CHAPT II:

MEDICAL SURGICAL NURSING OF

GASTROINTESTINAL SYSTEM
BY : Jean Bosco NDAYAMBAJE RN BSN MPH
Phone number:0783811480
email:jubini1998@gmail.com

5/29/16

Tut A Jean bosco RN MPH

GASTROINTESTINAL SYSTEM
OBJECTIVES:
After this unit the student will be able to indicate the different
conditions affecting gastrointestinal system
To assist in different surgical intervention for gastrointestinal
management
To collaborate with other health providers in management of
the different conditions affecting gastrointestinal system
To provide an accurate education for client and family with
gastrointestinal conditions
To use nursing process in providing nursing intervention for a
client suffering (GIC)
To perform different nursing skills aimed to help a client
with(GIC)
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Jean bosco RN BSN

GENERAL CONDITIONS
The gastro intestinal system is mainly affected by :
DISORDERS OF ORAL BUCCO CAVITY( stomatitis, pa
rotitis,CANDIDOSIS,DENTAL ABCESS,PULPITIS)
TEMPOMENDIBULO DISORDERS
DISORDERS OF ESOPHAGUS (gastroesophageal
reflex ,motility disorder
GASTRIC AND DUODENAL (gastritis, peptic ulcer,Hiatal
hernia
INTESTINAL AND RECTAL(intestinal obstruction,
peritonitis ,Anal fistula, hemorrhoids)
DISORDER OF FECAL ELIMINATION (Constipation
and Diarrhea, Fecal incontinence)
CANCERS AND MALNUTRITION
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Jean bosco RN BSN

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Jean bosco RN BSN

GENERAL MANAGEMENT
Surgical intervention:
Laparotomy
Gastrectomy
Intestinal resection
Vagotomy
Sclerotherapy
Hemorroidectomy
Apicectomy
Incision and drainage
Ileostomy
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Jean bosco RN BSN

Medical management
Spasmolytic

agents
Oral and IV antibiotic
Antifungal
Antacids
Antisecretory Drugs
Antidiarrheal
anti-inflammatory

Stool

softener
Antimotility
Peristaltic Stimulant
Antiemetic drugs
Anticholinergics
Cytoprotectives
Vitamin supplements

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Jean bosco RN BSN

General nursing interventions

Oral bucco care
2. Medication administration(
Full assessment :( Physicalantibiotics,
examination,
spasmolytics,antiparasite,a
History taking ,Laboratory ntitoxin,analgesics
exam and other
3. Give fluid replacement by
diagnostic studies)
perfusion or IV line taking
Analysis of findings
4.
assist in Surgical
intervention
Formulate the accurate nursing
diagnosis
5. Education providing
Plan the appropriate intervention:
6. Vital signs monitoring
7. Perform enema, gastric and
Drug administration
intestinal lavage
8. Physical activity and
Positioning
exercise are encouraged
1.

1.

2.
3.
4.
5.
6.
7.

Nasogastric insertion, feeding

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Jean bosco RN BSN

GENERAL INVESTIGATION
Other Clinical
Laboratory exam
investigations
Stool examination ( parasite
,appearance of the
Colonoscopy
stool, gravity of the stool and
Endoscopy
Full blood count ( rule out infection or
Ultrasound
inflammation
Laparoscopy
Hemoglobin levels (usually
decreased)
Biopsy
Electrolyte studies
CT scan
Albumin and protein measurement

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Jean bosco RN BSN

GI Focused Assessment
Physical
Vital

Signs
Height and Weight
Lab and diagnostic test results
Emesis ,amount, color, consistency
Stool , amount, color, consistency, odor.
Oral Assessment
Abdominal Assessment
Rectal Assessment
Anthropometric
BMI
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Jean bosco RN BSN

General clinical (signs and symptoms)

Abdominal

Pain
Indigestion
Intestinal

gas
Nausea and vomiting
Hematemesis
Changes in bowel habits
Stool characteristics
Dyspepsia
Heartburn
Regurgitation
Water brash
Nausea, vomiting

pain, cramps,

headache,
Myalgias, altered sensorium
Thirst, tachycardia,
orthostatic, decreased
urination,
Lethargy, decreased skin
turgor
Watery, bloody, mucous,
purulent, greasy stool
fever, tenesmus, blood and/or
pus in the stool)
weight gain and weigth loss
Some patients are woken at
night by choking as refluxed
fluid irritates the larynx

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Jean bosco RN BSN

CONTCLINICAL FEATURES
Hypo or hyper pigmentation
(difficulty swallowing)
Desquamation
Odynophagia (pain on swallowing)
Ulceration
Anemia
Pain with burning sensation
Chest pain
Redness and bleeding
sometimes
Signs of complication like dehydration
or shock
Bad odor
Severe palmar pallor
Swelling
Eye signs of vitamin A deficiency
Xerostomia mouth dryness
Pus
Localizing signs of infection
Sores
Fever or hypothermia
Hypersyarrhea or salivary
Mouth ulcers
gland decreased
Skin changes of kwashiorkor:

Dysphagia

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Jean bosco RN BSN

Related information
BY THIS WE NEED THE INFORMATION
ABOUT:
Previous GI disease
Past and current medication use.
Nutritional status and eating patterns or unexplained
weight gain or loss over the past year
Questioning about the use of tobacco and alcohol
The nurse records all abnormal findings and reports
them to the physician
Psychosocial, spiritual, or cultural factors that may
be affecting the patient
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Jean bosco RN BSN

Disorders of the Oral Cavity

This group combine the conditions that affect :( mouth,
lips glands, teeth oral mucus membrane or gums)
Tooth conditions infection or inflammation:
(pulpitis,gingivitis,dental abscess and dental decay)
Salivary Gland Disorders, both infectious or non
Oral mucus membrane affection: candidiasis or stomatitis
Disorders of the mouth and lips(Herpes Simplex Type I,
cold sores, fever blisters)
Cancer of the Oral Cavity, e.g. squamous cell carcinoma
Congenital defects, e.g. cleft palate

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Jean bosco RN BSN

Cause or risk factors

The most cause are infection due to bacterial, fungus, virus,
medications, product abuse
The risk factors are as follow :
Poor oral hygiene
Sugar consumption
Low immunity immune suppressed
Injury of mucus membrane
Tobacco use and alcohol consumption
The children and elder people are at more risk
People with chronic condition
People with malnutrition
Lack of phosphate and calcium
Other condition like otitis media
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Jean bosco RN BSN

Dental conditions
Dental abscess ,pulpitis ,gingivitis ,periodontitis
The most cause are inflammation that lead to
infection
Pulpitis( pus-producing inflammation of the
dental pulp) that arises from an infection
extending from dental caries
Gingivitis Painful, inflamed, swollen gums;
usually the gums bleed in response to light
contact

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Jean bosco RN BSN

Clinical manifestations

Pain

with burning sensation

Redness and bleeding sometimes
Bad odor
Swelling
Xerostomia mouth dryness
Pus
Sores
Hypersyarrorhea or salivary gland decreased
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Jean bosco RN BSN

Acute apical abscess

Acute apical abscess

Incision and drainage

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Jean bosco RN BSN

Dental abscess
Definition
Causes(food

and bacterial deposit, dental decay,

acute pulpitis
complications
Clinical manifestations
Medical management
Nursing management

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Jean bosco RN BSN

Dental abscess
This

infection of the soft tissue surrounding a

tooth or gum
This condition start with pulpitis ,The bacterial
invade the tissue after colonizing the area by
capturing the food content especially sugar then
they make tart after a long period the make
invasion of the tissue may be : staphylococcus
areus

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Jean bosco RN BSN

Cont
Predisposing Risk FactorsClinical manifestations
Localized, constant, deep,
Dental caries
throbbing pain
Poor dental hygiene
Pain worsens with
mastication or exposure to
Dental trauma

extreme temperatures
Tooth may be mobile
Gingival or facial swelling
and tenderness (or both) may
be present
inability to open the mouth.
Fever (rare but possible

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Jean bosco RN BSN

MANAGEMENT AND INTERVENTIONS

Medical management
Analgesics for mild to moderate pain:
(Acetaminophen, Ibuprofen
Oral antibiotic therapy: penicillin v or
amoxicillin for 60mg/kg/day in 7 days
For a client having allergic to
penicillin the Clindamycin

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Jean bosco RN BSN

Nursing management:
Nursing assessment (history taking,
physical examination)
History taking
Localized, constant, deep, throbbing pain
Pain worsens with mastication or
exposure to extreme temperatures
Tooth may be mobile
Gingival or facial swelling and
tenderness (or both) may be present
Fever (rare but possible)
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Jean bosco RN BSN

Physical Assessment
Facial swelling may be present
Carious tooth
Gingival edema and erythema
Tooth may be loose
Anterior cervical nodes enlarged and
tender

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Jean bosco RN BSN

Assess
ment

Nursing Goal/Ex
diagnosi pected
s
outcom
es

Assessm
ent:
Subjectiv
e data
Objective
data

Pain due
to
disease
process
as
manifest
ed by
facial
expressio
n
depresse
d,
inability
to talk,
inability

interven rational
tions
e

Patient
1. admin
will be
istrati
free from
on
pain in
analg
4hrs
esic
As
(aceta
evidence
minop
d bay
hen
normal
2. Oral
verbal
hygie
communi
ne
cation
with
,normal
Warm
facial
saline
expressio 5/29/16rinses
Jean bosco RN BSN

evaluati
on

Potential Complications

Cellulitis
Recurrent

abscess formation
Systemic infection
Osteomyelitis

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Jean bosco RN BSN

Surgical management
for acute Needle aspiration by a dentist surgeon
for relieving pain and for pus drainage
for chronic ,After using x-ray to discover the
blind dental abscess
extraction or root canal therapy may be used
( apicectomy )excision of the apex of the tooth
root for dentoalveolar abscess or blind dental
abscess

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Jean bosco RN BSN

Oral candidiasis
Fungal

infection, it is characterized by creamywhite patches in the oral cavity.

Untreated, oral candidiasis progresses to involve
the esophagus and stomach. oral candidiasis can
be disseminated to other body systems

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Jean bosco RN BSN

Clinical manifestations
Burning

Ulcerating oral lesions

sensation
Altered sense of taste
Plaques on or
pharyngeal
tissues or
Persistent (chronic), white papules
or plaques
bleeding for hyperplasiticcandidiasis
Erythematous plaques
Thick whitish/ yellowish Retrosternal pain
Focal erythema
Difficult and painful
swallowing

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Jean bosco RN BSN

Etiology AND RISK

Local factors
factors
Xerostomia
Physiological factors
radiotherapy, medications
infancy, old age
Medications
Endocrine disorders
broad spectrum antibiotics,
corticosteroids
diabetes mellitus, hypothyroidism
High-carbohydrate diet
Nutritional factors
Dentures
iron, folate, or vitamin B12 deficiency
changes in environmental
Blood dyscrasias and malignancies
conditions, trauma,
overnight denture wearing,
acute leukemia, agranulocytosis
denture hygiene
Immune defects, immunosuppression
Smoking
AIDS, thymic aplasia

Systemic

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Jean bosco RN BSN

Cont

Erythematous candidiasis before

and after

Candida-associated denture
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Jean bosco RN BSN
stomatitis.

Medical management
Oral

nystatin (mycostatin), amphotericin B,

clotrimazole,or ketoconazole ( in pill form or
but for suspension, instruct the patient to swish
vigorously for at least 1 minute and then swallow
Another therapy is application of 1% aqueous
gentian violet three times a day
Flucytosine and griseofulvin

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Jean bosco RN BSN

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Jean bosco RN BSN

DIAGNOSIS
After

assessment we have to analyze the data (cues) to

obtain nursing diagnosis as the priorities
For a client with oral candidiasis ,the nursing diagnosis :
Pain due to sores, and impaired of oral mucus as
manifested by ,inability to swallow, burning
sensations, scratching ,and depressed mood
Risk for systematic infection related to mucus sores,
decreased of mucus integrity,
Risk for imbalanced electrolyte and fluid imbalance
due to inability to take fluid or food by oral route
secondary to impaired of oral mucus integrity
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Jean bosco RN BSN

 ASSESSM
ENT d

NURSING
DIAGNOSI
S

GOAL/EXP
ECTED
OUTCOME
S

INTERVENTIONS

Subjec Impair The

Assess client
tive
ed
client
for and
data
oral
will
report signs
Object
mucus
have
and
ive
integri
a
symptoms of
data
ty
health
altered oral
sores,
relate
y oral
mucous
white
d to
cavity
membrane
papul
diseas
in
Reinforce
es,
e
7days
importance
erythe
proces
as
of and assist
matou
s as
evide
client with
s ,and
manif
nced
oral hygiene
edem
ested
by:
after meals
atous
by
absen Avoid use of

sores,
ce of
products that
5/29/16
Jean bosco RN BSN
cream
white
oral
contain

RATION
AL

EVALU
ATION

GORD (gastroesophageal reflex diseases)

Gastric or duodenal contents flow back into the esophagus.
It causes undesirable symptoms:
Dyspepsia
Heartburn
Regurgitation
Waterbrash
A history of weight gain
Some patients are woken at night by choking as refluxed fluid
irritates the larynx
Dysphagia (difficulty swallowing)
Odynophagia (pain on swallowing)
Anemia
Chest pain
5/29/16

Jean bosco RN BSN

Medical management
Antacids,

which are said to produce a protective

H2 receptor antagonist drugs, which reduce
gastric acid secretion,
Proton pump inhibitors are the treatment of
choice for severe symptoms and for complicated
reflux disease
Anti-reflux surgery.

5/29/16

Jean bosco RN BSN

Collaborative management
Weight

loss
Avoidance of tight-fitting garments
Avoidance of dietary items which the patient
finds worsens symptoms
Elevation of the bed-head in those who
experience nocturnal symptoms
Avoidance of late meals
Cessation of smoking

5/29/16

Jean bosco RN BSN

Hiatal hernia
A part

of the stomach protrudes through the diaphragm muscle

into the chest. When the hernia is in this position, stomach
acid and food do not drain out of it quickly. Over time, this
can result in tissue damage to the esophagus, lungs and mouth
Causes and risk factors
Ascites
pregnancy
Obesity
Constrictive clothes
Bending, straining,
Coughing
peptic ulcer
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Jean bosco RN BSN

Manifestations
Occur

in 30% of the population over the age of

50 years.
Often asymptomatic.
Heartburn and regurgitation can occur.
Gastric volumes may complicate large hernias

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Jean bosco RN BSN

TYPES
1.

Type I sliding hiatal hernias, where the gastroesophageal

junction migrates above the diaphragm6. The stomach remains
in its usual
2. Type II pure paraesophageal hernias, the gastroesophageal
junction remains in its normal anatomic position but a portion
of the fundus herniates through the diaphragmatic hiatus
adjacent to the esophagus.
3. Type III combination of Types I and II, with both the
gastroesophagea junction and the fundus herniating through the
hiatus. The fundus lies above the gastroesophageal junction.
4. Type IV the presence of a structure other than stomach, such
as the omentum, colon or small bowel within the hernia sac
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Jean bosco RN BSN

Types

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Jean bosco RN BSN

Management
Drink

1 to2 l of water within 5-10 minutes. Then

carefully jump down from a one to two foot step
but not in all condition(any health concerns)

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Jean bosco RN BSN

SURGICAL MANAGEMENT
All

symptomatic paraesophageal hiatal hernias

should be repaired
reduction of the stomach
Hernia sac excision

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Jean bosco RN BSN

Peptic ulcer
A peptic

ulcer is an quarry (hollowed-out area)

that forms in the mucosal wall of the stomach, in
the pylorus (opening between stomach and
duodenum), in the duodenum (first part of
small intestine), or in the esophagus.

5/29/16

Jean bosco RN BSN

CAUSES AND RISK FACTORS

OLD

New

Idiopathic
Stress
Smoking
Spicy food

Helicobacter Pylori
NSAID
Crohns disease
Gastronoma
Hyperparthyroidism

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Jean bosco RN BSN

Clinical manifestation
30% asymptomatic
Dyspepsia
Anaemia
Haematemesis / melaena
A dull pain or a burning sensation in the
midepigastrium or in the back.
Sharply localized Tenderness
pyrosis (heartburn),
vomiting, constipation
diarrhea and and bleeding
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Jean bosco RN BSN

complications
Bleeding:

anaemia, melaena, haematemesis

Pyloric Obstruction: vomiting, dysphagia,
weight loss, epigastric fullness
Perforation and Penetration: pain, peritonitis
Carcinoma in chronic gastric ulcer

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Jean bosco RN BSN

Management
The management is based on these following
steps
Treatment (Drugs)
Lifestyle and dietary modification
Operation

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Jean bosco RN BSN

Lifestyle change
Less

stress
Regular diet
Avoid NSAID
Quit smoking

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Jean bosco RN BSN

Drugs
Eradication

of HP
Gastric acid neutrolizers Antacids
Antisecretory
Cytoprotectives
Eradication of HP
First line treatment
Triple therapy- 2 antibiotics and 1 PPI for 1 week
Clarithromycin 500mg BD
Amoxicillin 1g BD
Nexium 20mg BD
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Jean bosco RN BSN

Second line therapy

One week quadruple therapy
Bismuth 120mg Tetracycline 500mg
Metronidazole 400mg QID, Nexium 20mg BD
Antisecretory Drugs
H2 antagonists(Inhibit the action of histamine at the H2
receptors of parietal cells)
Cimetidine (800mg), Famotidine (40mg),
Ranitidine(300mg) Once daily dose at bedtime 6-8 weeks
Proton pump inhibitors
Block the final step in gastric acid secretion ( Omeprazole
(20mg),Once daily dose at bedtime 4-6 weeks
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Jean bosco RN BSN

Cytoprotectives
Sucalfate (aluminum hydroxide + sucrose) Form a
paste to protect gastrointestinal mucosa 1 g QID

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Jean bosco RN BSN

Surgical interventions
Indications
Refractory ulcer
Complications
Bleeding
Perforation
Pyloric stenosis
Acid reduction surgery
Vagotomy
Gastrectomy
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Jean bosco RN BSN

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Jean bosco RN BSN

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Jean bosco RN BSN

Post-op Care
Nasogastric Gastric tube management
patency, position (co2, pH paper)
Bright
& stability observe, record and
report output
red/24
Dark red/ PO Day
Fluid replacement
1
IV fluids
Red/green PO Day
2
blood products
Bile color PO Day
Pain management
3
Cough, Deep Breathe, Ambulate

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Jean bosco RN BSN

Assessm Nursin
ent
g
diagno
sis

Goal
/expec
ted
outco
mes

Subjecti
ve and
objectiv
e data
Dyspep
sia
signs
of
Anaemi
a
Haema
temesi
s/
melaen

Patient
will
gain
the
normal
nutritio
n
status
as
evidenc
ed by
normal

Imbalan
ced
nutritio
n less
than
body
require
ment
related
to
changes
in diet
intake
As

Nursi Ration
ng
ale
interv
ention
s

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Jean bosco RN BSN

evaluation

Diagnosis
Analysis of cues or data as obtained from history and
physical examination
To obtain the priority nursing diagnosis
Epigastric pain
Electrolyte and fluid imbalance
Planning(care Plan)
Acute pain related to the effect of gastric acid secretion on
damaged tissue
Anxiety related to coping with an acute disease
Imbalanced nutrition related to changes in diet
Deficient knowledge about prevention of symptoms and
management of the condition
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Jean bosco RN BSN

GASTRITIS
Inflammation of the gastric or stomach mucosa) is a common GI
problem it may be acute or chronic
Causes and risk factors
Exposure to irritating agents
Hypochlorhydria(absence or low levels of hydrochloric acid [hcl]) or
with hyperchlorhydria(high levels of hcl)
Excessive alcohol intake
Bile reflux and radiation therapy
Acute systemic infection
Ingestion of strong acid or alkali
NB: chronic
Autoimmune diseases such as pernicious anemia;
Dietary factors ( caffeine; the use of medications nsaids; alcohol;
smoking; or reflux of intestinal contents)
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Jean bosco RN BSN

Type of chronic gastritis

Type A (autoimmune)

it involve autoimmune
activity against parietal cells
Type B (bacterial infection) :it provokes an
acute inflammatory response
Type C (reflux gastritis): the regurgitation of
duodenal contents into the stomach through the
pylorus

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Jean bosco RN BSN

COLLABORATIVE MANAGEMENT
Treatment

consists of diluting and neutralizing the

offending agent
To neutralize acids, common antacids (eg, aluminum
hydroxide)
to neutralize an alkali, diluted lemon juice or diluted
vinegar
If corrosion is extensive or severe, emetics and lavage
are avoided because of the danger of perforation and
damage
Nasogastric (NG) intubation, analgesic agents and
sedatives, antacids, and intravenous (IV) fluids.
Nothing by oral to stimulate mucosal healing
5/29/16

Jean bosco RN BSN

Assess
ment

Nursing Goal/ex
diagnosi pected
s
outcom
es

Subjectiv
e
objective
data
abdomin
al
discomfo
rt
headach
e
Lassitude
nausea
anorexia
vomiting

Anxiety
related
to coping
with an
acute
disease

Nursing rational
interven e
tions
1. Asses
s
what
patien
t
wants
to
know
about
the
diseas
e,
ande
valuat
e Jean bosco RN BSN
5/29/16

Evaluati
on

Peritonitis
Peritonitis

is an inflammation of the peritoneum

that lines the abdominal cavity and covers the
surfaces of abdominal organs and is marked by
exudations into the peritoneum of serum, fibrin,
cells and pus

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Jean bosco RN BSN

Causes
Primary

causes: the spread of an infection from the

blood and lymph nodes to the peritoneum and
accounts for less than 1% of all cases.
Secondary peritonitis is the commonest type and
occurs when bacteria enter the peritoneum from the
gut or biliary tract
Manifestations:
Vomiting, swelling of the abdomen
Severe abdominal pain and tenderness,
Weight loss, constipation
Moderate fever
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Jean bosco RN BSN

Why and when?

Perforations

of GIT wall
ruptured appendix
perforations the stomach( ulcers) and gallbladder
Pelvic inflammatory disease in sexually active women
after surgery
Peritoneal dialysis
Diagnostic studies
using X-rays or a CT scan (the presence of fluid,
accumulation of pus or infected organs in the abdomen.
samples of blood or abdominal fluid (causative
microorganism)
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Jean bosco RN BSN

Collaborative Management
Fluid and Electrolyte
Replace

Fluids & Electrolytes

Replace lost Proteins- albumin

Elimination

NG

Protection

or long intestinal tube to decompress

stomach & prevent aspiration

Incision

& Drainage
Wound Care w/ irrigations
wound drainage
Antibiotic Therapy
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Jean bosco RN BSN

Medical management
Antibiotic

administration(ampicilline)
Analgesic (morphine)
Immediate surgery to wash the pertonial cavity

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Jean bosco RN BSN

General management of Peritonitis

ABC
Oxygen
Fluid

resuscitation (large bore cannule,

bloods, IVF, catheter)
IV antibiotics (Augmentin and metronidazole)
Analgesia
Surgery (with or without preceeding CT
depending on availability and stability of
patients)

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Jean bosco RN BSN

Nursing Priorities
Assessment

Pain
Bowel sounds
Wound Care
Post-op
ARDS
Sepsis Septic Shock
IV fluids & antibiotic therapy
Teaching Wound Care
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Jean bosco RN BSN

Inflammatory Bowel Disease

Incidence 2 peaks
15-25 years
55-65 years
Male = female
White, urban, Jewish
Familial (10 x )
? Autoimmune

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Jean bosco RN BSN

Etiology: Not Clear

Current

Research: strong genetic component;

also autoimmune response
Caused by an inappropriate immune response
to an environmental trigger
Both intestinal and extra-intestinal CMs
Other causes
Bacterial trigger
Allergic response
destructive enzymes
protective substances
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Jean bosco RN BSN

Comparison

Crohns Disease

Ulcerative Colitis

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Jean bosco RN BSN

Crohns

Ulcerative
Colitis

Distributio
n
Inflammati
on

Anywhere common Rectum & Distal

at terminal ileum
colon

Common
CMs

Abdominal Cramping Diarrhea

Pain & Diarrhea
Rectal Bleeding
Weight loss, esp. if
Cramps & Pain
terminal ileum is
involved

Blood in
stool

Visible w/colon
involved

Carcinogene

Mild Risk

Discontinuous
Transmural

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Continuous
Mucosa & submucosa

Usually visible
Risk after 10

Jean bosco RN BSN

Management in acute phase

Hemodynamic

stability
Restore/maintain fluid & electrolyte balance
Nutritional support
Parenteral Nutrition (PN) bowel rest
Elemental or low residue diet
Decrease immune response
Immuno-suppressants : Azathioprine (Imuran)

5/29/16

Jean bosco RN BSN

Medical management

Diarrhea if severe(npo
Antidiarrheal(lomotil, imodium)
Aminosalicylates (anti-inflam. Prostaglandin
synthesis)
Corticosteroids
Immunosuppressives
Remicade blocks action of TNF
Anticholinergics
Anti-infectives
Sulfonamides
Flagyl
Cipro
5/29/16

Jean bosco RN BSN

Nursing Interventions
Diarrhea

Bowel rest
Help patient determine causative foods (caffeine, spicy)
Skin integrity
Encourage protein intake
Cleanse well, Sitz bath, moisturizer & barrier creams
Acute Pain r/t inflamed bowel mucosa
Assess, alert to complications
Use narcotics as needed (PRN)
Teach cancer screening (ulcerative colitis)
Ineffective coping
Identify ineffective coping behaviors
Include family, other staff in plan
Encourage expression of feelings
Stress reduction techniques
Referrals as necessary
Counseling, dietician
5/29/16

Jean bosco RN BSN

Surgical Management
Crohns Disease
Surgery not usually indicated except for
complications
Perforation
Hemorrhage
Obstruction
Ulcerative colitis
25-40% eventually will need surgery.
Permanent ileostomy
Continent ileostomy
5/29/16

Jean bosco RN BSN

Intestinal obstruction
A blockage

of the intestine typically resulting in

symptoms such as abdominal pain and vomiting. This
condition prevents the normal flow of intestinal
contents through the intestinal tract
TYPES:
Mechanical obstruction: An intraluminal obstruction or
a mural obstruction from pressure on the intestinal walls
occurs. neoplasms, or abscesses.
Functional obstruction: The intestinal musculature
cannot propel the contents along the bowel (Parkinsons
disease)
it can be partial or complete.
5/29/16

Jean bosco RN BSN

Mechanical cause of intestinal obstruction

5/29/16

Jean bosco RN BSN

Clinical Manifestations
High

Low
Gradual onset
Vomitus orange brown & foul smelling
d/t overgrowth of bacteria
Distention
Metabolic Acidosis
No fecal nor flatus that pass only blood
and mucus
Signs of shock

Rapid onset
Projectile vomitus of bile
Vomiting relieves pain
Distention minimal or absent
Large Bowel
Metabolic alkalosis
Bowel Sounds
Vomiting may be absent with ileocecal
valve competent or fecal vomiting signs
of constipation
high pitched
Lower abdominal clumpy pain
over area of obstruction Incompetent valve vomits fecal material
Loop of large intestine may be seen on
the outline of the abdominal wall
audible
5/29/16

Jean bosco RN BSN

Collaborative Management

Decompression(
NG tubes- Intestinal tubes (controversial)
Sigmoid tubes to reduce volvulus
Correct & maintain fluid balance
(IV normal saline w/ K+
TPN to correct nutritional deficiencies
Relief or removal of obstruction
(surgery
colonoscopy then cecostomy

5/29/16

Jean bosco RN BSN

Hemorrhoids
condition in which the portion of the anal became
dilated including the vascular tissue(veins) ,this
can occur on the internal or external sphincter and
it can result the sliding of the whole anal wall
including the vascular tissue in the(lumen) of anal
cavity
TYPES:
the hemorrhoid can be categorized into 2 mains
types: internal hemorrhoid (internal sphincter) anal
and external hemorrhoid(external sphincter) depend
on the location where the veins were dilated
5/29/16

Jean bosco RN BSN

5/29/16

Jean bosco RN BSN

5/29/16

Jean bosco RN BSN

Clinical manifestations
Itch

or bleed from the anus

Feel a mild burning.
Have swelling and pain during bowel movements.
Feel painful lumps around the anus
Discomfort during defection
bright red bleeding with defecation
Hemorrhoid seen outside for external hemorrhoid(Rectal
Prolapsed)
NB: for external hemorrhoid( severe pain from the inflammation and
edema caused by thrombosis ( clotting of blood within the
hemorrhoid)
Internal hemorrhoids are not usually painful until they
Bleed or prolapsed when they become enlarged
5/29/16

Jean bosco RN BSN

Causes
Constipation.
Hold

back or wait a long time before you have a bowel movement.

Diarrhea
Heavy lifting
Sit for a long time on the toilet
Risk factors :
pregnant women or give birth.
overweight or obese people.
Cough or sneeze a lot.
Sitting for a long time.
liver disease
Drink too much alcohol.
Anal sex
5/29/16

Jean bosco RN BSN

Complications
Ischemia
Hemorrhage
Anal

stenosis
Thrombos
Rectal obstruction
constipation
impactation

5/29/16

Jean bosco RN BSN

Nursing Management
Good

personal hygiene
Sitting for few minutes warm water a few times
a day may help(sitz baths)
Avoiding excessive strain during defecation.
Consume diet that contains fruit
Avoid intraobdomonial pressure
Increase fluid intake
Warm compresses
Bed rest allow the engorgement to subside..
5/29/16

Jean bosco RN BSN

Pharmacological interventions
Corticosteroid

creams
Nitroglycerin ointment
Analgesic ointment( Nupercainal)
Calcium dobisilate
The addition of hydrophilic agents psyllium
and mucilloid
Analgesic ointments or suppositories,
Astringents (eg, witch hazel),
Injecting sclerosing solutions
Stool softener
5/29/16

Jean bosco RN BSN

Surgical management
With

the anoscope hemorrhoid is visualized

Involves freezing the hemorrhoid to cause necrosis.
Internal hemorrhoids can be treated by banding
Hemorrhoidectomy, or surgical excision(the rectal sphincter
is usually dilated digitally and the hemorrhoids are removed
with a clamping and cauterization or are ligated and the
excised)
Large external or internal hemorrhoids by cutting out
surgically and then closing with absorbable sutures (stitches)
Sclerotherapy by inserting a special material to shrink and
stop bleeding
Burning and coagulating with special instruments such as
lasers or infrared emitting probe
5/29/16

Jean bosco RN BSN

Diarrhea
Frequent

passage of feces that are larger in

volume and more fluid than normal. It is not a
disease but a symptom of some other underlying
conditions that result in abrupt increases in
intestinal movement
Osmotic balance between GIT contents and ECF
in the intestinal tissue.(Secretory stimuli, NA/K
Atapase
Diarrhea may result from one of two principal
mechanisms, secretion and osmotic imbalance.
5/29/16

Jean bosco RN BSN

Types

how?

Osmotic

diarrhea
Secretory diarrhea
Infectious diarrhea
The aim of management :
To correct dehydration and electrolyte deficits.
By fluids replacement orally or intravenously

5/29/16

Jean bosco RN BSN

Risk factors
Consumption

of unsafe foods (e.G., Raw meats,

eggs, or fish; unpasteurized milk )
visiting a farm or petting zoo
knowledge of other ill persons (such as in a
dormitory or office or a social function);
Medications (antibiotics, antacids, antimotility
agents);
Underlying medical conditions predisposing to
infectious diarrhea (AIDS)
receptive anal intercourse or oral-anal sexual contact
Occupation as a food-handler or caregiver
5/29/16

Jean bosco RN BSN

Main features from diarrhea

5/29/16

Jean bosco RN BSN

General manifestations
Nausea,

vomiting
Abdominal pain, cramps, headache,
Myalgias, altered sensorium
Thirst, tachycardia, orthostatic, decreased
urination,
Lethargy, decreased skin turgor
Watery, bloody, mucous, purulent, greasy stool
Signs of dysentery(fever, tenesmus, blood and/or
pus in the stool)

5/29/16

Jean bosco RN BSN

MANAGEMENT
The

management depend on the cause and the

person
For infectious diarrhea or
immunocomprimised(AIDS) people
(antibiotic or additional of TMP-SMZ,
RECOMMENDATION
INITIAL REHYDRATION( IV for severe or unable
to take something by oral route, Oral rehydration
solutions for mild)
CLIENT EVALUATION
FECAL TEST
5/29/16

Jean bosco RN BSN

5/29/16

Jean bosco RN BSN

What to assess
When

and how the illness began (e.G., Abrupt or gradual onset and
duration of symptoms);
Stool characteristics (watery, bloody, mucous, purulent, greasy, etc.);
Frequency of bowel movements and relative quantity of stool
produced;
Presence of dysenteric symptoms (fever, tenesmus, blood and/or pus
in the stool);
Symptoms of volume depletion (thirst, tachycardia, or thostasis,
decreased urination, lethargy, decreased skin turgor); and
associated symptoms and their frequency and intensity (nausea,
vomiting, abdominal pain, cramps, headache, myalgias, altered
sensorium).
Risk factors
Observe for abnormal vital signs or other signs of volume depletion
5/29/16

Jean bosco RN BSN

Constipation
The difficult or unduly infrequent passage of
faeces or abnormal infrequency or irregularity
of defecation.
Abnormal hardening of stools ( difficult and
sometimes painful, a decrease in stool volume, or
retention of stool in the rectum for a prolonged
period)

5/29/16

Jean bosco RN BSN

Causes
Rectal

or anal disorders (e.g., hemorrhoids)

Obstruction (e.g., cancer of the bowel)
Metabolic, neurologic, and neuromuscular conditions ( diabetes
mellitus, Parkinson's disease)
endocrine disorders (e.g., hypothyroidism)
Lead poisoning
reduced food (including fiber) and fluid intake
reduced motility
reduced abdominal and pelvic muscle power
constipating drugs (e.g. opioids, drugs with anticholinergic
action)
reduced rectal/anal tone and sensation (neurological impairment

5/29/16

Jean bosco RN BSN

Complication

Abdominal

distension/pain;
Anorexia, nausea and/or vomiting
Faecal overflow incontinence
Hemorrhoids/anal fissure
Urinary retention/infection
Faecal impaction (that can lead to bowel
obstruction)
Agitated delirium.
5/29/16

Jean bosco RN BSN

Management
Goals

of Management
The main goal is to prevent the consequences of
constipation, or treat them if they have occurred.
Identify and treat any reversible causes if appropriate.
Proactive management with prophylactic laxatives in
patients at high risk of constipation (e.g. commencing
opioid).
Education of patient and carers about the importance of
close vigilance of bowel pattern, early intervention and
ongoing management of constipation.
Aggressive intervention to reverse severe
constipation/faecal impaction and to prevent recurrence.
5/29/16

Jean bosco RN BSN

Medical management
First

line laxative treatment

(Stool softener
I.
Coloxyl 1-2 x 120mg tablets po
II. Macrogol (Movicol)
Peristaltic Stimulant
I. Bisacodyl 1 - 2 x 5mg tablets
II. Senna 1 - 2 x 7.5mg tablets
Metoclopramide has a prokinetic effect for
treatment if nausea &/or vomiting are present as
addition
5/29/16

Jean bosco RN BSN

Second line
When

there is no bowel action for three days

consider a rectal examination
Rectum empty(please exclude obstruction)
There is impactation
Propulsive stimulant: bisacodyl (Durolax)
suppositories 1 - 2 PR; repeat twice daily until
good result
Movicol 8 sachets dissolved in 1 litre of water
orally, taken over 2 - 4 hours
If resolved give oral laxatative avoid recurence
5/29/16

Jean bosco RN BSN

Rectum full-hard stool

Glycerin

suppositories 1 - 2 PR to soften stools

(placed into substance of stool) +/- bisacodyl
(Durolax) suppositories 1 PR to stimulate
rectum/bowel from above (placed in contact with
rectal mucosa).
Once resolved resume oral laxatives at
appropriate dose
NB: Rarely manual evacuation under
sedative(lorazepam 1mg S/L) may be used

5/29/16

Jean bosco RN BSN

Rectum Full Soft Faeces

Senna 2 x 7.5mg tablets , increasing to 15mg bd

Bisacodyl propulsive stimulant 2 x 5mg tablets
PO increasing to 10mg bd (10-12 hour delay to
onset)
Bisacodyl suppositories 1-2 PR until resolved
NB: If the patient is having difficulty expelling
soft stool then add (or increase dose of)
propulsive agent (senna or bisacodyl

5/29/16

Jean bosco RN BSN

USEFUL QWESTION TO ASSESS

CONSTIPATION
ONSET
When/how did it begin?
What was your usual bowel pattern?
How much and how often? Before? Now?
Provoking/relieving
What medication are you on?
How is your appetite/food and fluid intake?
What treatments/laxatives have you tried previously?
What are you taking now?
How effective are these?
Do you get any side effects from these
treatments/laxatives?
5/29/16

Jean bosco RN BSN

CONT
Quality
What does it feel like?
Is using your bowels painful?
Is there a feeling of incomplete evacuation?
What do the stools look like?
Where do you most feel it? (abdomen? ano-rectal area?)
Severity
How bad is the constipation (on a scale of 0 to 10 with 0 being none
and 10 being
worst possible)? Right now? At best? At worst? On average?
How bothered are you by it?
Are there any other symptoms that accompany the constipation e.g.
anorexia,nausea, vomiting, abdominal pain, pain on defecation,
bloating
5/29/16

Jean bosco RN BSN

Colaborative management
The

record of bowel elimination, character of

stool, food and fluid intake,
level of activity, bowel sounds, medications, and
other assessment data are reviewed to develop the
plan of care.
Multiple approaches may be used to prevent
constipation
The diet should be well balanced and should
include adequate intake of high-fiber foods
(vegetables, fruits, bran) to prevent hard stools and
to stimulate peristalsis]
5/29/16

Jean bosco RN BSN

Cont
Fluid intake should be between 2 and 3 L/day unless
contraindicated. Prune juice or fig juice (120 mL)
taken 30 minutes before a meal once daily is helpful to
some cases
when constipation is a problem. Physical activity and
exercise are encouraged, as is self-care in toileting.
The patient is encouraged to respond to the natural urge
to defecate.
Privacy during toileting is provided.
Stool softeners, bulk-forming agents, mild stimulants and
suppositories may be prescribed to stimulate defecation
and to prevent constipation.
5/29/16

Jean bosco RN BSN

CANCER AND MALNUTRITION

Conditions
Causes

and risk factors

complications
Medical management
Nursing management

5/29/16

Jean bosco RN BSN

Malnutrition
a condition in which a client show poor nutrition due to
insufficient or excessive or imbalanced diet or from inability to
absorb foods.
RISK FACTORS OF MALNUTRITION
Elderly people
Hospitalized people for long time
Poor people (People with low income)
People with chronic eating disorder
People convalescing after serious illness such as measles,
pneumonia and diarrhea
Medications side effects can reduce dietary intake (proton
pump inhibitor)
Dysphagia
5/29/16

Jean bosco RN BSN

Types of malnutrition
Acute

malnutrition
Marasmus (wasting)
Kwashiorkor (oedematous)
Chronic malnutrition
Stunting
Growth faltering (underweight)
Composite of acute & chronic malnutrition
Specific nutrient deficiency
Anaemia, Iodine etc
Malnutrition secondary to disease
HIV / TB
Any illness
5/29/16

Jean bosco RN BSN

Forms of acute malnutrition

Kwashiorkor

Frequent infections, Electrolyte imbalance,

Frequent association with dehydration (often ,masked by
oedema) Generally apathetic, lethargic, miserable, and
irritable. They show no signs of hunger, and it is difficult to
persuade them to eat.
Marasmus(Extremely emaciated (fat & muscle tissue
grossly ,reduced).Thin flaccid skin, hanging in loose folds;
baggy pants,
old mans appearance, Normal hair, Frequent infections with
minimal signs,Electrolyte imbalance (no oedema),Frequent
association with dehydration, Alert & irritable
Marasmic-kwashorkor(signs of marasm but with edema)
5/29/16

Jean bosco RN BSN

Management
It start with initial assessment
History taking that include :
Recent intake of food and fluids
Diet
Duration and frequency of diarrhea and vomiting
history of diarrhea
Family circumstances
Chronic cough
Contact with TB
Known or suspected HIV infection
5/29/16

Jean bosco RN BSN

On physical Examination
Assessment

of Anthropometry:
(Age,Sex,Weight,Height,Bilateral edema,MUAC) Mid Upper
Arm Circumference ,BMI
Signs of complication like dehydration or shock
Severe palmar pallor
Eye signs of vitamin A deficiency
Localizing signs of infection
Fever or hypothermia
Mouth ulcers
Skin changes of kwashiorkor:
Hypo or hyper pigmentation
Desquamation
Ulceration
5/29/16

Jean bosco RN BSN

Management of complications

Hypoglycemia:

All severely malnourished are at risk of hypoglycemia.

Where blood glucose results can be obtained quickly (eg with
Dextrostix), this should be measured quickly.
Hypoglycemia is present when blood glucose is <3 mmol/l (<54 mg/dl)
Give 50mls of 10% glucose.
Give 2 hourly feeds, day and night at least for the first day.
If the child is unconscious. Treat with IV glucose.

Hypothermia(<35C):

Is associated with increased mortality in severely malnourished children.

Feeding the child, ensuring adequate clothing and appropriate antibiotics
forms the management.

5/29/16

Jean bosco RN BSN

Electrolyte imbalance:
Extra potassium should be added to the feeds during
their preparation.
All severely malnourished children have deficiencies of
potassium and magnesium which may take 2 weeks or
more to correct.
Infection:
In severe malnutrition, the usual signs of infection such
as fever are often absent, yet multiple infections are
common.
Therefore, assume all malnourished children have an
infection on their arrival at the hospital and treat with
broad spectrum antibiotics straight away

5/29/16

Jean bosco RN BSN

Micronutrient deficiencies:

All severely malnourished children have vitamin and

mineral deficiencies. Although anemia is not common, do
not give iron initially but wait until the child has good
appetite and starts gaining weight(usually in the 2 nd
week), because iron can make the infection worse.
Give daily (for at least 2 weeks)
Multivitamin supplement
Folic acid (5mg on day 1, then 1mg/day)
Zinc (2mg Zn/kg/day)
Copper (0.3mg Cu/kg/day)
Once gaining weight, ferrous sulphate (3mgFe/kg/day
5/29/16

Jean bosco RN BSN

CONT
Eye

problems:
If the child has eye signs of vitamin A deficiency (dry
conjunctiva or cornea, corneal ulceration, keratomalacia):
Give vitamin A orally on day 1,2 and 14 (aged <6
months5, 0000 IU; aged 6-12 months, 100000 IU; older
children, 200000 IU)
If the eyes shows signs of inflammation or ulceration
Instill Chloramphenicol or tetracycline eye drops, 3
hourly for 7-10 days.
Instill atropine eye drop.
Cover with saline-soaked eye pads.

5/29/16

Jean bosco RN BSN

Daily diet
Frequent

small feeds of low osmolality and low in lactose.

Oral or nasogastric feeds.
100kcal/kg/day.
Protein: 1-1.5 g/kg/day.
Liquid: 130 ml/kg/day.
Monitor and record
Amount of food offered and left
Vomiting
Stool frequency
Daily body weight.
Catch up growth;
Give a milk based formula.
5/29/16

Jean bosco RN BSN

1.

2.

3.

4.

Using nursing process indicate how will you

manage a client with diarrhea PLEASE other
collaborative measures
Using nursing process indicate how will you
manage a client with vomiting please indicate
other collaborative measures
Indicate the collaborative measure and also
use nursing process manage a client with
malnutrition
Indicate the collaborative measure and also
use the nursing to manage a client with
hemorrhoids
5/29/16

Jean bosco RN BSN