Alteration in Nurtition and Metabolism Short Bowel Syndrome

8/4/2019 Alteration in Nurtition and Metabolism Short Bowel Syndrome

1/188

ALTERATIONIN NUTRITION

AND

METABOLISM


2/188

REVIEW OF GI TRACT

GI tract 23-26 feet-long

passageway that extends from the

mouth up to anus


3/188

FUNCTIONS :

- To break down food particles into themolecular 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


4/188

CHEWING/

MASTICATION Start of digestion Aided by teeth, tongue & salivary glands

Saliva 1st

secretion that comes incontact with food

- secreted from submandibular, parotid

& sublingual glands- contains ptyalin (salivary amylase)digest starch


5/188

SWALLOWING/

DEGLUTITION

Swallowing voluntary act

-occurs in the throat

-food is pushed from mouth to pharynxto esophagus

- regulated by medulla oblongata

(swallowing center)


6/188

GASTRIC FUNCTION Stomach stores & mixes food with

secretions

-Gastric fluid (2.4L/day)

a. HCl; break down foods & destroy mostingested bacteria

-b. pepsin enzyme for CHON digestion

-c.mucin-d.gastrin- hormone


7/188

- 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 foodin the small intestine

- Chyme- food mixed with gastric secretion


8/188

ACCESSORY DIGESTIVE

ORGANS Pancreas, liver & gallbladder

PANCREAS contains pancreatic juice withalkaline pH neutralizes acid entering

duodenum

- serves as Exocrine & endocrine gland


9/188

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 totrypsin

- Lipase digest fats


10/188

LIVER largest gland in the body

- contains Kupffers cells remove bacteria inthe portal circulation

- removes excess glucose & amino acids from theportal blood

- synthesize glucose, amino acids & fats- stores & filters blood (200-400ml)

- stores Vit. A, D, B and iron

- secretes bile for emulsifying ingested fats (500-1000 ml/day)


11/188

GALLBLADDER- stores & concentrates bile

- it contracts to force bile into theduodenum

- Sphincter of Oddi guards the entrance

into the duodenum


12/188

SMALL INTESTINE FUNCTION

Primary function: Absorption

Secretes the ff: Enteric juice

- Mucus coats the cell & protects themucosa

- Hormones control rate of intestinal

secretions & influence GI motility

- Electrolytes

- Enzymes


13/188

Two types of contraction in the small

intestine:1. Segmentation produces mixing waves

that move contents back & forth in

churning motion2. Intestinal peristalsis propels the

content of small intestine into the colon


14/188

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


15/188

WASTE PRODUCT OF

INGESTION Feces undigested foodstuff, inorganic

material, water & bacteria- 75% fluid & 25% solid material

Flatus contains methane, hydrogen

sulfide & ammonia (150 ml)


16/188

Defecation - spinal reflex

(parasympathetic nerve fibers) that can

be inhibited voluntary by keeping the

external anal sphincter closed

Contracting abdominal muscle facilitatesemptying of the colon

Normal defecation: once daily


17/188

ASSESSMENT OF

GIT


18/188

HEALTH HISTORY

1. Pain

- OPQRST, location, frequency, duration,

relieving factors2. Indigestion/Dyspepsia

- Upper abdominal discomfort or distress

associated with eating


19/188

3. Intestinal gas

- Belching expulsion of gas from the stomachthru mouth

- Flatulence expulsion of gas from the rectum

Excessive flatulence may be a symptom ofgallbladder disease or food intolerance

4. Nausea & vomiting

- triggered by odor, activity or food intake- Emesis/vomitus contains undigested food

particles or blood (hematemesis)


20/188

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


21/188

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


22/188

PHYSICAL ASSESSMENT

Includes assessment of mouth, abdomen & rectumAbdomen 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, hyperresonancePalpation: Mass, tenderness, rebound tenderness, muscle

guarding, abdominal rigidity


23/188

DIAGNOSTIC &

LABORATORY

EXAMINATIONS


24/188

NON INVASIVETESTS

ABDOMINAL


25/188

ABDOMINAL

ULTRASOUND Use of high frequency sound waves

Image of abdominal organs & structures is produced on theoscilloscope

Useful in detecting cholelithiasis, cholecystitis, appendicitis &diverticulitis

Advantage: requires no ionizing radiation, no side effects &inexpensive

Disadvantage: cannot be used to examine structures that liebehind bony tissues


26/188

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


27/188

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


28/188

INVASIVETESTS


29/188

ESOPHAGOGASTRODUODENOSCOPY

(EGD)

Upper gastrointestinal fiberoscopy

Following sedation, an endoscope is

passed down the esophagus to view thegastric wall, sphincters & duodenum

Tissue specimen can be obtained


30/188

Preprocedure

The client must be NPO for 6-12 hours

before the test

A local anesthetic is administered alongwith midazolam IV (provides conscious

sedation & relieves anxiety) just before

the scope is inserted


31/188

Position the client left side to facilitate

saliva drainage & provide easy access ofthe endoscope

Airway patency is monitored during the

test & pulse oximetry is used to monitoroxygen saturation

Emergency equipment should be readily

available


32/188

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 analgesiccan relieve minor sore throat after the

gag reflex returns


33/188

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


34/188

BARIUM SWALLOW

Examination of upper GIT under fluoroscopy

after the client drink barium sulfate

PREPROCEDURE: NPO post midnight before

the day of the test


35/188

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


36/188

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


37/188

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


38/188

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


39/188

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


40/188

NGT is inserted entire stomach content are

aspirated by gentle suction into a syringe &

gastric samples are collected every 15 min forthe next hour

Gastric acid stimulation test is usually

performed in conjunction with gastric analysis.


41/188

COMMON

HEALTH

PROBLEMS


42/188

DISORDERS OF THEESOPHAGUS


43/188

GASTROESOPHAGEAL

REFLUX DISEASE (GERD)

Back-flow of gastric or duodenalcontents into the esophagus


44/188

Causes

1. Incompetent lower esophageal

sphincter

In cases likea.Congenital - pyloric stenosis,Motility

disorder, prematurity

c.Acquired-aging, tumor


45/188

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-weightlifting, defecation,urination

d. Obesity, tight clothings


46/188

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


47/188

Complications

GastritisUlcershemorrhage and shock

Esophagitisulcershemorrhage and shock

Scars, Strictures obstructionrupture

Baretts esopahgus

Esophageal Carcinomaobstruction


48/188

Diagnostic Tests

Endoscopy

Barium swallow

Ambulatory 12 or 24 or 36-houresophageal pH monitoring- check ph in

esophagus

Esophageal Manometry- check pressuresand peristalsis


49/188

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


50/188

Maintain normal body weight

Avoid tight fitting clothes

Elevate head of bed 6-8 inch blocks &upper body on pillows.


51/188

Medical Management

Antacids- 1-3 hrs after meals and at bedtime, checkRFT

Histamine receptor blockers (e.g. Ranitidine)-beforemeals and at bedtime, take with water,

Proton pump inhibitor (e.g. Omeprazole)- DOC forsevere GERD, 8 wks up to 3-6 months, before mealsand 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


52/188

Surgical Management

FUNDOPLICATION

- Wrapping of a portion of the gastric

fundus around the sphincter area of theesophagus

- Can be performed by laparoscopy


53/188

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.


54/188

Types

1. SLIDING (TYPE I)

- Occurs when the upper stomach &

gastroesophageal junction are displacedupward & slide in and out of the thorax

- may occur if have short esophagus,

weak anchor, inc. abd pressure


55/188

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


56/188


PARAESOPHAGEAL HERNIA: with GERD

- Heartburn

- Regurgitation- Dysphagia

- Feeling of fullness

* 50% asymptomatic


57/188

SLIDING HERNIA

- May be asymptomatic May have no GERD

C li i


58/188

Complications Hemorrhage

Obstruction Strangulationischemiainfarctiongangre

nous necrosis

DIAGNOSTIC TESTS X-ray studies

Barium swallow

Fluoroscopy

Management most px need


59/188

Management most px need

no txMEDICAL:manage like GERD

Frequent small feedings

Avoid lying 1 hour after eating

Elevate head of head 4-8 -inch blocks

SURGICAL:

- Herniorrhaphy, Nissen Fundoplication


60/188

ACHALASIA

Esophageal Motility Disorder

Unknown etiology

Increased peristalsis of the whole ordistal esophagus(spasms) accompanied

by failure of the esophageal sphincter to

relax in response to swallowing


61/188


Dysphagia to both solid and liquids-

primary symptom

Heartburn Chest pain severe and usually at rest

Chest fullness

Nighttime cough


62/188

Diagnostic Tests

X-ray

Barium swallow

CT Scan Endoscopy

MANOMETRY confirmatory test

- esophageal pressure is measured by

radiologist or gastroenterologist


63/188

Medical Management

Instruct pt to eat slowly and drink fluids

with meals.

Calcium channel blocker & nitrates -temporary measure to decrease

esophageal pressure & improve

swallowing


64/188

Surgical Management

BOTOX (Botolinum toxin) injection to

quadrants of esophagus via endoscopy

MOA: lower LES pressureDone q 6-9 months

PNEUMATIC DILATION stretch the

narrow area of esophagus using air


65/188

BALLON DILATATION OF LES

LAPAROSCOPIC ESOPHAGOMYOTOMY- Separates esophageal muscle fibers


66/188

ESOPHAGEALDIVERTICULA


67/188

DIVERTICULUM

Outpouching of mucosa & submucosathat protrudes thru a weak portion ofmuscle

DIVERTICULOSIS: asymptomatic

DIVERTICULITIS: with inflammation

Exact cause is unknown; predisposingfactors congenital (younger than 40),low intake of dietary fiber

ZENKERS DIVERTICULUM (PHARYNGEAL


68/188

ZENKERS DIVERTICULUM (PHARYNGEAL

POUCH) most common type

- people older than 60 yrs old

Other types: midesophageal, epiphrenic

& intramural diverticula


69/188


Dysphagia

Fullness in the neck

Belching Regurgitation of undigested foods

Gurgling noises after eating

Halitosis- accumulation of undigested

food

Sour taste in the mouth


70/188

Complications

Inflammation

Obstruction

Abscess

Perforation with peritonitis

Bleeding and shock


71/188

Diagnostic Tests

Barium swallow

Manometric studies

* Avoid esophagoscopy & NGT Insertion


72/188

Surgical Management

DIVERTICULECTOMY - Surgical removal

of diverticulum

MYOTOMY the muscle is dilated orreleased surgically

END-TO END ANASTOMOSIS if with

inflammation of surrounding GI mucosa


73/188

DISTURBANCE INDIGESTION

GASTRITIS


74/188

GASTRITISInflammation 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

CHRONIC GASTRITIS


75/188

CHRONIC GASTRITIS:

- Benign or malignant ulcers of stomach

- Helicobacter pylori

- Associated with autoimmune disease

- Use of caffeine- NSAIDS

- Smoking

- Reflux of untestinal content in thestomach

li i l if i


76/188


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

Di i T


77/188

Diagnostic Tests

ENDOSCOPY

Upper GI series

Biopsy & histologic exam of tissuespecimen for H. pylori

M di l M


78/188

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:


79/188

CHRONIC:

- Modifying the diet

- Promoting rest

- Reducing stress

- Antibiotic- for H. pylori- Proton pump inhibitor

N i P


80/188

Nursing Process

Assessment:

- Pt history s/sx, 72-hour diet recall, hx of

previous disease, medications taken

Nursing Diagnosis:


81/188

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

Promoting Optimal Nutrition


82/188

Promoting Optimal Nutrition 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

Relieving Pain


83/188

Relieving Pain

Instruct client on the diet to avoid irritation of gastricmucosa

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.


84/188

PEPTIC ULCERDISEASE (PUD)

PUD


85/188

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 &


86/188

GASTRIC ULCERDUODENAL

Incidence:

Age: 30-60

Male:female = 2-3:1

80% are duodenal

GASTRIC

Usually 50 and over

1:1

15% are gastric

Cli i l M if t ti


87/188


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 GASTRIC


88/188

- Ingestion of food

relieves pain- Vomiting is

uncommon

- Bleeding less likely, ifpresent melena is

common

- More likely toperforate than gastric

ulcer

- Vomiting relieves

pain- Vomiting is common

- Bleeding more likely

hematemesis

DUODENAL GASTRIC


89/188

Malignancy

possibility: Rare

Risk factors:

H. pylori, alcohol,smoking, cirrhosis,

stress

Occasionally

H. pylori, gastritis,

alcohol, smoking,NSAIDs, stress

Assessment & Diagnostic


90/188

g

Tests Physical exam: pain, epigastric

tenderness, abdominal distention

Barium study of upper GI

Endoscopy

Biopsy

Gastric analysis

Stool exam for occult blood

Medical Management


91/188

Medical Management

Combinations of the ff:

-Antibiotics

- Proton pump inhibitor- Bismuth salts

H2 receptor antagonist & proton pump

inhibitor for NSAIDs induced ulcer & notassociated with H. pylori

Reduce environmental stress


92/188

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


93/188

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


94/188

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


95/188

- 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


96/188

NURSING INTERVENTIONS

RELIEVING PAIN

- Taking prescribed medications.

- Avoid aspirin, foods that contain caffeine- Meals should be eaten regularly

- Relaxation techniques

MAINTAINING OPTIMAL NUTRITIONAL


97/188

MAINTAINING OPTIMAL NUTRITIONAL

STATUS

- Assess for malnutrition & weight loss

- Advise to comply on medication regimen

& dietary restrictions.

FOOD POISONING


98/188

FOOD POISONING

Sudden illness that occurs after ingestionof contaminated food or drink.

BOTULISM - serious form of food

poisoning that requires continual

surveillance.

Assessment


99/188

Assessment

Nausea

Vomiting

Diarrhea

Medical Management


100/188

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


101/188

GASTRIC LAVAGE

Aspiration of stomach content & washingout 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:


102/188

Purpose:

Urgent removal of ingested substance ordecrease systemic absorption

Empty the stomach before endoscopic

procedure

To diagnose gastric hemorrhage & to

arrest hemorrhage


103/188

DISTURBANCE INABSORPTION ANDELIMINATION

DISORDERS OF


104/188

DISORDERS OF

INTESTINAL

MOTILITY

DIARRHEA


105/188

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


106/188

Underlying Disease Process

- Irritable Bowel Syndrome (IBS)

- Inflammatory Bowel Disease (IBD)- Lactose Intolerance

Types


107/188

Types

ACUTE

- Associated with infection

- Self-limiting CHRONIC

- Persist for longer period of time

- May return sporadically

Causes


108/188

Causes 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



109/188


Increased frequency of stool fluid content of stool

Abdominal pain or cramps

Abdominal distention Intestinal rumbling (borborygmus)

Anorexia

Thirst Tenesmus (ineffectual straining

Diagnostic Tests


110/188

Diagnostic Tests

Stool Exam

CBC

Endoscopy

Barium enema

COMPLICATIONS:

Dehydration

Cardiac dysrhythmia

Medical Management


111/188

Medical Management

Antibiotic

Anti-inflammatory

Antidiarrheal IV therapy

Nursing Management


112/188

Nursing Management

Assess & monitor the characteristic &pattern of diarrhea

Health history

Abdominal auscultation & palpation

Obtaining stool samples

Encourage bed rest


113/188

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


114/188

CONSTIPATION

Abnormal infrequency or irregularity indefecation

Abnormal hardening of stool that makes

the passage difficult or painful

Decrease in stool volume

Retention of stool in the rectum for aprolonged period

Causes


115/188

Causes Medications (tranquilizer, antidepressant, antiHPN,

opioids, antacid with aluminum, iron) Rectal or anal disorder (hemorrhoids)

Obstruction (e.g.cancer of bowel)

Metabolic, neuroligic & neuromuscular condition (DM,

Hirschsprungsdisease, Parkinsons, multiple sclerosis) Endocrine disorders (hypothyroidism,

pheochromocytoma)

Lead poisoning

Connective tissue disorders (eg. SLE)

Other Causes


116/188

Other Causes

Weakness

Immobility

Fatigue Inability to

increase intra

abdominal pressure(emphysema)

Low fiber diet

Inadequate fluid

intake

Lack of exercise

Stress



117/188

Clinical Manifestations 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

Assessment & Diagnostic


118/188

Tests Patients Hx

Physical exam

Barium enema Sigmoidoscopy

Stool exam

Occult blood

Complications


119/188

Complications

Hypertension

Fecal impaction

Hemorrhoids Megacolon (dilated colon)

Medical Management


120/188

Medical Management

Bowel habit training

Increased fiber & fluid intake

Use of laxatives Routine exercise


121/188

IRRITABLE BOWEL( )


122/188

SYNDROME (IRS) Presence of spastic bowel contraction

One of the most common GI problems

Common in women Cause is unknown

Risk Factors


123/188

Risk Factors

Heredity

Psychological stress (depression, anxiety)

High fat diet Alcohol intake

Smoking



124/188


Alteration in bowel patternsconstipation, diarrhea or combination of

both

Pain, bloating & abdominal distention

Pain is precipitated by eating and

relieved by defecation

Diagnostic Tests


125/188

Diagnostic Tests

Stool exam

Barium enema

Colonoscopy Manometry

Medical Management


126/188

Medical Management

High fiber diet

Exercise

Stress reduction program

Antidiarrheal drugs

Andtidepressant

Anticholinergic & calcium channel blocker

decrease smooth muscle spasm, cramping &

constipation

FECAL INCONTINENCE


127/188

C CO C 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



128/188

Minor soiling

Occasional urgency & loss of control

Complete incontinence Poor control of flatus

Diarrhea

Constipation

Diagnostic Tests


129/188

Rectal examination

Sigmoidoscopy Barium enema

CT Scan

Medical Management

Treat the diarrhea or fecal impaction

Biofeedback Bowel training program

Surgical Management


130/188

Surgical reconstruction Sphincter repair

Fecal diversion

Nursing Management Setting schedule for bowel training

Maintain skin integrity

Assist in the use of incontinence briefs

STRUCTURAL &


131/188

STRUCTURAL &

OBSTRUCTIVE BOWEL

DISORDERS

INTESTINAL OBSTRUCTION


132/188

Presence of blockage that prevents the

normal flow of intestinal contents

through the intestinal tract

Two types of process that

impede the flo


133/188

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

h l l l


134/188

- The intestinal musculature cannot propel

its content along the bowel- E.g. amyloidosis, DM, Parkinsons disease

SMALL BOWELOBSTRUCTION


135/188

OBSTRUCTION- Intestinal contents, fluid & gas

accumulate above the intestinal

obstruction

CAUSES:

1. Intussusception

2. Volvulus3. Hernia



136/188

Crampy, colicky pain

Blood & mucus without fecal matter &

flatus

Vomiting (fecal vomiting)

Abdominal distention

Signs of dehydration

Diagnostic Tests


137/188

g

Abdominal x-ray Abdominal UTZ

Lab studies (electrolyte level, CBC)

Medical Management

DECOMPRESSION use of NGT

IV therapy Antibiotic

Surgical Management


138/188

Repairing hernia (Herniorrhapy)

Dividing the adhesionNursing 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

LARGE BOWELOBSTRUCTION


139/188

OBSTRUCTION Results in accumulation of intestinal

contents, fluids & gas proximal to the

obstruction

Leads to severe distention & perforation

Dehydration occurs more slowly

Intestinal strangulation & necrosis ifblood supply is cut-off



140/188

*Symptoms progress slowly

Constipation


Crampy low abdominal pain

Fecal vomiting

Diagnostic Tests


141/188

g

Abdominal x-ray (flat & upright)

Abdominal UTZ

Surgical Management


142/188

COLONOSCOPY - to untwist &decompress the bowel

CECOSTOMY- surgical opening in thececum

Rectal tube to decompress area lower

in the bowel

SURGICAL RESECTION remove the


143/188

obstructing lesion

Temporary or permanent colostomy

ILEOANAL ANASTOMOSIS

Nursing Management


144/188

Administer IV fluids & meds asprescribed

Prepare the pt for surgery

General abdominal wound care & post-

op care after surgery

CONTINENT ILEOSTOMY


145/188

Surgical creation of a pouch of small

intestine that can serve as internalreceptacle for fecal discharge.

A nipple valve is constructed at the

outlet.

IRRIGATING A COLOSTOMY


146/188

Select suitable time for irrigation

Irrigation should be performed at the same timeeach day.

Before the procedure, the pt will sit on the chair infront of the toilet or the toilet itself.

Hang 500-1500ml ml irrigating solution (lukewarmtap water) 18-20 above the stoma.

The dressing on pouch is removed

Allow pt to participate to learn to perform itunassisted.

DIVERTICULAR DISEASE


147/188

DIVERTICULUM saclike outpouching of thelining of the bowel that extends to a defectin the muscle layer

DIVERTICULOSIS multiple diverticula arepresent without inflammation or symptoms

DIVERTICULITIS infection & inflammationin diverticula

- Food & bacteri retained in diverticulum

- leads to perforation or abscess



148/188

Bowel irregularity Intervals of

diarrhea

Crampy pain in LLQ

Low-grade fever

Nausea Anorexia

Abdominaldistention

Diagnostic Tests


149/188

CT Scan procedure of choice- reveals abscess

Abdominal X-ray

Barium enema (diverticulosis)

Colonoscopy

Lab tests (CBC, ESR)

Complications


150/188

Peritonitis

Abscess formation

Bleeding

Shock

Medical Management Bedrest

Analgesic

Antispasmodic

Diet :


151/188

- 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


152/188

g g

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


153/188

ASSESSMENT- Assess the pain

- Review dietary habits

- Ask about Hx of constipation, tenesmus,distention

- Auscultation & palpation

- Stool inspection

- VS

NURSING DIAGNOSIS

C i i / i f h l


154/188

- Constipation r/t narrowing of the colon

from thickened segment & stricture

- Acute pain r/t inflammation & infection

MAINTAINING NORMALEMIMINATION PATTERN


155/188

EMIMINATION PATTERN

Fluid intake of 2L/day

High fiber diet

Exercise program

Set time for defecation

Stool softeners & oil retention enema asprescribed

RELIEVING PAIN


156/188

Analgesics & antispasmodics as

prescribed

Records the intensity, duration &

location of pain


157/188

MALABSORPTIONSYNDROME

CELIAC DISEASE OR SPRUE


158/188

Also known as GLUTEN ENTEROPATHY orTROPICAL SPRUE

Intolerance to GLUTEN CHON

component of wheat, barley, rye & oats

Accumulation ofglutamine (amino acid)

toxic to intestinal mucosa



159/188

Acute diarrhea Anorexia

Abdominal pain &

distention

Muscle wasting

(buttocks &extremities)

Vomiting Anemia

Irritability

CELIAC CRISIS


160/188

Precipitated by infection, fasting &ingestion of gluten

Lead to electrolyte imbalance, rapid

dehydration & severe acidosis

Causes profuse watery diarrhea &

vomiting

Medical Management


161/188

Gluten-free diet Substitute corn & rice as grain sources

Mineral & vitamin supplements (A,D,E,K)

Read food labels carefully

LACTOSE INTOLERANCE


162/188

Inability to tolerate lactose as a result of

absence or deficiency oflactase



163/188

Symptoms occurring after ingestion of milkproducts


Crampy, abdominal pain

Diarrhea

Excessive flatus

Medical Management


164/188

Eliminate the offending dairy product oradminister 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


165/188

Cause: resection of portions of small intestinesdue to tumors, infarction, incarcerated hernias, Crohnsdse, trauma, enteropathy from radiation

Effects:

More severe malabsorption after duodenum, jejunum,proximal and distal ileum resection vs mid-ileumresection

Transit time reduced

Impaired digestion

Adaptive process-villi enlarge and lengthen to increaseabsorptive surface

Nursing Diagnosis Fluid Volume Deficit


166/188

Fluid Volume Deficit

Impaired Nutrition: Less than Body Requirements Diarrhea

For many clients, absorption and bowel functionsreturn to preop or near-normal levels

Some have diarrhea, weight loss and nutrientdeficiencies

Diagnostics: serum protein, albumin, folate, iron,

electrolytes, vitamins, minerals, Hct,Hgb, PT

Mgmt


167/188

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 careRefer to dietitian or counselor


168/188

Diet: frequent, small,high calorie, high-proteinfeedings with vitamin and mineral

supplements TPN if severe

Meds: Antidiarhheals to reduce bowelmotility, allowing greater amount of time for

nutrient absorption

PPI as omeprazole(Prilosec) todecrease gastric acidity

ANORECTAL DISORDERS


169/188

HEMORRHOIDS


170/188

Dilated portions of veins in the analcanal.

50% of people age 50 yrs

Predisposing factors

Anal intercourse


171/188

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

4/13/2012 171

Types


172/188

1. INTERNAL HEMORRHOIDS above theinternal sphincter

2. EXTERNAL HEMORRHOIDS outside

the external sphincter

Clinical Manifestations Infection, mucus drainage

i ( l h h id )


173/188

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

4/13/2012 173

Diagnostic Tests


174/188

Rectal exam

Stool exam

Medical Management

High-residue diet

Good personal hygiene

Avoid excessive straining during defecation

Increase fluid intake

Warm compress

Sit b th


175/188

Sitz bath

Analgesic ointment & suppositories

(Faktu)

Bedrest

NON SURGICAL TREATMENT


176/188

Infrared photocoagulation

Bipolar diathermy Laser therapy

Injecting sclerosing solution

Surgery - Indications


177/188

D

isabling pain Prolonged bleeding

Intolerable itching

General unrelieved discomfort

4/13/2012 177

SURGICAL MANAGEMENT


178/188

RUBBER-BAND LIGATION PROCEDURE

- Hemorrhoid is visualized thru anoscope,

a rubber band is slipped over thehemorrhoid

- Distal tissues becomes necrotic & slough

off

CRYOSURGICAL HEMORRHOIDECTOMY

- Freezing the hemorrhoid for sufficient


179/188

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


180/188

g

Incontinence

Prolapse

Strangulation

AnemiaPatient Education

Encourage regular exercise, high-fiber diet, and

adequate fluid intake to avoid straining &

constipation

4/13/2012 180


181/188

LESIONS

ANAL FISSURE


182/188

Longitudinal tear or ulceration in thelining of anus

CAUSES:

- Trauma (passing large, firm feces)

- Stress & anxiety leads to constipation

- Childbirth- Overuse of laxatives

Clinical Manifestations Extreme painful defecation


183/188

Extreme painful defecation

Burning sensation

Bleeding

Medical Management

Stool softeners & bulk agents

Increase OFI

Sitz bath

Emolient suppositories

Surgical Management


184/188

Lateral internal sphincterotomy withexcision of fissure

ANAL FISTULA


185/188

Tiny, tubular, fibrous tract that extend inthe anal canal from an opening located

beside the anus

Causes


186/188

Infection

Trauma

Fissure

Regional enteritis



187/188

Leakage of pus or stool

Passage of flatus or feces from the vagina

or bladder

Surgical Management


188/188

FISTULECTOMY excision of the fistuloustract

- Probe is inserted to indentify the sinus

tract

- Fistula is dissected by incision from

rectal opening

Documents

Alteration in Nurtition and Metabolism Short Bowel Syndrome