Volume b. Ineffective Tissue Perfusion, gastrointestinal c. Ineffective Breathing PatternHome Care a. Home care referral as indicated b. Teaching about signs of recurrent obstruction
and seeking medical attention
Husni Rousan 108
Gastrointestinal Intubation It is the insertion of a rubber or plastic tube
into the stomach ,duodenum ,or intestine . The tube may inserted through the mouth ,
nose , or the abdomen Intubation may be performed to:-1. Decompress the stomach & remove gas &fluid2. Lavage the stomach & remove toxic ingested
substances3. Diagnose GI motility & other disorders4. Administer medication & feedings5. Treat an obstruction6. Compress a bleeding site
Husni Rousan 109
Gastrointestinal Intubation
Types1. Short tubes
2. Medium :
3. Long (nasoenteric) Nursing care includes Providing instructions Inserting the tube
Husni Rousan 110
Gastrointestinal Intubation
Confirming placement Securing the tube Advancing the nasoenteric decompression
tube Providing oral & nasal Hygiene Monitoring the patient & maintaining tube
function Monitoring & managing potential complications Removing the tube
Husni Rousan 111
Gastrointestinal Intubation
Gastrostomy
Is surgical procedure to create an opening into the stomach for the purpose of administer food & fluids
Elderly & debilitated patientsComatose patients Percutaneous endoscopic gastrostomy
Husni Rousan 112
TPN
Is a method of supplying nutrients to the body by an IV rout
Clinical Indications
1. Insufficient intake to maintain anabolic
2. Impaired ability to ingest food
3. Ingestion unwilling
4. prolonged pre & post op. nutritional needs
Husni Rousan 113
TPN
Types of nutritional solutions1. TPN (aminoacids + dextrose formula )2. Total nutrient admixture (aminoacids
+dextrose formula + intralipids ) Methods of Administration1. Peripheral Partial Method2. Central line Method D/C gradually