Interventions for clients with stomack and intestinal disorders

Interventions for Interventions for clients with stomack clients with stomack and intestinal and intestinal disorders.disorders.

Stomach DisturbancesStomach Disturbances

GastritisGastritis Peptic Ulcer DiseasePeptic Ulcer Disease Gastric SurgeryGastric Surgery Zollinger-Ellison SyndromeZollinger-Ellison Syndrome Dumping SyndromeDumping Syndrome

GastritisGastritis

Gastritis is defined as inflammation of Gastritis is defined as inflammation of the gastric mucosa; two types:the gastric mucosa; two types: Acute gastritisAcute gastritis Chronic gastritisChronic gastritis

Type A gastritisType A gastritis Type B gastritisType B gastritis Atrophic gastritisAtrophic gastritis

Helicobacter pylori, Escherichia coli Helicobacter pylori, Escherichia coli can cause gastritis.can cause gastritis.

Clinical ManifestationsClinical Manifestations

BloatingBloating HematemesisHematemesis Abdominal tendernessAbdominal tenderness MelenaMelena Intravascular depletion and shockIntravascular depletion and shock

Nonsurgical ManagementNonsurgical Management

Primary treatment: identification and Primary treatment: identification and elimination of causative factorselimination of causative factors

Drug therapyDrug therapy HH22-receptor antagonists-receptor antagonists AntacidsAntacids Antisecretory agentsAntisecretory agents Vitamin BVitamin B1212

Triple therapy for Triple therapy for H. pyloriH. pylori infection infection

Other TherapiesOther Therapies

Diet therapyDiet therapy Limit intake of foods and spices that Limit intake of foods and spices that

cause distress (tea, coffee, cola, cause distress (tea, coffee, cola, chocolate, mustard, paprika, cloves, chocolate, mustard, paprika, cloves, pepper, and hot spices), as well as pepper, and hot spices), as well as tobacco and alcohol.tobacco and alcohol.

Stress reductionStress reduction

Surgical ManagementSurgical Management

Partial gastrectomyPartial gastrectomy PyloroplastyPyloroplasty VagotomyVagotomy Total gastrectomyTotal gastrectomy

Peptic Ulcer DiseasePeptic Ulcer Disease

PUD is a mucosal lesion of the PUD is a mucosal lesion of the stomach or duodenum as a result of stomach or duodenum as a result of gastric mucosal defenses impaired gastric mucosal defenses impaired and no longer able to protect the and no longer able to protect the epithelium from the effects of acid and epithelium from the effects of acid and pepsin.pepsin.

Acid, pepsin, and Acid, pepsin, and Helicobacter pylori Helicobacter pylori infection play an important role in the infection play an important role in the development of gastric ulcers.development of gastric ulcers.

Duodenal UlcersDuodenal Ulcers

Most duodenal ulcers occur in the first Most duodenal ulcers occur in the first portion of the duodenum.portion of the duodenum.

Duodenal ulcers present as deep, Duodenal ulcers present as deep, sharply demarcated lesions that sharply demarcated lesions that penetrate through the mucosa and penetrate through the mucosa and submucosa into the muscularis submucosa into the muscularis propria.propria.

Differentiating Gastric Differentiating Gastric and Duodenal Ulcersand Duodenal Ulcers

Gastric UlcerGastric Ulcer Increase of pain with Increase of pain with

eating, antacids eating, antacids 30min30min

HematemesisHematemesis

Duodenal UlcerDuodenal Ulcer Relief with food, Relief with food,

antacids 90min-3hrantacids 90min-3hr Pain awakens at Pain awakens at

nightnight MelenaMelena

Stress UlcersStress Ulcers

Acute gastric mucosa lesions Acute gastric mucosa lesions occurring after an acute medical crisis occurring after an acute medical crisis or traumaor trauma

Associated with head injury, major Associated with head injury, major surgery, burns, respiratory failure, surgery, burns, respiratory failure, shock, and sepsis.shock, and sepsis.

Principal manifestation: bleeding Principal manifestation: bleeding caused by gastric erosioncaused by gastric erosion

Complications of UlcersComplications of Ulcers

Hemorrhage—hematemesisHemorrhage—hematemesis Perforation—a surgical emergencyPerforation—a surgical emergency Pyloric obstruction—manifested by Pyloric obstruction—manifested by

vomiting caused by stasis and gastric vomiting caused by stasis and gastric dilationdilation

Intractable disease—the client no longer Intractable disease—the client no longer responds to conservative management, or responds to conservative management, or recurrences of symptoms interfere with recurrences of symptoms interfere with ADLsADLs


Epigastric tenderness usually located Epigastric tenderness usually located at the midline between the umbilicus at the midline between the umbilicus and the xiphoid processand the xiphoid process

DyspepsiaDyspepsia Typically described as sharp, burning, Typically described as sharp, burning,

or gnawing painor gnawing pain Sensation of abdominal pressure or of Sensation of abdominal pressure or of

fullness or hungerfullness or hunger

Acute or Chronic PainAcute or Chronic Pain

One of the primary purposes for employing One of the primary purposes for employing drug therapy is to eliminate or reduce pain.drug therapy is to eliminate or reduce pain.

Analgesics are not the mainstay of pain Analgesics are not the mainstay of pain relief for PUD.relief for PUD.

Ulcer drug regimen itself promotes relief of Ulcer drug regimen itself promotes relief of pain by eradicatingpain by eradicating H. pylori H. pylori infection and infection and promoting healing of the gastric mucosa.promoting healing of the gastric mucosa.

Drug TherapyDrug Therapy

Four primary goals for drug therapy:Four primary goals for drug therapy: Provide pain reliefProvide pain relief Eradicate Eradicate H. pylori H. pylori infectioninfection Heal ulcerationsHeal ulcerations Prevent recurrencePrevent recurrence

Hyposecretory DrugsHyposecretory Drugs

Hyposecretory drugs produce a Hyposecretory drugs produce a reduction in gastric acid secretion.reduction in gastric acid secretion. Antisecretory agentsAntisecretory agents HH22-receptor antagonists-receptor antagonists

Prostaglandin analoguesProstaglandin analogues

Antisecretory AgentsAntisecretory Agents Antisecretory agents, also called proton pump Antisecretory agents, also called proton pump

inhibitors, include:inhibitors, include: PrilosecPrilosec PrevacidPrevacid AciphexAciphex ProtonixProtonix NexiumNexium

HH22-Receptor Antagonists-Receptor Antagonists Drugs that block histamine-stimulated gastric Drugs that block histamine-stimulated gastric

secretionsecretion May be used for indigestion and heartburnMay be used for indigestion and heartburn Block the action of the HBlock the action of the H2-2-receptors of the parietal receptors of the parietal

cells, thus inhibiting gastric acid secretioncells, thus inhibiting gastric acid secretion The most common: Zantac, Pepcid, and AxidThe most common: Zantac, Pepcid, and Axid

Prostaglandin AnaloguesProstaglandin Analogues

These agents reduce gastric acid These agents reduce gastric acid secretion and enhance gastric secretion and enhance gastric mucosal resistance to tissue injury.mucosal resistance to tissue injury.

Misoprostol (Cytotec) Misoprostol (Cytotec) helps preventhelps prevent NSAID-induced ulcers.NSAID-induced ulcers.

Uterine contraction is a significant Uterine contraction is a significant adverse effect of misoprostol.adverse effect of misoprostol.

AntacidsAntacids

Antacids buffer gastric acid and prevent the Antacids buffer gastric acid and prevent the formation of pepsin; they are effective in formation of pepsin; they are effective in accelerating the healing of duodenal ulcers.accelerating the healing of duodenal ulcers.

The most widely used preparations are The most widely used preparations are mixtures of aluminum hydroxide and mixtures of aluminum hydroxide and magnesium hydroxide, such as Mylanta or magnesium hydroxide, such as Mylanta or Maalox.Maalox.

For optimal effect, take about 2 hr after For optimal effect, take about 2 hr after meals.meals.

Antacids can interact with certain drugs Antacids can interact with certain drugs and interfere with their effectiveness.and interfere with their effectiveness.

Mucosal Barrier FortifiersMucosal Barrier Fortifiers

Sucralfate (Carafate) is a sulfonated Sucralfate (Carafate) is a sulfonated disaccharide that forms complexes with disaccharide that forms complexes with proteins at the base of a peptic ulcer; this proteins at the base of a peptic ulcer; this protective coat prevents further digestive protective coat prevents further digestive action of both acid and pepsin.action of both acid and pepsin.

Sucralfate binds bile acids and pepsins, Sucralfate binds bile acids and pepsins, reducing injury from these substances.reducing injury from these substances.

The main side effect of sucralfate is The main side effect of sucralfate is constipation.constipation.

Diet TherapyDiet Therapy

Diet therapy may be directed toward Diet therapy may be directed toward neutralizing acid and reducing neutralizing acid and reducing hypermotility. hypermotility.

A bland, nonirritating diet is A bland, nonirritating diet is recommended during the acute recommended during the acute symptomatic phase.symptomatic phase.

Avoid bedtime snacks.Avoid bedtime snacks. Avoid alcohol and tobacco.Avoid alcohol and tobacco.

Irritable Bowel Syndrome Irritable Bowel Syndrome (IBS)(IBS)

IBS is a chronic gastrointestinal disorder IBS is a chronic gastrointestinal disorder characterized by chronic or recurrent diarrhea, characterized by chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating.constipation, and/or abdominal pain and bloating.

Manning criteria are present:Manning criteria are present: Abdominal pain relieved by defecationAbdominal pain relieved by defecation Abdominal distentionAbdominal distention

The sense of incomplete evacuation of stoolThe sense of incomplete evacuation of stool The presence of mucus with stool passageThe presence of mucus with stool passage

A flare-up of symptoms usually brings the client to A flare-up of symptoms usually brings the client to the health care provider. the health care provider.

TreatmentTreatment

Education—teaching the client to avoid problem Education—teaching the client to avoid problem stimulantsstimulants

Diet therapy—elimination of offending or upsetting Diet therapy—elimination of offending or upsetting foodsfoods

Drug therapy—bulk-forming laxatives, antidiarrheal Drug therapy—bulk-forming laxatives, antidiarrheal agents, anticholinergic agents, tricyclic agents, anticholinergic agents, tricyclic antidepressants, and 5-HTantidepressants, and 5-HT4 4 agonists.agonists.

Stress management based on the client’s current Stress management based on the client’s current

and ongoing stressorsand ongoing stressors Complementary and alternative therapies used to Complementary and alternative therapies used to

reduce symptoms and discomfort reduce symptoms and discomfort

HerniationHerniation

Weakness in the abdominal muscle wall Weakness in the abdominal muscle wall through which a segment of bowel or other through which a segment of bowel or other abdominal structure protrudesabdominal structure protrudes

Types of hernia include:Types of hernia include: Indirect inguinal Indirect inguinal Direct inguinal Direct inguinal Femoral Femoral Umbilical Umbilical Incisional or ventral Incisional or ventral


Preoperative care—NPO day of surgeryPreoperative care—NPO day of surgery Operative procedureOperative procedure

Minimally invasive inguinal hernia repair (MIIHR)Minimally invasive inguinal hernia repair (MIIHR) Conventional herniorrhaphyConventional herniorrhaphy

Postoperative care in minimally invasive Postoperative care in minimally invasive inguinal hernia repair includes:inguinal hernia repair includes: Elevate scrotum to prevent and control swelling.Elevate scrotum to prevent and control swelling. Address difficulties in voiding that may occur. Address difficulties in voiding that may occur. Observe for signs and symptoms of Observe for signs and symptoms of

complications.complications.

Colorectal CancerColorectal Cancer

ColorectalColorectal refers to the colon and the refers to the colon and the rectum, which together make up the large rectum, which together make up the large intestine.intestine.

95% of cancers of the colon or rectum are 95% of cancers of the colon or rectum are adenocarcinomas.adenocarcinomas.

EtiologyEtiology Genetic considerationsGenetic considerations Personal factorsPersonal factors Dietary factorsDietary factors Inflammatory bowel diseaseInflammatory bowel disease


Rectal bleeding, hematochezia, Rectal bleeding, hematochezia, passage of red blood via the rectumpassage of red blood via the rectum

AnemiaAnemia Change in stool textureChange in stool texture Mass in abdomenMass in abdomen

Laboratory AssessmentLaboratory Assessment

Hemoglobin and hematocrit values Hemoglobin and hematocrit values usually decreasedusually decreased

Fecal occult blood testFecal occult blood test Possible elevation of Possible elevation of

carcinoembryonic antigencarcinoembryonic antigen Radiographic assessmentRadiographic assessment Other diagnostic assessmentsOther diagnostic assessments


Colon resectionColon resection ColectomyColectomy Abdominoperineal resection Abdominoperineal resection ColostomyColostomy Transanal approachTransanal approach


Preoperative care includes:Preoperative care includes: Consultation with enterostomal therapistConsultation with enterostomal therapist Discussions with surgeon of risk of Discussions with surgeon of risk of

sexual and urinary dysfunctionssexual and urinary dysfunctions Bowel prepBowel prep Nasogastric tube and IV line placed for Nasogastric tube and IV line placed for

use after surgeryuse after surgery Assignment of case manager for long-Assignment of case manager for long-

term consequencesterm consequences


Postoperative care includes:Postoperative care includes: Colostomy and wound managementColostomy and wound management Nasogastric tubeNasogastric tube Colostomy managementColostomy management Wound managementWound management

Colostomy CareColostomy Care

Normal appearance of the stomaNormal appearance of the stoma Signs and symptoms of complicationsSigns and symptoms of complications Measurement of the stomaMeasurement of the stoma Choice, use, care, and application of Choice, use, care, and application of

appropriate appliance to cover stomaappropriate appliance to cover stoma Measures to protect the skinMeasures to protect the skin Dietary measures to control gas and odorDietary measures to control gas and odor Resumption of normal activitiesResumption of normal activities

Intestinal ObstructionIntestinal Obstruction

Mechanical obstructionMechanical obstruction Nonmechanical obstruction, known as Nonmechanical obstruction, known as

paralytic ileusparalytic ileus Strangulated obstruction resulting Strangulated obstruction resulting

from tumors, hernias, fecal from tumors, hernias, fecal impactions, strictures, impactions, strictures, intussusception, volvulus, fibrosis, intussusception, volvulus, fibrosis, vascular disorder, and adhesionsvascular disorder, and adhesions

Clinical Manifestations of Clinical Manifestations of Mechanical ObstructionMechanical Obstruction

Midabdominal pain or crampingMidabdominal pain or cramping VomitingVomiting ObstipationObstipation DiarrheaDiarrhea Alteration in bowel pattern and stoolAlteration in bowel pattern and stool Abdominal distentionAbdominal distention BorborygmiBorborygmi Abdominal tendernessAbdominal tenderness

Clinical Manifestations of Clinical Manifestations of Nonmechanical ObstructionNonmechanical Obstruction

Constant diffuse discomfortConstant diffuse discomfort Abdominal distentionAbdominal distention Decreased to absent bowel soundsDecreased to absent bowel sounds VomitingVomiting Obstipation Obstipation

AssessmentAssessment

Laboratory assessmentLaboratory assessment Radiographic assessmentRadiographic assessment EndoscopyEndoscopy Barium enemaBarium enema Computed tomographyComputed tomography


Preoperative carePreoperative care TeachingTeaching Nasogastric intubation and suction if time Nasogastric intubation and suction if time

permitspermits Operative procedure: exploratory Operative procedure: exploratory

laparotomy to determine procedurelaparotomy to determine procedure

Postoperative carePostoperative care Exploratory laparotomyExploratory laparotomy Nasogastric tube in placeNasogastric tube in place Usual postoperative careUsual postoperative care

Abdominal TraumaAbdominal Trauma

Injury to the structures located between the Injury to the structures located between the diaphragm and the pelvis, including the diaphragm and the pelvis, including the large or small bowel, liver, spleen, large or small bowel, liver, spleen, duodenum, pancreas, kidneys, and urinary duodenum, pancreas, kidneys, and urinary bladderbladder

Blunt abdominal trauma, which often Blunt abdominal trauma, which often occurs in motor vehicle accidentsoccurs in motor vehicle accidents

Penetrating abdominal trauma caused by Penetrating abdominal trauma caused by gunshot wounds, stabbinggunshot wounds, stabbing

AssessmentAssessment

Assess airway, breathing, and Assess airway, breathing, and circulationcirculation

Assess for the following:Assess for the following: Hypovolemic shockHypovolemic shock Cullen’s signCullen’s sign Turner’s signTurner’s sign Ballance’s signBallance’s sign Kehr’s signKehr’s sign

Emergency Care: Abdominal Emergency Care: Abdominal TraumaTrauma

Two large-bore intravenous lines are placedTwo large-bore intravenous lines are placed Central venous catheterCentral venous catheter Balanced saline solution, crystalloids, and Balanced saline solution, crystalloids, and

possibly bloodpossibly blood Arterial blood gas assessmentArterial blood gas assessment Fluid and electrolyte managementFluid and electrolyte management Continuous hemodynamic monitoringContinuous hemodynamic monitoring Surgical managementSurgical management

PolypsPolyps

Small growths in the intestinal tract Small growths in the intestinal tract that are covered with mucosa and are that are covered with mucosa and are attached to the surface of the intestineattached to the surface of the intestine

Various typesVarious types Usually asymptomatic, but can cause Usually asymptomatic, but can cause

gross rectal bleeding, intestinal gross rectal bleeding, intestinal obstruction, and intussusceptionobstruction, and intussusception

Nursing care focused on teachingNursing care focused on teaching

HemorrhoidsHemorrhoids

Unnaturally swollen or distended Unnaturally swollen or distended veins in the anorectal regionveins in the anorectal region

Internal hemorrhoidsInternal hemorrhoids External hemorrhoids External hemorrhoids Nonsurgical managementNonsurgical management Surgical management: Surgical management:

hemorrhoidectomyhemorrhoidectomy

Malabsorption SyndromeMalabsorption Syndrome

Syndrome associated with a variety of Syndrome associated with a variety of disorders and intestinal surgical disorders and intestinal surgical proceduresprocedures

Primary clinical manifestations: Diarrhea Primary clinical manifestations: Diarrhea and steatorrheaand steatorrhea

Interventions:Interventions: Dietary managementDietary management Surgical or nonsurgical managementSurgical or nonsurgical management Drug therapyDrug therapy

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Interventions for clients with stomack and intestinal disorders