Presentation by:Group 1PERITONITIS

and other GIT complications..PREPARED BY;

1. Nur Syafiqah Bt Kamaruzaman(08DIN0050)2. Haryani Jakarsi (08DIN0086)3. Nabilah Bt Abu Samah

(08DIN0021)4. Nur Izzati Bt Ismail (08DIN0028)5. Warsana A/P Bonsi (08DIN0412)

C/O

You’ve been diagnosed with..

FINALLY..

PERITONITIS

Mr. Tan m/60yrs

A&E DEPT

DEFINITION OF PERITONITIS

Peritonitis is a serious disorder caused by an inflammation of the peritoneum, most often due to bacterial infection.

It is a life threatening illness which is often associated with various abdominal disorders and is routinely assessed for in all client with abdominal complaints or symptoms.

The peritoneum is a two-layered membrane that lines the abdominal cavity and encloses the stomach, intestines, and other abdominal organs. The membrane supports the abdominal organs and protects them from infection. However, occasionally the peritoneum itself may become infected by bacteria or other organisms.

LOCATION OF PERITONEUM

PERITONEUM

TYPES OF PERITONITIS • Primary peritonitis

usually caused by liver disease. Fluid builds up in the abdomen, creating a prime environment for the growth of bacteria.

• Secondary peritonitis

caused by other conditions that allow bacteria, enzymes, or bile into the peritoneum from a hole or tear in the gastrointestinal or biliary tracts. Such tear can be caused by pancreatitis, a ruptured appendix, stomach ulcer, Crohn's disease, or diverticulitis. Peritoneal dialysis, which uses the blood vessels in the peritoneum to filter waste from your blood when your kidneys are not able to do so, also may cause peritonitis.

CAUSES OF PERITONITIS1. Infected peritonitisPerforation of a hollow viscus is the most common cause of peritonitis. E.g perforation of the distal oesophagus, of the stomach of the duodenum of the remaining intestine (e.g. appendicitis, diverticulitis, inflammatory bowel disease (IBD), intestinal infarction,colorectal carcinoma, meconium peritonitis).

Other possible reasons for perforation include abdominal trauma, ingestion of a sharp foreign body, perforation by an endoscope or catheter, and anastomotic leakage.

In most cases of perforation of a hollow viscus, mixed bacteria are isolated; the most common agents include Gram-negative bacilli (e.g. Escherichia coli) and anaerobic bacteria (e.g. Bacteroides fragilis).

CAUSES OF PERITONITIS2.Disruption of the peritoneum

It occurs even in the absence of perforation of a hollow viscus, may also cause infection simply by letting micro-organisms into the peritoneal cavity. Examples include trauma, surgical wound, continuous ambulatory peritoneal dialysis, intra-peritoneal

CLINICAL MANIFESTATIONS

VOMITING LOW URINE

OUTPUT

DEHYDRATE

HIGH FEVER

DIZZINESSABDO

DISTENTION

INABILITY TO PASS

FLATUS OR STOOL

Plain abdominal X-ray may reveal dilated, oedematous intestines, although it is mainly useful to look for pneumoperitoneum (free air in the peritoneal cavity), which may also be visible on chest X-rays.

INVESTIGATIONS

1. X-RAYS

2. PHYSICAL EXAMINATIONThe abdomen is hard and painful. There are no bowel movements or sounds.

3. BLOOD TESTS To check for which bacteria are responsible.

4. LAPAROSCOPY A slender tube is inserted through an abdominal incision and the insides examined.

If reasonable doubt still persists, an exploratory peritoneal lavage may be performed (e.g. in cases of trauma, in order to look for white blood cells, red blood cells, or bacteria).

6. PARACENTASIS

In patients with ascites, a diagnosis of peritonitis is achieved via paracentesis (abdominal tap): more than 250 polymorphonucleate cells per μL is considered diagnostic. In addition, Gram stain and culture of the peritoneal fluid can determine the microrganism responsible and determine their sensibility to antimicrobial agents.

5. PERITONEAL LAVAGE

PATHOPHYSIOLOGYPeritoneal infected

Inflammatory reaction at walls of localised area

Vascular dilatationIncrease capillary

permeability

hyperemia

Fluid shift

Peristalsis slow

caused abdominal distension

PERITONITIS

Decrease circulatory volume

Bacteremia Septicemia

NURSING CARE PLAN 1Alteration in comfort : pain

related to abdominal distension

Date:25.10.2009Time:8.15 am

Nursing Problem : Alteration in comfort : pain related to abdominal distension .

Supporting Data:1)Patient verbalized that he in pain at the abdomen . 2)Patient face looked pale

3)Patient blood pressure

140/80mmHg, pulse 70 4) Patient choose number 6 out of 10

from pain scale which is consider as moderate pain.

Goal : Patient’s pain will be reduced 1-2 hours after nursing interventions carried out and during hospitalization .

Nursing interventions:

1. Assess patient’s level of pain by asking patient whether the pain is mild , moderate or severe using pain scale and site of pain.

® As a baseline data and to plan proper nursing interventions to reduce pain

I-I assessed my patient’s level of pain using pain scale 1-10 and he choose 6-7 that moderate pain at the abdomen .

2)Monitor vital signs especially blood pressure and pulse rate .

®Elevated blood pressure and pulse indicate patient’s in pain

I-I had monitored my patient’s vital signs especially blood pressure and pulse rate

3) Position patient to semi flower’s position as indicated .® to keep patient comfortable and to reduce diaphragmatic irritation and abdominal tension .I-I had position my patient to a semi fowler’s and ensure my patient is comfortable .

4) Teach patient deep breathing exercises .

® deep breathing exercise may relax the muscle by divertional therapy and reduce pain .

I-I thought my patient to do deep breathing exercise when his condition was alert and I encouraged him to perform when he feels the pain

5) Provide call bell near to patient.® To get nurses help when necessary.I-I put the call bell near to the patient and ask him to

press if needed help.

6)Inform doctor if patient’s pain still persist

® for further management

I-I didn’t informed doctor because my patient’s pain has reduced .

7)Administer medication as ordered by doctor such as Antiemetics hydroxyzine (vistaril) .

® hydroxyzine (vistaril) is for reduces nausea and vomiting .

I-I administer hydroxyzine to my patient and explain to his for pain management.

Date:25.10.09

Time:10.15 am

Evaluation :Patient’s pain reduce after 2 hour nursing intervention carried out.

Supporting Data:1)Patient’s verbalized that pain is reduce.

2)Patient’s vital signs stable :BP: 120/80 mmHg and Pulse 86 bpm

NURSING CARE PLAN 2

Fluid volume deficit related to active fluid loss

Date/time : 25.10.2009 @ 0900 hours

Nursing Diagnosis : Fluid Volume Deficit Related To Active Fluid Loss such as Vomiting.

Supporting Data : pt c/o vomit x4. pt look pale, poor skin turgor,

dry mucous membranes.

Goal : patient will be improved fluid balance within 2 hours after nursing intervention given during hospitalization.

Nursing intervention :1) Monitor vital signs, noting presence of

hypotension (including postural changes)® As a baseline data for further intervention.I I assess patient condition such as vital signs

and patient look pale, poor skin turgor, and dry mucous skin membrane.

2) Maintain accurate I/O chart.® Reflects hydration status.

I I record accurately his input and output in chart in my shift.

3) Observe skin/mucous membrane dryness, turgor.

® Hypovolemia, fluid shifts, and nutritional deficits contribute to poor skin turgor, taut edematous tissues.

I I assess his condition and its show that he had poor skin turgor and dry mucous membrane.

4) Encourage patient to drink more water.® To rehydrate fluid loss from body.I I give patient mineral water and advice him to

drink it for rehydration.

5) Provide and maintain IV replacement therapy as ordered.® Use of IV replacement is based on the degree of

dehydration, ongoing losses, insensible water loss and electrolyte results.

I I maintain and make sure the drip is on the right regime.

6) Compare admission weight to preadmission weight, take daily weight.

® The degree of dehydration can be determined by the percentage of weight loss. Daily weights aid in determining progress toward rehydration.

I I compare his weight from his on admission to this day and his weight decreased 2kg.

7) Report patient condition to the Dr if patient condition still persist.

® For further intervention.

I I report patient condition to Dr when he did round.

Date/Time : 25.10.2009 @ 1000 hours

Evaluation : Patient will be remain hydrated within 2 hours after nursing intervention given and during hospitalization.

Evidence : Patient more comfortable, improved skin turgor, dry mucous membrane.

Signature : STN VZ.

PREVENTIONSPeritonitis focused on prompt recognition and treatment of condition that lead to perforation of abdominal viscera or any condition that release bacteria or chemicals into peritoneum cavity.

Intake of fiber diet LaxativeEnema~can help prevent appendicitis or diverticulitis.

PREVENTIONS

Pre-operative and postoperative antibiotics therapy are also being use to help in preventing peritonitis as and early treatment of GI inflammatory conditions.

If patient receiving peritoneal dialysis, you can help avoid peritonitis by cleaning the area around the catheter with antiseptic and washing hands before touching the catheter.

GASTROENTRITIS

CA COLON

GERDCHOLELITHIASIS

IBSGASTRITIS

APPENDICITISPEPTIC ULCER

OTHER EXPECTED DISEASES

FOR EN.TAN

CHOLELITHIASIS (39) Pancreas: Acute hemorrhagic pancreatitis.

Digital

Legends for

LabsLab 1 | Lab 2 | Lab 3 | Lab 4 | Lab 5 | Lab 6 | Lab 7 | Lab

8 | La

b 9 | Lab1

0 | Lab1

1 | Lab

12 | Lab

13 | Lab

14 | Lab

15 | Lab

16 | Lab

17 | Lab 18

601 Hom

e | Syllabus

| Differenti

al Diagnosi

s Medical II Updated April

7, 200

9

(39) Pancreas: Acute hemorrhagic pancreatitis.

Digital

Legends for

LabsLab 1 | Lab 2 | Lab 3 | Lab 4 | Lab 5 | Lab 6 | Lab 7 | Lab

8 | La

b 9 | Lab1

0 | Lab1

1 | Lab

12 | Lab

13 | Lab

14 | Lab

15 | Lab

16 | Lab

17 | Lab 18

601 Hom

e | Syllabus

| Differenti

al Diagnosi

s Medical II Updated April

7, 200

9

DEFINITION

• Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder.

• Gallstones tend to be asymptomatic.

MANIFESTATIONS CHOLELITHIASISPain Abrupt onset

Severe, steadyLocalized to epigastrium and RUQ of abdomen May radiate to back, right scapula, and shoulderLast 30 minutes to 5 hours

Associated symptoms Nausea, vomiting

Complications CholecystitisCommon bile duct obstruction with possible jaundice and liver damageCommon duct obstruction with pancreatitis

RISK FACTOR OF CHOLELITHIASIS

Age Family history of cholelithiasisRace or ethnicityObesity, hyperlipidemiaRapid weight lossFemale gender; use of oral contraceptivesBiliary stasis: pregnancy, fasting, prolonged parenteral

nuritionDisease or condition: cirrhosis; ileal disease or resection;

sickle cell anemia; glucose intolerance

Treatment Of CholelithiasisMedical optionsCholelithiasis can be dissolved by oral ursodeoxycholic

acid, but it may be required that the patient takes this medication for up to two years.

Sometimes can be relieved by endoscopic retrograde sphincterotomy (ERS) following endoscopic retrograde cholangiopancreatography (ERCP).

Can be broken up using a procedure called lithotripsy (Extracorporeal Shock Wave Lithotripsy), which is a method of concentrating ultrasonic shock waves onto the stones to break them into tiny pieces.

Surgical options1. Open cholecystectomy: This procedure is performed via an incision into the abdomen (laparotomy) below the right lower ribs. Recovery typically consists of 3–5 days of hospitalization, with a return to normal diet a week after release and normal activity several weeks after release.2. Laparoscopic cholecystectomy: This procedure, introduced in the 1980s,is performed via three to four small puncture holes for a camera and instruments. Post-operative care typically includes a same-day release or a one night hospital stay, followed by a few days of home rest and pain medication. Laparoscopic cholecystectomy patients can generally resume normal diet and light activity a week after release, with some decreased energy level and minor residual pain continuing for a month or two. The procedure also has the benefit of reducing operative complications such as bowel perforation and vascular injury.

IRRITABLE BOWEL SYNDROME

IRRITABLE BOWEL SYNDROME (IBS)

DEFINITION …• Known as spastic bowel or functional colitis .• Motility disorder with no identifiable organic

cause .

( Medical-Surgical Nursing ,critical thinking in client care, Fourth Edition : Priscilla LeMone,RN,DSN,FAAN . Karen Burke,RN,MS(page : 762) )

ETIOLOGY

• Unknown.• Psychosocial factors :

* distress

* anxiety

* Physical abuse

* Depression

* Sleep disturbances

• Physiologic factors :

* Constipation* various genetic* abdominal discomfort* environmental factor

GASTROENTERITIS

DEFINITION OF GASTROENTERITIS

Is an inflammation of the stomach and small intestine. Enteritis may be caused by a bacteria, viruses, parasites, or toxins.

The infectious organism usually enters the body in contaminated water or food. For this reason, gastroenteritis often is called “food poisoning”.

SIGNS & SYMPTOMS OF GASTROENTERITIS

Nausea

Vomiting

Diarrhea

Mild fever

Severe abdominal cramp

GASTROINTESTINAL EFFECTS

Anorexia, nausea, and vomiting.

Abdominal pain and cramping.

Borborygmi

diarrhea

GENERAL EFFECTSMalaise, weakness, and muscle aches.

Headache.

Dry skin and mucous membrane.

Poor skin turgor.

Orthostatic hypotension, tachycardia.

Fever.

COLORECTAL CANCER

Colorectal cancer, also called colon cancer or large bowel cancer, includes cancerous growths in the colon, rectum and appendix.

Many colorectal cancers are thought to arise from adenomatous polyps in the colon. These mushroom-shaped growths are usually benign, but some may develop into cancer over time. The majority of the time, the diagnosis of localized colon cancer is through colonoscopy. Therapy is usually through surgery, which in many cases is followed by chemotherapy.

DEFINITION OF COLORECTAL CANCER

1. Age: risk of developing cancer increases with age.

2.History of cancer: Individuals who have previously been diagnosed and treated for colon cancer are at risk for developing colon cancer in the future. Women who have had cancer of the ovary, uterus, or breast are at higher risk of developing colorectal cancer. 3. Smoking. Smokers are more likely to die of colorectal cancer than non-smokers.

4. Diet. Studies show that a diet high in red meat and low in fresh fruit, vegetables, poultry and fish increases the risk of colorectal cancer.

RISK FACTORS OF CA COLON

LOCAL SYMPTOMS Feeling of incomplete defecation Diarrhea or constipation Reduction in diameter of stool Malena stool

CONSTITUTIONAL SYMPTOMS

•iron deficiency anaemia •fatigue,• palpitations •pallor •weight loss, •a decreased appetite

METASTASIS SYMPTOMS~ca colon most commonly spreads to liver and cause:

JaundiceAbdominal pain

SYMPTOMS OF CA COLON

GASTRO-ESOPHAGEAL REFLUX DISEASE

(GERD)

Gastroesophageal reflux disease (GERD), gastric reflux disease, or acid reflux disease is defined as chronic symptoms or mucosal damage produced by the abnormal reflux in the esophagus.

This is commonly due to transient or permanent changes in the barrier between the esophagus and the stomach. This can be due to incompetence of the lower esophageal sphincter, transient lower esophageal sphincter relaxation, impaired expulsion of gastric reflux from the esophagus, or a hiatal hernia. Respiratory and laryngeal manifestations of GERD are commonly referred to as extraesophageal reflux disease (EERD).

DEFINITION OF GERD

Signs and Symptoms of GERD

Heart burn

Regurgitation

Nausea

Trouble swallowing (dysphagia)

Pain with swallowing (odynophagia)

Excessive salivation

The following may exacerbate the symptoms of GERD:1. Coffee and alcohol stimulate gastric acid secretion. Taking these before bedtime especially can cause evening reflux. 2. Antacids based on calcium carbonate (but not aluminum hydroxide) were found to actually increase the acidity of the stomach. However, all antacids reduced acidity in the lower esophagus, so the net effect on GERD symptoms may still be positive.

Lifestyle modificationsDietary modification

TREATMENTS OF GERD

3. Foods high in fats and smoking reduce lower esophageal sphincter competence, so avoiding these may help. Fat also delays stomach emptying. Eating within 2–3 hours before bedtime. Large meals. Having smaller, more frequent meals reduces GERD risk, as it means there is less food in the stomach at any one time.

4. Carbonated soft drinks with or without sugar.

5.Chocolate and peppermint should be avoided.

Positional therapy

• Sleeping on the left side has been shown to reduce nighttime reflux episodes in patients.

Medications

•Proton pump inhibitors

•Gastric H2 receptor blockers•Antacids

Surgical treatments for GERD

•The standard surgical treatment is the Nissen fundoplication. In this procedure the upper part of the stomach is wrapped around the LES to strengthen the sphincter and prevent acid reflux and to repair a hiatal hernia. The procedure is often done laparoscopically. When compared to medical management laparoscopic fundoplication had better results at 1 year.An obsolete treatment is vagotomy ("highly selective vagotomy"), the surgical removal of vagus nerve branches that innervate the stomach lining.

PEPTIC ULCER DISEASE

•peptic ulcer, also known as ulcus pepticum, PUD or peptic ulcer disease, is an ulcer (defined as mucosal erosions equal to or greater than 0.5 cm) of an area of the gastrointestinal tract that is usually acidic and thus extremely painful.

CLASSIFICATIONS1. Stomach (called gastric ulcer)2. Duodenum (called duodenal ulcer) 3. Oesophagus (called Oesophageal ulcer) 4. Meckel's Diverticulum (called Meckel's Diverticulum ulcer)

DEFINITION

Symptoms of a peptic ulcer can be;

1. abdominal pain, 2. waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus) 3. nausea, 4. vomiting5. loss of appetite and weight loss6. hematemesis (vomiting of blood); 7.melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin);

WEIGHTLOSS

Types of peptic ulcers:•Type I: Ulcer along the lesser curve of stomach

•Type II: Two ulcers present - one gastric, one duodenal

•Type III: Prepyloric ulcer •Type IV: Proximal gastroesophageal ulcer •Type V: Anywhere along gastric body, NSAID induced

Complications1.Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life-threatening. It occurs when the ulcer erodes one of the blood vessels. 2.Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain. Posterior wall perforation leads to pancreatitis; pain in this situation often radiates to the back. 3.Penetration is when the ulcer continues into adjacent organs such as the liver and pancreas. Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting. 4.Pyloric stenosis

APPENDICITIS

APPENDICITIS•Is the inflammation of the vermiform appendix, the small, finger-like pouch attached to the ceacum of colon.

•Usual location of appendix is right iliac region.

•Acute appendicitis is most common cause of acute inflammation in right lower quadrant.

ETIOLOGY

1. Ulceration of the appendiceal of mucosa

2. Obstruction within the colon

3. Kinking of appendix

4. Enlarged lymphoid follicle

5. Trapped barium

INCIDENCE1. Occur at any age

2. Peak incidence between age of age 20-30 years.

3. Male and female affected equally

4. Perforation more common in infants and elderly.

PREVENTION1. Aimed at reducing risk of obstruction or

inflammation of appendiceal lumen.

2. Regularity of bowel elimination pattern.

3. Adequate amount of dietary intake.

CLINICAL MANIFESTATION

1. Abdominal pain – begin in epigastric area

2. Nausea and vomiting

3. Pain – shift to right lower quadrant within few hours

4. Urge to defecate or pass flatus

5. Tenderness – absent in early stage

6. Temperature – usually normal sometimes slightly elevated

INVESTIGATION

1. Full blood count – WBC elevated

2. X-ray – some patient show a fecal in right lower quadrant on abdominal x-ray

GASTRITIS

GASTRITISDefinition of gastritis;• Inflammation of gastric

mucosa

• May classified as

1. acute or

2. chronicInflamed stomach

lining

ACUTE GASTRITIS• Inflammation of gastric mucosa

or submucosa after expose to local irritants

• There are various degree of

mucosal necrosis and

inflammatory reaction.

CHRONIC GASTRITIS• The diffuse chronic inflammatory process

involving the mucosal lining of stomach• May divided into 3 categories:

i) Superficial gastritis

- consist of infiltration of lamina propria by

lymphocytes and plasma cell

- it’s localized in outer area of mucosa

- superficial gastritis cause inflamed, edematous mucosa with hemorrhage

ii) Atrophic Gastritis

- occur in all layer of stomach, decreased number of fundal, parietal and seen with gastric ulcer and gastric cancer

iii) Gastric Atrophy

- refer to total loss of fundal glands, minimal inflammation and thining of gastric mucosa

ACUTE CHRONIC1. Local irritant a. Drug b. Acid or alkalis c. Reserpine d. Anti inflammatory agents,

aspirin e. Cytotoxics agents f. Corticosteroids

2. Bacterial Endotoxins

3. Life style a. Heavy cigarette smoking b. Use of alcohol

1. Chronic irritant a. Alcohol b. Drug – Digitalis

2. Endogenous agent a. Reflux of bile b. Pancreatic enzyme c. Radiation d. Peptic ulcer disease e. Renal disease

ETIOLOGY

CLINICAL MANIFESTATIONS1. Pain

2. Epigastric discomfort

3. Abdominal terndeness

4. Cramps

5. Indigestion

6. Nausea and vomiting

PREVENTION

1. Precaution ingestion of drug

2. Avoid irritating substances include drug

3. Moderation use of alcohol

INVESTIGATIONS

1. Full blood count

2. Stool FEME

3. X-ray

4. Gastroscopy

IS THERE ANY QUESTIONS??

Thanks

Thanks a lot for lending your ears..

syafiqah

haryani

warsana

nabilah

izzati

From: