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1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Chapter 38
Digestive Tract Disorders
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Learning Objectives
• Identify the nursing responsibilities in the care of patientsundergoing diagnostic tests and procedures for disorders of the digestive tract.
• List the data to be included in the nursing assessment ofthe patient with a digestive disorder.
• Describe the nursing care of patients with gastrointestinalintubation and decompression, tube feedings, totalparenteral nutrition, digestive tract surgery, and drugtherapy for digestive disorders.
• Describe the pathophysiology, signs and symptoms,complications, and medical treatment of selected digestivedisorders.
• Assist in developing nursing care plans for patients receivingtreatment for digestive disorders.
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Anatomy and Physiology of the Digestive Tract
• Mouth• Where teeth, tongue, and salivary glands begin food digestion
• Pharynx • Muscular structure shared by the digestive and respiratory
tracts • It joins the mouth and nasal passages to the esophagus
• Esophagus• Long muscular tube that passes through the diaphragm into
the stomach
• Stomach • Churns and mixes food with gastric secretions until a
semiliquid mass called chyme
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Anatomy and Physiology of the Digestive Tract
• Small intestine• Chemical digestion and absorption of nutrients take
place• Approximately 20 feet long and consists of three
sections: the duodenum, the jejunum, and the ileum• Liver and pancreatic secretions enter the digestive
tract in the duodenum
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Anatomy and Physiology of the Digestive Tract
• Large intestine and anus• The first section of the large intestine is the cecum • Ascending colon goes up right side of the abdomen • Transverse colon crosses abdomen just below waist • Descending colon goes down left side of abdomen • The last 6 to 8 inches of the large intestine is the
rectum, which ends at the anus, where wastes leave the body
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Figure 38-1
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Age-Related Changes
• Teeth are mechanically worn down with age • The jaw may be affected by osteoarthritis • A significant loss of taste buds with age • Xerostomia (dry mouth) is common• Walls of esophagus and stomach thin with aging, and
secretions lessen • Production of hydrochloric acid and digestive enzymes
decreases • Gastric motor activity slows• Movement of contents through the colon is slower • Anal sphincter tone and strength decrease
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Health History
• Chief complaint and history of present illness • A detailed description of the present illness • Complaints include weight changes, problems with
food ingestion, symptoms of digestive disturbances, or changes in bowel elimination
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Health History
• Past medical history• Recent surgery, trauma, burns, or infections • Serious illnesses, such as diabetes, hepatitis,
anemia, peptic ulcers, gallbladder disease, and cancer
• Alternative methods of feeding or fecal diversion• Prescription and over-the-counter medications• Food allergy or intolerance
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Health History
• Review of systems • Description of the patient’s general health state • Changes in skin: dryness, bruising, and pruritus• Whether the patient has any mouth problems• Document if the patient has dentures, partial plates,
or natural teeth, and record the last dental examination
• Problems with chewing or swallowing • Changes in appetite, food intake, and weight • Nausea, vomiting, dyspepsia, heartburn, flatus,
abdominal distention, or pain• Assessment of elimination
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Health History
• Functional assessment• Information about general dietary habits should
include the daily pattern of food intake• Attitudes and beliefs about food, and changes in
dietary habits related to health problems • Effects of chief complaint on usual functioning • Note whether the patient is able to obtain and
prepare food, and eat independently
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Physical Examination
• Head and neck • Inspect the mouth
• Abdomen • Inspection • Auscultation • Percussion • Palpation
• Rectum and anus • Palpate for lumps and tenderness in the rectum
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Figure 38-2
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Diagnostic Tests and Procedures
• Radiographic studies• Upper gastrointestinal (UGI or GI) series • Small bowel series• Barium enema examination
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Diagnostic Tests and Procedures
• Endoscopic examinations• Upper GI
• Esophagoscopy, gastroscopy, gastroduodenoscopy, esophagogastroduodenoscopy, endoscopic retrograde cholangiography
• Lower GI• Colonoscopy, proctoscopy, and sigmoidoscopy
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Diagnostic Tests and Procedures
• Laboratory studies • Gastric analysis • Occult blood test • Stool examination
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Figure 38-3
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Figure 38-4
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Therapeutic Measures
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Gastrointestinal Intubation
• Tube feedings • Delivered by gravity flow or by infusion pump
• Gastrointestinal decompression • For the relief or prevention of distention• Levin and gastric sump tubes
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Total Parenteral Nutrition
• Bypasses digestive tract by delivering nutrients directly to the bloodstream
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Figure 38-5
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Figure 38-6
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Figure 38-7
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Figure 38-9
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Gastrointestinal Surgery
• Preoperative nursing care• The digestive tract is usually cleansed
• Magnesium citrate or large-volume cathartic (laxative) solutions; enemas
• Diet limited to liquids 24 hours before surgery• Intravenous fluids• Oral antibiotics• Nasogastric tube inserted and attached to suction
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Gastrointestinal Surgery
• Postoperative nursing care• Be sure gastrointestinal suction is draining • Inspect, describe, and measure the drainage • Abdomen for distention and bowel sounds• Administer intravenous fluids • Keep strict intake and output records • Drug therapy
• Emetics, antiemetics, laxatives, cathartics, antidiarrheals, antacids, anticholinergics, mucosal barriers, histamine-2 (H2)-receptor blockers, prostaglandins, and antibiotics
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Disorders of the Digestive Tract
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Anorexia
• Causes• Nausea, decreased sense of taste or smell, mouth
disorders, and medications • Emotional problems such as anxiety, depression, or
disturbing thoughts
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Anorexia
• Medical diagnosis • Physician assesses for malnutrition • Weight may be monitored over several weeks • Complete history and physical examination• Serum hemoglobin, iron, total iron-binding capacity,
transferrin, calcium, folate, B12, zinc
• Thyroid function tests
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Anorexia
• Medical treatment • Correctable causes of anorexia are treated, but
sometimes no physical cause is found • Nutritional supplements
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Anorexia
• Assessment• Record chronic and recent illnesses,
hospitalizations, medications, and allergies • Female patient’s obstetric history• Symptoms: pain, nausea, dyspnea, extreme fatigue • The functional assessment reveals patterns of
activity and rest, usual dietary patterns, current stressors, and coping strategies—all can affect appetite
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Anorexia
• Interventions• Assist with oral hygiene before and after meals• Teach proper oral hygiene; refer for dental care • Relieve nausea before presenting a meal tray • Before serving meal tray, remove bedpans/emesis
basins from sight, conceal drains and drainage collection devices, deodorize room if necessary
• Socialization during mealtime• Respect food likes and dislikes• Position patient comfortably with easy access to
food
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Feeding Problems
• Patients with paralysis, arthritis, neuromuscular disorders, confusion, weakness, or visual impairment are likely to need assistance
• Medical diagnosis and treatment • Identifying problems, prescribing treatment• Patients often referred to physical therapy and
occupational therapy
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Feeding Problems
• Assessment• Assess each patient’s ability to feed self • Determine nature of patient’s difficulty and identify
remaining abilities • Assess visual acuity, range of motion and muscle
strength in both arms, and range of motion and grip strength in both hands; ability to follow instructions
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Feeding Problems
• Interventions• Proper positioning and arrangement of the meal tray• Provide assistive devices• Open milk cartons, cut meat, butter bread, and
season food
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Stomatitis
• A general term for inflammation of the oral mucosa
• Medical treatment is directed toward determining the cause and eliminating it; a soft, bland diet may be ordered
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Vincent’s Infection
• Bacterial infection that causes a metallic taste and bleeding ulcers in the mouth, foul breath, and increased salivation
• Topical antibiotics and mouthwashes to treat infection; rest, a nutritious diet, and good oral hygiene
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Herpes Simplex
• Caused by the herpes simplex virus, type 1 • Ulcers and vesicles in mouth and on lips • Occur with upper respiratory tract infections,
excessive sun exposure, or stress • Spirits of camphor, topical steroids, and
antiviral agents as treatment
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Aphthous Stomatitis (“Canker Sore”)
• May be caused by a virus • Characterized by ulcers of the lips and mouth
that recur at intervals • Topical or systemic steroids may be used
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Candida albicans
• Yeastlike fungus causes the oral condition known as thrush or candidiasis
• Bluish white lesions on the mucous membranes
• Patients at high risk include those on steroid or long-term antibiotic therapy
• Treated with oral or topical antifungal agents; vaginal nystatin tablets can be used like lozenges and allowed to dissolve in the mouth
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Nursing Care
• Assessment• Pain location, onset, and precipitating factors • Record any known illnesses and treatments,
including drugs and radiation therapy • Describe habits, including diet, oral care practices,
alcohol intake, and use of tobacco • Assess patient’s stress level • Inspect lips and oral cavity for redness, swelling,
and lesions
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Nursing Care
• Interventions• Gentle oral hygiene, prescribed mouthwashes• The teeth and tongue can be cleansed with a soft-
bristle toothbrush, sponge, or cotton-tipped applicator
• Medications must be given as ordered
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Dental Caries
• A destructive process of tooth decay• The only treatment for dental caries is removal
of the decayed part of the tooth, followed by filling the cavity with a restorative material
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Periodontal Disease
• Begins with gingivitis; progresses to involve the other structures that support the teeth
• Gums red, swollen, painful, and bleed easily• Primarily from inadequate oral hygiene• Treatment in early stage: dental care for teeth
cleaning and correction of contributing problems
• Untreated, abscesses develop around the roots, the teeth loosen, and extraction is necessary
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Figure 38-10
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Nursing Care
• Assessment• Observe condition of teeth and gums • Document missing or broken teeth, caries, redness
or lesions of the gums, and gum recession
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Nursing Care
• Interventions• Most patients are treated for dental and gum
conditions in dentists’ offices • Interventions directed at minimizing pain until the
problem can be corrected by a dentist • Provide oral care for patients who cannot do it
themselves
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Oral Cancer
• Squamous cell carcinoma and basal cell carcinoma
• Risk factors • Cancer of the lip related to prolonged exposure to
irritants, including sun, wind, and pipe smoking • Factors that increase the risk of cancers inside the
mouth include tobacco and alcohol use, poor nutritional status, and chronic irritation
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Oral Cancer
• Signs and symptoms • Tongue irritation, loose teeth, and pain in the tongue
or ear • Malignant lesions may appear as ulcerations,
thickened or rough areas, or sore spots • Leukoplakia: hard, white patches in the mouth;
premalignant
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Oral Cancer
• Medical diagnosis and treatment • A biopsy of suspicious lesions• Treatment includes surgery, radiation, or
chemotherapy, or a combination of these
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Oral Cancer
• Assessment• History of prolonged sun exposure, tobacco use, or
alcohol consumption • Assess for difficulty swallowing or chewing,
decreased appetite, weight loss, change in fit of dentures, and hemoptysis
• The physical examination should focus on examination of the mouth for lesions
• Assess the neck for limitation of movement and enlarged lymph nodes
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Figure 38-11
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Oral Cancer
• Interventions• Impaired Oral Mucous Membrane • Ineffective Breathing Pattern • Pain• Imbalanced Nutrition: Less Than Body
Requirements• Impaired Verbal Communication • Disturbed Body Image • Risk for Infection • Ineffective Tissue Perfusion
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Parotitis
• Inflammation of the parotid glands• Causes painful swelling of the salivary glands
below the ear next to the lower jaw; pain increases during eating
• Treated with antibiotics, mouthwashes, and warm compresses; surgical drainage or removal may be necessary
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Achalasia
• Progressively worsening dysphagia • Failure of the lower esophageal muscles and
sphincter to relax during swallowing • Thought to be a neuromuscular defect affecting
the esophageal muscles• Treatment includes drug therapy, dilation, and
surgical measures
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Esophageal Cancer
• Pathophysiology• No known cause, but predisposing factors are
cigarette smoking, excessive alcohol intake, chronic trauma, poor oral hygiene, and eating spicy foods
• Signs and symptoms • Progressive dysphagia
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Esophageal Cancer
• Medical diagnosis • Barium swallow, computed tomography,
esophagoscopy, and endoscopic ultrasonography
• Medical and surgical treatment • Surgery, radiation, chemotherapy, or various
combinations
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Figure 38-12
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Esophageal Cancer
• Assessment• Dysphagia, pain, and choking • Hoarseness, cough, anorexia, weight loss, and
regurgitation • The functional assessment documents the use of
alcohol and tobacco and dietary practices
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Esophageal Cancer
• Interventions• Pain • Imbalanced Nutrition: Less Than Body
Requirements • Anxiety• Risk for Injury • Impaired Gas Exchange • Deficient Knowledge
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Nausea and Vomiting
• Nausea: sometimes referred to as queasiness• Vomiting: forceful expulsion of stomach
contents through the mouth • Complications
• Significant losses of fluids and electrolytes• Aspiration
• Medical treatment• Antiemetics • Intravenous fluids • Oral fluids may be limited to clear liquids or withheld• Nasogastric tube
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Nausea and Vomiting
• Assessment• Onset, frequency, and duration of present illness • Conditions under which nausea and vomiting occur • Amount, color, odor, and contents of the vomitus • Surgeries, chronic illnesses, allergies, and
medications • General appearance; record vital signs,
height/weight • Assess pulse and blood pressure, tissue turgor,
mental status, and muscle tone • Inspect, auscultate, and palpate the abdomen for
distention, bowel sounds, and tenderness
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Nausea and Vomiting
• Interventions• Imbalanced Nutrition and Deficient Fluid Volume • Risk for Aspiration
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Hiatal Hernia
• Pathophysiology • Protrusion of lower esophagus and stomach up
through the diaphragm and into the chest
• Causes
• Weakness of diaphragm muscles where esophagus and stomach join, but exact cause is not known
• Factors are excessive intra-abdominal pressure, trauma, and long-term bed rest in a reclining position
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Hiatal Hernia
• Signs and symptoms • Many people have no symptoms at all; others report
feelings of fullness, dysphagia, eructation, regurgitation, and heartburn
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Figure 38-13
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Hiatal Hernia
• Medical diagnosis • Barium swallow examination with fluoroscopy• Esophagoscopy• Esophageal manometry
• Medical treatment • Drug therapy, diet, and measures to avoid
increased intra-abdominal pressure• Surgery: fundoplication and placement of the
synthetic Angelchik prosthesis
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Figure 38-14
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70Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
Figure 38-15
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Hiatal Hernia
• Assessment• Document symptoms• Record factors that trigger symptoms as well as
measures that aggravate or relieve them • Patient’s dietary habits, use of alcohol and tobacco,
and medication history
• Interventions• Chronic Pain • Risk for Aspiration • Imbalanced Nutrition: Less Than Body
Requirements
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Hiatal Hernia
• Postoperative care• Turning, coughing, and deep breathing • Patient might have nasogastric tube in place and
connected to suction for a day or two• Until bowel function returns, the patient is given only
intravenous fluids • Tell the patient to expect mild dysphagia for several
weeks
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GERD
• Backward flow of gastric contents from the stomach into the esophagus• Pathophysiology
• Abnormalities around the LES, gastric or duodenal ulcer, gastric or esophageal surgery, prolonged vomiting, and prolonged gastric intubation
• Eventually causes esophagitis
• Signs and symptoms • Painful burning sensation that moves up and down,
commonly occurs after meals, and is relieved by antacids
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GERD
• Medical diagnosis • Suggested by the signs and symptoms• Endoscopy, biopsy, gastric analysis, esophageal
manometry, 24-hour monitoring of esophageal pH, and acid perfusion tests
• Medical treatment and nursing care • Like those described earlier for hiatal hernia
• Drug therapy may include H2-receptor blockers,
prokinetic agents, and proton pump inhibitors• If medical care unsuccessful, surgical fundoplication
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Gastritis
• Pathophysiology • Inflammation of the lining of the stomach • Mucosal barrier that normally protects the stomach
from autodigestion breaks down • Hydrochloric acid, histamine, and pepsin cause
tissue edema, increased capillary permeability, possible hemorrhage
• Helicobacter pylori thought to be prime culprit
• Signs and symptoms • Nausea, vomiting, anorexia, a feeling of fullness,
and pain in the stomach area
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Gastritis
• Medical diagnosis • Gastroscopy• Laboratory studies to detect occult blood in the
feces, low blood hemoglobin and hematocrit, and low serum gastrin levels; H. pylori can be confirmed by breath, urine, stool, or serum tests, or by gastric tissue biopsy
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Gastritis
• Medical treatment • Oral fluids and foods withheld until the acute
symptoms subside; IV fluids administered• Medications to reduce gastric acidity and relieve
nausea• Analgesics for pain relief and antibiotics for H. pylori • Surgical intervention may be needed
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Gastritis
• Assessment• Patient’s present illness• Pain, indigestion, nausea, and vomiting • Determine the onset, duration, and location of pain • Note factors that trigger or relieve the symptoms • Diet, use of alcohol and tobacco, activity/rest patterns • Patient’s general appearance for signs of distress • Compare vital signs, height, weight to previous readings • Note the skin color and check turgor • Inspect abdomen for distention; palpate for tenderness • Auscultate abdomen for increased bowel sounds
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Gastritis
• Interventions• Pain• Imbalanced Nutrition: Less Than Body
Requirements• Deficient Fluid Volume • Ineffective Coping
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Peptic Ulcer
• Pathophysiology • Loss of tissue from lining of the digestive tract • Classified as gastric or duodenal
• Causes • Contributing factors: drugs, infection, stress • Most ulcers are caused by the microorganism H.
pylori
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Peptic Ulcer
• Signs and symptoms • Burning pain • Nausea, anorexia, weight loss
• Complications • Hemorrhage, perforation, or pyloric obstruction
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Peptic Ulcer
• Medical diagnosis • Barium swallow examination, gastroscopy, and
esophagogastroduodenoscopy • H. pylori can be detected by antibodies in the blood
or stool, and by a breath test
• Medical treatment • Drug therapy • Diet therapy • Managing complications
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Peptic Ulcer
• Care of the patient managed medically • Assessment
• Pain, including location, aggravating factors, and measures that bring relief; relationship between pain and food intake
• Recent serious illnesses, previous peptic ulcer disease, and a medication history
• Functional assessment: patient’s usual diet, use of alcohol and tobacco, activities, sleep patterns, and stressors
• Vital signs; height and weight; skin and mucous membranes for turgor and moisture
• Inspect abdomen for distention and palpate for tenderness • Auscultate for bowel sounds
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Peptic Ulcer
• Care of the patient managed medically• Interventions
• Pain• Imbalanced Nutrition: Less Than Body Requirements • Risk for Injury • Ineffective Coping
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Peptic Ulcer
• Care of the patient managed surgically• Assessment
• Pain, nausea, and vomiting
• Measure vital signs at frequent intervals
• Note the amount and type of IV fluids, and check the infusion site for swelling or redness
• Document patency of the nasogastric tube as well as the color and amount of drainage
• Breath sounds; inspect the wound dressing for bleeding
• Inspect abdomen for distention and auscultate for bowel sounds
• Monitor urine output and palpate for bladder distention
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Peptic Ulcer
• Care of the patient managed surgically• Interventions
• Risk for Injury • Imbalanced Nutrition: Less Than Body Requirements • Decreased Cardiac Output
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Stomach Cancer
• Pathophysiology• Begins in the mucous membranes, invades the
gastric wall, and spreads to the regional lymphatics, liver, pancreas, and colon
• No specific signs or symptoms in the early stages• Late signs and symptoms are vomiting, ascites, liver
enlargement, and an abdominal mass
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Stomach Cancer
• Risk factors • H. pylori infection, pernicious anemia, chronic
atrophic gastritis, and achlorhydria, type A blood, and a family history
• Cigarette smoking, alcohol abuse, and a diet high in starch, salt, pickled foods, salted meats, and nitrates
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Stomach Cancer
• Medical diagnosis • Gastroscopy, endoscopic ultrasound, upper GI
series, CT, PET scan, MRI, laparoscopy • Laboratory studies include hemoglobin and
hematocrit, serum albumin, liver function tests, and carcinoembryonic antigen
• Medical treatment • Surgery, chemotherapy, and radiation therapy
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Figure 38-16
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Stomach Cancer
• Preoperative care of the patient with stomach cancer • Inform about the nasogastric tube and IV fluids;
teach coughing, deep breathing, and leg exercises • Identify/support patient’s coping methods • Include sources of support, such as family members
or a spiritual counselor, in the preoperative care
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Stomach Cancer
• Postoperative care of the patient with stomach cancer • Assessment
• Comfort, appetite, and nausea and vomiting • Monitor weight changes and determine dietary preferences • Identify the patient’s support system and coping strategies
• Interventions• Pain • Imbalanced Nutrition: Less Than Body Requirements • Ineffective Coping
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Obesity
• Increased weight caused by excessive body fat • Causes
• Heredity, body build/metabolism, psychosocial factors
• Basic problem: caloric intake exceeds metabolic demands
• Complications • Cardiovascular and respiratory problems,
polycythemia, diabetes mellitus, cholelithiasis (gallstones), infertility, endometrial cancer, and fatty liver infiltration
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Obesity
• Medical diagnosis • Standard weight tables • Measuring skinfold thickness • Endocrine function tests
• Medical and surgical treatment • Weight reduction diet accompanied by a planned
exercise program • Drug therapy• Bariatric surgery
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Obesity
• Assessment• Identify factors that contribute to obesity • Ask about usual dietary practices • Identify factors that trigger overeating and reactions
to overeating • Collect data about previous efforts to lose weight
and current interest in losing weight
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Obesity
• Interventions for the obese patient managed nonsurgically • Imbalanced Nutrition: More Than Body
Requirements • Ineffective Tissue Perfusion • Ineffective Breathing Pattern • Disturbed Body Image
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Obesity
• Interventions after bariatric surgery• Impaired Gas Exchange • Impaired Tissue Perfusion • Impaired Skin Integrity • Imbalanced Nutrition: Less Than Body
Requirements
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Malabsorption
• One or more nutrients are not digested or absorbed
• Many causes: bacteria, deficiencies of bile salts or digestive enzymes, alterations in the intestinal mucosa, and absence of all or part of the stomach or intestines
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Malabsorption
• Signs and symptoms • Steatorrhea • Weight loss, fatigue, decreased libido, easy
bruising, edema, anemia, and bone pain• Bloating, cramping, abdominal cramps, and diarrhea
are symptoms of lactase deficiency
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Malabsorption
• Medical diagnosis • Sprue: based on laboratory studies, endoscopy with
biopsy, and radiologic imaging studies • Lactase deficiency: based on the health history, the
lactose tolerance test, a breath test for abnormal hydrogen levels, and if necessary, biopsy of the intestinal
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Malabsorption
• Medical treatment • Sprue: diet and drug therapy; foods that aggravate
symptoms eliminated from the diet • Celiac disease: avoid products that contain gluten• Tropical sprue: antibiotics, oral folate, and vitamin
B12 injections
• Lactase deficiency: eliminate milk and milk products
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Malabsorption
• Nursing care• Document the patient’s symptoms • Note stool characteristics • In the case of celiac sprue, teach the patient how to
eliminate gluten from the diet • Give antibiotics as ordered for tropical sprue • If folic acid therapy continued, instruct patient in
self-medication • The effect of therapy is evaluated by the return of
normal stool consistency • Advise the patient with lactase deficiency of dietary
restrictions and alternative products
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Diarrhea
• The passage of loose, liquid stools with increased frequency
• May have cramps, abdominal pain, and a feeling of urgency before bowel movements
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Diarrhea
• Causes • Spoiled foods, allergies, infections, diverticulosis,
malabsorption, cancer, stress, fecal impactions, and tube feedings
• Adverse effect of some medications
• Complications • Dehydration, electrolyte imbalances, and metabolic
acidosis • Malnutrition and anemia
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Diarrhea
• Medical treatment • Acute diarrhea usually treated by resting the
digestive tract and giving antidiarrheal drugs • Severe, persistent diarrhea may require TPN
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Diarrhea
• Assessment• Diarrhea and onset, severity, precipitating factors,
and measures that bring relief • Ask about stool characteristics, including amount,
color, odor, and unusual contents, such as blood, mucus, or undigested food
• Functional assessment focuses on usual diet, dietary changes, recent and current medications, recent travel to a foreign country
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Diarrhea
• Interventions• Deficient Fluid Volume and Imbalanced Nutrition:
Less Than Body Requirements • Impaired Skin Integrity • Pain • Self-Care Deficit
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Constipation
• Hard, dry, infrequent stools that are passed with difficulty
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Constipation
• Causes• Frequently ignoring the urge to defecate• Frequent use of laxatives or enemas• Inactivity• Inadequate water intake • Diet low in fiber and high in cheese, lean meat,
pasta• Drugs that slow intestinal motility/increase urine
output• Diseases of the colon or rectum, as well as brain or
spinal cord injury; abdominal surgery
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Constipation
• Complications• Valsalva maneuver
• The rapid changes in blood flow can be fatal to a patient with heart disease
• Hemorrhoids• Fecal impaction
• Medical treatment • Laxatives, suppositories, enemas, or combination
for prompt results • Stool softeners
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Constipation
• Assessment• Usual pattern of bowel elimination, including
frequency, amount, color, unusual contents, and pain associated with defecation
• Information about diet, exercise, and drug therapy• Any aids to elimination; type and frequency of use• Examine abdomen for distention or visible
peristalsis • Auscultate for bowel sounds in all four quadrants of
the abdomen
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Constipation
• Interventions• Maintained with diet, fluids, exercise, and regular
toilet habits • Megacolon
• Regular enemas for bowel cleansing
• Fecal impaction • Assess for impaction by inserting a gloved, lubricated
finger into the rectum • Remove impaction following agency protocol or specific
physician’s orders
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Intestinal Obstruction
• Causes• Strangulated hernia, tumor, paralytic ileus, stricture,
volvulus (twisting of the bowel), intussusception (telescoping of the bowel into itself), and postoperative adhesions
• Signs and symptoms • Vomiting (possibly projectile), abdominal pain, and
constipation • Blood or purulent drainage passed rectally • Abdominal distention, especially with colon
obstruction
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Intestinal Obstruction
• Complications • Fluid and electrolyte imbalances and metabolic
alkalosis• Gangrene and perforation of the bowel
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Figure 38-17
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Intestinal Obstruction
• Medical diagnosis • History, physical examination, and laboratory
studies; confirmed by radiologic studies
• Medical treatment • Gastrointestinal decompression; intravenous fluids;
and surgical intervention
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Intestinal Obstruction
• Assessment • Symptoms, including pain and nausea • Onset and progression of symptoms • Hernia, cancer of the digestive tract, and abdominal
surgeries • Ask when the patient’s last bowel movement was
and if the characteristics were normal
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Intestinal Obstruction
• Interventions • Acute Pain • Deficient Fluid Volume • Risk for Infection • Ineffective Breathing Pattern • Anxiety
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Appendicitis
• Pathophysiology• Inflammation of the appendix• A ruptured appendix allows digestive contents to
enter the abdominal cavity, causing peritonitis
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Appendicitis
• Signs and symptoms • Pain at McBurney’s point, midway between the
umbilicus and the iliac crest • Temperature elevation, nausea, and vomiting • Elevated WBC count (10,000-15,000/mm3 )• Peritonitis: absence of bowel sounds, severe
abdominal distention, increased pulse and temperature, nausea/vomiting; rigid abdomen
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Figure 38-18
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Appendicitis
• Medical treatment• Nothing by mouth• A cold pack to the abdomen may be ordered • Laxatives and heat applications should never be
used for undiagnosed abdominal pain • Immediate surgical treatment indicated• Ruptured appendix: surgery may be delayed 6-8
hours while antibiotics and IV fluids given
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Appendicitis
• Assessment• Location, severity, onset, duration, precipitating
factors, and alleviating measures in relation to the pain
• Previous abdominal distress, chronic illnesses, surgeries; record allergies and medications
• Temperature; abdominal pain, distention, and tenderness; presence and characteristics of bowel sounds
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Appendicitis
• Preoperative interventions• Semi-Fowler or side-lying position with the hips
flexed • Until physician determines the diagnosis, analgesics
may be withheld • If rupture suspected, elevate patient’s head to
localize the infection
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Appendicitis
• Postoperative interventions• Administer antibiotics, intravenous fluids, and
possibly gastrointestinal decompression • Assist the patient in turning, coughing, and deep
breathing; incentive spirometry• Splint the incision during deep breathing • Early ambulation• Assess abdominal wound for redness, swelling, and
foul drainage • Wound care as ordered or according to agency
policy
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Peritonitis
• Pathophysiology • Inflammation of peritoneum caused by chemical or
bacterial contamination of the peritoneal cavity
• Signs and symptoms • Pain over affected area, rebound tenderness,
abdominal rigidity and distention, fever, tachycardia, tachypnea, nausea, and vomiting
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Peritonitis
• Medical diagnosis • History and physical • Complete blood cell count, serum electrolyte
measurements, abdominal radiography, computed tomography, and ultrasound
• Paracentesis
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Peritonitis
• Medical treatment • Gastrointestinal decompression, intravenous fluids,
antibiotics, and analgesics• Surgery to close a ruptured structure and remove
foreign material and fluid from the peritoneal cavity
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Peritonitis
• Assessment• Onset, location, and severity of the pain and any
related symptoms • Record a history of abdominal trauma, including
surgery • Take and record vital signs • Inspect abdomen for distention and auscultate for
the presence of bowel sounds
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Peritonitis
• Interventions• Acute Pain• Decreased Cardiac Output • Imbalanced Nutrition: Less Than Body
Requirements • Anxiety
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Abdominal Hernia
• Pathophysiology • Weakness in the abdominal wall that allows a
portion of the large intestine to push through• Weak locations include the umbilicus and the lower
inguinal areas of the abdomen; may also develop at the site of a surgical incision
• Classified as reducible or irreducible
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Abdominal Hernia
• Signs and symptoms • A smooth lump on the abdomen• With incarceration, the patient has severe
abdominal pain and distention, vomiting, and cramps
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Figure 38-19
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Abdominal Hernia
• Medical diagnosis• Health history and physical examination
• Medical treatment• Surgical repair
• Herniorrhaphy • Hernioplasty
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Abdominal Hernia
• Assessment• Chief complaint • Ask about pain and vomiting• Inspect for abnormalities, and listen for bowel
sounds in all four abdominal quadrants
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Abdominal Hernia
• Preoperative interventions • Risk for Injury• Impaired Skin Integrity
• Postoperative interventions • Impaired Urinary Elimination • Constipation • Acute Pain • Risk for Injury
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Inflammatory Bowel Disease
• Pathophysiology • Ulcerative colitis and Crohn’s disease• Inflammation and ulceration of intestinal tract lining
• Exact cause is unknown • Possible causes: infectious agents, autoimmune
reactions, allergies, heredity, and foreign substances
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Inflammatory Bowel Disease
• Signs and symptoms • Ulcerative colitis
• Diarrhea with frequent bloody stools, abdominal cramping
• Crohn’s disease
• If the stomach and duodenum are involved, symptoms include nausea, vomiting, and epigastric pain
• Involvement of the small intestine produces pain and abdominal tenderness and cramping
• An inflamed colon typically causes abdominal pain, cramping, rectal bleeding, and diarrhea
• Systemic signs and symptoms include fever, night sweats, malaise, and joint pain
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Inflammatory Bowel Disease
• Complications • Hemorrhage, obstruction, perforation (rupture),
abscesses in the anus or rectum, fistulas, and megacolon
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Inflammatory Bowel Disease
• Medical diagnosis • History and physical examination • Abdominal radiography • Barium enema examination with air contrast;
colonoscopy with biopsy, ultrasonography, CT, and cell studies
• Video capsule • Medical treatment
• Drug therapy, diet, and rest
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Inflammatory Bowel Disease
• Assessment• Onset, location, severity, and duration of pain • Note factors that contribute to the onset of pain• Onset and duration of diarrhea; presence of blood • Vital signs, height and weight, measures of
hydration• Inspect perianal area for irritation or ulceration• Maintain accurate intake and output records • Measure diarrhea stools if possible and count as
output
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Inflammatory Bowel Disease
• Interventions• Acute Pain • Diarrhea • Deficient Fluid Volume • Imbalanced Nutrition: Less Than Body
Requirements • Ineffective Coping• Risk for Injury
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Diverticulosis
• Pathophysiology• Small saclike pouches in intestinal wall: diverticula • Weak areas of the intestinal wall allow segments of
the mucous membrane to herniate outward
• Risk factors • Lack of dietary residue• Age, constipation, obesity, emotional tension
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Diverticulosis
• Signs and symptoms • Often asymptomatic, but many people report
constipation, diarrhea, or periodic bouts of each• Rectal bleeding, pain in left lower abdomen, nausea
and vomiting, and urinary problems
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Figure 38-20
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Diverticulosis
• Complications• Diverticulitis
• Bleeding, obstruction, perforation (rupture), peritonitis, and fistula formation
• Medical diagnosis • Symptoms• Abdominal CT and barium enema examination
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Diverticulosis
• Medical treatment • High-residue diet without spicy foods• Stool softeners or bulk-forming laxatives;
antidiarrheals; broad-spectrum antibiotics; anticholinergics
• Surgical intervention may be necessary
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Diverticulosis
• Assessment• Assess patient’s comfort and stool characteristics;
note nausea and vomiting • Monitor patient’s temperature • Assess abdomen for distention and tenderness
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Diverticulosis
• Interventions• Fluids as permitted; monitor intake and output • Antiemetics, analgesics, anticholinergics as ordered• Be alert for signs of perforation• Teach patient about diverticulosis, including the
pathophysiology, treatment, and symptoms of inflammation
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Colorectal Cancer
• Pathophysiology• Cancer of the large intestine• People at greater risk for colorectal cancer are
those with histories of inflammatory bowel disease, or family histories of colorectal cancer or multiple intestinal polyps
• High-fat, low-fiber diet and inadequate intake of fruits and vegetables also contribute to development
• Can develop anywhere in the large intestine • Three fourths of all colorectal cancers are located in the
rectum or lower sigmoid colon
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Figure 38-21
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Colorectal Cancer
• Signs and symptoms • Right side of the abdomen
• Vague cramping until the disease is advanced • Unexplained anemia, weakness, and fatigue related to
blood loss may be the only early symptoms
• Left side or in the rectum • Diarrhea or constipation and may notice blood in the stool • Stools may become very narrow, causing them to be
described as pencil-like • Feeling of fullness or pressure in the abdomen or rectum
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Colorectal Cancer
• Medical and surgical treatment • Usually treated surgically• Combination chemotherapy postoperatively if tumor
extends through the bowel wall or if lymph nodes involved
• Early stage rectal cancer sometimes treated with radiation and surgery
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Colorectal Cancer
• Assessment• Vital signs, intake and output, breath sounds, bowel
sounds, and pain • Appearance of wounds and wound drainage • If there is a colostomy, measure and describe the
fecal drainage
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Colorectal Cancer
• Interventions• Risk for Injury • Ineffective Tissue Perfusion • Acute Pain • Sexual Dysfunction • Ineffective Coping
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Polyps
• Small growths in the intestine • Most benign but can become malignant• Inherited syndromes: familial polyposis and
Gardner’s syndrome• Usually asymptomatic; found on routine testing • Complications are bleeding and obstruction • Diagnosed by barium enema or endoscopic
exam • Colectomy for familial polyposis or Gardner’s
syndrome because of the high risk of malignancy
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Hemorrhoids
• Internal or external dilated veins in the rectum • Thrombosed
• Blood clots form in external hemorrhoids; become inflamed and very painful
• Risk factors • Constipation, pregnancy, prolonged sitting or
standing
• Signs and symptoms • Rectal pain and itching • Bleeding with defecation• External hemorrhoids easy to see; appear red/bluish
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Figure 38-22
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Hemorrhoids
• Medical diagnosis and treatment • Diagnosed by visual inspection• Nonsurgical treatment
• Topical creams, lotions, or suppositories soothe and shrink inflamed tissue
• Sitz baths often comforting • The physician may order heat or cold applications
• Outpatient procedures: ligation, sclerotherapy. Thermocoagulation/electrocoagulation, laser surgery
• Hemorrhoidectomy • The surgical excision (removal) of hemorrhoids
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Hemorrhoids
• Assessment• After hemorrhoidectomy, monitor vital signs, intake
and output, and breath sounds. Assess the perianal area for bleeding and drainage
• Interventions• Acute Pain• Impaired Skin Integrity • Constipation
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Anorectal Abscess
• An infection in the tissue around the rectum • Signs and symptoms are rectal pain, swelling, redness,
and tenderness • Treated with antibiotics followed by incision and
drainage • Preoperatively, pain is treated with ice packs, sitz
baths, and topical agents as ordered
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Anorectal Abscess
• Postoperatively, pain treated with opioid analgesics • Patient teaching emphasizes importance of
thorough cleansing after each bowel movement• Advise patient to consume adequate fluids and a
high-fiber diet to promote soft stools
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Anal Fissure
• Laceration between the anal canal and the perianal skin
• May be related to constipation, diarrhea, Crohn’s disease, tuberculosis, leukemia, trauma, or childbirth
• Signs and symptoms include pain before and after defecation and bleeding on the stool or tissue
• If fissure chronic, the patient may experience pruritus, urinary frequency or retention, and dysuria
• Usually heal spontaneously, but can become chronic • Conservative treatment: sitz baths, stool softeners, and
analgesics • Surgical excision may be necessary
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Anal Fistula
• Abnormal opening between anal canal and perianal skin
• Develops from anorectal abscesses or related to inflammatory bowel disease or tuberculosis
• Patient typically complains of pruritus and discharge• Sitz baths provide some comfort• Surgical treatment is excision of fistula and surrounding
tissue • Sometimes a temporary colostomy to allow the surgical
site to heal • Postoperative care: analgesics and sitz baths for pain
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Pilonidal Cyst
• Located in the sacrococcygeal area • Results from an infolding of skin, causing a
sinus that is easily infected because of its closeness to the anus
• Once infected, it is painful and swollen and may form an abscess
• Surgical excision usually recommended • Care is similar to that for the patient having a
hemorrhoidectomy
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Patient Education to Promote Normal Bowel Function
• Good hand washing and proper food handling • People who recognize that stress affects their
gastrointestinal function may benefit from relaxation techniques and stress management training
• Signs and symptoms of digestive problems should be reported for prompt diagnosis and treatment if indicated
• Teaching patients what is normal, how to promote normal function, and how to detect problems can help to avoid serious gastrointestinal dysfunction