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1 Chapter 44: (pages 635 647) Introduction to the Gastrointestinal System and Accessory Structures I.

. Anatomy and Physiology a. Mouth i. Where food enters the GI system, where it is chewed, mixed with the enzyme salivary amylase for digestion. b. Esophagus i. Begins at the base of the pharynx and ends at the opening of the stomach. ii. Coordinated movements of the muscles surrounding the esophagus propels food into the stomach called peristalsis c. Stomach i. Temporarily holds ingested food and prepares it by mechanical and chemical action to pass in semi liquid form into the small intestine ii. Pyloric sphincter- opening between the stomach and duodenum iii. Gastric secretions: hydrochloric acid (HCl), Pepsin, and Gastric lipase d. Small Intestine i. Divided into 3 portions: 1. Duodenum, jejunum, and ileum ii. Primary function: to absorb nutrients from the chyme iii. Enzyme secretions: Peptidases, Lactase, Maltase, Sucrase, Intestinal lipase e. Large Intestine i. Receives waste from the small intestine and propels waste toward the anus ii. Absorbs: water, some electrolytes, and bile acids iii. Consists of: 1. Cecum, colon, rectum, and anal canal 2. Colon divided into 5 parts: a. Ascending, transverse, descending, and sigmoid colons, and rectum. iv. The colon develops the fecal matter. Accessory Structures a. Peritoneum i. A membrane that lines the inner abdomen; allows the abdominal organs to move about without creating frictions ii. Peritonitis microorganisms and enzymes can cause a severe inflammation and infection of the surrounding tissue. b. Liver i. Functions: 1. Stores and releases bile 2. Stores glycogen 3. Contributes to blood coagulation 4. Metabolizes and biotransforms many chemicals (including drugs), bacteria, and foreign matter 5. Forms antibodies and immunizing substances c. Gallbladder i. Attached to the midportion of the under surface of the liver ii. Forms approximately 1 L of bile each day iii. Bile activates the pancreas to release its digestive enzymes d. Pancreas i. Both an exocrine and endocrine gland ii. Produces hormones: insulin and glucagon iii. Pancreatic enzymes are used to digestion

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2 Assessment a. History i. Chief complaint, focus assessment of current nutritional, metabolic, and eliminations patterns, and past history ii. Obtain food allergies b. Physical Examination i. General Appearance 1. Weight, height, and vital signs 2. Hygiene, energy, breathing patterns, emotional attitude, and mental status ii. Skin 1. Inspect skin for any abnormal color: a. A yellowish tint indicating jaundice. b. Spider angiomas- superficial red discolorations consisting of blood vessels that assume a spider-shaped pattern c. Caput meduseae- distended abdominal veins d. Scars e. Dryness of the oral mucosa and skin turgor iii. Mouth iv. Abdomen 1. Contour, auscultation, palpation v. Anus 1. Asses for external hemorrhoids, skin tags, fissures, skin creaks, lesions, rash, inflammation, and drainage 2. Inspect stool Diagnostics a. Barium Swallow or Upper GI series i. Barium Swallow fluoroscopic observation of the client actually swallowing a flavored barium solution and its progress down the esophagus ii. Upper GI series radiographic observation of the barium moving into the stomach and the first part of the small intestine iii. Both detect structural abnormalities in and below the esophagus iv. PATIENT PREP: 1. For several days client on low-residue diet 2. NPO for 8-12 hours before the test 3. Laxative may be given to clean out the GI tract 4. NO smoking the day of the procedure 5. Medications are withheld (except anticonvulsants and insulin) v. POST test: 1. Barium is very constipating so fluids are encouraged to promote its elimination from the GI tract 2. Stools will appear white, streaky, or clay colored from the barium 3. Laxative may help evacuation vi. Nutrition Notes 44-1 The client undergoing diagnostic GI testing (pg 640)
1. 2. 3. Many GI tests require at least an 8 hours fast beforehand and can compound potential or existing nutritional problems Encourage adequate fluid intake to promote dilution and elimination of dyes and other test substances Observe for subsequent s/s of intolerance in clients whose tests requires ingesting a special solution client may experience cramping, abdominal distention, and diarrhea after ingestion of the substrate used for testing.

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Small Bowel Series

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3 i. Fluoroscopy of the small intestine after the ingestion of a contract medium ii. Used to identify tumors, inflammation, or obstruction of the jejunum or the ileum. iii. Client must swallow more barium for the small intestine to be well visualized. iv. Takes 5-6 hours Enteroclysis i. Also know as small bowel enema ii. Nasal or oral placement of a flexible feeding tube the tip is positioned in the proximal jejunum iii. Uses two contrast media: barium and methylcellulose iv. Examiner observes the intestine continuously by fluoroscopy and takes periodic radiographs of the carious secretions of the small intestine v. Can take up to 6 hours vi. Risk of aspiration 1. Position client on his or her side 2. Suction should be available Barium Enema or Lower GI Series i. Used to identify polyps, tumors, inflammation, strictures, and other abnormalities of the colon ii. Taken in the radiology department iii. Uses barium solution and client must make multiple position changes iv. May take up to 30 mins v. During the test, the client may experience abdominal cramping and a strong urge to defecate vi. To reduce the formation of stool and remove any residual stool, the client follows prescribed restrictions and procedures 24-48 hours before the barium enema: (pages 640-641) vii. Encourage rest and fluids after test Oral Cholecystography or Gallbladder Series i. Identifies stones in the gallbladder or common bile duct, and tumors of other obstructions ii. Determines the ability of the gallbladder to concentrate and store a dye-like iodine based radio opaque contrast medium iii. PRE TEST INSTRUCTIONS 1. Eat a fat-free meal the night before the test 2. Allergies to iodine 3. Swallow 6 iodine-containing contrast tablets 4. NPO after midnight iv. POST TEST 1. Dye causes nausea and vomiting Cholangiography i. Determines the patency of the ducts from the liver and gallbladder ii. 4 specific types: 1. Endoscopic retrograde cholangiopancreatography (ERCP) dye is injected through a catheter into the common bile duct and the pancreatic duct 2. Intraoperative Cholangiography contrast agent is injected directly into the bile duct during gallbladder surgery 3. Magnetic resonance cholangiopancreatography (MRCP) uses an MRI to obtain computerized images to provide clear and detailed views.

4 Percutaneous transhepatic Cholangiography (PTC) ultrasound is used to guide a needle into the bile ducts so that dye ca be directly injected. iii. Client must sign a consent from iv. Check for allergies v. Tell client they may experience a warm sensation and nausea when the dye is instilled vi. Encourage liquids after to excrete dye g. Radionuclide Imaging i. Detects lesions of the liver or pancreas and assists in evaluating gastric emptying. ii. Pretest: weight of client, pump out breast milk so child who is nursing remains safe, and contraindicated in pregnant women h. CT i. Continuous-motion, three-dimensional CT scans aka: colongraphy; a small tube is inserted into the colon, air is introduced to inflate the colon, and computer images are produced. i. MRI j. Magnetic Resonance Elastrography (MRE) i. Combines MRI with low-frequency sound waves ii. Allows the physician to predict clients who are at risk for developing fibrosis and eventually cirrhosis (hardening of the liver) k. Ultrasonography (ultrasound) l. Percutaneous Liver Biopsy i. Physician obtains a small core of liver tissue by placing a needle through the clients lateral abdominal wall directly into the liver ii. Nursing measures: 1. Client in supine position 2. Rolled towel beneath the right lower ribs 3. Before the physician inserts the needle, tell client to take a deep breath and hold it to keep the liver as near to the abdominal wall as possible 4. After procedure: client to lie on the right side and place a small pillow under the costal margin must remain in this position for at least 2 hours to prevent the release of blood, bile, or both. 5. Client should remain in bed for 8-12 hours after. Client should avoid coughing or straining during this time. m. Gastrointestinal Endoscopy i. Direct visual examination of the lumen of the GI tract ii. BOX 44-1 Common GI Endoscopic Procedures (pg 644) 4.
1. Esophagogastroduodenoscopy (EGD) examination of the esophagus, stomach, and duodenum through an endoscope advanced orally to inspect, treat, or obtain specimens from any one or all of the upper GI structures. a. Patient must spray or gargle with a local anesthetic b. Anxiolytic agent given: midazolam (Versed) for sedation and to relieve anxiety Colonoscopy examination of the entire large intestine with a flexible fiberoptic colonoscope. Clients are sedated briefly. The scope is advanced anally from the rectum to the cecum allowing visualization. Air may be instilled to promote visualization of the mucosa folds. a. Anxiolytic agent given: midazolam (Versed) for sedation and to relieve anxiety

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3. Virtual Colonoscopy or CT Colonography a small flexible rubber catheter is inserted in the rectum, and air or carbon dioxide is pumped through the tube to distend the colon. Proctosigmoidoscopy examination of the rectum and sigmoid colon using a rigid endoscope inserted anally about 10 inches. Client must lie in a knee-chest position. Peritoneoscopy examination of GI structures through an endoscope inserted percutanously through a small incision in the abdominal wall with the client receiving an anesthetic. Also called laparoscopy. Small Bowel Enteroscopy endoscopic examination and visualization of the lumen of the small bowel Panendoscopy examination of both the upper and lower GI tracts.

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iii. PRE-test 1. Dietary and fluid restrictions 2. Bowel prep procedures for lower GI structures iv. During test 1. Monitor respirations and vital signs, level of pain and discomfort v. POST-test 1. Assess v/s, respiratory status, LOC, and abdominal symptoms 2. Monitor for complications such as: fever, abdominal distention, abdominal or chest pain, vomiting blood, or bright red rectal bleeding 3. Offer the client light food and fluids (unless EGD) 4. After an EGD: a. Client may NOT have food or fluids until the gag reflex returns b. Then may introduce clear fluids and advance diet according to client tolerance c. Client may complain of sore throat vi. Client and Family Teaching 44-1 Discharge Instructions Following Colonoscopy (pg 644)
1. 2. 3. 4. 5. Mild cramping and flatulence are expected; these symptoms will resolve within 24 hours If you had a small polyp or growth removed, you may experience slight amount of bleeding that resolved on its own Avoid eating high fat or high fiber foods for at lease 24 hours following the procedure Biopsy results will be available in 5 to 7 days Report the following problems that may indicate bowel perforation, hemorrhage, or infection: nausea, vomiting, fever, and excessive bleeding Resume your usual medication regimen unless instructed otherwise

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Laboratory Tests i. Gastric Analysis 1. NPO 8-12 hours before test 2. A small NG tube is inserted into the stomach 3. Gastric contents are aspirated every 15 minutes for at lease an hour. ii. Helicobacter pylori Tests 1. Responsible for the majority of peptic ulcers 2. Blood tests are used to determine whether there are antibodies to H. pylori in the blood 3. Urea breath tests are also used client drinks or eats a urea solution/capsule and tests are conducted by having the client blow up a small balloon or blowing bubbles

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6 into a small container. Carbon will be released if H. pylori is present (Figure 44-4 page 645) 4. Fecal matter may also be tested iii. Hydrogen Breath Testing 1. Lactose malabsorption is a common disorder investigated using this test iv. Stool Analysis 1. Used to identify: a. White blood cells indicating inflammation b. Red blood cells indicating GI blood loss c. Fat indicating malabsorption 2. Substances that may cause false-positive results: a. Aspirin (greater than 325 mg per day), other NSAIDS, and excessive alcohol 3. Substances that may cause false-negative results: a. Vitamin C (greater than 251 mg per day), and Iron supplements Nursing Process (pages 645-646) a. This is what I found important i. Teach client to expel gas and test fluids from the bowel when he or she experience the urge. Ignoring the urge to expel bowel contents increases pain and discomfort ii. Weigh client and monitor the color and amount of urine. These data provide a baseline for the clients response to tests, fluid loss related to diarrhea or vomiting, or both iii. Report dizziness and confusion. Indicated dehydration iv. Encourage client to drink at least 2000 mL of fluid per 24 hours after tests using barium. This amount provides sufficient fluid to facilitate evacuation of stool. v. Monitor stool passage, observing the stool for barium. Stool with barium appear light-colored or white-streaked

7 Chapter 45: (pages 648 673) Caring for Clients with Disorders of the Upper Gastrointestinal Tract I. Disorders that Affect Eating a. Anorexia i. Lack of appetite; common symptom of many diseases ii. Pathophysiology and Etiology 1. The appetite center is located in the hypothalamus 2. Brief periods of anorexia are not life-threatening but can cause temporary malnutrition iii. Assessment Findings 1. Signs and Symptoms a. Hunger is absent; no desire for food b. Nauseous when they smell food or even think about eating c. Amounts of weight loss vary, depending on how long the anorexia and reduced food intake have lasted d. Hypovitaminosis vitamin deficiency i. Fat soluble vitamins (A, D, E, and K), Water soluble vitamins (folic acid, and vitamin C) ii. Cystic Fibrosis, Pancreatitis, and Liver disease result in deficiency of fatsoluble vitamins 2. Diagnostic Findings a. Hemoglobin level and blood cell counts may be reduced b. RBCs become abnormally enlarged iv. Medical and Surgical Management 1. High-calorie diet, high-calorie supplemental feedings, tube feeding, and TPN 2. Psychological support, psychiatric treatment, or both 3. Anorexia Nervosa a psychiatric disorder v. Nursing Management 1. Maintain sufficient nutrition and sustain normal body weight 2. Monitor daily weight b. Nausea and Vomiting i. If these symptoms are prolongs, weakness, weight loss, nutritional deficiency, dehydration, and electrolyte and acid-base imbalances may result. ii. Pathophysiology and Etiology 1. Common Causes: a. Drugs, infections and inflammatory conditions of the GI tract, intestinal obstruction, system infections, lesions of the CNS, food poisoning, emotional stress, early pregnancy, and uremia. 2. Usually results from distention of the duodenum 3. Vomiting center is located in the medulla 4. Valsalva maneuver causes dizziness, hypotension, and bradycardia. iii. Assessment Findings 1. Signs and Symptoms a. Unpleasant feeling, loss of appetite and refusal to eat

8 Vomiting causing dehydration causes excessive thirst and report of decreased or no urine production. Eyes and oral mucosa appear dry or dull, poor skin turgor 2. Diagnostic Findings a. Low levels of serum sodium and chloride iv. Medical and Surgical Management 1. IV fluids, electrolyte replacement, and drug therapy 2. Antiemetic agents a. Drug Therapy Table 45-1 Antiemetic Medications (pg 651) b.
Ondansetron (Zofran) blocks nausea and vomiting receptors. Side effects: headache, dizziness, myalgia, malaise, fatigue, and drowsiness. ii. Prochlorperazine (Compazine) inhibits the vomiting center of the brain; Side effects: drowsiness, hypotension, and changes in heart rhythms, photophobia, blurred vision, dry mouth, and discolored urine. iii. Hydroxyzine (Atarax, Vastaril) Blocks H1 receptors decreasing stimulation of vomiting center. Side effects: Drowsiness, tremor, dry mouth, loss of coordination, sore muscles or spasms. iv. Promethazine (Anergan, Phenergan) Blocks H1 receptors decreasing stimulation of vomiting center. Side effects: dizziness, drowsiness, poor coordination, confusion, restlessness, excitation, thickened bronchial secretions, urinary frequency, and dysuria. Avoid drinking alcohol with this medication. v. Dimenhydrinate (Dramamine) Inhibits vestibular stimulation in the ear, thereby relieving motion sickness. Side effects: drowsiness, confusion, nervousness, restlessness, headache, dizziness, tingling, heaviness of hands, low BP, nasal stuffiness, chest tightness, rash, photosensitivity. Do not take if pregnant or lactating. No alcohol. i.

Restrict food intake Nutrition Notes 45-1 The Client with Nausea (page 650) a. The client should eat small meals and eat and drink slowly b. Dry, salty foods, such as crackers and pretzels, may relieve nausea c. Fried food, spicy food, and foods with strong odors should be avoided d. Cold foods may be preferable to hot foods. v. Nursing Process (pages 650-652) 1. This is what I found important: a. Recommend commercial OTC beverages such as Gatorade. Gatorade replaces fluids and electrolytes. b. Inform the physician if urine output is below 500 mL/day or serum electrolyte levels are abnormal. Indicates severe dehydration.

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9 c. Discourage caffeinated of carbonated beverages. Such drinks may decrease appetite and lead to early satiety.

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Cancer of the Oral Cavity i. Pathophysiology and Etiology 1. Linked with smoking, chewing tobacco, and drinking alcohol in excess. 2. Most common oral cancer: squamous cell carcinoma 3. Usually occurs on the lips, sides of the tongue, or floor of the mouth ii. Assessment Findings 1. Early stage: asymptomatic 2. Lesion, lump, or other abnormality of the lips or mouth 3. Pain, soreness, and bleeding 4. Pain and numbness 5. Leukoplakia white patch on the tongue or inner check that may become cancerous iii. Medical and Surgical Management 1. In cases of hemorrhages, blood transfusions are given 2. Ligation of the bleeding vessel 3. Antianxiety agents 4. Surgical tumor excision 5. Radiation and chemo 6. Neck dissection if the cancer has spread to the lymph nodes near the jaw or below the ears 7. Trach and tube feedings to maintain an adequate airway and provide nourishment. iv. Nursing Management 1. Maintain patent airway 2. Promote adequate fluid and food intake 3. Support communication a. Magic slate, paper and pencil, alphabet board, hand signals 4. POST op pt. should be positioned flat on abdomen or side with the head turned to the side to facilitate drainage from the mouth 5. After recovery from anesthetic, place pt. with hob elevated for breathing a. Trach tray should be at bedside 6. Do NOT irrigate pt mouth unless the pt is awake and alert 7. Nutritional management is a challenge. a. Avoid hot and cold liquids and spicy foods Gastrointestinal Intubation for Feedings or Medications a. Used to provide nutrition, medications, or both; to carry our gastric decompression; to lavage the stomach to remove ingested toxins; to diagnose GI disorders, to treat GI obstruction; or to apply pressure to a GI bleed. b. Nasogastric intubation tube passes through nose into stomach via esophagus c. Orogastric intubation tube passes though mouth into the stomach d. Nasoenteric intubation tubes passes though the nose, esophagus, and stomach to the small intestine e. Gastrostomy tube enters the stomach through a surgically created opening in the abdominal wall f. Jejunostomy tube enters jejunum or small intestine through a surgically created opening into the abdominal wall

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Tube Type NASOGASTRIC TUBES Levin Gastric sump Salem Moss

Smaller, more flexible tubes are used for feedings and are longer. Larger tubes are used for decompression Table 45-1 Nasogastric, Nasoenteric, and Feeding tubes (pg 653)
Length Size (French) 14-18 12-18 12-16 Lumen Other Characteristics

125 cm 120 cm 90 cm

Single Double Triple

Circular markings serve as guidelines for insertion Smaller Lumen acts as a vent Tube contains both a gastric decompression and a duodenal lumen for postop feedings Two lumen are used to inflate the gastric and esophageal balloons; one is attached to suction to aspirate gastric contents th As above, but 4 lumen is attached to suction esophageal contents

SengstakenBlakemore

100 cm

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Triple

Minnesota

100 cm

12-16

Quadruple

NASOENTERIC DECOMPRESSION TUBES Andersen

2.44 m

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Used for temporary management of early mechanical obstruction. One lumen is Tungsten weighted; other is used as a vent

NASOENTERIC FEEDING TUBES Dobbhoff or Keofeed II

160-175 cm

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Tip is tungsten weighted, radiopaque

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Nursing Process for the Client Receiving Tube Feedings (pg 654 655) i. The following is what I found important: 1. Keep mucous membranes moist because they tend to dry from mouth breathing and restricted oral fluids 2. Discard any premixed formula after 24 hours 3. Aspirate and measure residual content before each intermittent feeding. Delay feeding if residual content measure more than 100 mL. Readminister the residual amount. 4. Maintain tube function by: a. Administering 15 to 30 mL of water before and after medications and feedings. This measure ensures tube patency and decreases the risk of bacterial infection and crusting or blockage of the tube. 5. Monitor weight daily 6. Place client in semi-fowlers position during and 30 to 60 minutes after an intermittent feeding, and at all times for a continuous feeding 7. Stop feeding if client vomits or aspiration is suspected 8. Administer feedings at room temperature ii. BOX 45-1 Tube Feeding Methods (pg 654)
1. Bolus Tube Feedings a. Allow introduction of 250 to 400 mL formula through the tube in a short period (usually 15 to 30 mins) b. Administered by syringe or gravity flow system attached to the distal end of the feeding tube.

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2. Intermittent Tube Feedings a. Allow delivery of between 250 and 400 mL formula over 30 to 60 minutes b. Delivered by gravity flow system or an electronic feeding pump Continuous Tube Feedings a. Allow formula to be administered at lower rates usually 1.5 mL/minute over a longer tine (usually 12 to 24 hrs) b. Delivered by gravity flow system or an electronic feeding pump Cyclic Tube Feedings a. Allow formula to be administered continuously for 812 hours during sleep followed by a 12-16 hour pause b. Ensure adequate nutrition during weaning from tube or oral feeding c. Alternate with oral food intake until client can take most nutrition orally

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iii. Table 45-2 Medication Administration by Way of Feeding Tube (pg 654)
Type Liquid Simple compressed tablets Buccal or sublingual tablets Enteric-coated tablets Time-release tablets Preparation None Crushed and dissolved in water Give as intended CANNOT be crushed; change in form required Some can be opened; cannot be crushed because doing so may released too much drug to quickly (overdose); check with pharmacist

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Gastrointestinal Intubation for Decompression a. The larger GI tube is used to relieve abdominal distention cause by problems after surgery, episodes of acute upper GI bleeding, or symptoms associated with intestinal obstruction, or for diagnostic purposes. b. Sump tubes decrease the possibility of the stomach wall adhering to and obstruction the tube openings during gastric decompression c. Nursing Guidelines 45-2 Managing the Care of a Client Needing GI Suction and Decompression (pg 656) - READ Gastrostomy Tubes for Long-Term Feeding a. General Considerations i. Percutaneous endoscopic gastrostomy (PEG) surgical opening through the abdominal wall into the stomach for feedings. (Creates a stoma) 1. FIGURE 45-2 (pg 656) ii. Bolus feedings are not given through tubes inserted below the pylorus because it causes abdominal cramping and diarrhea. iii. BOX 45-2 Prevention of Complications Related to PEG Tubes (pg 657)
1. 2. PEG tubes are most often stabilized with internal and external bumpers Bumpers that are too tight may cause: a. Pressure ulcer on the abdomen b. Buried bumper syndrome the internal bumper because buried in the abdominal wall, possibly leading to GI bleeding, perforation, or peritonitis. Bumpers that are too loose may cause: a. Free movement of the tube, leading to irritation, ulceration of the tract, or both. b. Dislodgment A new PEG tube insertion site may have a slight amount of bleeding, mucus, or both; report any prolonged drainage or other problems

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5. 6. 7. The tube insertion site should be inspected for signs of irritation, infection, drainage, or gastric leakage New PEG tubes are usually taped or sutured until the tract heals Once the tract heals, there is less risk for trauma to the abdominal wall. The PEG tube is more easily replaced in a healed tract.

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Nursing Management i. Before insertion: weigh the client, assess v/s, auscultated bowel sounds, and offer opportunity to empty the bladder ii. Monitor the characteristics and pattern of bowel elimination and trends in daily weight iii. Notify the physician immediately if accidental removal of the gastrostomy devise 1. If so, can maintain patency of the tract by inserted a clean catheter and inflating the balloon to hold the catheter in place it is safe to administer gastric feedings through a catheter until it is replaced. Disorders of the Esophagus a. Gastroesophageal Reflux Disease (GERD) i. Common disorder that develops when gastric contents flow upward into the esophagus ii. Pathology and Etiology 1. Results from an inability of the lower esophageal sphincter (LES) to close fully, allowing the stomach contents to flow freely into the esophagus 2. Obesity and pregnancy increase susceptibility to GERD iii. Assessment Findings 1. Signs and Symptoms a. Most common: Epigastric pain or discomfort (dyspepsia), burning sensation in the esophagus (pyrosis), and regurgitation. b. Difficulty swallowing (dysphagia) c. Painful swallowing (odynophagia) d. Inflammation of the lining of the esophagus (esophagitis) e. Aspiration pneumonia f. Respiratory distress g. Bleeding from the lining of the esophagus 2. Diagnostic Findings a. Barium-swallow findings show inflammation or stricture formation from chronic esophagitis b. Upper Endoscopy with biopsy confirms esophagitis c. Stool tests positive for blood d. Radiotelemetry technology e. Gastric emptying study evaluates the effectiveness of the stomach to empty its contents into the duodenum. May help determine what medications and/or surgery are needed iv. Medical and Surgical Management 1. Education and lifestyle changes include: a. Weight loss b. Maintaining an upright position following meals c. Elevating head of bed when sleeping d. Avoiding food and fluids 2 to 3 hours before bedtime

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13 e. Avoiding foods that intensify symptoms Antacids: aluminum, magnesium, or calcium-based they neutralize stomach acids If GI bleeding present: H2 antagonists and proton-pump inhibitors used for 2 to 3 months Ranitidine, cemetidine, or famotidine used for short term treatment of duodenal and gastric ulcers Metoclopramide (Reglan) increase LES pressure and promote movement of food through the stomach Most common surgical procedure: a. Fundoplication procedure that tightens the esophagus and suturing it into place Other surgical devices: a. The Stretta system uses electrodes to create tiny lesions on the LES. As the lesions heal, the tissue tightens, increasing the muscle mass of the LES and preventing reflux b. The Bard EndoCinch suturing system creates small tucks in the LES with sutures to strengthen the muscle. c. The Eneryx implant injects a solution in the LES. The liquid becomes spongy and reinforces the LES, preventing reflux. DRUG THERAPY TABLE 45-2 Medications Used to Treat Problems in the Upper GI Tract (pg 659-660) READ
a. Antacids: neutralize gastric acid to relieve heartburn and sour stomach i. Ex: calcium carbonate (Tums), aluminum hydroxide (AlternaGel, Gaviscon), and aluminum hydroxide with magnesium hydroxide (Maalox, Mylanta) H2 Antagonists: suppress gastric acid by blocking H2 receptors i. Ex: cemetidine (Tagament), ranitidine (Zantac), and famotidine (Pepcid) 1. **Give drugs with meals and at bedtime Anti-ulcer/Cytoprotective Agents: protect ulcers form acid and pepsin i. Ex: sucralfate (Carafate) 1. **Give drug on an empty stomach 1 hr before or 2 hrs after meals and at bedtime Proton Pump Inhibitors: Suppress gastric acid by clocking enzymes associated with the final step of acid production i. Ex: omeprazole (Prilosec), and Iansoprazole (Prevacid) 1. **Give before meals to prevent upset stomach GI Motility Agents: Stimulate upper GI tract and gastric emptying without stimulating release of gastric acid i. Ex: Metoclopramide (Reglan), cisapride (Propulsid) (*give 15 min before each meal and at bedtime), and bethanechol (Urecholine) (*administer on empty stomach) Anticholinergics: Relaxes smooth muscles of GI tract and inhibits gastric secretions

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Ex: atropine sulfate (Atropine), dicyclomine HCl (Bentyll), and propantherline bromide (Pro-Banthine) 1. **Give 30 mins before meals and ensure adequate fluid intake Combination Drugs for PUD: Combination medications of anti-ulcer and antibiotic to treat PUD and remove H. pylori infection i. Ex: bismuth subsalicylate (BSS), metronidazole (MTZ), and tetracycline hydrochloride (TCN) (Helidac) i.

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v. Nursing Management 1. Educate client with GERD about diet and lifestyle changes 2. Dietary Management a. Avoid items that lower pressure in the LES (alcohol, chocolate, peppermint, licorice, citrus fruits, caffeine, high-fat foods) b. Stop smoking c. Avoid food and drinks for several hours before bedtime Esophageal Diverticulum i. A sac or pouch in one or more layers of the wall found at the junction of the pharynx and the esophagus or in the middle or lower portion of the esophagus. ii. Pathophysiology and Etiology 1. Most Common: Zenkers Diverticulum 2. Men more likely than women 3. Congenital or acquired weakness of the esophageal wall 4. Causes esophagitis or mucosal ulceration iii. Assessment Findings 1. Foul breath 2. Difficulty or pain when swallowing, belching, regurgitating, or coughing 3. Barium swallow determines structural abnormalities iv. Medical and Surgical Management 1. Bland, soft, semisoft, or liquid diet to facilitate passage of food 2. Eat 4 to 6 small meals a day 3. Surgery v. Nursing Management 1. Oral hygiene will not alleviate the foul breath 2. Dietary modifications HIATAL HERNIA i. A protrusion of part of the stomach into the lower portion of the thorax. 2 types: 1. Axial or sliding the junction of the stomach and esophagus and part of the stomach slide in and out through the weakened portion of the diaphragm. (FIGURE 45-3A pg 664) 2. Paraesophageal the fundus is displaced upward, with greater curvature of the stomach going through the diaphragm next to the Gastroesophageal junction (FIGURE 45-3B pg 664) ii. Pathophysiology and Etiology 1. Results from a defect in the diaphragm at the point where the esophagus passes through it. 2. Common in women

15 Congenital muscle weakness or weakness resulting from trauma 4. Increasing risk factors: multiple pregnancies, obesity, and loss of muscle strength and tone that occurs with aging 5. In 60% of people other than 70 yrs of age. iii. Assessment Findings 1. Heartburn, belching, nausea, and feeling of substernal or Epigastric pressure or pain after eating and when lying down. 2. If scars form, swallowing becomes difficult 3. Vomiting 4. Sliding hernias associated with reflux 5. Barium swallow confirms diagnosis iv. Medical and Surgical Management 1. Narrow esophagus is stretched endoscopically v. Nursing Process for the Client with an Esophageal Disorder (pg 661-664) READ 1. The following is what I found Important: 3.
a. Post op will likely involve intubation for gastric decompression to prevent stomach distention and avoid pressure on the surgical site. Suggest that the client avoid foods and beverages that cause discomfort Record daily weights Tell the client to avoid very hot or cold fluids or spicy foods because these foods stimulate esophageal spasm and secretion of HCl in the stomach Inform client to remain upright for at least 2 hours after meals Discourage client from eating before bedtime

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vi. NURSING CARE PLAN 45-1 The Client Undergoing GI Surgery (PG 662-663) READ 1. The following is what I found Important:
a. b. When bowel sounds return, advance oral diet as ordered and tolerated. *DUMPING SYNDROME i. Withhold oral fluids at heals, provide fluids 1 hour after meals ii. Encourage client to lie down for about 30 minutes after a meal

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Cancer of the Esophagus i. Pathophysiology and Etiology 1. Affects men more than women 2. 2 types: a. Most common: squamous cell carcinoma b. Adenocarcinoma 3. Major cause: chronic irritation of the esophagus from any source. 4. Strongly correlated with alcohol abuse and cigarette smoking ii. Assessment Findings 1. Beginning symptoms: Vague discomfort and difficulty swallowing 2. Weight loss, progressive dysphagia 3. Consume liquids only 4. Regurgitation of foods and liquids 5. Tumor causes back pain and respiratory distress 6. Late symptom: Pain

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16 7. Weight loss and weakness 8. Barium swallow identifies mass 9. Biopsy iii. Medical and Surgical Management 1. Surgery, chemotherapy, and radiation 2. Resection of the esophagus, Laser therapy iv. Nursing Management 1. Goal: adequate or improved nutrition and eventually stable weight 2. Soft foods or high-calorie, high-protein semi-liquid foods 3. Sometimes TPN 4. Post op - No nourishment until bowel sounds return GASTRIC DISORDERS a. GASTRITIS i. Inflammation of the stomach lining ii. Pathophysiology and Etiology 1. Causes:
a. b. c. d. Dietary indiscretions; reflux of duodenal contents; Use of aspirin, steroids, NSAIDS, alcohol, or caffeine Cigarette smoking; ingestion of poisons or corrosive substances Food allergies; infection; and gastric ischemia secondary to vasoconstriction cause by a stress response. Helicobacter pylori (H. pylori)

e.

b.

2. Chronic irritation leads to ulceration iii. Assessment Findings 1. Complains of Epigastric fullness, pressure, pain, anorexia, nausea, and vomiting 2. Bacterial/viral vomiting, diarrhea, fever, and abdominal pain 3. Blood emesis or note a darkening of their stool color 4. Diagnostics: Stool testing, gastroscopy, H. pylori testing iv. Medical and Surgical Management 1. Ingestion of toxins require emergency treatment 2. Eating is restricted and IV fluids given to correct dehydration and electrolyte imbalances 3. Avoid alcohol and NSAIDS 4. Antacids, H2 antagonists, and proton pump inhibitors 5. Drugs to treat H. pylori v. Nursing Management 1. Observe color and characteristics of vomitus or stool that the client passes 2. Teach PEPTIC ULCER DISEASE (PUD) i. A circumscribed loss of tissue in an area of the GI tract that is in contact with hydrochloric acid and pepsin ii. Most occur in the duodenum iii. Men more affected iv. Pathophysiology and Etiology 1. Occurs when the normal balance between factors that promote mucosal injury (gastric acid, pepsin, bile acid, ingested substances) and factors that protect the mucosa (intact epithelium, mucus, and bicarbonate secretion) is disrupted 2. Greatest Risk Factor: H. pylori

17 H. pylori secrete an enzyme that theoretically depletes gastric mucus, making it more vulnerable to injury. 3. Other Risk factors: family history, chronic use of NSAIDS, cigarette smoking, and physiologic stress, aging and chronic stomach inflammation 4. Ulcers develop when there is prolonged hyperacidity or chronic reduction in mucus 5. Client may be at high risk for pernicious anemia because of poor absorption of vitamin B12 v. Assessment Findings 1. Signs and Symptoms a. Abdominal pain burning b. Pain occurs 1 to several hours after meals and disturbs sleep c. Eating food may relieve the pain d. Back pain suggests the ulcer is irritating the pancreas e. Bleeding first sign of ulcer f. Unexplained weight loss 2. Diagnostic Findings a. Upper GI series or EGD (Esophagogastroduodenoscopy pg 642) b. Biopsy, tests for H. pylori vi. Medical and Surgical Management 1. Goals: to eradicate the bacteria and reduce the acid levels in the digestive system to relieve pain and promote healing 2. Drugs: a.
a. Antibiotics amoxicillin (Amoxil) and clarithromycin (Biaxin); exerts bactericidal effects to eradicate H. pylori. H2 Antagonists -Tagamet; blacks H2 receptors and decrease HCl secretion in the stomach, relieving pain and promoting healing Antacids used to neutralize existing stomach acid and provide quick pain relief Proton Pump Inhibitors black the final step in acid production; promotes healing and appear to inhibit the growth of H. pylori Cytoprotective agents - forms a seal over the ulcer, protecting it from irritation

b.

c. d.

e.

3. 4.

Gastric intubation TABLE 45-3 Surgical Procedures to Treat PUD (pg 669)
a. b. Vagotomy a branch of the vagus nerve is cut to reduce gastric acid secretion Pyloroplasty the pylorus is repaired or reconstructed to expand the stomach outlet narrowed by scarring or improve gastric motility and emptying Antrectomy the antrum (lower stomach) is removed to eliminate a benign ulcer in the lesser curvature of the stomach if the ulcer has not healed after 12 weeks of medical treatment or is recurring *Gastroduodensotomy (Billroth I) part of the stomach is removed, while the remaining portion is connected to the duodenum. Usually, a vagotomy also is performed. This procedure is done to remove an ulcerated area in the stomach that is prone to hemorrhage, perforation, and obstruction.

c.

d.

18
e. *Gastrojejunostomy (Billroth II) Same as above, except the remaining portion is connected to the jejunum in cases of extensive duodenal inflammation or perforation. Total Gastrectomy The entire stomach is removed and the esophagus is jointed to the jejunum to remove an ulcer high in the stomach near the Gastroesophageal junction. It is performed to treat a gastric malignancy.

f.

c.

d.

DUMPING SYNDROME produces weakness, dizziness, sweating, palpitations, abdominal cramps, and diarrhea from the rapid emptying (dumping) of large amounts of hypertonic chyme (a liquid mass of partly digested food) into the jejunum a. Risk for pts with Gastrojejunostomy b. *Causes hypovolemia, syncope, and hypoglycemia. vii. Nursing Management 1. Assess type of pain, dietary history, bowel patterns and stool characteristics, fluids status, and vitals 2. Nursing Process for the Client with a Gastric Disorder (pg 668) Cancer of the Stomach i. Pathophysiology and Etiology 1. A malignancy characterized by either an enlarged mass or ulcerating lesion that expands or penetrates several tissue layers 2. Risk factors: heredity, chronic inflammation, achlorhydria (absence or free hydrochloric acid in the stomach), chronic ingestion of highly salted, smokes, or pickled foods, nitrates and nitrites, tobacco and alcohol use. 3. Most common type: Adenocarcinoma ii. Assessment Findings 1. Early symptoms: vague 2. Prolonged feeling of fullness, anorexia, weight loss, and anemia 3. Occult blood in stool 4. Late symptom: pain 5. Barium swallow, CT scan, and tissue biopsy iii. Medical and Surgical Management 1. Subtotal (partial) or total Gastrectomy 2. Chemotherapy and radiation iv. Nursing Management 1. Teaching: diet, lifestyle changes, warning signs 2. Client and Family Teaching 45-1 Discharge Instructions for the Client with Stomach Cancer (pg 670) Morbid Obesity i. Defined as a body mass index (BMI) of 40 or higher or a body weight of more than 20% of ideal ii. BOX 45-3 Calculating Body Mass Index (BMI) (pg 671) 2 1. BMI = (weight in pounds/ (height in inches) ) x 703
a. b. c. d. e. Underweight = < 18.5 Normal weight = 18.5 to 24.9 Overweight = 25 to 29.9 Obesity = >30 Morbid obesity = >40

5.

iii. Pathophysiology and Etiology 1. 1/3 or population in US is obese

19 Risk factors: genetic predisposition, diet, and lifestyle habits. 3. Results from excessive caloric intake, too much food, and a sedentary lifestyle; also a low metabolic rate 4. At risk for: diabetes, heart disease, hypertension, stroke, osteoarthritis, gallbladder disease, sleep apnea, and some forms of cancer. iv. Assessment Findings 1. Often weight 100 pounds more than ideal body weight 2. Hypertension, heart disease, type 2 diabetes. 3. Short of breath 4. Poor self-esteem and suffer from depression. v. Medical and Surgical Management 1. Prescription medications 2. Lifestyle changes, weight loss, diet restriction 3. Antidepressants 4. Bariatric surgery gastric bypass surgery; designed to help clients reduce their weight through surgical changes to the upper GI digestive system. a. Restrictive, Malabsorptive, or Combination vi. Nursing Management 1. CPAP and CIPAP, pain management, breathing and mobility exercises 2. Discharge teaching related to lifestyle changes 2.

20 Chapter 46: (pages 674 701) Caring for Clients with Disorders of the Lower Gastrointestinal Tract I. Altered Bowel Elimination a. Constipation i. Pathophysiology and Etiology 1. Condition in which stool becomes dry, compact, and difficult and painful to pass. 2. Causes: diet low in fiber and water, ignoring or resisting the urge to defecate, emotional stress, use of drugs that tend to slow intestinal motility, or inactivity. 3. May also occur from chronic use of laxatives because such use can cause a loss of normal colonic motility and intestinal tone. 4. Common problem in older adults, resulting from inadequate intake of dietary fiber, lack of exercise, and decreased fluid intake. ii. Assessment Findings 1. Signs and Symptoms a. Bowel elimination is infrequent or irregular b. Feel bloated, distended abdomen c. Hypoactive bowel sounds d. Rectal fullness, pressure, and pain when her or she attempts to eliminate stool e. Stool passed is hard and dry f. Rectal bleeding may result g. Encopresis liquid stool that passes around an obstructed stool mass (*Sometimes misinterpreted as diarrhea) 2. Diagnostic Findings a. History and physical examination, Barium enema, Radiographs iii. Medical and Surgical Management 1. Treating the cause provides the best relief 2. Enema or laxative in oral or suppository form, stool softener 3. Dietary management promoted 4. Drug Therapy Table 46-1 Agents Used to Treat Constipation (pg 676)
a. Chemical Stimulants directly stimulates the nerve plexus in the intestinal wall, causing increased movement and stimulation of local reflexes. Leads to intestinal evacuation Bulk Forming Agents increases intestinal motility by increasing fluids in intestinal contents. This in turn enlarges bulk, stimulates local stretch receptors, and activates bowel reflex activity i. Ex: magnesium sulfate (Epsom salts), magnesium citrate (Citrate of Magnesium), magnesium hydroxide (Milk of Magnesia), polycarbophil (FiberCon), and psyllium (Metamucil). 1. Magnesium products may cause EKG changes with prolonged use Hyperosmotic Agents Pulls water into intestine resulting in distention and peristalsis, leads to evacuation. Action of drug limited to large intestine. Emollients and Lubricants

b.

c.

d.

21 5. Nutrition Notes 46-1 The Client with Constipation (pg 677)


a. Consume approximately cup of dried peas or beans daily. These veggies are low-fat, high-fiber alternatives to meat. Legumes include splint peas, black eyed peas, pinto, kidney, and navy beans, and red and yellow lentils Consume plenty of fruits and veggies daily. Skin and seeds of fruit are rich in insoluble fiber; whole fruits are recommended over canned fruit or fruit juice. Consider slowly adding coarse, unprocessed wheat bran, a natural laxative, to the diet. Mix with juice or milk; add to muffins, quick bread, or casseroles; or sprinkle it over cereal, applesauce, or other foods. Seeds and nuts are also sources of fiber

b.

c.

d.

iv. Nursing Process for the Client with Constipation (pg 675 678) 1. The following is what I found Important:
a. b. Increase fluids to 6 to 8 glasses per day For rectal discomfort: apply lubricant in rectum and around anus with glove; assist client to soak rectal area in tub of warm water.

b.

Diarrhea i. Pathophysiology and Etiology 1. The passage of larger-than-normal amounts of liquid or semiliquid stools (more than 3 bowel movements per day) 2. Results from increased peristalsis 3. 3 major problems associated with severe diarrhea: a. Dehydration, electrolyte imbalances, and vitamin deficiencies. 4. May be related to bacterial or viral infection; lactose intolerance; food allergies; uremia; intestinal disease; overuse of laxatives; adverse effects of drugs; metabolic disorders and diseases; overeating, concurrent medication, and irritable bowel syndrome ii. Assessment Findings 1. Signs and Symptoms a. Stools are watery and frequent b. Urgency and abdominal discomfort c. Hyperactive bowel sounds d. Malaise 2. Diagnostic Findings a. Stool cultures, Colonoscopy, Upper GI series and Endoscopy iii. Medical and Surgical Management 1. Limit intake of clear liquids 2. Antidiarrheal agent, Probiotics 3. Fluid and electrolyte replacement by either the oral or IV route 4. Dietary adjustments, TPN if diarrhea is severe and prolonged 5. Nutrition Notes 46-2 The Client with Diarrhea (pg 679)
a. b. c. Diet low in insoluble fiber to reduce the volume of stool Foods high in soluble fiber. Ex: oatmeal, ripe bananas, and applesauce. Mashed potatoes, pasta, bread made with white flour, white rice, and low-fiber cereals are easy to tolerate.

22
d. e. Yogurt is usually tolerated well and contains Probiotics. Milk should be avoided. Encourage potassium rich foods as tolerated. Examples: bananas, canned apricots and peaches, apricot nectar, orange juice, grapefruit juice, tomato juice, fish, potatoes, and meat.

iv. Nursing Process for the Client with Diarrhea (pg 679 -680) 1. The following is what I found Important:
a. b. Limit high sugar drinks aggravate diarrhea Encourage client to rest in a comfortable position with legs bent toward the abdomen. This position relaxes abdominal muscles and reduces discomfort. If dehydrated, offer electrolyte solutions (Gatorade) Report urine output of less than 240 mL in 4 hours Observe for symptoms of sodium and potassium loss, such as weakness, abdominal or leg cramping, and dysrhythmias. Avoid caffeine and milk

c. d. e.

f.

c.

IRRITABLE BOWEL SYNDROME (IBS) i. Chronic illness characterized by exacerbations and remissions; refers to several chronic digestive disorders including Crohns disease and ulcerative colitis. ii. Crohns Disease 1. Chronic inflammatory condition can occur in any portion of the GI tract but predominantly affects the bowel in the terminal portion of the ileum 2. Pathophysiology and Etiology a. Hyperemia, edema, and ulcerations characterize affected areas. b. Inflamed areas alternating with healthy tissue (skip lesions) c. Fistula inflammatory channels containing blood, mucus, pus, or stool d. Causes: unknown; genetic predisposition, allergic and autoimmune responses, recurrent attacks on the tissue, stress 3. Assessment Findings a. Signs and Symptoms i. Insidious onset ii. Abdominal pain, distention, and tenderness in the lower abs iii. Growth failure common symptom in children and adolescents iv. Fever, anorexia, weight loss, dehydration, and signs of nutritional deficiencies v. Exacerbations and remissions b. Diagnostic Findings i. Stool cultures occult blood and WBCs in stool ii. Anemia iii. WBC count and erythrocyte sedimentation rate elevated iv. Barium enema, EGD with biopsy 4. Medical Management a. High fiber diet or low fiber diet depending on inflammation and stool patterns b. Nutritional supplements

c.

d. e.

23 Vitamins, iron, Antidiarrheal and antiperistalic drugs, anti-inflammatory corticosteroids, and antibiotics First line treatment: 5-ASA medications (act as an anti-inflammatory) Drug Therapy Table 46-2 Agents for Disorders of the Lower GI Tract (Pages 684 -686) READ!! (Lots of info)
Antidiarrheals: 1. Absorbent antidiarrheals - act by coating the walls of the GI tract and absorbing substances 2. Opiate-related antidiarrheals - act by slowing overall GI motility ii. Laxatives, Cathartics, and Bulk-Forming Agents iii. Anti-inflammatory 5-Acetylsalicylic Acid Medications (5-ASA) act in response to inflammation; anti-inflammatory properties iv. Anti-inflammatory Corticosteroids modify enzyme activity in the body and inhibit inflammatory immune response. v. Immune Modulating Agents inhibit the synthesis and function of RNA and DNA, impacting immune suppression. vi. Biologic Agents works through the monoclonal antibodies and is specific for certain tumor necrosis factors. i.

Surgical Management a. Reserved for complications b. Intestinal transplant c. Surgical removal of a large amount of intestine results in the loss of absorptive surface, called short bowel syndrome. d. Removal of colon requires a permanent ilesotomy 6. Nursing Management a. Determine the onset, duration, and nature of the clients GI problems iii. Ulcerative Colitis 1. Chronic inflammation limited to the mucosal and submucosal layers of the colon and rectum 2. Most common in young and middle aged adults 3. Pathophysiology and Etiology a. Causes: genetic predisposition, infection, allergy, and abnormal immune response. b. Inflammation usually begins in the rectum c. When the inflammation extends beyond the sigmoid colon the client has ulcerative colitis d. The lining of colon is thin and tends to bleed easily 4. Assessment Findings a. Signs and Symptoms i. Abrupt onset ii. Severe diarrhea and expel blood and mucus along with fecal matter iii. Cramps and abdominal pain in the lower left quadrant (LLQ) accompany diarrhea

5.

II.

24 iv. Anorexia, dehydration, and fatigue, weight loss v. Sudden urge to defecate, Incontinence during sleep vi. 10 to 20 stools per day vii. Exacerbations and remissions b. Diagnostic Findings i. Barium enema inflammation, Colonoscopy with biopsy c. Medical and Surgical Management i. Diet increased caloric and nutritional content ii. Blood transfusions and iron to correct anemia iii. Meds: corticosteroids, iv. Sometimes removal of colon d. Nursing Management i. Assess the nature of abdominal pain, number and frequency of stools, anorexia, and weight loss ii. Teach self care Acute Abdominal Inflammatory Disorders a. Appendicitis i. Inflammation of a narrow, blind protrusion called the vermiform appendix located at the tip of the cecum in the right lower quadrant (RLQ) of the abdomen. ii. Pathophysiology and Etiology 1. Inflammation begins when the opening of the appendix narrows or becomes obstructed 2. The appendix enlarges and distends, and the swelling compresses surrounding blood vessels 3. Unless the inflammation resolves, the appendix can become gangrenous or rupture, spilling bacteria throughout the peritoneal cavity. iii. Assessment Findings 1. Attack of abdominal pain 2. Later pain localizes in the RLQ at McBurneys point, an area midway between the umbilicus and the right iliac crest. 3. Rovsings sign LLQ palpated and can feel pain in the RLQ 4. Fever, nausea, and vomiting 5. Pain with defecation 6. Paralytic ileus intestine lacks peristalsis 7. CT scan or abdominal ultrasound show enlarged cecum 8. BOX 46-1 Precautions When Assessing a Client for Appendicitis (pg 689)
a. Avoid multiple or frequent palpation of the abdomen there is a danger of causing the appendix to ruptures Perform the test for rebound tenderness at the end of the examination. Do NOT administer laxatives or enemas to a client who is experiencing fever, nausea, and abdominal pain, even though the client may complain of feeling constipated. Laxatives and cathartics may cause the appendix to rupture.

b. c.

iv. Medical and Surgical Management

III.

25 Antibiotics Appendectomy removal of the appendix; before it spontaneously ruptures v. Nursing Management 1. Assess v/s, pain, response to antibiotics, comfort b. Peritonitis i. Pathophysiology and Etiology 1. The peritoneum becomes inflamed 2. Caused by perforation of a peptic ulcer, the bowel, or the appendix; abdominal trauma; IBD; ectopic pregnancy; or infection 3. Vascular shifts to the abdomen, lowering BP and producing hypovolemic shock or septic shock ii. Assessment Findings 1. Signs and Symptoms a. Severe abdominal pain, distention, tenderness, nausea, and vomiting b. Pain worsens when abdomen moves to breathe c. Knees toward abdomen lessen pain d. Abdomen feels rigid and board-like e. Bowel sounds absent (paralytic ileus) f. Pulse rate is elevated and respirations are rapid and shallow g. If unresolved severe weakness, hypotension, and a drop in body temperature occur as the client nears death 2. Diagnostic Findings a. Abdominal radiographs, CT scan or Ultrasonography b. Blood and peritoneal fluid cultures reveals bacteria iii. Medical and Surgical Management 1. NG tube used to relieve abdominal distention 2. Antibiotics, analgesics, antiemetics 3. Perforation is surgically closed iv. Nursing Management 1. Provide frequent explanations and emotional support Intestinal Obstruction a. Occurs when a blockage interferes with the normal progression of the intestinal contents through the intestinal tract b. Classified as mechanical or functional (paralytic ileus) c. Pathophysiology and Etiology i. Mechanical obstruction results from a narrowing of the bowel lumen with or without a space-occupying mass. 1. TABLE 46-2 Mechanical Causes of Obstruction (pg 691) 1. 2.
a. Adhesions loops of intestine adhere to areas that heal slowly or scar after abdominal surgery. The adhesions cause the intestinal look to kink 3 to 4 days later. Intussusception one part of the intestine slips into another lower part (like a telescope shortening). The intestinal lumen narrow. Volvulus the bowel twists and turns on itself, obstructing the intestinal lumen. Gas and fluid accumulate in the trapped bowel. Hernia the intestine protrudes through a weakened area in the abdominal muscle or wall. Intestinal flow and blood flow to the area may be completely obstructed.

b.

c.

d.

26
e. Tumor a tumor in the intestinal wall extends into the intestinal lumen; or a tumor outside the intestine causes pressure on the intestinal wall. The lumen becomes partially obstructed; if the tumor is not removes, complete obstruction results.

IV.

ii. Functional obstruction intestine becomes adynamic from an absence or normal nerve stimulation to intestinal muscle fibers 1. Can result from inflammatory conditions, electrolyte disturbances, or adverse drug effects d. Assessment Findings i. Signs and Symptoms 1. Nausea and abdominal distention 2. Vomiting seems to contain bile or fecal matter 3. Severe intermittent cramps 4. Sudden, sustained pain, abdominal distention, and fever are symptoms of perforation. 5. Functional obstruction peristalsis is absent, no bowel sounds 6. Mechanical obstruction bowel sounds are high pitched above the obstructed area 7. Pulse and respiratory rates are elevated 8. BP falls, urine output decreases if shock develops 9. Symptoms of shock ii. Diagnostic Findings 1. Radiographic study of the abdomen 2. Barium enema 3. Metabolic alkalosis e. Medical and Surgical Management i. NPO, Antibiotics ii. Intestinal decompression to relieve intestinal distention, cramping, and vomiting iii. NG tubes, Surgery for mechanical obstruction f. Nursing Management i. Manage pain, maintain fluid balance, help client deal with fear related to severe condition ii. Monitor urinary output hourly report less than 50 mL/hour (indicates shock) Diverticular Disorders a. Diverticulosis and Diverticulitis i. Diverticula sacs or pouches caused by herniation of the mucosa through a weekend portion of the muscular coat of the intestine or other structure; they can appear anywhere in the GI tract. ii. Diverticulosis asymptomatic diverticula iii. Diverticulitis inflamed diverticula iv. Pathophysiology and Etiology 1. Higher in people who have a low intake of dietary fiber 2. Causes: congenital predisposition, weakness associated with aging 3. Diverticula become inflamed when fecal material is trapped in one or more blind pouches 4. Has the potential to rupture into the peritoneal cavity or form a fistular connection with an adjacent organ v. Assessment Findings 1. Constipations with diarrhea, flatulence, pain and tenderness in the LLQ, fever, and rectal bleeding 2. Palpable mass may be felt in the lower abdomen 3. Stool appear maroon and resemble currant jelly

27 Diagnostics: Barium enema, colonoscopy, CT scan, CBC, and stool specimen vi. Medical and Surgical Management 1. Require no treatment if they do not cause symptoms 2. Avoid foods that contain seeds is recommended 3. High fiber diet, Bulk forming agent, Low-residue foods 4. Inflammation subsides with antibiotic therapy 5. Surgery: portion of the colon with diverticula is removed vii. Nursing Management 1. Assessment of abdomen for pain, tenderness, and masses 2. Teaching: 4.
a. b. c. d. e. Bran adds bulk to the diet and can be sprinkled over cereal or added to fruit juice Avoid the use of laxatives or enemas except when recommended by the physician Avoid constipation Drink at least 8 to 10 large glasses of fluid each day Exercise regularly

V.

Abdominal Hernia a. Hernia the protrusion of the intestine through a defect in the abdominal wall. b. Reducible hernia when the protruding structures can be replaced in the abdominal cavity; placing the client in a supine position and applying manual pressure over the area may reduce the hernia c. Irreducible/incarcerated hernia the intestine cannot be replaced in the abdominal cavity because of edema of the protruding segment and constriction of the muscle opening through which it has emerged. d. Strangulated hernia blood supply in the trapped segment of the bowel can be cut off leading to gangrene e. Pathophysiology and Etiology i. BOX 46-2 Types of Hernias (pg 694)
1. Inguinal part of the hernial sac contains the intestine at the inguinal opening (most common type; more prevalent in men than women) a. Direct hernia extends through inguinal ring; it follows spermatic cord in males and round ligament in females b. Indirect protrusion follows the posterior inguinal wall; it often descends into the scrotum in males Umbilical hernia occurs in the umbilical region, through which the hernial sac protrudes. This type occurs in children when the umbilical orifice fails to close shortly after birth. It may occur in obese adults who have prolonged abdominal distention. (More frequent in women) Femoral intestines descend through the femoral ring where the femoral artery passes into the femoral canal, below the inguinal ligament. Incidence of strangulation is high. (More frequent in women) Incisional this type occurs through the scar of a surgical incision when healing is impaired. Careful surgical technique, particularly prevention of wound infection, can prevent incisional hernias. Obese, older, or malnourished clients are prone to the development of incisional hernias.

2.

3.

4.

f.

ii. Hernias develop when intra-abdominal pressure increases, such as while straining to lift something heavy, having a bowel movement, or coughing or sneezing forcefully Assessment Findings i. Swelling in the abdomen; protrusion more obvious when coughing or bearing down

VI.

28 ii. Pain subsides when hernia is reduced iii. Can cause intestinal obstruction g. Medical and Surgical Management i. Surgery is the only method of eliminating a hernia ii. Truss an apparatus that presses over the hernia and prevents protrusion of the bowel iii. Client may lie supine which manual pressure is applied over the protruding area to reduce the hernia periodically iv. Herniorrhaphy the surgical repair of a hernia; recommended treatment 1. Performed under anesthesia v. Hernioplasty the weakened area is reinforced with wire, fascia, or mesh; usually for obese patients with reoccurring hernias. vi. Strangulation is an acute emergency and gangrenous part of the intestine must be excised h. Nursing Management i. Teaching: ways to avoid constipation, control a cough, and perform proper body mechanics. ii. Client using a Truss observe for and treat skin irritation form friction caused by the continuous rubbing; 1. Tell client they may use cornstarch to absorb moisture. 2. Truss may produce localized edema iii. Preop: surgery history, drug history, vital signs, auscultates lungs to identify infectious or respiratory risk factors, clients weight, duration of hernia, urinary and bowel patterns. iv. Postop: the nurse inspects the scrotum of male clients because it is common for edema to follow surgical repair v. Teaching post op complications: bleeding, infection must report to physician; avoid strenuous exertion and heavy lifting Cancers of the Colon and Rectum rd a. Colorectal cancer ranks as the 3 most common cancer among men and women in the US b. *For colorectal screening, occult blood testing is recommended every 1 to 2 years and colonoscopy every 5 to 10 years in clients older than 50 yrs of age. c. Pathophysiology and Etiology i. Most common: Adenocarcinoma ii. Risk factors: genetic disposition; environmental and lifestyle factors spark the transformation of benign to cancerous state. d. Assessment Findings i. Chief characteristic: change in bowel habits, such as alternating constipation and diarrhea ii. Occult or frank blood in stool iii. Client feels dull, vague abdominal discomfort iv. Late sign: Pain v. Distended abdomen with palpable mass vi. BOX 46-3 Symptoms of Colorectal Cancer Related to Location of the Lesion (pg 696)
1. 2. Right-Sided Lesions: dull abdominal pain; melena (black, tarry stools) Left-Sided Lesions: abdominal pain and cramping; narrowing of stool; constipation, abdominal distention; bright red blood in stool Rectal Lesions: tenesmus (ineffective painful straining with defecation attempts); rectal pain; feeling of incomplete evacuation after a bowel movement; alternating constipation and diarrhea; bloody stools

3.

e.

f.

29 vii. Diagnostics: fecal occult blood test; sigmoidoscopy; barium enema; colonoscopy; digital rectal examination viii. Carcinoembryonic antigen (CEA) elevated test results suggest a tumor. Medical and Surgical Management i. Removal of polyps or tumor ii. Colectomy surgical removal of the colon iii. Segmental resection removal of the cancerous portion of the colon and rejoins with the remaining portions of the GI tract to restore normal intestinal continuity iv. Abdominoperineal resection wide excision of the rectum and creation of a sigmoid colostomy; for cancers in the lower third of the rectum v. Radiation, chemo, Colostomy Nursing Management i. Advise and prepare for routine colorectal screening ii. Client and Family Teaching 46-2 Fecal Occult Blood Testing (FOBT) (pg 697)
1. 7 to 10 days before and throughout the test: a. Do not drink alcohol or take aspirin, NSAIDS, vitamin C, or iron preparations b. Check with physician if anticoagulants, steroids, colchicines (for gout), or cemetidine (for peptic ulcer) have been prescribed 2 days before and throughout the test: a. Consume a high-fiber diet and avoid red meat, substituting with poultry and fish b. Avoid turnips, cauliflower, broccoli, cantaloupe, horseradish, and parsnips During the test: a. Collect stool within a toilet liner or bedpan b. Use an applicator stick and remove a sample from the center of the stool c. Apply a thin smear of stool onto the test area supplied with the screening kit d. Take care to cover the entire space e. Place two drops of developer solution onto the test area f. Wait 60 seconds g. Observe for a blue color, indicating a positive reaction (for more valid results, test samples from several stool over 3 to 6 days)

2.

3.

VII.

Anorectal Disorders a. Hemorrhoids i. Dilated veins outside or inside the anal sphincter. Thrombosed hemorrhoids are veins that contain clots ii. Pathophysiology and Etiology 1. Chronic straining to have a bowel movement or frequent defecation with chronic diarrhea likely weakens the tissue supporting the veins 2. Dry stool passes by the engorged hemorrhoids, which stretches and irritates the mucosa, giving rise to the local symptoms of burning, itching, and pain; Passing dry, hard stool causes the hemorrhoids to bleed. iii. Assessment Findings 1. External hemorrhoids pain, itching, and soreness of the anal area; they appear small, reddish-blue lumps at the edge of the anus 2. Thrombosed external hemorrhoids painful best seldom cause bleeding

b.

c.

30 Internal Hemorrhoids bleeding; less pain unless they protrude into the anus; usually protrude each time the client defecates but retract after defecation 4. Diagnostic: anoscope (instrument for examining the anal canal) allows visualization of internal hemorrhoids; Colonoscopy rules out colorectal cancer iv. Medical Management 1. Small external hemorrhoids may disappear w/o tx 2. Warm soaks, ointment with local anesthetic relief of pain and itching, topical astringent pads to relieve swelling, diet to correct constipation, stool softener 3. Tied off with rubber hand v. Surgical Management 1. Hemorrhoidectomy the surgical removal of hemorrhoids; for chronic and severe cases a. T-binder holds the absorbent gauze in place vi. Nursing Management 1. Health teaching for self-management Anorectal Abscess i. An infection with a collection of pus in an area between the internal and external sphincters ii. Pathophysiology and Etiology 1. Common in clients with Crohns disease 2. Caused by infection by microorganisms from inside the intestine or through anal intercourse, or insertion of foreign bodies 3. May eventually develop into a fistulous tract iii. Assessment Findings 1. Pain aggravated by walking and sitting or other activities that increase intra-abdominal pressure such as coughing, sneezing, and straining to have a bowel movement 2. Swollen mass in the anus 3. Fever and abdominal pain if abscess extends into deeper tissues 4. Foul smelling drainage leaking from the anus if abscess ruptures 5. Culture of anal drainage reveals microorganism iv. Medical and Surgical Management 1. Analgesics and sitz baths 2. Antibiotics 3. Incision to remove infected material v. Nursing Management 1. Teach client to have scrupulous hand washing after each bowel movement, use separate hygiene articles, cleanse the bathtub after each use, and use a condom if having anal intercourse Anal Fissure i. A linear tear in the anal canal tissue ii. Pathophysiology and Etiology 1. Constipation is the leading cause of anal fissures 2. Causes: tear during vaginal deliver, trauma to anus iii. Assessment Findings 1. Severe pain and bleeding on defecation 2. Constipation 3. Torn area may be visible when inspected iv. Medical and Surgical management 3.

d.

e.

31 Applying anesthetic creams, ointments, or suppositories; taking sitz baths and analgesics; prevent constipation v. Nursing Management 1. Teach client how to insert a suppository 2. Instruct the client in how to take a sitz bath 3. Discuss strategies to relieve constipation 4. Nursing Care Plan 46-1 The Client With an Anorectal Condition (pg 699) a. The following is what I found Important i. Increase intake of water to 2 L/day ii. warm compresses/ sitz baths 3-4 times daily to relax the rectal sphincter spasm and sooth irritated tissues Anal Fistula i. A tract that forms in the anal canal ii. Pathophysiology and Etiology 1. Connection of the original abscess with perianal skin (FIGURE 46-7 pg 700) iii. Assessment Findings 1. Pain on defecation 2. Opening of the fistula appears red, and pus leaks for external opening 3. If superficial, feels cordlike on palpation 4. Diagnostics: colonoscopy or Proctosigmoidoscopy iv. Medical and Surgical Management 1. Antibiotics, treatment of underlying cause 2. Fistulotomy incising the fistula along with partial sphincter divisions 3. Fistulectomy involves the excision of the fistulous tract; recommended surgery 4. Secton nonabsorbable suture of drain that is passed from the cutaneous opening of the fistula into the lumen of the anal canal and then back out onto the skin, where it is tied to itself v. Nursing Management 1. Teaching Pilonidal Sinus i. An infection in the hair follicles in the sacrococcygeal area above the anus ii. Pathophysiology and Etiology 1. Occurs after puberty 2. Causes: inadequate personal hygiene, obesity, and trauma to the area 3. FIGURE 46-8 (pg 700) iii. Assessment Findings 1. Pain and swelling at the base of the spine and purulent drainage 2. Dilated pits of the hair follicles in the sinus are a unique characteristic iv. Medical and Surgical Management 1. Abscess is drained and tissue is incised 2. Purulent material and hair are removed 3. Packing is inserted into the cavity v. Nursing Management 1. Teach client how to minimize discomfort and facilitates postop bowel elimination 1.

32 Chapter 47: (pages 702 732) Caring for Clients with Disorders of the Liver, Gallbladder, or Pancreas I. Disorders of the Liver a. BOX 47-1 Functions of the Liver (pg 703)
Metabolize glucose Regulates blood glucose concentration Converts glucose to glycogen to glucose to maintain normal glucose levels iv. Synthesizes amino acids from the breakdown of protein or from lactate that muscles produce during exercise to form glucose v. Converts ammonia into urea vi. Metabolizes proteins and fats vii. Stores vitamins A, B12, D, and some B-complex vitamins, as well as iron and copper viii. Metabolizes drugs, chemicals, bacteria, and other foreign elements ix. Forms and excretes bile x. Excretes bilirubin xi. Synthesizes factors needed for blood coagulation i. ii. iii.

b.

c.

Jaundice i. Also called icterus, is a greenish-yellow discoloration of tissue ii. It is a sign of disease iii. Results from abnormally high concentration of the pigment bilirubin in the blood 1. Normal levels: 0.2 to 1.3 mg/dL 2. Levels increase when there is excessive destruction of RBCs or the liver cannot excrete bilirubin normally iv. Visible on the skin, oral mucous membranes, and especially the sclera v. Two forms of bilirubin: indirect/unconjugated and direct/conjugated vi. 3 forms of Jaundice: 1. Hemolytic caused by excess destruction of RBCs 2. Hepatocellar caused by liver disease 3. Obstructive caused by a block in the passage of bile between the liver and intestinal tract 4. Table 47-1 Types of Jaundice (pg 705) CIRRHOSIS i. A degenerative liver disorder caused by generalized cellular damage ii. Pathophysiology and Etiology 1. Types: a. Laennecs/Alcoholic cirrhosis the most common type; results from chronic alcohol intake and is frequently associated with poor nutrition; develops over a long period of 30 or more years i. Liver takes on hobnail appearance islands of normal tissue, regenerating tissue, and scar tissue. b. Biliary cirrhosis scarring occurs around the bile ducts in the liver caused from obstruction and infection 2. Prognosis based on bilirubin and albumin levels, presence or ascites, neurologic involvement, and nutritional status a. Table 47-2 Child-Pugh Classification of Severity of Liver Disease (pg 705)

33 iii. Assessment Findings 1. Signs and Symptoms a. BOX 47-2 Clinical Manifestations of Cirrhosis (pg 706)
i. Compensated: 1. Intermittent mild fever; vascular spiders, palmar erythema (reddened palms); unexplained Epistaxis; ankle edema; vague morning indigestion; flatulent dyspepsia; abdominal pain; firm, enlarged liver; splenomegaly Decompensated: 1. Ascites, Jaundice, weakness, muscle wasting, weight loss, continuous mild fever, clubbing of the fingers, purpura, spontaneous bruising, Epistaxis, hypotension, sparse body hair, white nails, gonadal atrophy

ii.

2.

Compensated less severe; signs and symptoms are more vague c. Decompensated as disease progresses; signs and symptoms are very pronounced and indicate liver failure d. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation e. Clay-colored or whitish stools as result of no bile in the GI tract f. Dark or tea-colored urine g. Enlarged liver h. Gynecomastia (enlarged breasts) and testicular atrophy i. Palmar erythema (bright pink palms) j. Cutaneous spider angiomata (tiny, spider-like blood vessels) Diagnostic Findings a. Liver biopsy obtained percutanously or through a surgical incision b. CT, MRI, blood tests, or PT tests c. Box 47-3 Common Blood Test Findings in Cirrhosis (pg 706)
Increased: bilirubin levels; AST, ALT, and GGT; globulin level ii. Decreased: leukocytes and thrombocytes; platelet count iii. Low: RBC count; fibrinogen level; albumin level iv. Prolonged PT v. Hypokalemia i.

b.

iv. Medical and Surgical Management 1. Aim of therapy is to prevent further deterioration 2. Improved nutritional status 3. NO alcohol, sodium restriction 4. Transfusion of platelets 5. Cholestryamine 6. Liver transplantation BOX 47-4 Liver Transplants and Organ Donation (pg 707) 7. Nutrition Notes 47-1 The Client with Cirrhosis (pg 707) READ

34
a. b. High-calorie, high-protein, carb controlled, with small frequent meals and use of supplements Fluid restriction for clients with hyponatremia

d.

v. Nursing Management 1. Rise in BP, pulse, and temperature correlates with alcohol withdrawal 2. Daily weights, I&O 3. *Measure abdomen girth take largest diameter of the abdomen (around the umbilicus) 4. Educational teaching a. May be rejected as a blood donor because of liver disease 5. **CARE PLAN 47-1 The Client with a Liver Disorder (pg 709-711) a. READ!! (its longer) Complications of Cirrhosis i. Portal Hypertension 1. Congestion and increased fluid pressure in the portal system 2. Treatment a. Reduce fluid accumulation and venous pressure b. Sodium restricted; diuretic prescribed c. Surgical shunt uses a graft to decompress the portal system by diverting blood into the systemic circulation d. Transjugular intrahepatic portosystemic shunt (TIPS) invasive radiologic procedure involves the creation of a tract from the hepatic to the portal vein; relieves portal hypertension e. DRUG THERAPY TABLE 47-1 Selected Meds Used for Liver, Gallbladder, and Pancreatic Disorders (pg 713-714)
i. Liver: 1. Procoagulant: promotes blood coagulation in bleeding conditions resulting from liver disease a. Ex: vitamin K Aminoglycoside antibiotic: decreased intestinal bacterial, thereby decreasing serum ammonia level a. Ex: kanamycin (Kantrex) Laxative and ammonia reduction agent: degrades intestinal bacteria a. Ex: lactulose Bile acid sequestrant: reduces puritus by binding bile slats for excretion in feces a. Ex: Cholestryamine (Questran) Potassium sparing diuretic: promotes excretion of sodium and water, particularly in cases of ascites a. Ex: spironolactone (Aldactone, Spirotone) Immune agents: promotes virusfighting capacities

2.

3.

4.

5.

6.

35
ii. Immunosuppressives: prevents rejection of transplanted organ Gallbladder 1. Gallstone dissolving agents: suppresses hepatic synthesis of cholesterol and cholic acid Pancreas 1. Pancreatic enzymes: promote digestion and fat, protein, and carb absorption 7.

iii.

ii. Esophageal Varices 1. Dilated, bulging esophageal veins 2. Vulnerable to bleeding 3. Figure 47-6 Pathogenesis of esophageal varices (pg 712)
a. b. c. Portal hypertension results from increased resistance to portal flow and increased portal venous inflow Pressure gradient increased b/w portal vein and inferior vena cava Venous collateral circulation develops from high portal system pressure to systemic veins, forming esophageal, gastric, and hemorrhoidal varices. Varices may rupture, causing life-threatening hemorrhage

d.

4. 5. 6.

Cardinal sign: Esophageal bleeding Diagnostic: Barium swallow or esophagoscopy Treatment a. Reduce the potential for bleeding b. Antitussives and stool softeners c. Injection sclerotherapy physician passes an endoscope orally to locate the varix; then passes a needle through the endoscope into the varix and directly injects a sclerosing agent to solidify and stop circulation to the varix d. Variceal banding device with rubber bands at the end of the endoscope; places the rubber band over the varix to restrict blood flow to the varix e. Distal splenorenal shunt (DSRS) f. Balloon Tamponade compresses the varices and stems the blood flow; uses a SengstakenBlakemore tube; temporary

iii. Ascites 1. Collection of fluid in the peritoneal cavity. 2. Leads to hepatorenal syndrome cascade of events that alter fluid distribution and interfere with fluid excretion 3. Treatment a. Abdominal paracentesis removes ascitic fluid in the abdominal cavity; relieves breathing difficulty b. Diuretic therapy, sodium-restricted diet iv. Hepatic Encephalopathy 1. CNS manifestation of liver failure that often leas to coma and death 2. Related to increased serum ammonia level 3. Signs and Symptoms a. Disorientation, confusion, personality changes, memory loss, flapping tremor (asterixis), a

4.

36 positive babinski reflex, sulfurous breath odor (fetor hepaticus), and lethargy to deep coma b. S/s worsen after client eats a high-protein meal of has active GI bleeding Treatment a. Eliminate dietary protein and removing residual protein b. Antibiotics - kanamycin c. Lactulose, Levadopa

e.

HEPATITIS i. Inflammation of the liver; may be acute or chronic ii. Pathophysiology and Etiology 1. Causes: hepatotoxic chemicals or drugs; lengthy alcohol abuse; invasion of an infectious microorganism 2. TABLE 47-3 Forms of Viral Hepatitis (pg 716)
CAUSE MODE OF TRANSMISSION Oral-fecal/saliva; water, food, and equipment contaminated with HAV Infected blood or plasma; sexually transmitted INCUBATION 3-5 weeks SIGNS AND SYMPTOMS With or without symptoms Preicteric phase: headache, malaise, fatigue, anorexia, fever Icteric phase: dark urine, jaundice, tender liver Arthralgias, rash; may occur without symptoms OUTCOME Mild with full recovery

TYPE Hepatitis A

Hep A virus (HAV)

Hepatitis B

Hep B virus (HBV)

2-5 months

Hepatitis C

Hep C virus (HCV)

Infected blood or blood products

2-20 weeks

Similar to HBV, although less severe and without jaundice Similar to HBV

Hepatitis D

Hep D virus (HDV)

Same as HBV; cannot infect alone; occurs as dual infection with HBV Fecal-oral routes

2-5 months

Hepatitis E

Hep E virus (HEV) Hep G virus (HGV, GB virus-c, or GBV-C)

2-9 weeks

Hepatitis G

Infected blood or blood products

14-145 days

Similar to HAV very severe in pregnant women Similar to HCV

May be severe; carrier state possible; increased risk of chronic hepatitis, cirrhosis, and cancer Frequent occurrence of chronic carrier state and chronic liver disease; risk of cancer Similar to HBV with greater likelihood of carrier state; chronic hepatitis, and cirrhosis Similar to HAV very severe in pregnant women Causes persistent infection; does not affect clinical course or cause chronic liver disease

3.

4.

Other Types of Hepatitis: a. Autoimmune hepatitis, Toxic hepatitis, and Drug-induced hepatitis BOX 47-5 Risk Factors for Acquiring Blood-borne Hepatitis (pg 717)
a. b. c. d. e. f. g. h. i. History of illicit IV drug use Occupational exposure through sharps injuries Perinatal exposure Blood transfusion Organ transplant Exposure to contaminated equipment that penetrates the skin Sexual contact with infected persons Hemodialysis Impaired immune response

37 iii. Assessment Findings 1. Signs and Symptoms


a. b. Incubation phase: virus replicated within the liver; asymptomatic; client is considered infectious Preicteric or prodromal phase: nausea, vomiting; anorexia; fever; malaise; arthralgia; headache; RUQ discomfort; enlargement of spleen, liver, and lymph nodes; weight loss; rash; and uticaria Icteric phase: jaundice, pruritus, clay-colored or light stools, dark urine, fatigue, anorexia, and RUQ discomfort Posticteric phase: liver enlargement, malaise, and fatigue; liver function tests begin to return to normal

c.

d.

II.

Diagnostic Findings a. RNA testing to detect virus b. ALT and AST levels rise in incubation period and fall once symptoms appear c. Prolonged PT and PTT reflects poor liver function d. Liver biopsy iv. Medical and Surgical Management 1. Treatment is symptomatic and includes: bed rest, balanced diet, IV fluids, vitamins supplements 2. Drug therapy 3. Liver transplant 4. BOX 47-3 Measures for Preventing Viral Hepatitis Transmission (pg 718) a. READ! v. Nursing Management 1. Preventative techniques to control spread 2. Teaching f. Tumors of the Liver i. Pathophysiology and Etiology 1. Increased incidence in people with previous hepatitis B or D virus infections or cirrhosis 2. Causes: TB and fungal and parasitic infections; oral contraceptives and anabolic steroids 3. They may obstruct bile flow leading to jaundice, liver failure, portal hypertension, and ascites. ii. Assessment Findings 1. Jaundice, rain in RUQ, weight loss, bleeding tendencies, distended abdomen 2. Alpha fetoprotein serum protein marker for malignant liver tumor 3. Diagnostics: liver scan, ultrasound, MRI, CT, biopsy iii. Medical and Surgical Management 1. Hepatic lobectomy remove primary malignant or benign tumor 2. Metastatic tumors are inoperable 3. Cryosurgery or cryoablation used liquid nitrogen to destroy tumors 4. Chemo, radiation iv. Nursing Management 1. Keep client comfortable 2. Safety measures 3. Nursing Process for a client having Surgery for a Liver Disorder (pg 720) a. READ Disorders of the Gallbladder

2.

a.

38 Cholelithiasis and Cholecystitis i. Cholelithiasis stones that form in the gallbladder ii. Choledo-cholithiasis stones located in the common bile duct iii. Cholecystitis inflammation or infection of the gallbladder; may be acute or chronic iv. Pathophysiology and Etiology 1. Always coexist 2. More frequent in women than men 3. Causes: bile stasis, dietary factors, and infection v. Assessment Findings: 1. Signs and Symptoms a. Belching, nausea, and RUQ discomfort, with pain or cramps after high-fat meals b. Acute Cholecystitis very sick with fever, vomiting, tenderness over the liver, and sever pain called biliary colic. c. Gallbladder swollen d. Slight jaundice e. Urine appears dark brown; stools light colored 2. Diagnostic Findings a. Cholecystography gallbladder imaging b. Ultrasound, CT, or radionuclide imaging c. Endoscopic retrograde cholangiopancreatography (ERCP) locates stones that have collected in the common bile duct d. MRI to detect gallstones and gallbladder disorders vi. Medical and Surgical Management 1. If gallbladder inflamed NPO; NG tube is inserted and antibiotics and parenteral fluids are prescribed 2. Low-fat diet 3. Analgesics, anticholingerics, and nitroglycerin for pain 4. Questran to relieve pruritus 5. Agents to dissolve gallstones 6. Lithotripsy nonsurgical procedure using shock waves generated by a machine, that may be able to break up some types of gallstones 7. Laparoscopic cholecystectomy the preferred surgical procedure for gallbladder removal a. Figure 47-10 (pg 722) 8. Open cholecystectomy 9. T-tube a tube used to drain bile vii. Nursing Management 1. Rest, antispasmodics, or analgesics 2. Low-fat diet 3. After surgery check for increased pain, shock, or signs of internal bleeding 4. Same-Day Surgery a. On day of surgery nurse does skin prep, inserts IV line, and administers sedation. b. After provide teaching and instructions 5. Cholecystectomy a. Nursing Care Plan 47-2 (pg 724-725) READ! b. T-tube collector should be kept below the level of the incision

c.

39 Measure drainage every 8 hours if more than 500 mL of bile drains in 24 hours notify physician

III.

Disorders of the Pancreas a. Acute Pancreatitis i. Inflammation of the pancreas; ranges from mild to severe and can be fatal ii. Pathophysiology and Etiology 1. Pancreas becomes inflamed with its own enzymes (trypsin) and causes the pancreas to digest itself (autodigestion caused by reflux of bile and duodenal contents into the pancreatic duct) 2. Causes: structural abnormalities, abdominal trauma, infections, metabolic disorders, vascular abnormalities, inflammatory bowel disease, hereditary factors, ingestion of alcohol or certain other drugs, or refeeding after prolonged fasting or anorexia. 3. Complications: hyperglycemia, necrosis and hemorrhage, peritonitis, fluid and electrolyte imbalance, shock, pleural effusion, acute respiratory distress syndrome, and blood coagulation problems iii. Assessment Findings 1. Signs and Symptoms a. Severe mid to upper abdominal pain radiating to both sides and straight to the back b. Nausea, vomiting, and flatulence c. Stools are frothy and foul-smelling from increased fat in the stool d. Symptoms worsen after eating fatty foods e. Relieved when client sits up and leans forward or curls into a fetal position f. Bowel sounds are diminished or absent g. Hypotensive h. Breathing is shallow from severe pain i. Bruising around the umbilicus or on the flanks 2. Diagnostic Findings a. Pancreatic edema and necrosis appear on CT scan b. Ultrasound, endoscopic examinations c. Serum levels iv. Medical and Surgical Management 1. Relieve pain, reduce secretions, restore fluid and electrolyte losses, and prevent or treat systemic complications 2. NPO, NG tube inserted 3. Antibiotics 4. Surgical management involves opening the abdomen to debride necrotic tissue 5. Sump drains are inserted into the cavity to remove debris and attached to continuous irrigation a. FIGURE 47-12 (pg 727) v. Nursing Management 1. Monitor client for alcohol withdrawal 2. Maintain tube patencies 3. Cardiac monitoring because of dysrhythmias caused by electrolyte imbalances b. Chronic Pancreatitis

c.

40 i. Pathophysiology and Etiology 1. Prolonged and progressive inflammation of the pancreas 2. Caused by alcohol ii. Assessment Findings 1. Signs and Symptoms a. Severe to persistent pain, weight loss, and digestive disturbances such as flatulence, diarrhea, and vomiting b. Firm mass may be palpable in the ULQ c. Urine is dark; stools are light colored and foul smelling d. Peripheral edema and ascites develop 2. Diagnostic Findings a. CT scans, MRI, ultrasound, and ERCP studies b. Glucose tolerance test iii. Medical and Surgical Management 1. Depends on cause 2. Alcohol abstinence, clear liquid to blan fat-free diet 3. Drug therapy a. Demerol, narcotics, pancreatic enzyme replacements 4. Surgery partial or total pancreatectomy (removal of some or all of the pancreas) iv. Nursing Process for the Client with Pancreatitis (pg 728-730) 1. The following is what I found important: a. Position client with hob elevated or in semifowlers position reduces pressure on the diaphragm from abdominal distention and promotes lung expansion b. Maintain low-fat diet c. Provide a safe environment for the client if at risk for injury related to alcohol withdrawal d. Seizure precautions Carcinomas of the Pancreas i. Just read. It is basically the same as the other cancers.