This document provides an overview of nursing care for clients with gastrointestinal alterations. It reviews anatomy and physiology of the GI tract and includes assessment factors such as health history, medications, physical exam, and lab/diagnostic tests. Physical exam focuses on vital signs, abdomen, rectum/anus. Labs include CBC, occult blood test, CEA, chemistries. Diagnostics include upper/lower GI series, CT scans, endoscopic exams like EGD, colonoscopy. Nursing responsibilities are outlined for prepping clients and monitoring diagnostic procedures.
This document provides an overview of nursing care for clients with gastrointestinal alterations. It reviews anatomy and physiology of the GI tract and includes assessment factors such as health history, medications, physical exam, and lab/diagnostic tests. Physical exam focuses on vital signs, abdomen, rectum/anus. Labs include CBC, occult blood test, CEA, chemistries. Diagnostics include upper/lower GI series, CT scans, endoscopic exams like EGD, colonoscopy. Nursing responsibilities are outlined for prepping clients and monitoring diagnostic procedures.
This document provides an overview of nursing care for clients with gastrointestinal alterations. It reviews anatomy and physiology of the GI tract and includes assessment factors such as health history, medications, physical exam, and lab/diagnostic tests. Physical exam focuses on vital signs, abdomen, rectum/anus. Labs include CBC, occult blood test, CEA, chemistries. Diagnostics include upper/lower GI series, CT scans, endoscopic exams like EGD, colonoscopy. Nursing responsibilities are outlined for prepping clients and monitoring diagnostic procedures.
This document provides an overview of nursing care for clients with gastrointestinal alterations. It reviews anatomy and physiology of the GI tract and includes assessment factors such as health history, medications, physical exam, and lab/diagnostic tests. Physical exam focuses on vital signs, abdomen, rectum/anus. Labs include CBC, occult blood test, CEA, chemistries. Diagnostics include upper/lower GI series, CT scans, endoscopic exams like EGD, colonoscopy. Nursing responsibilities are outlined for prepping clients and monitoring diagnostic procedures.
The key takeaways are an overview of gastrointestinal anatomy and physiology and assessment of gastrointestinal problems, including health history, physical examination and diagnostic tests.
Some common gastrointestinal disorders discussed include hemorrhoids, anal fissures, anorectal abscesses.
Some nursing interventions for hemorrhoids include sitz baths, topical creams or suppositories, prevention of constipation through increased fiber and fluid intake, and postoperative care like pain management and cleansing after bowel movements.
N107 – Nursing Care of Clients with Alterations in the - Diet (!
), frequency of elimination as well as stool
Gastrointestinal Tract (Gaspar, 2/6/17) characteristics o Brown color – attributed to the P.S – texts from slides were lifted off, and placed with presence of BILE. added info during lec and ‘reading’ assignments by Sir o TOO brown color – high protein in the Aldin. diet o White stool – Post Cholecystectomy Review of Anatomy and Physiology (run-through) OR ingestion of barium sulfate for laboratory procedures o Melena – dark-colored, tarry stool; indicates bleeding in the upper GI tract o Hematokesia – Fresh blood in stool; indicates bleeding in lower GIT - Past Medical History o Recent Surgery, trauma, burns, or infections o Serious illness, such as diabetes, hepatitis, anemia, peptic ulcers, gall bladder disease and cancer o Alternative methods of feeding or fecal diversion o Food allergy or intolerance o IMMUNIZATIONS - Medications – OTC medications, prescription - Esophagus --- at the lower end is the cardiac drugs, herbal products, nutritional supplements sphincter which prevents backflow of gastric - Functional assessment contents. o Health perception and management – - Diaphragm – Separates the respiratory system General dietary habits, recent travel, from the digestive system attitudes, and beliefs about food, and - Stomach – esophageal sphincter, fundus, body, changes in dietary habits related to pylorus, pyloric sphincter health problems - Small Intestine – jejunum, duodenum, ileum o Nutritional – metabolic pattern; 24- - Large Intestine – separated from the small hour food recall, allergies, intolerance intestine by the ileoceccal valve. Ascending, o Elimination pattern – changes in Transverse, Descending and Sigmoid colon. pattern (correlate with nutritional - Rectum pattern) - Liver, pancreas, gall bladder, appendix o Activity-exercise pattern – note (appendix determined to be a safe house for whether patient is able to obtain and good bacteria) prepare food, eat independently, - Messentery (newly considered organ) – effects of chief complaint on usual transports blood and lymph from the intestine to functioning other parts of the body. o Sleep-rest pattern – changes in quality Assessment of sleep or rest? Individual routines - Health History – chief complaint of present o Cognitive-perceptual pattern – illness changes in taste or smell, vertigo, heat o A detailed description of the present and cold sensitivity, patient’s illness understanding of the illness and its o Complaints of weight changes, treatment problems with food ingestion, o **Self perception and self-concept – symptoms of digestive disturbances, or VERY COMMON PROBLEM with changes in bowel elimination OSTOMY CLIENTS
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 1
o Role-relationship pattern – ability to ***Vitamin C – can produce a FALSE maintain usual roles and relationships; NEGATIVE result support system o Radiographic Studies o Sexuality-reproductive pattern – Upper GI series – barium patient’s confidence regarding sexual sulfate fluoroscopy – looks activity; effect of ostomy and milky, thin or thick, colorless alcoholism tasteless, non-granulated. o Coping-stress tolerance pattern and NOT ABSORBED BY THE value-belief pattern – spiritual and BODY. cultural beliefs regarding food and Nursing Responsbilites – food preparation (1) instruct NPO post 12 - Physical Examination midnight in prep for o Vital signs, and anthropometric procedure, (2) INCREASE measurements – FILIPINO STANDARDS FLUID INTAKE DOST graph maximum Lower GI tract – No NPO allowance for BMI – 19.0 to needed 24.8 is the normal range Tumors, neoplasms, and [walang masyadong varices are seen / inflamed mahanap na specific lining appearance in film standards, pero this will do I indicates ULCER, dense white guess]. appearance indicates o Head and neck – inspect mouth possible neoplasm o Abdomen – remember IAPerPal 15-30 minute procedure (Inspection, Auscultation, Percussion, Need for low-residue diet 2 Palpation) weeks before procedure o Rectum and anus – palpate for lumps Usually laxatives are ordered and tenderness in the rectum o CT Scans o Bimanual Palpation – liver palpation, Better anatomic view of GIT upon percussion should be DULL NPO 6 to 8 hours before - Laboratory and Diagnostic Procedures procedure o CBC – increased WBC indicates Laxatives are administered to infection; important to note anemia empty the GI tract and other blood dyscrasias If w/ barium series, CT Scan o Fecal Occult Blood test – send certain is done FIRST and then amount of stool -> RBC checked in barium swallow stool to see probable bleeding -> if (+), o Endoscopic Examinations followed up with other diagnostic tests Upper GI o CEA (Carcinoembryonic Antigen) – for (Esophogastroduodenoscopy detection of colorectal cancer/s = or EGD) normal value is less than 3ug/mL Lower GI (Colonoscopy, o BUN, Albumin, Gastric Analysis, Liver proctoscopy, sigmoidoscopy) Function Tests, ERCD – Endoscopic o Stool Exam – DO NOT PERFORM IF retrograde WITH ACTIVE BLEEDING! Will produce cholangiopancreatography – False Positive result to visualize pancreas as well ***Intake of Broccoli, salmon, turnip, as gall bladder through the horse radish, liver/igado, must be ampulla of vater STOPPED before taking FOBT to prevent NURSING RESPONSIBILITIES false positive result (1) Prevent vomiting / ***Ferrous sulfate DOES NOT produce a aspiration – because false positive result sedatives, muscle relaxants,
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 2
and topical anesthetics are appear as ulcerations, thickened or given rough areas, or sore spots / (2) NO FOOD INTAKE until Leukoplakia: hard, white patches in the GAG REFLEX RETURNS (1-2 mouth that are premalignant hours in other references) o Medical Diagnosis and Treatment – A ***ATROPINE is given to decrease secretions, biopsy of suspicious lesions; treatment GLUCAGON is given as muscle relaxant includes surgery, radiation, or (Respiratory smooth muscle relaxation) chemotherapy, or combination of o LIVER BIOPSY these *** Instruct to INHALE-EXHALE during o ASSESSMENT puncture History of prolonged sun th th *** Puncture is between the 6 – 7 rib exposure, tobacco use and ***NEED FOR RESPIRATORY alcohol consumption MANAGEMENT – prepare pulse oximeter, Assess for difficulty possible intubation, and thoracoscopy swallowing or chewing, *** IF RISK FOR PUNCTURING LUNGS – decreased appetite, weight Biopsy done through right intrajugular vein loss, change in fit of *** POST-PROCEDURE POSITION – RIGHT dentures, and hemoptysis SIDE LYING POSITION PE Should focus on o Bleeding precautions examination of mouth for o Remain immobile for 2 hours, avoid lesions straining, coughing to prevent bleeding Assess the neck for limitation st o Every 15 minutes VS for 1 hour, of movement and enlarged q30mins for the next 2-3 hours lymph nodes DISORDERS OF THE ORAL CAVITY (lymphadenopathy in neck - Sialadenitis – inflammation of salivary glands indicates possible oral or ear - ORAL CANCER infection) o Types: oral cavity cancer and o Nursing Diagnosis oropharyngeal cancer IF LATE STAGE – PRIORITY o 2x more in men DIAGNOSIS IS AIRWAY (!!!) o 5-year survival rate is 59% Nutrition – possible o More common after age 35 parenteral nutrition admin o Common in the lower lip Psychosocial problems o NOTE: Documentation of the neoplasm Pain, Impaired verbal (e.g. (+) lesion in the right inner buccal communication, Disturbed mucosa, minimal erythema, with body image, Risk for yellowish discharge, 2cm in diameter) infection, Ineffective tissue o RISK FACTORS perfusion Smoking, lipsticks because o Collaborative Care of lead (CHECK FOR LEAD Elimination of risk factors CONTENT – ikiskis daw sa (alcoholism, poor dental piso or sag into) care, infection with HPV) Poor nutritional status, Correct oral hygiene and chronic irritation, alcohol use preventive dental care Cancer of the lip related to Radical Neck Dissection – prolonged exposure to surrounding tissues and irritants, including sun, wind, affected lymph nodes are and pipe smoking. removed o Signs and symptoms – tongue ***Nursing Responsibilities (1) Airway, (2) pain irritation, loose teeth, and pain in the management, (3) wound care, (4) v/s tongue or ear / Malignant lesions may
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 3
monitoring, (5) psychosocial care, (6) (2) smoking cessation, communication, (7) mobility (3) avoid chocolate, *** To facilitate better neck mobility – peppermint, tomatoes, (1) first 24 hours or until wound is healed, coffee, tea, milk, tomato- IMMOBILIZE NECK based products, orange, (2) 48 hours onwards, teach ROM, practive neck juice, cola, red wine, movement (4) small, frequent meals, (3) WOF: Bleeding, infection, cranial nerve (5) avoid late evening meals damage (V, IX, XI) and nocturnal snacking, DISORDERS OF THE ESOPHAGUS (6) take fluids in between - Gastroesophageal Reflux Disease (GERD) - rather than with meals, backward flow of gastric contents from stomach (7) chewing gum, oral to esophagus. lozenges o Most common upper GI problem in (8) high-protein, low-fat diet adults (9) avoid alcohol, o Incidence of 14-16% in Asia (10) avoid lying down 2-3 o Pathophysiology – Abnormalities hours post meals, wearing of around the Lower Esophageal tight clothing, and bending Sphincter, gastric or duodenal ulcer, over after eating, gastric oresophageal surgery, (11) sleeping with head of prolonged vomiting, and prolonged bed elevated, gastric intubation; eventually causes (12) weight reduction. esophagitis - Hiatal Hernia – Most common abnormality o Signs and Symptoms – painful burning found on X-ray examination of GI tract; common sensation that moves up and down, in older adults and more common in women commonly occurs after meals, and is than in men. relieved by antacids o Types o Association with Barret’s Esophagus – lining similar to stomach replaces the lining of the esophagus o Diagnostics Suggested by signs and symptoms Endoscopy, biopsy, gastric analysis, esophageal manometry, 24-hour monitoring of esophageal Sliding – Hernias that move pH, acid perfusion tests up and down, in and out of o Collaborative Care the chest area (more than Drug Therapy – 80% are of this type); (1)H2-receptor blockers heartburn, regurgitation, and (CIMETIDINE, RANITIDINE), dysphagia are common Sx. (2)prokinetic agents Paraesopahgeal/rolling – (METOCLOPRAMIDE, part of the stomach pushes ONDANSENTRON), and up through the hole in the (3) proton pump inhibitors diaphragm next to the (OMEPRAZOLE) esophagus ; patient’s usually Surgical Fundoplication – to feel a sense of fullness or tighten the sphincter chest pain after eating Lifestyle modifications – o Pathophysiology (1) Avoidance of triggers,
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 4
Protrusion of lower o Patophysiology – loss of tissue from esophagus and stomach up lining of the digestive tract /classified through the diaphragm and as either GASTRIC or DUODENAL into the chest o Causes – contributing factors include o Causes drugs, infection, stress / most ulcers Weakness of diaphragm are caused by H. pylori muscles where esophagus o Signs and symptoms - burning pain, and stomach join, but exact nausea, anorexia, weight loss cause is not known o Complications – haemorrhage, Factors are excessive intra- perforation, pyloric obstruction abdominal pressure, trauma, o Diagnostics –Barium swallow and long-term bed rest in a examination, EGD; H. Pylori detected reclining position by antibiotics in blood or stool and by a o Diagnostics breath test Barium swallow examination o Medical/surgical treatment – Drug with fluoroscopy Therapy, Diet Therapy, Managing Esophagoscopy Complications, Gastroduodenostomy Esophageal manometry or Billroth 1 Operation. o Collaborative Care ***BILLROTH 1 – Antrectomy – portion of the Reduction of intraabdominal stomach distal to the antrum is excised. LOWER pressure RECURRENCE OF PUD. Drug Therapy, diet, and ***BILLROTH 2 – Gastrojejunostomy – 10 to 20% measures to avoid increased recurrence of PUD intra abdominal pressure ***VAGOTOMY – removal of partial or complete (Head of bed elevation) Vagus nerve. Eating smaller and frequent meals Avoid lying down for three hours after drinking or eating Sugery: fundoplication and placement of the synthetic Angelchik prosthesis
o Dumping Syndrome –happens due to a
part of the stomach removed Symptoms that may be felt 10-30 minutes after eating: Nausea, vomiting, abdominal cramps, diarrhea, flushing, dizziness, lightheadedness, rapid heart rate HYPOGLYCEMIA due to DISORDERS OF THE STOMACH pancreas oversecreting - Peptic Ulcer Disease insulin in an attempt to catch faster flow of food through the GI tract
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 5
o Assessment NPO Pain, including location, Hemodynamic monitoring aggravating factors, and - Upper Gastrointestinal Bleeding – Overt measures that bring relief; bleeding / Clinically Important bleeding / Occult relationship between pain bleeding and food intake. o Causes Recent serious illness, Drug-induced: previous peptic ulcer disease, corticosteroids, NSAIDs, and a medication history salicylates Functional Assessment: Esophagus: BEV (Bleeding patient’s usual diet, use of Esophageal Varices?), alcohol and tobacco, Esophagitis, Mallory-weiss activities, sleep patterns and tear stressors. Stomach and Duodenum: Vital signs: Height and Stomach CA, hemorrhagic weight; skin and mucous gastritis, PUD, stress-related membranes for turgor and mucosal disease moisture Systemic Diseases: Blood Inspect abdomen for dyscrasias, renal failure distention and palpate for o Signs/symptoms tenderness Melena Auscultate for bowel sounds Hematemesis Gastric PUD Duodenal PUD “coffee-ground” material in - More common in ages 50- - more common in ages 30- nasogastric aspirate 60 y/o 50 y/o Ocasionally hematochezia - thinner lining of gastric - equal incidence in both S/sx of hypovolemia mucosa men and women Tense, board-like abdomen - greater in male because of - pain is relived by food alcohol intake and stress intake (pain 2-3 hours (perforation and peritonitis) - pain induced by food, postmeal) Abdominal distention, right after eating (15- - clients are not guarding 30minutes) malnourished o Diagnostics – Endoscopy - malnourished client, o Medical and surgical treatment – usually sugery, PPI, RBL, somatostatin, blood o Nursing Diagnosis transfusion, vasopressin Pain o GASTRIC LAVAGE – cleaning the Imbalanced nutrition: less… stomach through suction. Ineffective self-health mgt MEASURE (!) volume of Nausea blood loss in coffee ground PC: Hemorrhage nasogastric aspirate o Collaborative Care Cold application – to depress Adequate rest bleeding Drug Therapy: Antacids, PPI, Normal – yellowish to green H2-receptor blockers, aspirate (bilous) cytoprotective drugs o Nursing Diagnoses Elimination of smoking and Risk for aspiration r/t active alcoholism bleeding and altered LOC Dietary modifications if Decreased Cardiac output, needed r/t blood loss NGT placement Fluid Volume Deficit r/t Rehydration blood loss Blood Transfusion
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 6
Ineffective tissue perfusion Document the patient’s r/t loss of circulatory volume symptoms Anxiety Note stool characteristics Acute pain In the case of celiac sprue, o Collaborative Care teach the patient how to Health and teaching about eliminate gluten from the gastric irritant drugs diet Avoidance of alcohol and Give antibiotics as ordered smoking for tropical sprue Prompt treatment of URTI to If folic acid therapy prevent severe sneezing and continued, instruct patient in coughing self-medication Fluid/blood replacement The effect of therapy is Hemodynamic monitoring (I evaluated by the return of and O) normal stool consistency Lavage Advise the patient with Avoid red meat/chocolates lactase deficiency of dietary - Malabsorption - one ormore nutrients are not restrictions and alternative digested or absorbed products o Causes: bacteria, deficiencies of bile ***Important to note STOOL salts, or digestive enzymes, alterations CHARACTERISTICS in the intestinal mucosa, and absence ***Supplements for Vitamin A, D, E, of all or part of the stomach or and K are recommended intestines. - APPENDICITIS – inflammation of the appendix; a o Signs and symptoms – Steatorrhea ruptured appendix allows digestive contents to (fatty stool), weight loss, fatigue, enter the abdominal cavity, causing decreased libido, easy bruising, edema, PERITONITIS. anemia, and bone pain; o Signs and symptoms bloating, cramping, Pain at McBurney’s point, abdominal cramps, and midway between the diarrhea are symptoms of umbilicus and the iliac crest lactase defiency. Right lower quadrant pain – o Diagnostics rebound tenderness Sprue: based on laboratory Temperature elevation, studes, endoscopy with nausea, and vomiting biopsy, and radiologic Elevated WBC count (10,000- imaging studies 15,000/mm^3) / Neutrophil Lactase deficiency: based on count 75% more than normal the health history, the Peritonitis: absence of bowel lactose tolerance test, a sounds, severe abdominal breath test for abnormal distention, increased pulse hydrogen levels, and if and temperature, necessary, biopsy of the nausea/vomiting; rigid intestinal [lining]. abdomen o Medical Treatment ROVSING’S SIGN – Pressure Celiac Disease, avoid on the LLQ causes pain in the products that contain gluten RLQ / ACUTE APPENDICITIS Lactase Deficiency: eliminate o Medical Treatment milk and milk products. Nothing by mouth o Collaborative Care A cold pack to the abdomen may be ordered
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 7
Laxatives and heat Assess abdominal wound for applications should never be redness, swelling and foul used for undiagnosed drainage abdominal pain Wound care as ordered or Immediate surgical according to agency policy treatment indicated - PERITONITIS – Inflammation of peritoneum Ruptured appendix: surgery caused by chemical or bacterial contamination of may be delayed 6-8 hours the peritoneal cavity while antibiotics and IV fluids o Risk factors – Abdominal surgery, are given ectopic pregnancy, perforation: o Assessment trauma, ulcer, appendix rupture, Location, severity, onset, diverticulum duration, precipitating o Signs and Symptoms – pain over factors and alleviating affected area, rebound tenderness, measures in relation to the abdominal rigidity, and distension, pain fever, tachycardia, tachypnea, nausea, Previous abdominal distress, and vomiting, decreased bowel chronic illnesses, surgeries; sounds, board-like abdomen, record allergies and hypertension, dehydration. medications o Diagnostics – complete blood cell Temperature; abdominal count, serum electrolyte pain, distention and measurements, abdominal tenderness,; presence and radiography, computed tomography, characteristics of bowel ultrasound, and Paracentesis (removal sounds of fluid that accumulated in the o Preoperative interventions abdominal cavity) Semi-fowler or side-lying o Medical Treatment – gastrointestinal position with the hips flexed decompression, intravenous fluids, Until physician determines antibiotics, and analgesics; surgery to the diagnosis, analgesics may close a ruptured structure and remove be withheld foreign material and fluid from the If rupture suspected, elevate peritoneal cavity patient’s head to localize the o Assessment infection Onset and location and o Postoperative interventions severity of the pain and any Administer antibiotics, related symptoms intravenous fluids, and Record a history of possibly gastrointestinal abdominal trauma including decompression surgery Assist the client in turning, Take and record Vital Signs coughing, and DBE; incentive Inspect abdomen for spirometry. distention and auscultate for ***Incentive spiromtery done as common PC is the presence of bowel pneumonia due to pain and refusal to breath. sounds Done every hour, during waking hours, for 10- o Nursing Diagnoses 20 minutes unless indicated. Acute pain Splint the incision during Decreased cardiac output – deep breathing due to dehydration Early ambulation Imbalanced nutrition: less than body requirements Anxiety
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 8
*** If with infection – metabolism is faster and o Preoperative interventions fluids is not absorbed well Risk for injury (1) INCREASE OFI Impaired skin integrity (2) Observe for Na and K effects o Postoperative interventions *** Paracentesis is done if stomach is large Impaired urinary elimination already Constipation o Nursing Care: Acute Pain IVs and electrolyte and fluid Risk for Injury balance and GI distention Decrease pain: position with knees flexed, analgesics, and quiet environment Prevent complications: immobility, pulmonary, fluid balance - Abdominal Hernia – weakness in the abdominal wall that allows a portion of the large intestine to push through; weak locations include the umbilicus and the lower inguinal areas of the abdomen; may also develop at the site of a surgical incision. o Can be classified as reducible or irreducible. - INFLAMMATORY BOWEL DISEASE Reducible – contents can be o Pathophysiology – Ulcerative colitis, easily returned to their and Crohn’s disease; Inflammation and original compartment ulceration of intestinal tract lining original compartment o Cause - UNKNOWN; possible causes: Incarcerated – Cannot easily infectious agents, autoimmune returned to its original reactions, allergies, heredity, and compartment; with SEVERE foreign substances ABDOMINAL PAIN Ulcerative Colitis Crohn’s Disease Strangulated – SURGICAL -Diarrhea w/ frequent -Symptoms depend on EMERGENCY; blood supply bloody stools location to herniated tissue is -Rectal bleeding (colon is -Variety of symptoms the site for water (mentioned after this table) compromised absorption, diarrhea -Common with females o Signs and Symptoms common symptom) -Common in older adults A smooth lump in the -Common in Caucasian and 50-80 y/o; disseminated to abdomen Jewish people different parts of colon Incarcerated; distention, -Common in younger -2x more common in vomiting, and cramps people smokers o Medical Treatment -10-15% colon cancer Location: anywhere along possibility the Gi tract Surgical repair through – Location: colon typically Inflammation: may occur in Herniorraphy (suture of the only affected site patches edges) or Hernioplasty (with Inflammation: continuous Pain: commonly use of mesh) throughout affected areas experienced in the right o Assessment Pain: is common in the lower abdomen Chief Complaint lower left part of the Appearance: Thickened, abdomen rocky colon wall Ask about pain or vomiting Appearance: Colon wall is appearance ; ulcers along Inspect for abnormalities, thinner and shows the tract are deep and may and listen for bowel sounds continuous inflammation ; extend into all layers of the in all four quadrants mucus lining of colon may bowel wall
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 9
have ulcers, but they do not Bleeding: bleeding from the Maintain accurate intake and extend beyond the inner rectum during bowel output records lining. movements is not common Measure diarrhea stools if Bleeding: bleeding from the possible and count as output rectum during bowel o Nursing Diagnoses movements o Signs and Symptoms (Ulcerative Acute pain Colitis) Diarrhea Diarrhea w/ frequent bloody Deficient fluid volume stools, abdominal cramping Imbalanced nutrition: Less o Signs and symptoms (Crohn’s disease) than Body Requirements If the stomach and Risk for impaired skin duodenum are involved integrity symptoms include nausea, Ineffective coping vomiting, and epigastric pain o Collaborative Care Small intestine – produces Pain Control pain and abdominal Hemodynamic stability tenderness and cramping monitoring Colon – causes abdominal Monitor frequency and pain, cramping, rectal appearance of stools bleeding and diarrhea Stress management Systemic signs and Coping strategies symptoms include fever, Adequate rest night sweats, malaise and Keep client clean, dry and joint pain free of odor o Complications – Hemorrhage, Perianal care obstruction, perforation (rupture), - Diverticulosis – small saclike pouches in abscesses in the anus or rectum, intestinal wall: diverticula ; weak areas of the fistulas, and megacolon intestinal wall allow segments of the mucous o Diagnostics – membrane to herniate outward. Abdominal enema o Risk factors - lack of dietary residue, examination with air age, constipation, obesity, emotional contrast; colonoscopy with tension biopsy, ultrasonography, CT o Signs and symptoms – and cell studies Often asymptomatic, but Video Capsule – some may report of constipation, capsules are affected by HCl; diarrhea. caution with use Rectal bleeding, pain in left o Medical treatment – Drug therapy, lower abdomen, nausea and diet, and rest vomiting, and urinary o Assessment problems Onset, location, severity, and o Complications – bleeding, obstruction, duration of pain perforation, peritonitis, and fistula Note factors that continue to formation the onset of pain o Diagnostics – abdominal CT and Onset and duration of barium enema examination diarrhea; presence of blood o Asessment Vital signs, height and Patient’s comfort and stool weight, measures of characteristics, note N/V hydration Monitor patient’s temp Inspect perianal area for Abdomen for distention and irritation and ulceration tenderness
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 10
o Medical Treatment disease is advanced ; High-residue diet without Unexplained anemia, spicy foods weakness, and fatigue to Stool softeners or bulk- blood loss may be the only forming laxatives; early symptoms antidiarrheals; broad- Left Side or in the rectum – spectrum antibiotics; diarrhea or constipation and anticholinergics may notice blood in the stool Surgical intervention ; stools may become very *** Frequency of colonoscopy – EVERY 10 YEARS narrow causing to be o Collaborative Care described as PENCIL-LIKE ; Fluids as permitted; monitor feeling of fullness or pressure intake and output in the abdomen or rectum Antiemetics, analgesics, o Medical and Surgical Treatment anticholinergics as ordered Usually treated surgically Be alert for signs of Combination chemotherapy perforation postoperatively if tumor Teach patient about extends through the bowel diverticulosis, including the wall or if lymph nodes pathopthysiology, treatment, involved and sx of inflammation Early rectal cancer - Colorectal cancer – people at greater risk for sometimes treated with colorectal cancer are those with history of IBD radiation and surgery (inflammatory bowel disease, or family history of o Assessment CA and intestinal polyps. Vital signs, I/O, breath and o Pathophysiology – High fat and low bowel sounds, pain fiber diet and inadequate intake of Apperance of wounds and fruits and veggies also contribute to wound drainage development ; can develop anywhere If with COLOSTOMY, in the colon – ¾ of all Colorectal CAs measure and describe the are located in the RECTUM or LOWER fecal drainage SIGMOID COLON o Nursing Diagnoses Diarrhea or constipation r/t altered bowel elimination patterns Acute pain r/t difficulty in passing stools because of partial or complete obstruction from tumor Risk for injury Ineffective tissue perfusion Sexual Dysfunction Ineffective Coping o Collaborative Care Peri-operative Care Psychological Support Colostomy / Ostomy care - Color of stoma should be BEEFY RED, DRY, NO o Signs and Symptoms SURROUNDING LESIONS Right side of the abdomen – - Colostomy Types: vague cramping until the o Ascending Colostomy
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 11
o Transverse Colostomy o Do not use moistened wipes, baby o Descending and Sigmoid Colostomy wipes, or towelettes that contain lanolin or other oils o Unless recommended, do not apply powders or creams to the skin around the stoma. o Patient can shower, bathe, swim or even get in a hot tub with pouching system on. o The opening of the skin barrier should be no more than 1/8 inch away from the edge of the stoma. o Eat meals regularly / no overeating / DO NOT SKIP MEALS
- Nursing diagnoses (Ostomy surgery)
o Risk for deficient fluid volume o Risk for impaired skin integrity o Deficient knowledge: ostomy care o Disturbed Body image - Ostomy Care o Stoma is less active before eating or drinking in the morning o Empty the pouch when it is one-third full o Remove the old pouching in the direction of hair growth o Warm water may be used to remove the old pouching o IF STOMA RETRACTS – REFER ASAP!! o Frequency of ostomy bag change – PRN PGH: Reusable, BUT clean very well, especially the inside part of the bag o Foods that can block the stoma site: NUTS, BONY FOODS Do not eat or just swallow large green leaf vegetables! ADVISE TO CHEW FOOD WELL o Clean the area around the stoma with - WATCH OUT FOR: warm water o Purple, black, or white stoma o Dry the skin well before putting the o Severe cramps lasting more than 6 new pouch hours o Use a gentle touch when cleaning o Severe watery discharge from the around the stoma, do not scrub stoma lasting more than 6 hours o Do not use alcohol or any other harsh o No output from the colostomy for 3 chemicals to clean the stoma days o Excessive bleeding from the stoma
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 12
o Swelling of the stoma to more than ½- o Nursing Diagnosis inch larger than usual Acute pain o Pulling inward of stoma below skin Impaired Skin Integrity level Constipation o Severe skin irritation or deep ulcers o Collaborative Care o Bulging or other changes in the Prevention of constipation abdomen Avoidance of prolonged standing or sitting RECTAL DISOREDERS Sitz Bath 15-20min, 2-3x/day, - HEMORRHOIDS for 7-10 days o Internal or external dilated veins in the Pain rectum Stool softener o Thrombosed – Blood clots form in - ANORECTAL ABSCESS external haemorrhoids; become o An infection in the tissue around the inflamed and very painful rectum o Risk Factors o Sx are rectal pain, swelling, redness, Constipation, pregnancy, and tenderness prolonged sitting, or standing o Treated with antibiotics, followed by o Signs and Symptoms incision and drainage Rectal pain and itching o Preoperatively, pain is treated with ice Bleeding with defecation packs, sitz bath, and topical agents as External haemorrhoids easy ordered to see; appear red/bluish o Postoperatively, pain treated with o Medical Diagnosis and Treatment opiod analgesics Diagnosed visual inspection Patient teaching emphasizes Non Surgical Treatment importance of thorough (1)Topical Creams, Lotions or cleansing after each bowel suppositories soothe and movement shrink inflamed tissue Advise patient to consume (2) Sitz Bath – comforting adequate fluids and a high- (3) Heat and Cold fiber diet to promote soft applications stools Outpatient procedures: - ANAL FISSURE ligation, sclerotherapy, o Laceration between the anal canal and thermocoagulation/electroco the perianal skin agulation, laser surgery o Develops from anorectal abscesses or Hemorrhoidectomy – related to inflammatory bowel disease surgical excision of and tuberculosis haemorrhoid o Patient typically complains of pruritus ***INTRA-OP POSITIONING = and discharge Lithotomy or prone o Sitz baths provide some comfort Post-op = INDIVIDUALIZED, kung saan o Surgical treatment is excision of fistula komportable ang pasyente and surrounding tissue ***Lessen head of bed from 60 o Sometimes a temporary colostomy to degrees, decrease height on operative allow the surgical site to heal site o Postoperative care: analgesics and sitz o Assessment baths for pain After hemorrhoidectomy, PATIENT EDUCATION TO PROMOTE NORMAL BOWEL monitor VS, I/O, and breath FUNCTION sounds. Assess perianal area - Good hand washing and proper food handling for bleeding and drainage
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 13
- People who recognize that stress affects their GI function may benefit from relaxation techniques and stress management training - Signs and symptoms of digestive problems should be reported for prompt diagnosis and treatment if indicated - Teaching patients what is normal, how to promote normal function, and how to detect problems can help to avoid serious gastrointestinal dysfunction. -----------------Nothing Follows--------------------------------
N107- Nursing Care of Clients with GI Problems – BAYONITO, K.A.D. Page 14