medical surgical care of the patient with a gastrointestinal disorder edited by m. myers mosby items...
TRANSCRIPT
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Medical SurgicalMedical Surgical
Care of the Patient with aGastrointestinal Disorder
Edited by M. Myers
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
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Slide 2Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Digestive system◦ Organs and their functions
Mouth: Beginning of digestion Teeth: Bite, crush, and grind food Salivary glands: Secrete saliva Esophagus: Moves food from mouth to stomach Stomach: Churn and mix contents with gastric juices Small intestine: Most digestion occurs here Large intestine: Forms and expels feces Rectum: Expels feces
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Slide 3Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Location of digestive organs.
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
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Slide 4Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Accessory organs of digestion◦ Organs and their functions
Liver: Produces bile; stores it in the gallbladder Pancreas: Produces pancreatic juice
Regulation of food intake◦ Hypothalamus
One center stimulates eating and another signals to stop eating
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Slide 5Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Upper GI series Gastric analysis Esophagogastroduodenoscopy (EGD) Barium swallow Bernstein test Stool for occult blood Sigmoidoscopy Barium enema Colonoscopy Stool culture and sensitivity; stool for ova
and parasites Flat plate of the abdomen
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Slide 6Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Dental plaque and caries◦ Etiology/pathophysiology
Erosive process that results from the action of bacteria on carbohydrates in the mouth, which produces acids that dissolve tooth enamel
◦ Medical management/nursing interventions Remove affected area and replace with dental
material
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Slide 7Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Candidiasis◦ Etiology/pathophysiology
Infection caused by a species of Candida, usually Candida albicans
Fungus normally present in the mouth, intestine, and vagina, and on the skin
Also referred to as thrush and moniliasis◦ Clinical manifestations/assessment
Small white patches on the mucous membrane of the mouth
Thick white discharge from the vagina
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Slide 8Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Candidiasis (continued)◦ Medical management/nursing interventions
Pharmacological management Nystatin Ketoconazole oral tablets
Half-strength hydrogen peroxide/saline mouthwash Meticulous handwashing Comfort measures
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Slide 9Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Carcinoma of the oral cavity◦ Etiology/pathophysiology
Malignant lesions on the lips, oral cavity, tongue, or pharynx
Usually squamous cell epitheliomas◦ Clinical manifestations/assessment
Leukoplakia Roughened area on the tongue Difficulty chewing, swallowing, or speaking Edema, numbness, or loss of feeling in the mouth Earache, face ache, and toothache
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Slide 10Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Carcinoma of the oral cavity (continued)◦ Diagnostic tests
Indirect laryngoscopy Excisional biopsy
◦ Medical management/nursing interventions Stage I: Surgery or radiation Stage II & III: Both surgery and radiation Stage IV: Palliative
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Esophagus
• Tracheoesophageal fistula
• Newborn: copious saliva
choking, coughing
cyanosis on food intake
• Most common form: lower part of esophagus joins the trachea (near the bifurcation)
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Esophagus
• Tracheoesophageal fistula
• Newborn: copious saliva
choking, coughing
cyanosis on food intake
• Most common form: lower part of esophagus joins the trachea (near the bifurcation)
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Esophageal diverticula
• Outpocketing of the esophageal wall• False( pulsion) type: the mucosa herniates into
the muscular layer• True (traction) type: outpocketing of all the
layers• 3 common locations:• 1. above UES (Zenker diverticulum)• 2. midpoint of the esophagus• 3. above LES (Epiphrenic diverticulum)
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Zenker’s diverticulum Epiphrenic diverticulum
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Slide 16Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Gastroesophageal reflux disease (continued)◦ Diagnostic tests
Esophageal motility and Bernstein tests Barium swallow Endoscopy
◦ Medical management/nursing interventions Pharmacological management
Antacids or acid-blocking medications Dietary recommendations Lifestyle recommendations Comfort measures Surgery
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Slide 17Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Gastroesophageal reflux disease◦ Etiology/pathophysiology
Backward flow of stomach acid into the esophagus◦ Clinical manifestations/assessment
Heartburn (pyrosis) 20 min to 2 hours after eating Regurgitation Dysphagia or odynophagia Eructation
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Gastroesophageal reflux
• Reflux of gastric contents into the esophagus
• Heartburn, substernal pain, burning sensation
• Predisposing factors: alcohol, smoking, pregnancy
• May lead to: esophagitis, strictures, Barrett esophagus
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Barrett esophagus
• Normal epithelium: squamous type
• Barrett: becomes columnar with many Goblet cells
• Precursor for adenocarcinoma of the esophagus
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Barrett esophagus
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Barrett esophagus
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Cancer of the esophagus
• Most frequent type: squamous cell carcinoma
• Dysphagia, weight loss, anorexia
• Upper and middle thirds of the esophagus
• Adenocarcinoma type : lower third of the esophagus
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Slide 23Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Carcinoma of the esophagus◦ Etiology/pathophysiology
Malignant epithelial neoplasm that has invaded the esophagus 90% are squamous cell carcinoma associated with
alcohol intake and tobacco use 6% are adenocarcinomas associated with reflux
esophagitis
◦ Clinical manifestations/assessment Progressive dysphagia over a 6-month period Sensation of food sticking in throat
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Slide 24Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Carcinoma of the esophagus (continued)◦ Medical management/nursing interventions
Radiation: May be curative or palliative Surgery: May be palliative, increase longevity, or
curative Types of surgical procedures
Esophagogastrectomy Esophagogastrostomy Esophagoenterostomy Gastrostomy
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Cancer of the esophagus
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Slide 26Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Achalasia◦ Etiology/pathophysiology
Cardiac sphincter of the stomach cannot relax Possible causes: Nerve degeneration, esophageal
dilation, and hypertrophy◦ Clinical manifestations/assessment
Dysphagia Regurgitation of food Substernal chest pain Loss of weight; weakness Poor skin turgor
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Slide 27Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Achalasia (continued)◦ Diagnostic tests
Radiologic studies; esophagoscopy◦ Medical management/nursing interventions
Pharmacological management Anticholinergics, nitrates, and calcium channel blockers
Dilation of cardiac sphincter Surgery
Cardiomyectomy
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Gastritis
• Acute gastritis• Causes:
NSAIDSsmokingalcholic drinksburns :
Curlings ulcerCushings ulcer
• Chronic gastritis• Chronic inflammation,
atrophy of the mucosa
• Helicobacter pylori gastritis: most common form
• Increases risk of gastric cancer
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Acute Gastritis
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Peptic ulcers
• Common locations:lesser curvatureantrumprepyloric areas
• Causes: H.pylori infection bile-induced gastritis
• Not a precursor lesion of carcinoma of the stomach
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Benign Gastric Ulcers
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Slide 32Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Acute gastritis◦ Etiology/pathophysiology
Inflammation of the lining of the stomach May be associated with alcoholism, smoking, and
stressful physical problems◦ Clinical manifestations/assessment
Fever; headache Epigastric pain; nausea and vomiting Coating of the tongue Loss of appetite
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Slide 33Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Acute gastritis (continued)◦ Diagnostic tests
Stool for occult blood; WBC; electrolytes◦ Medical management/nursing interventions
Pharmacological management Antiemetics Antacids Antibiotics IV fluids
NG tube and administration of blood, if bleeding NPO until signs and symptoms subside Monitor intake and output
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Slide 34Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Gastric ulcers and duodenal ulcers◦ Ulcerations of the mucous membrane or deeper
structures of the GI tract◦ Most commonly occur in the stomach and
duodenum◦ Result of acid and pepsin imbalances◦ H. pylori
Bacterium found in 70% of patients with gastric ulcers and 95% of patients with duodenal ulcers
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Slide 35Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Gastric ulcers (continued)◦ Etiology/pathophysiology
Gastric mucosa are damaged, acid is secreted, mucosal erosion occurs, and an ulcer develops
Duodenal ulcers (continued)◦ Etiology/pathophysiology
Excessive production or release of gastrin, increased sensitivity to gastrin, or decreased ability to buffer the acid secretions
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Slide 36Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Gastric and duodenal ulcers (continued)◦ Clinical manifestations/assessment
Pain: Dull, burning, boring, or gnawing, epigastric Dyspepsia Hematemesis Melena
◦ Diagnostic tests Esophagogastroduodenoscopy (EGD) Breath test for H. pylori
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Slide 37Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Fiberoptic endoscopy of the stomach.
(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.)
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Slide 38Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Gastric and duodenal ulcers (continued)◦ Medical management/nursing interventions
Pharmacological management Antacids Histamine H2 receptor blockers Proton pump inhibitor Mucosal healing agents Antibiotics
Dietary recommendations High in fat and carbohydrates; low in protein and milk
products; small frequent meals; limit coffee, tobacco, alcohol, and aspirin use
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Slide 39Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Gastric and duodenal ulcers (continued)◦ Medical management/nursing interventions
Surgery Antrectomy Gastroduodenostomy (Billroth I) Gastrojejunostomy (Billroth II) Total gastrectomy Vagotomy Pyloroplasty
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Slide 40Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Types of gastric resections with anastomoses.
A, Billroth I. B, Billroth II.
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Slide 41Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Gastric and duodenal ulcers (continued)◦ Complications after gastric surgery
Dumping syndrome Pernicious anemia Iron deficiency anemia
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Cancer of the Stomach
• Common: more than 50 years old, men, Blood group A
• Predisposing factors:H. pylori infectionNitrosaminesexcessive salt intakelow fresh fruits, vegetables dietachlorhydiachronic gastritis
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Cancer of the stomach
• Most common type: adenocarcinoma• Rare in the fundus• Aggressive spread to adjacent organs• Virchow node: large supraclavicular node• Krukenberg tumors: bilateral, enlarged ovaries,
“signet ring” cells• Two types:• 1. intestinal type: fungating mass; ulcer with
irregular necrotic base and firm, raised margins• 2. infiltrating or diffuse type: linitis plastica
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Signet ring cells
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Cancer of the stomach
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Krukenberg tumors
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Slide 47Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Cancer of the stomach◦ Etiology/pathophysiology
Most commonly adenocarcinoma Primary location is the pyloric area Risk factors:
History of polyps Pernicious anemia Hypochlorhydria Gastrectomy; chronic gastritis; gastric ulcer Diet high in salt, preservatives, and carbohydrates Diet low in fresh fruits and vegetables
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Slide 48Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Cancer of the stomach (continued)◦ Clinical manifestations/assessment
Early stages may be asymptomatic Vague epigastric discomfort or indigestion Postprandial fullness Ulcer-like pain that does not respond to therapy Anorexia; weight loss Weakness Blood in stools; hematemesis Vomiting after fluids and meals
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Slide 49Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Cancer of the stomach (continued)◦ Diagnostic tests
GI series Endoscopic/gastroscopic examination Stool for occult blood RBC, hemoglobin, and hematocrit
◦ Medical management/nursing interventions Surgery
Partial or total gastric resection Chemotherapy and/or radiation
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Congenital pyloric stenosis
• Hypertrophy of the circular muscle layer of the pylorus
• Projectile vomiting in 1st 2 weeks of life
• Palpable mass
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Slide 51Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Infection◦ Etiology/pathophysiology
Invasion of the alimentary canal by pathogenic microorganisms
Most commonly enters through the mouth in food or water
Person-to-person contact Fecal-oral transmission Long-term antibiotic therapy can cause an
overgrowth of the normal intestinal flora (C. difficile)
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Slide 52Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Infection (continued)◦ Clinical manifestations/assessment
Diarrhea Rectal urgency Tenesmus Nausea and vomiting Abdominal cramping Fever
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Slide 53Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Infection (continued)◦ Diagnostic tests
Stool culture◦ Medical management/nursing interventions
Antibiotics Fluid and electrolyte replacement Kaopectate Pepto-Bismol
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Slide 54Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Irritable bowel syndrome◦ Etiology/pathophysiology
Episodes of alteration in bowel function Spastic and uncoordinated muscle contractions of the
colon◦ Clinical manifestations/assessment
Abdominal pain Frequent bowel movements Sense of incomplete evacuation Flatulence, constipation, and/or diarrhea
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Slide 55Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Irritable bowel syndrome (continued)◦ Diagnostic tests
History and physical examination◦ Medical management/nursing interventions
Pharmacological management Anticholinergics Milk of magnesia Mineral oil Opioids Antianxiety agents
Dietary recommendations Bulking agents
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Crohn disease
• Chronic inflammatory disease of ALL the layers of the intestinal wall with thickening; narrow lumen
• 20 – 30 year old, Jewish descent• Small intestine and colon• May lead to carcinoma• Skip lesions• Cobblestone appearance• Fistulas• Noncaseating granulomas
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Crohn’s disease
• Presents as:
abdominal pain
diarrhea
fever
malabsorption
obstruction
fistula to bladder, vagina, skin
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Crohn’s disease
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Meckel’s diverticulum
• Most common congenital abnormality of the small intestine
• Remnant of the vitelline duct in the distal small bowel
• Peptic ulceration, bleeding, perforation
• Intussusception
• volvulus
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Celiac disease
• Malabsorption disease
• Sensitivity to gluten products
• Blunting of the intestinal villi
• Diarrhea:bulky, frothy, foul-smelling
• Weight loss, failure to thrive, weakness
• Treatment: gluten-free diet
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Cancer of the small intestine
• Mostly adenocarcinoma• Appendix: carcinoid type; when it metastasizes
to the liver carcinoid syndrome:• Flushed skin• Watery diarrhea, abdominal cramps• Bronchospasm• Valvular lesions of the heart
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Colon
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Ulcerative colitis
• Ulcers in the large intestine or entire colon• Pseudopolyps• Crypt abscesses• Chronic diarrhea• Most frequent presentation: rectal bleeding• Complications:
Toxic megacolonColon perforationColon cancer
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Slide 65Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Ulcerative colitis◦ Etiology/pathophysiology
Ulceration of the mucosa and submucosa of the colon
Tiny abscesses form that produce purulent drainage, slough the mucosa, and ulcerations occur
◦ Clinical manifestations/assessment Diarrhea—pus and blood; 15 to 20 stools per day Abdominal cramping Involuntary leakage of stool
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Slide 66Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Ulcerative colitis (continued)◦ Diagnostic tests
Barium studies, colonoscopy, stool for occult blood◦ Medical management/nursing interventions
Pharmacological management Azulfidine, Dipentum, Rowasa, corticosteroids, Imodium
Dietary recommendations: No milk products or spicy foods; high-protein, high-calorie; total parenteral nutrition
Stress control Assist patient to find coping mechanisms
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Slide 67Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Ulcerative colitis (continued)◦ Medical management/nursing interventions
Surgical interventions Colon resection Ileostomy Ileoanal anastomosis Proctocolectomy Kock pouch
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Slide 68Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Kock pouch (Kock continent ileostomy).
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Slide 69Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Ileostomy with absence of resected bowel.
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Slide 70Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Crohn’s disease◦ Etiology/pathophysiology
Inflammation, fibrosis, scarring, and thickening of the bowel wall
◦ Clinical manifestations/assessment Weakness; loss of appetite Diarrhea: 3 to 4 daily; contain mucus and pus Right lower abdominal pain Steatorrhea Anal fissures and/or fistulas
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Slide 71Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Crohn’s disease (continued)◦ Medical management/nursing interventions
Pharmacological management Corticosteroids Azulfidine Antibiotics Antidiarrheals; antispasmodics Enteric-coated fish oil capsules B12 replacement
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Slide 72Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Crohn’s disease (continued)◦ Medical management/nursing interventions
Dietary recommendations High-protein Elemental Hyperalimentation Avoid
Lactose-containing foods, brassica vegetables, caffeine, beer, monosodium glutamate, highly seasoned foods, carbonated beverages, fatty foods
Surgery Segmental resection of diseased bowel
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Slide 73Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Appendicitis◦ Etiology/pathophysiology
Inflammation of the vermiform appendix Lumen of the appendix becomes obstructed, the
E. coli multiplies, and an infection develops◦ Clinical manifestations/assessment
Rebound tenderness over the right lower quadrant of the abdomen (McBurney’s point)
Vomiting Low-grade fever Elevated WBC
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Slide 74Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Appendicitis (continued)◦ Diagnostic tests
WBC Roentgenogram Ultrasound Laparoscopy
◦ Medical management/nursing interventions Appendectomy
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Slide 75Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Diverticular disease◦ Etiology/pathophysiology
Diverticulosis Pouch-like herniations through the muscular layer of the
colon Diverticulitis
Inflammation of one or more diverticula
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Slide 76Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Diverticulosis.
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Slide 77Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Diverticular disease (continued)◦ Clinical manifestations/assessment
Diverticulosis May have few, if any, symptoms Constipation, diarrhea, and/or flatulence Pain in the left lower quadrant
Diverticulitis Mild to severe pain in the left lower quadrant Elevated WBC; low-grade fever Abdominal distention Vomiting Blood in stool
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Slide 78Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Diverticular disease (continued)◦ Medical management/nursing interventions
Diverticulosis with muscular atrophy Low-residue diet; stool softeners Bed rest
Diverticulosis with increased intracolonic pressure and muscle thickening High-fiber diet Sulfa drugs Antibiotics; analgesics
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Slide 79Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Diverticular disease (continued)◦ Medical management/nursing interventions
(continued) Surgery
Hartmann’s pouch Double-barrel transverse colostomy Transverse loop colostomy
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Slide 80Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Peritonitis◦ Etiology/pathophysiology
Inflammation of the abdominal peritoneum Bacterial contamination of the peritoneal cavity from
fecal matter or chemical irritation◦ Clinical manifestations/assessment
Severe abdominal pain; nausea and vomiting Abdomen is tympanic; absence of bowel sounds Chills; weakness Weak rapid pulse; fever; hypotension
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Slide 81Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Peritonitis (continued)◦ Diagnostic tests
Flat plate of the abdomen CBE
◦ Medical management/nursing interventions Pharmacological management
Parenteral antibiotics Analgesics IV fluids
Position patient in semi-Fowler’s position Surgery
Repair cause of fecal contamination Removal of chemical irritant
NG tube to prevent GI distention
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Slide 82Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
External hernias◦ Etiology/pathophysiology
Congenital or acquired weakness of the abdominal wall or postoperative defect Abdominal Femoral or inguinal Umbilical
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Slide 83Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
External hernias (continued)◦ Clinical manifestations/assessment
Protruding mass or bulge around the umbilicus, in the inguinal area, or near an incision
Incarceration Strangulation
◦ Diagnostic tests Radiographs Palpation
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Slide 84Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
External hernias (continued)◦ Medical management/nursing interventions
If no discomfort, hernia is left unrepaired, unless it becomes strangulated or obstruction occurs
Truss Surgery
Synthetic mesh is applied to weakened area of the abdominal wall
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Slide 85Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Hiatal hernia◦ Etiology/pathophysiology
Protrusion of the stomach and other abdominal viscera through an opening in the membrane or tissue of the diaphragm
Contributing factors: obesity, trauma, aging◦ Clinical manifestations/assessment
Most people display few, if any, symptoms Gastroesophageal reflux
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Slide 86Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Hiatal hernia. A, Sliding hernia. B, Rolling hernia.
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Slide 87Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Hiatal hernia (continued)◦ Medical management/nursing interventions
Head of bed should be slightly elevated when lying down
Surgery Posterior gastropexy Transabdominal fundoplication (Nissen)
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Slide 88Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Intestinal obstruction◦ Etiology/pathophysiology
Intestinal contents cannot pass through the GI tract Partial or complete Mechanical Non-mechanical
◦ Clinical manifestations/assessment Vomiting; dehydration Abdominal tenderness and distention Constipation
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Slide 89Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Intestinal obstructions. A, Adhesions. B, Volvulus.
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Slide 90Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Intestinal obstruction (continued)◦ Diagnostic tests
Radiographic examinations BUN, sodium, potassium, hemoglobin, and
hematocrit◦ Medical management/nursing interventions
Evacuation of intestine NG tube to decompress the bowel Nasointestinal tube with mercury weight
Surgery Required for mechanical obstructions
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Slide 91Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Colorectal cancer◦ Etiology/pathophysiology
Malignant neoplasm that invades the epithelium and surrounding tissue of the colon and rectum
Second most prevalent internal cancer in the United States
◦ Clinical manifestations/assessment Change in bowel habits; rectal bleeding Abdominal pain, distention, and/or ascites Nausea Cachexia
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Slide 92Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Cancer of the colon (continued)◦ Diagnostic tests
Proctosigmoidoscopy with biopsy Colonoscopy Stool for occult blood
◦ Medical management/nursing interventions Radiation Chemotherapy
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Slide 93Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Cancer of the colon (continued)◦ Medical management/nursing interventions
(continued) Surgery
Obstruction One-stage or two-stage resection Two-stage resection
Colorectal cancer Right or left hemicolectomy Anterior rectosigmoid resection
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Slide 94Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Hemorrhoids◦ Etiology/pathophysiology
Varicosities (dilated veins) External or internal
Contributing factors Straining with defecation, diarrhea, pregnancy, CHF,
portal hypertension, prolonged sitting and standing
◦ Clinical manifestations/assessment Varicosities in rectal area Bright red bleeding with defecation Pruritus Severe pain when thrombosed
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Slide 95Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Hemorrhoids (continued)◦ Medical management/nursing interventions
Pharmacological management Bulk stool softeners Hydrocortisone cream Topical analgesics
Sitz baths Ligation Sclerotherapy; cryotherapy Infrared photocoagulation Laser excision Hemorrhoidectomy
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Slide 96Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Anal fissure◦ Linear ulceration or laceration of the skin of the
anus◦ Usually caused by trauma◦ Lesions usually heal spontaneously◦ May be excised surgically
Anal fistula◦ Abnormal opening on the surface near the anus◦ Usually from a local abscess◦ Common in Crohn’s disease◦ Treated by a fistulectomy or fistulotomy
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Slide 97Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing diagnoses Activity intolerance Anxiety Body image,
disturbed Constipation Coping, ineffective Diarrhea Fear Fluid volume,
deficient, risk for
Home management, impaired Management of therapeutic
regimen, ineffective Nutrition, imbalanced: less
than body requirements Pain, chronic/acute Skin integrity, risk for impaired Sleep pattern, disturbed Social isolation Tissue perfusion, ineffective
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Slide 98Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Fecal incontinence◦ Potential causes◦ Medical management/nursing interventions
Biofeedback training Bowel training Patient education Dietary recommendations
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Small Intestine
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Peptic ulcer of the Small intestine
• Always associated with increased secretion of gastric acid and pepsin
• High risk in H. pylori infection• Other predisposing factors:
aspirin, NSAIDSsmokingZollinger-Ellison syndrome: gastrin-secreting tumor of the pancreasprimary hyperparathyroidism
• Not a precursor of malignancy
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Colon Polyps
• Elevation of he intestinal surface
• Peutz-Jeghers polyps: polyps in the colon + dark spots on lips, hands, genitalia
• Villous adenomas: highest potential of the adenomatous polyps to become malignant
• Familial polyposis: malignant changes in 100% of cases
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Adenocarcinoma of the colon
• 60 to 70 years old• Cancer marker: CEA • Predisposing factors:
adenomatous polypsfamilial polypposis4x higher in relatives with colon cancerlow fiber, high animal fat diet
• Cancer of the rectosigmoid: annular enlargement; obstruction
• Cancer of the right colon: late obstruction; chronic blood loss; iron deficiency anemia