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NUR 250 Complex Health Alterations II
L. Taylor
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P icaFood picasNonfood picas
Foreign bodiesNursing considerations
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First meconium should be passed within24 to 36 hours of life; if not assess for:
Hirschsprung disease, hypothyroidismMeconium plug, meconium ileus (CF)
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InfancyOften related to dietConstipation in
exclusively breastfedinfant almost unknownInfrequent stool mayoccur because of minimal residue from
digested breast milkFormula-fed infantsmay developconstipation
ChildhoodOften due toenvironmental
changes or controlover body functionsEncopresis:inappropriate passageof feces, often with
soilingMay result from stress
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Also called congenital aganglionic megacolon
Mechanical obstruction from inadequatemotility of intestineIncidence: 1 in 5000 live births; morecommon in males and in Down syndrome
Absence of ganglion cells in colon
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Most common congenital malformation of the GI tract
Occurs in 1% to 3% of populationP athophysiology
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Constriction of the pyloric sphincter with obstruction of the gastric outlet
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Telescoping or invagination of oneportion of intestine into another
Occasionally due to intestinal lesionsOften cause is unknown
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Malrotation is due to abnormal rotationaround the superior mesenteric artery
during embryonic development Volvulus occurs when intestine is twistedaround itself and compromises bloodsupply to intestinesMay cause intestinal perforation,peritonitis, necrosis, and death
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Imperforate anusP ersistent cloaca
Cloacal exstrophyGenitalia may be indefinite
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Fig. 42-1
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Reflux of gastric contents into esophagus1 to 2 hrs after eating
Cleared in 1 to 3 minutesInflammatory responseCharacteristic of contentsLength of time in esophagus
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Inflammatory responseIncreased capillary permeability
EdemaTissue fragilityErosionFibrosis
Basal cell hyperplasiaP recancerous lesions (Barrett esophagus)
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Fig. 42-6
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Nursing assessmentNursing diagnosesP lanningNursing implementation
Health promotion Acute interventionx P reoperative carex P ostoperative care Ambulatory and home care
Evaluation
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Fig. 42-9
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AcuteErodes surface epitheliumDrugs NSAIDS ASA ChemicalsH. P ylori
Chronic
Thinning and degeneration of stomach wall
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Type A Fundal - atopic gastritis
Type B AntralH. P yloriBile reflux
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Esophagus stomach or duodenumSuperficial erosionDeep
RisksH. P ylori, smoking, NSAIDS, ETOH emphysema,arthritis, cirrhosis, stress
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Fig. 42-16
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H P yloriIncreased secretion of acid and pepsin
P enetrate mucosaClinical Manifestations
Epigastric pain p.c. 30 to 2 hrNocturnal
P ain food - relief
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Management AntacidsH2 receptor blockers inhibit secretion of acidTriple AntibioticsUlcer coating
Anticholinergic drugsP
roton pump inhibitors
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Duodenal reflux of bileBile salt disrupts mucosa
P ain Immediately p.c.More anorexia, wt loss, vomiting
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Decreased blood flowIschemic Curlings ulcer after burnsCushing ulcerx Over stimulation of vagal nucleix Increase acid production
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LGIUltrasoundCT
MRIColonoscopy
P roctosigmoidoscopyLaparoscopyFecal Analysis
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Average risk screening After age 50 Annual FOBT Flexible sigmoidoscopy every 5yr
Annual FOBT plus flexible sigmoidoscopy every5 yr Double-contrast barium enema every 5-10 yr
Colonoscopy every 10 yr
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Diarrhea AcuteChronic
AssessP lanImplementation
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Decreased fiberDecreased fluidsMedication
Altered exerciseDietComplications
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Assess Vitals immediatelyP ain location, duration, intensity, frequency
N/VBowel and bladder Vaginal drainage
P lan
Decrease inflammationDecrease pain Avoid complications
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InterventionsP re-op CBC, T&X, P T, P TT, N P OP ost opx NP Ox NG LISx I&O, acid basex NG out when peristalsis resumes
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IBSP UDDiverticulitisP IDHepatitis
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P ain AnorexiaN/VMcBurneys pointRovsing signComplications
Treatment
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Chemical or bacterialTenderness with reboundMuscular rigidity spasmComplicationsP lanImplement
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Etiology inflammation of the mucosa of the stomach and small intestine (virus orinfection)Clinical Manifestations N&V diarrheaabd cramping, distentionOther poss. Manifestations-fever
leukocytosis, blood/mucous in stool
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N/VDiarrhea
Abd crampingDiarrheaManagement
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GOALS maintain fluid volume atfunctional level
Verbalize understanding of causativefactors and therapeutic interventionsDemonstrate behaviors to monitor andcorrect deficit
Fluid volume deficit R/T diarrhea
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Restrict oral intake if orderedGradually progress from fluids to smallmealsIVF if indicatedInfection precautions wash handsSkin care (oral, rectal)
Monitor VS
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Chronic with exacerbationsDiffuse inflammation
Abscess ulcerationP seudopolypsBloody diarrhea
Abd painSevere can indicate perforation
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Mild2 stools / day
Moderate4 5 stools / day
Severe10-20 stools / day
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Etiology unknown inflammation andulceration of colon and rectumClinical manifestations bloody diarrheaIncrease stools
Abd pain, fever, malaise, anorexia, wtloss, anemia, tachycardia, dehydration
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Drug Therapy AntibioticsCorticosteroidsBowel rest IVFImmunosuppressive drugs
Anticholinergicantidiarrheal
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SurgicalIlleostomyContinent IlleostomyTotal colectomy with Illeal reservoir
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GOALS decrease number and severityof exacerbationsMaintain fluid and elyte balanceP ain managementComply with medical regimenMaintain nutritional balance
Risk for fluid volume deficit R/T diarrhea
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Nursing diagnosisDiarrhea R/T irritated bowelP ain R/T inflamed intestine
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ImplementationP ainI&OSkin careMonitor stoolsEmotional support
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Maintain food and fluid restrictionsMonitor signs of anxietyExplain treatments, test, and meds
Assess and document signs of malnutritionDaily wtNutritional supplementsSmall bites and eat slowlyIdentify ineffective behaviors
Monitor hypovolemia
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Inflammatory Bowel sections All layers of bowel wallUlcerations deep cobblestonesNon-bloody diarrheaComplications
Fistula, stricture, perforation, peritonitis,
absorption
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EtiologyInflammation of segments of GI tractMost often affects terminal ileum,
jejunum and colonInflammation involves all layers of bowel
wallThickening of bowel wall and narrowingof lumen with stricture
Abscesses and fistuals may develop
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Clinical manifestationsNon-bloody diarrhea
Abdominal pain
FatigueWeight loss
Abdominal cramping and tendernessFever
pain at umbilicus and RLQ
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Goal Develop healthy coping behaviorIneffective individual coping R/T chronicdisease, lifestyle changes, stressGoal Correct informationIneffective management of therapeutic regimenR/T lack of knowledgeGoal adequate nutritional intake
Altered nutrition: less than body requirementsR/T decrease intake and nutrient loss
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Drug therapy
Nutrition Therapy
Surgical therapy
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MechanicalOcclusion of the lumen of the intestine.
Non-mechanicalNeuro or vascularP aralytic illeus
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P ain VomitingBowel movements
Abdominal distention
NG insertionDiagnosticsIV Fluids
Surgical interventions
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Adenocarcinoma most commonStaging
DukesTNM
Surgical therapyRadiation and chemo
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Etiology unclearRisk factors age (40+), familialpolyposis, colorectal polyps, Chronic IBD,family history, previous history, History of genital or breast cancer (women),High fat and/or low fiber diet
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LeftRectal bleeding
Alternate
constipation anddiarrheaChange in stoolcaliber
Sensation of incompleteevacuation
RightUsuallyasymptomatic
Vague discomfort orcolicky painIron deficiencyanemia
Occult bleedingWeakness andfatigue
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GOAL P t understands disease processKnowledge deficit R/T new diagnosis andpreop preparationGOAL bowel sounds w/in 9 6 hrs postop
Altered bowel elimination R/T generalanesthesia and manipulation of bowel
during surgery
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Teach pt about Colon Cancer: riskfactors, signs and symptoms, method of spread
Teach pt about diagnostic procedures:colonoscopy, CEA, CT, CBC, types of surgery.Teach pt about steps to prepare thebowel for surgery: CL diet, antibiotics,Colyte, Golytely and other osmoticagents
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IlleostomyColostomy
End stomaHartmans pouchLoop stomaDouble barrel stoma
Kock P ouchIlleoanal reservoir
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END STOMA divide the bowel and bringout proximal end. Distal portion of GItract removed. End colostomy orileostomy distal bowel removed topermanent stomaDOUBLE BARREL 2 separate stomas
proximal functioning distal isnonfunctioning and temporary
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LOO P STOMA loop of bowel through abdsurface. Open anterior wall of bowel asfecal diversion. One stoma. TemporaryKOCK P OUCH eliminates use of deviceover stoma. Covered with cap ordressing. Continent ileostomy
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ILEOANAL RESERVOIR combination of 2procedures colectomy, recatalmucosectomy, ileal reservoirconstruction, ileoanal anastomosis withtemporary ileostomy. Then closure of ileostomy.
HARTMANNS P OUCH distal bowelremains intact and oversewn potential forreanastomosis and stoma closure
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Stoma pinkSkin barriers
ApplianceColostomy irrigation
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GOALS normal bowel function,verbalizeacceptance of self in situation, relief of anxiety to altered body image, seekinformation and pursue growth, useadaptive devices appropriately, developsocial support system.
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Risk for impaired skin integrityRisk for diarrhea/constipationBody image disturbanceImpaired social interactionRisk for sexual dysfunctionKnowledge deficit R/T changes in
physiological functions
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Assess peristomal skin for erythema, burning,itching, leakage. Skin careInstruct on odor control
Assess pt ability to care for stoma Assess nutritional intake Assess pt attitude about impact of ostomy onsexual functioning
Assess signs weakness, poor skin tugor,
hypokalemia, hyponatremia, oliguria
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EtiologyNo known cause but deficiency in dietaryfiber is associated. Cause related toretention of stool and bacterial in thediverticulum and forms a massprogressing to inflammation and small
perforations
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Clinical manifestationsMajority have no symptomsCrampy abd pain in LLQ
Alternating constipation and diarrheaFever, chills nausea anorexiaLeukocytosis
Bleeding is a complication of diverticulitis
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GOAL P t will maintain adequatenutrition with minimal trauma to thebowel and cope with lifestyle changes
Altered nutrition: less than bodyrequirements R/T decrease intake andmalabsorption
Anxiety R/T management of chronicdiseaseDiarrhea related to inflammatorychanges in LGI tract
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Record IO Assess anorexiaTotal bowel restP rovide optimum nutrition
Assess abd pain Assess for signs of anemiaP hysical and mental restObserve for skin breakdownP revent and control infection
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TypesClinical manifestationsNursing andcollaborative management:Hernias
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Etiology and pathophysiologyClinical manifestationsDiagnostic studies and collaborativecare
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Clinical manifestationsCollaborative care
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Etiology and pathophysiologyClinical manifestationsDiagnostic studies andcollaborative careNursing management:Hemorrhoids
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Fig. 43-18
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Fig. 43-20