ALTERATION IN NUTRITION AND METABOLISM

REVIEW OF GI TRACT
GI tract 23-26 feet-long passageway that extends from the mouth up to anus

 FUNCTIONS : - To break down food particles into the molecular form for digestion - To absorb into the bloodstream the small molecules produced by digestion To eliminate undigested & unabsorbed foodstuff & other waste products from the body Provide environment for microorganisms to synthesize nutrients such as Vit. K & B

 Start of digestion Aided by teeth, tongue & salivary glands Saliva 1st secretion that comes in contact with food - secreted from submandibular, parotid & sublingual glands - contains ptyalin (salivary amylase) digest starch

CHEWING/ MASTICATION

SWALLOWING/ DEGLUTITION
Swallowing voluntary act -occurs in the throat -food is pushed from mouth to pharynx to esophagus - regulated by medulla oblongata (swallowing center)

GASTRIC FUNCTION
Stomach stores & mixes food with secretions -Gastric fluid (2.4L/day) a. HCl; break down foods & destroy most ingested bacteria -b. pepsin enzyme for CHON digestion -c.mucin -d.gastrin- hormone

- Intrinsic factor secreted by gastric mucosa to combine with Vit B12 to be absorbed in the ileum - Peristalsis & contraction of pyloric sphincter enter of partially digested food in the small intestine - Chyme- food mixed with gastric secretion

ACCESSORY DIGESTIVE ORGANS

Pancreas, liver & gallbladder PANCREAS contains pancreatic juice with alkaline pH neutralizes acid entering duodenum - serves as Exocrine & endocrine gland

Pancreatic enzymes: Amylase digests starch to maltose Maltase reduce maltose to glucose Lactase split lactose to galactose & glucose - Nucleoses split nucleic acid to nucleotides - Enterokinase activates trypsinogen to trypsin - Lipase digest fats

LIVER largest gland in the body

- contains Kupffers cells remove bacteria in the portal circulation - removes excess glucose & amino acids from the portal blood - synthesize glucose, amino acids & fats - stores & filters blood (200-400ml) - stores Vit. A, D, B and iron - secretes bile for emulsifying ingested fats (5001000 ml/day)

GALLBLADDER- stores & concentrates bile - it contracts to force bile into the duodenum - Sphincter of Oddi guards the entrance into the duodenum

SMALL INTESTINE FUNCTION

Primary function: Absorption Secretes the ff: Enteric juice - Mucus coats the cell & protects the mucosa - Hormones control rate of intestinal secretions & influence GI motility - Electrolytes - Enzymes

 Two types of contraction in the small intestine: 1. Segmentation produces mixing waves that move contents back & forth in churning motion 2. Intestinal peristalsis propels the content of small intestine into the colon

COLONIC FUNCTION
Primary function: 1.reabsorption of water & electrolytes 2. fecal formation Bacteria make up major component of the contents of large intestine Electrolyte solution (bicarbonate) & mucus colonic secretions that are added to residual material in the colon

WASTE PRODUCT OF INGESTION

Feces undigested foodstuff, inorganic material, water & bacteria - 75% fluid & 25% solid material Flatus contains methane, hydrogen sulfide & ammonia (150 ml)

 Defecation - spinal reflex (parasympathetic nerve fibers) that can be inhibited voluntary by keeping the external anal sphincter closed Contracting abdominal muscle facilitates emptying of the colon Normal defecation: once daily

ASSESSMENT OF GIT

HEALTH HISTORY
1. Pain - OPQRST, location, frequency, duration, relieving factors 2. Indigestion/Dyspepsia - Upper abdominal discomfort or distress associated with eating

3. Intestinal gas - Belching expulsion of gas from the stomach thru mouth - Flatulence expulsion of gas from the rectum Excessive flatulence may be a symptom of gallbladder disease or food intolerance 4. Nausea & vomiting - triggered by odor, activity or food intake - Emesis/vomitus contains undigested food particles or blood (hematemesis)

5. Change in bowel habits & stool characteristics - may signal colon disease - Diarrhea abnormal increase in frequency & liquidity of stool - Constipation decrease in frequency of stool; or stools that are hard, dry, and of smaller volume than usual

 Stool color can be greatly affected by medications & certain foods Melena- black tarry stool - upper GI bleeding Hematochezia fresh blood in the stool - lower GI bleeding

PHYSICAL ASSESSMENT
Includes assessment of mouth, abdomen & rectum Abdomen Inspection, auscultation, percussion, palpation (IAPP) Inspect for abdominal skin color, scars, veins, hernia, contour Bowel sounds heard every 5-20 seconds - HYPOACTIVE 1-2 sounds in 2 minutes - HYPERACTIVE - 5-6 sounds in < 30 sec - ABSENT no sound in 3-5 minutes
Percussion: flatness, dullness , tympany, hyperresonance Palpation: Mass, tenderness, rebound tenderness, muscle guarding, abdominal rigidity

DIAGNOSTIC & LABORATORY EXAMINATIONS

NON INVASIVE TESTS

ABDOMINAL ULTRASOUND
Use of high frequency sound waves Image of abdominal organs & structures is produced on the oscilloscope Useful in detecting cholelithiasis, cholecystitis, appendicitis & diverticulitis Advantage: requires no ionizing radiation, no side effects & inexpensive Disadvantage: cannot be used to examine structures that lie behind bony tissues

Nursing Management
Maintain pt on NPO 8-12 hours before the test decrease amount of gas in the bowel Fat-free meal in the evening before the test for gallbladder studies

STOOL EXAM
Inspecting for consistency, color, parasites, fat, nitrogen, food substances & testing for occult (not visible) blood Some specimen requires certain diet to be followed

INVASIVE TESTS

ESOPHAGOGASTRODUODENOSCOPY (EGD)

Upper gastrointestinal fiberoscopy Following sedation, an endoscope is passed down the esophagus to view the gastric wall, sphincters & duodenum Tissue specimen can be obtained

Preprocedure
The client must be NPO for 6-12 hours before the test A local anesthetic is administered along with midazolam IV (provides conscious sedation & relieves anxiety) just before the scope is inserted

 Position the client left side to facilitate saliva drainage & provide easy access of the endoscope Airway patency is monitored during the test & pulse oximetry is used to monitor oxygen saturation Emergency equipment should be readily available

Postprocedure
Client must be on NPO until the gag reflex returns (1-2 hours) Monitor for signs of perforation (pain, bleeding, unusual difficulty swallowing, elevated temp) Lozenges, saline gargles or oral analgesic can relieve minor sore throat after the gag reflex returns

COLONOSCOPY, PROCTOSIGMOIDOSCOPY, PROCTOSCOPY, ANOSCOPY

It requires the use of flexible scope to examine the lower GIT Client is placed on the left side with the right leg bent Biopsies & polypectomies can be performed Preprocedure: Enemas are given until the returns are clear Postprocedure: Monitor for rectal bleeding & signs of perforation

BARIUM SWALLOW
Examination of upper GIT under fluoroscopy after the client drink barium sulfate PREPROCEDURE: NPO post midnight before the day of the test

 POSTPROCEDURE: 1. A laxative may be prescribed 2. Instruct the client to increase oral fluid intake to help pass the barium 3. Monitor stool for passage of barium (stool may appear chalky white) because barium can cause bowel obstruction

BARIUM ENEMA
Examination of lower GIT under fluoroscopy after the client is given barium sulfate solution via a rectal tube PREPROCEDURE: clear diet for 3 days, NPO post midnight before the day of the test, enema, laxatives

 POSTPROCEDURE: 1. A laxative may be prescribed 2. Instruct the client to increase OFI to help pass the barium 3. Monitor stool for passage of barium (stool may appear chalky white) because barium can cause bowel obstruction

GASTRIC SECRETION ANALYSIS

Analysis of gastric juice To know the secretory activity of the gastric mucosa & presence of gastric retention for client with pyloric or duodenal obstruction. Ph, Helicobacter pylori, AFB

Preprocedure
NPO 8-12 hours before the procedure Drugs that affect gastric secretions are withheld 24-48 hours before the test. Do not do oral care(gargle, brush) Do not smoke

 NGT is inserted entire stomach content are aspirated by gentle suction into a syringe & gastric samples are collected every 15 min for the next hour Gastric acid stimulation test is usually performed in conjunction with gastric analysis.

COMMON HEALTH PROBLEMS

DISORDERS OF THE ESOPHAGUS

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Back-flow of gastric or duodenal contents into the esophagus

Causes
1. Incompetent lower esophageal sphincter In cases like a.Congenital - pyloric stenosis,Motility disorder, prematurity c.Acquired-aging, tumor

 2. Increased Abdominal pressure In cases of a. Overeating or eating while drinking or eating while talking b. Lying down after eating, bending forward c. Straining-weight lifting, defecation, urination d. Obesity, tight clothings

Clinical Manifestations
Pyrosis (burning sensation in the chest, heartburn) Burning epigastric pain Dyspepsia (indigestion) Regurgitation, belching Dysphagia (difficulty swallowing) Odynophagia (pain on swallowing) Hypersalivation, acidic vomitus

Complications
GastritisUlcershemorrhage and shock Esophagitisulcershemorrhage and shock Scars, Strictures obstructionrupture Baretts esopahgus Esophageal Carcinomaobstruction

Diagnostic Tests
Endoscopy Barium swallow Ambulatory 12 or 24 or 36-hour esophageal pH monitoring- check ph in esophagus Esophageal Manometry- check pressures and peristalsis

Nursing Management
Low fat diet, small frequent feeding avoid caffeine, tobacco, beer, milk, spicy foods & carbonated drinks, acidic, ASA, NSAIDS Avoid eating or drinking 2-3 hours before bedtime, remain upright after meals

 Maintain normal body weight Avoid tight fitting clothes Elevate head of bed 6-8 inch blocks & upper body on pillows.

Medical Management
Antacids- 1-3 hrs after meals and at bedtime, check RFT Histamine receptor blockers (e.g. Ranitidine)-before meals and at bedtime, take with water, Proton pump inhibitor (e.g. Omeprazole)- DOC for severe GERD, 8 wks up to 3-6 months, before meals and bedtime, check LFT Prokinetic agents (e.g. Domperidone)- before meals and bedtime, cause drowsiness and EPS Cytoprotective-( eg. Sucralfate)- before meals and at bedtime, take IOF and fibers to prevent constipation

Surgical Management
FUNDOPLICATION - Wrapping of a portion of the gastric fundus around the sphincter area of the esophagus - Can be performed by laparoscopy

HIATAL HERNIA
Presence of opening(hiatus) in the diaphragm thru which part of the upper stomach tends to move up into the lower portion of the thorax.

Types
1. SLIDING (TYPE I) - Occurs when the upper stomach & gastroesophageal junction are displaced upward & slide in and out of the thorax - may occur if have short esophagus, weak anchor, inc. abd pressure

2. PARAESOPHAGEAL HERNIA (TYPE II,III,IV) - Occurs when all or part of the stomach pushes thru the wider diaphragmatic hiatus beside the esophagus -stomach remains in its original position

Clinical Manifestations
PARAESOPHAGEAL HERNIA: with GERD - Heartburn - Regurgitation - Dysphagia - Feeling of fullness * 50% asymptomatic

 SLIDING HERNIA - May be asymptomatic May have no GERD

 Hemorrhage Obstruction Strangulationischemiainfarctiongangre nous necrosis DIAGNOSTIC TESTS X-ray studies Barium swallow Fluoroscopy

Complications

Management most px need no tx

MEDICAL:manage like GERD Frequent small feedings Avoid lying 1 hour after eating Elevate head of head 4-8 -inch blocks SURGICAL: - Herniorrhaphy, Nissen Fundoplication

ACHALASIA
Esophageal Motility Disorder Unknown etiology Increased peristalsis of the whole or distal esophagus(spasms) accompanied by failure of the esophageal sphincter to relax in response to swallowing

Clinical Manifestations
Dysphagia to both solid and liquidsprimary symptom Heartburn Chest pain severe and usually at rest Chest fullness Nighttime cough

Diagnostic Tests
X-ray Barium swallow CT Scan Endoscopy MANOMETRY confirmatory test - esophageal pressure is measured by radiologist or gastroenterologist

Medical Management
Instruct pt to eat slowly and drink fluids with meals. Calcium channel blocker & nitrates temporary measure to decrease esophageal pressure & improve swallowing

Surgical Management
BOTOX (Botolinum toxin) injection to quadrants of esophagus via endoscopy MOA: lower LES pressure Done q 6-9 months PNEUMATIC DILATION stretch the narrow area of esophagus using air

 BALLON DILATATION OF LES LAPAROSCOPIC ESOPHAGOMYOTOMY - Separates esophageal muscle fibers

ESOPHAGEAL DIVERTICULA

DIVERTICULUM
Outpouching of mucosa & submucosa that protrudes thru a weak portion of muscle DIVERTICULOSIS: asymptomatic DIVERTICULITIS: with inflammation Exact cause is unknown; predisposing factors congenital (younger than 40), low intake of dietary fiber

 ZENKERS DIVERTICULUM (PHARYNGEAL POUCH) most common type - people older than 60 yrs old Other types: midesophageal, epiphrenic & intramural diverticula

Clinical Manifestations
Dysphagia Fullness in the neck Belching Regurgitation of undigested foods Gurgling noises after eating Halitosis- accumulation of undigested food Sour taste in the mouth

Complications
Inflammation Obstruction Abscess Perforation with peritonitis Bleeding and shock

Diagnostic Tests
Barium swallow Manometric studies

* Avoid esophagoscopy & NGT Insertion

Surgical Management
DIVERTICULECTOMY - Surgical removal of diverticulum MYOTOMY the muscle is dilated or released surgically END-TO END ANASTOMOSIS if with inflammation of surrounding GI mucosa

DISTURBANCE IN DIGESTION

Inflammation of gastric mucosa Acute or chronic Causes :ACUTE GASTRITIS: Contaminated foods Spicy foods Overuse of aspirin & NSAIDS Excessive alcohol intake Bile reflux Radiation therapy Ingestion of strong acid or alkali

GASTRITIS

CHRONIC GASTRITIS: Benign or malignant ulcers of stomach Helicobacter pylori Associated with autoimmune disease Use of caffeine NSAIDS Smoking Reflux of untestinal content in the stomach

Clinical Manifestations
ACUTE: Abdominal discomfort Headache Nausea & vomiting Anorexia hiccups
CHRONIC: -Anorexia -Heartburn -Belching -Sour taste in the mouth -Nausea & vomiting -Evidence of malabsorption of Vit. B12

Diagnostic Tests
ENDOSCOPY Upper GI series Biopsy & histologic exam of tissue specimen for H. pylori

Medical Management
ACUTE: - Instruct the pt to refrain from alcohol & food until the symptoms subside - Non-irritating diet - Parenteral fluids - Analgesics & Antacids (e.g. Maalox) - Nasogastric intubation

CHRONIC: Modifying the diet Promoting rest Reducing stress Antibiotic- for H. pylori Proton pump inhibitor

Nursing Process
Assessment: - Pt history s/sx, 72-hour diet recall, hx of previous disease, medications taken

 Nursing Diagnosis: - Imbalance Nutrition less than body reqts r/t inadequate intake of nutrients - Risk for imbalance fluid volume r/t insufficient intake & excessive fluid loss subsequent to vomiting - Acute pain r/t irritated stomach mucosa - Anxiety r/t treatment

 NPO until symptoms subside Monitor IV therapy Discourage the intake of caffeinated beverages, alcohol & smoking Promoting Fluid Balance Daily I&O monitoring IV fluids are prescribed at 3L/day Assess electrolyte values

Promoting Optimal Nutrition

Relieving Pain
Instruct client on the diet to avoid irritation of gastric mucosa Instruct about medications as prescribed Assist in non pharmacologic pain mngt Reduce Anxiety Use a calm approach to assess the client. Answer all questions as completely as possible. Explain all procedures & treatments to clients level of understanding.

PEPTIC ULCER DISEASE (PUD)

PUD
An excavation (hollowed-out area) that forms in the mucosal wall of the stomach, in the pylorus, duodenum & esophagus Gastric, duodenal, esophageal depending on location

COMPAIRING DUODENAL & GASTRIC ULCER

DUODENAL Incidence: Age: 30-60 Male:female = 2-3:1 80% are duodenal GASTRIC Usually 50 and over 1:1 15% are gastric

Clinical Manifestations
DUODENAL - Hypersecretion of HCl - Weight gain - Pain occurs 2-3 hours after meal - Pain awakens px between 1-2 am GASTRIC - Hyposecrretion of HCl - Weight loss - Pain occurs to 1 hour after meal - No nighttime pain

DUODENAL - Ingestion of food relieves pain - Vomiting is uncommon - Bleeding less likely, if present melena is common - More likely to perforate than gastric ulcer

GASTRIC - Vomiting relieves pain - Vomiting is common - Bleeding more likely hematemesis

DUODENAL Malignancy possibility: Rare Risk factors: H. pylori, alcohol, smoking, cirrhosis, stress

GASTRIC Occasionally

H. pylori, gastritis, alcohol, smoking, NSAIDs, stress

Assessment & Diagnostic Tests

Physical exam: pain, epigastric tenderness, abdominal distention Barium study of upper GI Endoscopy Biopsy Gastric analysis Stool exam for occult blood

Medical Management
Combinations of the ff: -Antibiotics - Proton pump inhibitor - Bismuth salts H2 receptor antagonist & proton pump inhibitor for NSAIDs induced ulcer & not associated with H. pylori

 Reduce environmental stress Smoking cessation Dietary modifications: -Avoid extremes of temp. - Avoid overconsumption of meat extracts, coffee, alcohol & other caffeinated beverages & diet rich in milk & cream

SURGICAL MANAGEMENT
PYLOROPLASTY- dilatation of pyloric sphincter ANTRECTOMY-removal of distal third of stomach VAGOTOMY resection or removal of CN 10to decrease stimulation of parietal cells that form HCl and decrease gastric motility BILLROTH I-gastroiduodenostomy BILLROTH II-gastrojejunostomy

Nursing Process
ASSESSMENT: - Describe the pain, methods used to relieve pain - Describe emesis if present - 72-hour food recall - Lifestyle & medications - Vital signs tachycardia & hypotension

 DIAGNOSIS - Acute Pain r/t the effect of gastric acid secretion on damaged tissue - Imbalance Nutrition r/t changes in diet - Anxiety r/t coping with an acute disease - Deficient Knowledge about prevention of symptoms & management of the condition

NURSING INTERVENTIONS
RELIEVING PAIN Taking prescribed medications. Avoid aspirin, foods that contain caffeine Meals should be eaten regularly Relaxation techniques

 MAINTAINING OPTIMAL NUTRITIONAL STATUS - Assess for malnutrition & weight loss - Advise to comply on medication regimen & dietary restrictions.

FOOD POISONING
Sudden illness that occurs after ingestion of contaminated food or drink. BOTULISM - serious form of food poisoning that requires continual surveillance.

Assessment
Nausea Vomiting Diarrhea

Medical Management
Food, vomitus, gastric contents, serum & feces are collected for examination Monitor VS, sensorium, CVP (if indicated) & muscular activity Monitor for electrolyte & acid-base imbalance Antiemetic given parenteral

GASTRIC LAVAGE
Aspiration of stomach content & washing out of stomach by means of a large-bore gastric tube. Contraindicated for acid or alkali ingestion, seizures or after ingestion of hydrocarbons or petroleum distillates

Purpose:
Urgent removal of ingested substance or decrease systemic absorption Empty the stomach before endoscopic procedure To diagnose gastric hemorrhage & to arrest hemorrhage

DISTURBANCE IN ABSORPTION AND ELIMINATION

DISORDERS OF INTESTINAL MOTILITY

DIARRHEA
Increased frequency of bowel movement ( more than 3x per day) Increased amount of stool ( more than 200 g per day) Altered consistency (looseness) of stool Increased intestinal secretions Decreased mucosal absorption Altered motility

Underlying Disease Process

- Irritable Bowel Syndrome (IBS) - Inflammatory Bowel Disease (IBD) - Lactose Intolerance

Types
ACUTE Associated with infection Self-limiting CHRONIC Persist for longer period of time May return sporadically

 Medications (laxatives, thyroid hormone replacement, antibiotics, chemotherapy, antacids) Tube feeding formula Metabolic & endocrine disorders (DM, Addisons) Viral or bacterial infection (Dysentery, shigellosis, food poisoning) Anal sphincter defect Zollinger- Ellison syndrome Paralytic ileus Intestinal obstruction AIDS

Causes

Clinical Manifestations
Increased frequency of stool fluid content of stool Abdominal pain or cramps Abdominal distention Intestinal rumbling (borborygmus) Anorexia Thirst Tenesmus (ineffectual straining

Diagnostic Tests
Stool Exam CBC Endoscopy Barium enema COMPLICATIONS: Dehydration Cardiac dysrhythmia

Medical Management
Antibiotic Anti-inflammatory Antidiarrheal IV therapy

Nursing Management
Assess & monitor the characteristic & pattern of diarrhea Health history Abdominal auscultation & palpation Obtaining stool samples

Encourage bed rest. Advise intake of liquids & foods low in bulk Bland diet of semi solid & solid foods Avoid caffeine, carbonated drinks, very hot or very cold foods, milk products, fat, whole grain, fresh fruits & vegetables Administer medication as prescribed. Monitor electrolyte levels Report immediately presence of dysrhythmia or change in LOC

CONSTIPATION
Abnormal infrequency or irregularity in defecation Abnormal hardening of stool that makes the passage difficult or painful Decrease in stool volume Retention of stool in the rectum for a prolonged period

Causes antiHPN, Medications (tranquilizer, antidepressant,

opioids, antacid with aluminum, iron) Rectal or anal disorder (hemorrhoids) Obstruction (e.g.cancer of bowel) Metabolic, neuroligic & neuromuscular condition (DM, Hirschsprungs disease, Parkinsons, multiple sclerosis) Endocrine disorders (hypothyroidism, pheochromocytoma) Lead poisoning Connective tissue disorders (eg. SLE)

Other Causes
Weakness Immobility Fatigue Inability to increase intra abdominal pressure (emphysema) Low fiber diet Inadequate fluid intake Lack of exercise Stress

Abdominal distention Borborygmus from passage of gas thru the intestine Pain & pressure Decrease appetite Headache Fatigue Indigestion A sensation of incomplete emptying Straining at stool Elimination of small-volume, hard, dry stools

Clinical Manifestations

Assessment & Diagnostic Tests

Patients Hx Physical exam Barium enema Sigmoidoscopy Stool exam Occult blood

Complications
Hypertension Fecal impaction Hemorrhoids Megacolon (dilated colon)

Medical Management
Bowel habit training Increased fiber & fluid intake Use of laxatives Routine exercise

Nursing Management
Patient education of the ff; - Maintaining regular pattern of elimination - Ensuring adequate intake of high fibers & fluids - Learn method to avoid constipation - Relieving anxiety - Avoiding complications

IRRITABLE BOWEL SYNDROME (IRS)

Presence of spastic bowel contraction One of the most common GI problems Common in women Cause is unknown

Risk Factors
Heredity Psychological stress (depression, anxiety) High fat diet Alcohol intake Smoking

Clinical Manifestations
Alteration in bowel patterns constipation, diarrhea or combination of both Pain, bloating & abdominal distention Pain is precipitated by eating and relieved by defecation

Diagnostic Tests
Stool exam Barium enema Colonoscopy Manometry

Medical Management
High fiber diet Exercise Stress reduction program Antidiarrheal drugs Andtidepressant Anticholinergic & calcium channel blocker decrease smooth muscle spasm, cramping & constipation

 Involuntary passage of stool from the rectum Factors: - Ability of the rectum to sense and accommodate stool - Amount & consistency of stool - Integrity of the anal sphincter & musculature - Rectal motility

FECAL INCONTINENCE

Clinical Manifestations
Minor soiling Occasional urgency & loss of control Complete incontinence Poor control of flatus Diarrhea Constipation

 Rectal examination Sigmoidoscopy Barium enema CT Scan Medical Management Treat the diarrhea or fecal impaction Biofeedback Bowel training program

Diagnostic Tests

Surgical Management
Surgical reconstruction Sphincter repair Fecal diversion Nursing Management Setting schedule for bowel training Maintain skin integrity Assist in the use of incontinence briefs

STRUCTURAL & OBSTRUCTIVE BOWEL DISORDERS

INTESTINAL OBSTRUCTION
Presence of blockage that prevents the normal flow of intestinal contents through the intestinal tract

Two types of process that impede the flow:

1. MECHANICAL OBSTRUCTION - Intraluminal or mural obstruction from pressure of intestinal wall - E.g. intussusception, polypoid tumor & neoplasm, stenosis, stricture, adhesion, hernia & abscess

2. FUNCTIONAL OBSTRUCTION - The intestinal musculature cannot propel its content along the bowel - E.g. amyloidosis, DM, Parkinsons disease

SMALL BOWEL OBSTRUCTION

- Intestinal contents, fluid & gas accumulate above the intestinal obstruction CAUSES: 1. Intussusception 2. Volvulus 3. Hernia

Clinical Manifestations
Crampy, colicky pain Blood & mucus without fecal matter & flatus Vomiting (fecal vomiting) Abdominal distention Signs of dehydration

Diagnostic Tests
Abdominal x-ray Abdominal UTZ Lab studies (electrolyte level, CBC) Medical Management DECOMPRESSION use of NGT IV therapy Antibiotic

Surgical Management
Repairing hernia (Herniorrhapy) Dividing the adhesion Nursing Management Maintaining the function of NGT Assess & measure NGT output Assess F&E imbalance If pts condition doesnt improve, the nurse prepare the pt for surgery

 Results in accumulation of intestinal contents, fluids & gas proximal to the obstruction Leads to severe distention & perforation Dehydration occurs more slowly Intestinal strangulation & necrosis if blood supply is cut-off

LARGE BOWEL OBSTRUCTION

Clinical Manifestations
*Symptoms progress slowly Constipation Abdominal distention Crampy low abdominal pain Fecal vomiting

Diagnostic Tests
Abdominal x-ray (flat & upright) Abdominal UTZ

Surgical Management
COLONOSCOPY - to untwist & decompress the bowel

CECOSTOMY- surgical opening in the

cecum Rectal tube to decompress area lower in the bowel

 SURGICAL RESECTION remove the obstructing lesion Temporary or permanent colostomy

ILEOANAL ANASTOMOSIS

Nursing Management
Administer IV fluids & meds as prescribed Prepare the pt for surgery General abdominal wound care & postop care after surgery

CONTINENT ILEOSTOMY
Surgical creation of a pouch of small intestine that can serve as internal receptacle for fecal discharge. A nipple valve is constructed at the outlet.

 Select suitable time for irrigation Irrigation should be performed at the same time each day. Before the procedure, the pt will sit on the chair in front of the toilet or the toilet itself. Hang 500-1500ml ml irrigating solution (lukewarm tap water) 18-20 above the stoma. The dressing on pouch is removed Allow pt to participate to learn to perform it unassisted.

IRRIGATING A COLOSTOMY

DIVERTICULAR DISEASE
DIVERTICULUM saclike outpouching of the lining of the bowel that extends to a defect in the muscle layer DIVERTICULOSIS multiple diverticula are present without inflammation or symptoms DIVERTICULITIS infection & inflammation in diverticula
- Food & bacteri retained in diverticulum

- leads to perforation or abscess

Clinical Manifestations
Bowel irregularity Abdominal distention Intervals of diarrhea Crampy pain in LLQ Low-grade fever Nausea Anorexia

Diagnostic Tests
CT Scan procedure of choice - reveals abscess Abdominal X-ray Barium enema (diverticulosis) Colonoscopy Lab tests (CBC, ESR)

 Peritonitis Abscess formation Bleeding Shock Medical Management Bedrest Analgesic Antispasmodic

Complications

 Diet : - clear liquid until inflammation subsides; then a high-fiber low-fat is recommended Antibiotics 7 to 10 days Bulk-forming laxative (e.g Metamucil) IV fluids

Surgical Management
ONE-STAGE RESECTION - Inflamed area is removed & a primary end-to-end anastomosis is completed MULTIPLE STAGED PROCEDURE - For complications such as obstruction or perforation

Nursing Process
ASSESSMENT Assess the pain Review dietary habits Ask about Hx of constipation, tenesmus, distention - Auscultation & palpation - Stool inspection - VS

 NURSING DIAGNOSIS - Constipation r/t narrowing of the colon from thickened segment & stricture - Acute pain r/t inflammation & infection

MAINTAINING NORMAL EMIMINATION PATTERN

Fluid intake of 2L/day High fiber diet Exercise program Set time for defecation Stool softeners & oil retention enema as prescribed

RELIEVING PAIN
Analgesics & antispasmodics as prescribed Records the intensity, duration & location of pain

MALABSORPTION SYNDROME

CELIAC DISEASE OR SPRUE

Also known as GLUTEN ENTEROPATHY or TROPICAL SPRUE Intolerance to GLUTEN CHON component of wheat, barley, rye & oats Accumulation of glutamine (amino acid) toxic to intestinal mucosa

Clinical Manifestations
Acute diarrhea Vomiting Anorexia Anemia Abdominal pain & Irritability distention Muscle wasting (buttocks & extremities)

CELIAC CRISIS
Precipitated by infection, fasting & ingestion of gluten Lead to electrolyte imbalance, rapid dehydration & severe acidosis Causes profuse watery diarrhea & vomiting

Medical Management
Gluten-free diet Substitute corn & rice as grain sources Mineral & vitamin supplements (A,D,E,K) Read food labels carefully

LACTOSE INTOLERANCE
Inability to tolerate lactose as a result of absence or deficiency of lactase

Clinical Manifestations
Symptoms occurring after ingestion of milk products Abdominal distention Crampy, abdominal pain Diarrhea Excessive flatus

Medical Management
Eliminate the offending dairy product or administer enzyme replacement. In infants, soy-based formula can be a substitute. Provide calcium & Vit. D supplement Encourage consumption of hard cheese, cottage cheese or yogurt instead of drinking milk

SHORT BOWEL SYNDROME

Cause: resection of portions of small intestines due to tumors, infarction, incarcerated hernias, Crohns dse, trauma, enteropathy from radiation Effects: More severe malabsorption after duodenum, jejunum, proximal and distal ileum resection vs mid-ileum resection Transit time reduced Impaired digestion Adaptive process-villi enlarge and lengthen to increase absorptive surface

Fluid Volume Deficit Impaired Nutrition: Less than Body Requirements Diarrhea For many clients, absorption and bowel functions return to preop or near-normal levels Some have diarrhea, weight loss and nutrient deficiencies Diagnostics: serum protein, albumin, folate, iron, electrolytes, vitamins, minerals, Hct,Hgb, PT

Nursing Diagnosis

Mgmt
GOAL: ALLEVIATE SYMPTOMS Diagnostics: Vital signs I and O Daily wt Skin turgor, mucous membranes Number and character of stools Tx : Provide adequate fluid intake esp during hot weather and strenous exercise Provide perianal care Refer to dietitian or counselor

Diet: frequent, small,high calorie, high-protein feedings with vitamin and mineral supplements TPN if severe Meds: Antidiarhheals to reduce bowel motility, allowing greater amount of time for nutrient absorption PPI as omeprazole(Prilosec) to decrease gastric acidity

ANORECTAL DISORDERS

HEMORRHOIDS
Dilated portions of veins in the anal canal. 50% of people age 50 yrs

Predisposing factors
Anal intercourse Hatching, sneezing, vomiting Hereditary Anal infection, rectal surgery, or episiotomy Pregnancy, prolonged sitting/standing Liver cirrhosis

Loss of muscle tone due to old age Oh alcohol Straining of stool

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Types
1. INTERNAL HEMORRHOIDS above the internal sphincter 2. EXTERNAL HEMORRHOIDS outside the external sphincter

 Infection, mucus drainage

Clinical Manifestations

Pain (more on external hemorrhoids) Anal itching Sensation of incomplete fecal evacuation Sudden rectal pain due to thrombosis Ulceration Constipation Kitang-kita at palpable mass (if external) Bleeding during defecation
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Diagnostic Tests
Rectal exam Stool exam Medical Management High-residue diet Good personal hygiene Avoid excessive straining during defecation Increase fluid intake

 Warm compress Sitz bath Analgesic ointment & suppositories (Faktu) Bedrest

NON SURGICAL TREATMENT

Infrared photocoagulation Bipolar diathermy Laser therapy Injecting sclerosing solution

Surgery - Indications

D isabling pain P rolonged bleeding I ntolerable itching G eneral unrelieved discomfort

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SURGICAL MANAGEMENT
RUBBER-BAND LIGATION PROCEDURE - Hemorrhoid is visualized thru anoscope, a rubber band is slipped over the hemorrhoid - Distal tissues becomes necrotic & slough off

 CRYOSURGICAL HEMORRHOIDECTOMY - Freezing the hemorrhoid for sufficient time to cause nercrosis HEMORRHOIDECTOMY - Surgical excision of hemorrhoid - Rectal sphincter is dilated & hemorrhoid is removed with a clamp & cautery and excised.

Complications
Hemorrhage Incontinence Prolapse Strangulation Anemia Patient Education Encourage regular exercise, high-fiber diet, and adequate fluid intake to avoid straining & constipation

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LESIONS

ANAL FISSURE
Longitudinal tear or ulceration in the lining of anus CAUSES: - Trauma (passing large, firm feces) - Stress & anxiety leads to constipation - Childbirth - Overuse of laxatives

Clinical Manifestations
Extreme painful defecation Burning sensation Bleeding Medical Management Stool softeners & bulk agents Increase OFI Sitz bath Emolient suppositories

Surgical Management
Lateral internal sphincterotomy with excision of fissure

ANAL FISTULA
Tiny, tubular, fibrous tract that extend in the anal canal from an opening located beside the anus

Causes
Infection Trauma Fissure Regional enteritis

Clinical Manifestations
Leakage of pus or stool Passage of flatus or feces from the vagina or bladder

Surgical Management
FISTULECTOMY excision of the fistulous tract - Probe is inserted to indentify the sinus tract - Fistula is dissected by incision from rectal opening - The wound is packed with gauze