AssessmentAndManagementOfPatientsWithLowerGI [EDocFind.com]
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Transcript of AssessmentAndManagementOfPatientsWithLowerGI [EDocFind.com]
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Assessment And Management OfPatients With Lower GI TractDisorders
NUR 111Common Health Problems
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Anatomy and Function of Lower GI Tract
GI Tract = 23- 26 feet long: extends from mouththrough esophagus, stomach, and intestines to theanus
Small Intestine Function:Small Intestine Function:
Longest segment of GI tract, absorption of
nutrients into bloodstream through intestinal walls 3 anatomic parts: duodenum, jejunum, ileum
Digestive enzymes and bile in the duodenumcome from pancreas, liver, gallbladder and glands
within the intestines Intestinal glands secrete mucus, hormones,
electrolytes and enzymes
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Ileal Villi
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2 types of contractions: Small Intestine
Segmentation contractions:
Intestinal peristalsis:
Colonic Function: (Ascending, Transverse,Descending, Sigmoid, and Rectum)
Within 4 hrs of eating residual wastematerial passes through ileocecal valveinto colon
Bacteria make up a major part of thecontents of large intestine
2 types of secretions: bicarbonate(neutralize) and mucus (protects colonicmucosa)
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Ileocecal Valve
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Colonic Function, Cont.
Slow, weak peristaltic activity movescolonic contents along tract, allowing
efficient reabsorption of H2O andelectrolytes
Fecal material is approx. 75% fluid,
25% solid, brown in color frombreakdown of bile, odor comes frombacteria byproduct
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Health Hx. And Clinical
Manifestations
Tobacco and alcohol
Medications
Surgeries Unexplained Wt. Gain or Loss
Pain (location, duration, frequency etc.)
Indigestion
Intestinal Gas
Nausea and Vomiting
Changes in Bowel Habits and Stool
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Physical Assessment & Diagnostic Evaluation
Assessment: mouth, abdomen, rectum
Mouth: teeth, gums, tongue
Abdomen: look, listen, then feel
Anal and perineal area
Diagnostic Evaluation
Blood work: CBC, liver panel
Stool test: occult blood, parasites, etc.
Hematest: most common for occultblood
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Diagnostic Evaluation
Lower GI tract studies: Barium Enema: detect polyps, tumors,
lesions of colon Radiopaque substance instilled rectally Gastrografin (water-soluble iodine
contrast) used in inflammatory diseaseor perforated colon
Nursing Interventions: May vary accordingto MD orders, condition of client etc.
Computed Tomography: cross-sectionalimages Nursing Interventions: NPO for 6-8 hrs
prior, assess for allergies to contrast dye
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Diagnostic Evaluation
Magnetic Resonance Imaging: Noninvasive,uses magnetic fields and radio waves:
Useful in evaluating soft tissues, vessels
Nursing Interventions: NPO for 6-8 hrs
prior, remove all jewelry, procedure takes30-90 minutes, close fitting scanner maycause feelings of claustrophobia
Anoscopy, Proctoscopy, Sigmoidoscopy:
Nursing Interventions: Minimal bowelcleansing, monitor vital signs during andafter procedure
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Diagnostic Evaluation
Colonoscopy: Direct visual inspection of colon tocecum
Flexible fiberoptic colonoscope, can obtainbiopsies and remove polyps
Usually takes one hour, pt on left side, legs drawn
toward chest Nursing Interventions: May vary according to MD
orders
Bowel cleansing (Colyte, Golytely) clear liquids daybefore, Informed consent, NPO night before, IV
midazolam (Versed) for sedation. During procedure monitor vital signs, O2
saturation, color and temp of skin, level ofconsciousness, vagal response
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Colonoscopy
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Gerontologic Considerations
Oral Cavity
Tooth loss or decay Atrophy of taste buds
Esophagus
Weakened gag reflex
Stomach Decrease gastric secretions
Decrease motility
Small Intestine
Atrophy of muscle and mucosal surfaces Large Intestine
Decrease mucus production
Decrease tone of anal sphincter
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Abnormalities of Fecal Elimination
Constipation: irregular, hard stool: may be caused
by certain meds, hemorrhoids, obstructions,neuromuscular diseases Complications: Hypertension, fecal impaction, hemorrhoids,
megacolon
Nursing Management: increase fiber, fluids, laxatives as ordered
Diarrhea: Increase in frequency, amount andaltered consistency (looseness): Irritable Bowel
Syndrome (IBS), Inflammatory Bowel Disease (IBD),and lactose intolerance are frequently underlyingdisease processes Acute or Chronic
Complications: dehydration, cardiac dysrhythmias (low potassium)always be aware of Potassium levels
Nursing Management: Stool specimen, bed rest, low bulk diet inacute phase, advance to bland diet, no caffeine, carbonated drinks,antidiarrheal meds as ordered, diphenoxylate (Lomotil), loperamide(Imodium)
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Irritable Bowel Syndrome (IBS)
Common GI problem, cause unknown, certain factors
associated with syndrome: heredity, depression,anxiety, high fat diet, smoking, alcohol
Results from functional disorder of intestinal motility
Clinical manifestations: constipation, diarrhea, orboth, pain, bloating
Assessment and diagnostic findings: diagnosis madewhen tests rule out structural or other colon disease
Medical management: Treatment aimed at relievingpain, constipation and diarrhea, reducing anxiety and
stress
Nursing Management: patient education, reinforcegood diet, not smoking and no alcohol
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Zelnorm
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Acute Inflammatory Intestinal Disorders
Appendicitis: most common reason forabdominal surgery, appendix becomesinflamed from obstruction, may become pusfilled
Clinical manifestations: Right lowerquadrant pain, low grade temp, N/V,rebound tenderness, rupture causes diffusepain and condition worsens
Assessment and Diagnostic: CBC, CT of
abdomen, Ultrasound
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Opening of Appendix
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Appendicitis
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Appendicitis
Complications: Perforation leading toperitonitis or abscess
Medical Management: Surgery as soon aspossible, IV fluids and antibiotics,analgesics, Appendectomy may beperformed with low abdominal incision orby laparoscopy
Nursing Management: Goals include,relieving pain, preventing fluid and
electrolyte imbalance, dehydration, andinfection
Surgery may be outpatient, if complications ofperitonitis are suspected pt may remain in hospital
for several days
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Acute Inflammatory Intestinal Disorders
Diverticulitis: Diverticulum is saclikepouching of lining of bowel extendingthrough defect in muscle. Most commonin sigmoid colon
Clinical Manifestations: Chronicconstipation, intervals of diarrhea, leftlower quadrant pain, anorexia, fatigue
Assessment and Diagnostic: CT scan
procedure of choice, CBC
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Diverticula Diverticula seen on
colonoscopy
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Diverticula Diverticula seen on
barium enema
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Diverticulitis Complications: peritonitis, abscess formation,
bleeding
Medical Management: Usually treatedoutpatient with diet and medicine therapy,antispasmodics, antibiotics, bulk laxative,clear liquids until inflammation resolved then
high fiber, low fat Acute case may require hospitalization,
especially for elderly andimmunocompromised
Surgery may be necessary with abscess formation orperforation
Nursing Process: encourage high fiber diet, exercise,bulk laxatives
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Peritonitis
Inflammation of the peritoneum, the serous
membrane lining the abdominal cavity and coveringthe organs.
Clinical Manifestations: Affected area of abdomenbecomes tender, distended, rigid. Reboundtenderness, paralytic ileus, N/V
Assessment and Diagnostic: CBC, Abdominal CT scanor X-ray, peritoneal aspiration and culture of fluid
Complications: Generalized sepsis (major cause ofdeath), inflammation may cause bowel obstruction
Medical Management: Fluid & electrolyte
replacement, analgesics, antiemetics, NG suction,massive antibiotics, surgery to remove infectedmaterial
Nursing Management: Ongoing assessment of vitalsigns, pain, GI function, intake and output
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Inflammatory Bowel Disease (IBD)
Refers to 2 chronic inflammatory GI
disorders: regional enteritis (Crohnsdisease) and ulcerative colitis. Both havesimilarities but are ultimately different.
Cause of IBD is unknown. Occurs equally inwomen and men.
Believed to be triggered by environmentalagents such as food additives, tobacco, and
radiation, also allergies and immune disorders
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Inflammatory Bowel Disease (IBD)
Regional Enteritis (Crohns disease):Occurs anywhere along the GI tract mostcommon in distal ileum and colon
Chronic inflammation that extends through alllayers of bowel wall
Periods of remission and exacerbation, ulcersform on inflamed mucosa, separated bynormal tissue,
Advanced cases the bowel wall thickens andbecomes fibrotic, intestines narrow
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Crohns Disease
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Inflammatory Bowel Disease (IBD)
Regional Enteritis (Crohns disease):
Clinical Manifestations: lower right quadrantpain, diarrhea unrelieved with defecation,colon spasm, result in decrease PO intake,malnutrition, wt loss, steatorrhea, abscesses
and fistulas Assessment and Diagnostic: Stool sample,
barium swallow or enema, CT scan, CBC,albumin
Complications: Intestinal obstruction, fluid &electrolyte imbalance, malnutrition, fistulaand abscess formation, increase risk coloncancer
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Inflammatory Bowel Disease (IBD)
Ulcerative
Colitis: recurrent ulcerative andinflammatory disease of the mucosal and
submucosal layers of colon and rectum
Multiple ulcers occurring one after the other,diffuse inflammation, usually begins in rectumand spreads proximally to entire colon;abscesses form and eventually the bowelnarrows and shortens
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Ulcerative Colitis
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Inflammatory Bowel Disease (IBD)
Ulcerative Colitis:
Clinical Manifestations: Exacerbation andremission, diarrhea and left lower quadrantpain, rectal bleeding, anorexia, wt loss,dehydration, 10-20 liquid stools/day
Assessment and Diagnostic: Assess hydration,nutritional status, signs of bleeding, stoolspecimen, CBC, Sigmoidoscopy, Colonoscopy,CT scan
Complications: Toxic megacolon, perforation,bleeding, vomiting, fatigue
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Inflammatory Bowel Disease (IBD)
Medical Management of Chronic IBD:Reduction of inflammation, provide rest fordiseased bowel, preventing complications
Nutritional Therapy: Oral fluids, lowresidue, high protein and calorie diet withvitamin and iron supplements
Pharmacologic Therapy: Sedatives andantidiarrheal meds, Aminosalicylates suchas sulfasalazine (Azulfidine), mesalamine(Pentasa) are used for long term
maintenance. Corticosteroids (prednisone)also help reduce inflammation
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Inflammatory Bowel Disease (IBD)
Surgical Management: May require
total colectomy (removal of entirecolon) and placement of ileostomy;
Nursing Management: goals;prevention of fluid volume deficit,maintenance of optimal nutrition andwt, avoidance of fatigue, promoting
effective coping
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Small Bowel Obstruction
Intestinal contents, fluid, gas accumulate above the
intestinal obstruction: Adhesions, Intussusception,Volvulus, Hernia, Tumor are all causes of obstruction.
Clinical Manifestations: Cramping pain, pass bloodand mucus but no stool, vomiting (intestinal
contents), dehydration, abdominal distention Medical Management: Decompression of bowel
through Nasogastric (NG) tube, if obstruction iscomplete then surgical intervention is warranted
Nursing Management: maintain function of NG tube,assess for fluid and electrolyte imbalance
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Large Bowel Obstruction
Obstruction of larger bowel is similar to small
bowel obstruction, however the symptomsdevelop and progress relatively slowly
Constipation may be only symptom for days,eventually abdominal distention and vomitingof fecal contents
Colonoscopy may be performed to untwistand decompress bowel
Usual treatment is bowel resection to removethe obstruction, colostomy may be necessary
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Polyps of Colon and Rectum
Polyp is a mass of tissue that protrudes into
lumen of bowel Can occur anywhere in colon or rectum
Neoplastic (carcinomas) or non-neoplastic(benign)
Most common sign rectal bleeding
Diagnosis based on digital rectal exam,colonoscopy, barium enema
Polyps should be removed either throughcolonoscopy or laparoscopy
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Polyps of the colon
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Diseases of the Anorectum
Anorectal abscess: obstruction of anal gland,infection, deep abscesses may result in low
abdominal pain and fever Treatment include incision and drainage, sitz
baths and analgesics
Anal fistula: Tiny, tubular tract that extends into the
anal cavity from an opening located beside the anus,usually result from an infection
Surgery recommended for removal of fistula,wound is packed with gauze
Anal fissure: longitudinal tear or ulceration in the
lining of the anal canal, caused by large firm stool, orchildbirth or trauma
Most heal with management by stool softener, sitzbaths and increase fluid intake
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Diseases of the Anorectum
Hemorrhoids: dilated portions of veins in the
anal canal. Increased pressure in thehemorrhoidal tissue due to pregnancy mayinitiate or aggravate hemorrhoids
Two types: internal and external
Cause itching and pain, most commoncause of bright red bleeding withdefecation
High fiber diet, increase fluids, bulklaxatives, sitz baths, may require rubberband ligation or more extensive surgery
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Hemorrhoids
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Treatment for hemorrhoids