lower gi and accessory system alterations

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Yolanda Chandler, MSN,RN

Lower GI and Accessory System Alterations

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Increased frequency of BMIncreased amount of stoolAltered consistencyAll acute diarrhea considered infectious until

cause knownViralBacterialParasitic

Diarrhea

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Antidiarrheal DrugsDemulcent

Soothes, coats, protects mucous membranes Pepto-Bismol

AnticholinergicInhibits GI motility

Lomotil/ImodiumAntisecretory

Prolongs intestinal transit time Sandostatin

OpiodDecreases CNS stimulation of GI tract motility &

secretion-directly inhibits GI motility Paregoric

Diarrhea

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Involuntary passage of stoolRisk factors:

ConstipationDiarrheaObstetric traumaFecal impactionOther

Prevention/tx may be managed by bowel training program

Fecal Incontinence

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Decrease in frequency of BM from pt. “normal”

Hard, difficult-to-pass stoolsDecrease in stool volumeRetention of feces in rectumGoals:

Increase intake of fiber/fluidsIncrease physical activityHave soft, formed stoolsNo complications

Constipation

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Drug TherapyBulk forming

MetamucilStool softeners

Colace Lubricants

Oil retention enemaSaline and osmotic solutions

MOM, GoLYTELY, Fleet enemaStimulants

Cascara, DulcolaxSelective chloride channel activator

AmitizaSerotonin type 4 receptor partial agonist

Zelnorm

Constipation

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Intermittent & recurrent abd. pain and stool pattern irregularities-classified as:

IBS w/diarrheaIBS w/constipationIBS w/diarrhea & constipation

Irritable Bowel Syndrome

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Management

Irritable Bowel Syndrome

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Most common causesObstruction of lumen by fecalith (accumulated feces)Foreign bodiesTumor of cecum or appendix Intramural thickening from excessive growth of lymphoid

tissue Clinical manifestations

Persistent/continuous pain beginning in peri umbilical area eventually shifting to right lower quadrant (McBurney’s point)

AnorexiaNausea/vomitingLocalized/rebound tendernessMuscle guardingMay or may not have low grade feverRovsing’s sign

Appendicitis

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Diagnostic StudiesComplete history/physicalWBC countUA*Ultrasound*CT

ManagementAppendectomy

PreoperativePostoperative

Appendicitis

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Etiology/pathophysiologyClinical Manifestations

Abdominal pain-most common symptomTenderness over involved area-universal signRebound tendernessMuscle rigidity/Spasm Lie still/shallow respirationsAbd distention/ascitesFever 100-101TachycardiaTachypneaN/VAltered bowel habits

Peritonitis

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ComplicationsDiagnosticsManagement

Peritonitis

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Crohn’s DiseaseUlcerative Colitis

Inflammatory Bowel Disease

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PathophysiologyClinical ManifestationsAssessment/Diagnostic FindingsComplications

Inflammatory Bowel Disease-Crohn’s

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PathophysiologyClinical ManifestationsAssessment/Diagnostic FindingsComplications

Inflammatory Bowel Disease-Ulcerative Colitis

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ManagementNutritional TherapyPharmacologic TherapySurgical Management

Inflammatory Bowel Disease

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May occur in small intestine/colonMay be partial/complete

MechanicalFunctional

Intestinal Obstruction

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Small BowelPathophysiologyClinical ManifestationsAssessment/Diagnostic Management

Intestinal Obstruction

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Large BowelPathophysiologyManifestationsAssessment/diagnosticManagement

Intestinal Obstruction

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NeoplasticNon –neoplastic

ManifestationsDiagnosis

Polyps

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PathophysiologyManifestationsAssessment/Diagnostic FindingsComplicationsManagement

Colorectal Cancer

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Ostomy Surgical procedure that allows intestinal contents to

pass from bowel through opening in skin on abdomen

Used when normal elimination route no longer possible

Described according to location and typeIleostomy

ostomy in ileum Sigmoid colostomy

ostomy in sigmoid colonTransverse colostomy

ostomy in transverse colon, etc.

Ostomies

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Major types End stomaLoop stomaDouble barreled ostomy

Ostomies

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Ostomy surgeryPre-op

Selection of op siteAssess

Physical Psychological Social Cultural Educational

Bowel prepProphylactic antibiotics

Post-opAssess

Stoma /surrounding tissue/pouching systemTeach

Ostomy care

Ostomies

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Colostomy care Ascending/transverse colon

Semiliquid stools Sigmoid/descending colon

Semiformed/formed stools Dietary modifications to decrease gas/odor Irrigations

Ileostomy care Liquid stool Stoma protrusion of 1-1.5 cm makes care easier Pouch at all times Always use skin barrier Monitor for fluid/electrolyte imbalances Increase fluid to 2-3Liters daily (include sports drinks) Low fiber initially-reintroduce fiber gradually Stoma may bleed easily

Ostomies

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Adaptation to ostomyGrief reactionADLs resumed 6-8 weeks-avoid heavy liftingSexual dysfunction

Pelvic surgeryRadiationChemoMedsFatigue Body image

Ostomies

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PathophysiologyClinical ManifestationsAssessment/DiagnosticsComplicationsManagement

Diverticular Disease

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May be:ReducibleIrreducible/incarceratedStrangulated

Types

Hernias

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Clinical ManifestationsManagement

Hernias

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PathophysiologyClinical ManifestationsAssessment/DiagnosticManagement

Conditions of Malabsorption

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Dilated veins of anal canalRectal bleeding w/defecation-bright redPruritisProlapsePainBurning

Hemorrhoids

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Nursing Management

Hemorrhoids

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Anorectal Abscess

Collections of perianal pusSecondary to:

Anal fissures Trauma Inflammatory Bowel

disease Immunosuppressive (AIDS)

Diagnosed by Rectal exam

Surgical therapy I&D

Possible packingTeaching

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Anal Fistula

Abnormal tunnel leading from anus or rectum

Complication of Crohn’s

Feces may enter fistula causing infection

Surgical Therapy

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Pilonidal Sinus

Hairs penetrate into epithelium/SQ tissue

No symptoms unless infected

Abscess requires I&D

Pack woundsSitz baths

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Yellowish discoloration of body tissuesResults when concentration of bilirubin in

blood becomes abnormally increasedA symptom rather than a diseaseUsually 1st detected in sclera and skinTypes

HemolyticHepatocellularObstructive

Jaundice

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Viral Hepatitis

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Fecal-oral routeSources of infection/spread of disease

Crowded conditionsPoor personal hygienePoor sanitationContaminated food/drinkInfected food handlers

Hepatitis A

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Sources of infection/spread of diseasePerinatally by mothers infected w/ HBVPercutaneous (IV drug use)Mucosal exposure to infectious blood, blood

products, or other body fluids (semen, vaginal secretions, saliva)

Tattoos/body piercing w/contaminated needlesBites

Hepatitis B

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Mode of transmission/sources of infectionPrimarily PercutaneousMucosal exposureHigh risk sexual contactPerinatal contact

Hepatitis C

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Cannot survive on its ownRequires HBV to replicateRoutes of infection same as Hepatitis BSource of infection same as Hepatitis BBlood is infectious at all stages of HDV

infection

Hepatitis D

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TransmissionFecal-oralMost common mode of transmission-drinking

contaminated waterPrimarily in underdeveloped countries

Hepatitis E

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TransmissionParenteralSexually

Coexists with other viral infections

Hepatitis G

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Toxic HepatitisDrug Induced Hepatitis

Non Viral Hepatitis

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Hepatitis

Manifestations-Acute Anorexia N/V Right upper quad pain Constipation/diarrhea Decreased taste/smell Malaise/fatigue Headache Fever Arthralgia Urticaria Hepatomegaly/splenomegaly Weight loss Jaundice/pruritis Dark urine Bilirubinuria Light stools

Manifestations-chronic

MalaiseFatigueHepatomegaly

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ManifestationsDiagnosticsManagement

Cirrhosis

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TypesAlcoholicPost necrotic Biliary

Cirrhosis

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Tortuous veins at lower end of esophagus, enlarged & swollen as result of portal HTN

Bleeding esophageal varicies most life threatening complication of cirrhosis

*Massive hemorrhage is medical emergency

Esophageal Varices

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Management of nonbleeding variciesβ-blockers

Management of bleeding variciesDrugsSandostatinVasopressinNitroglycerinβ-adrenergic blockers

Endoscopic therapiesSclerotherapyLigation of varicesShunt therapyBalloon tamponade

Minnesota or Sengstaken-Blakemore tube

Esophageal Varices

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ManifestationsManagement

Ascites

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Neuropsychiatric manifestation of liver damageDisorder of protein metabolism/excretionLarge quantities ammonia in systemic

circulationGrading system used to classify stages Asterixis Fetor hepaticus

TreatmentAntibioticsLactuloseCathartics/enemasTreat precipitating causes (Table 44-12)Possible liver transplant

Hepatic Encephalopathy

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IndicationsComplicationsManagement

Liver Transplant

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Liver Cancer

Primary carcinomaHepatocellular carcinoma most common

primary CACholangiomasCommonly metastasize to lung

Metastatic carcinomaMore common than primary

ManifestationsDiagnosticsManagement

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PathoManifestationsDiagnosticsManagement

Acute Pancreatitis

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Chronic Pancreatitis

ManifestationsAssessment/DiagnosticsManagement

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Causes ManifestationsDiagnosticsManagement

Pancreatic Cancer

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Cholecystitis (inflammation of gallbladder)

Cholecystitis

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Gall stones

Cholelithiasis

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Primary cancer uncommonOften not detected until advanced diseaseTreatmentNursing management

Gallbladder Cancer

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Major indication for liver transplant in childrenManifestations

Appears healthy at birthAcholic stools (light in color d/t absence of bile)Bile-stained urineHepatomegaly

DiagnosticsLiver function studiesClotting studiesUrine/stool studiesPercutaneous liver biopsyCholangiography

Biliary Atresia

Biliary Atresia

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ManagementExploratory laparotomyKasai procedureMange malnutritionProvide symptom relief

Biliary Atresia

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Nursing interventions directed toward:Nutritional supportSkin careDevelopmental stimulationContinued assessmentEducationEmotional support

Biliary Atresia

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Serious inflammatory condition of intestinesMost common GI medical/surgical emergency in

neonatesEtiology remains elusiveManifestations-(one or more of following)

Feeding intoleranceDelayed gastric emptyingAbdominal distention/tenderness Ileus/decreased bowel soundsAbdominal wall erythema (advanced stages) Change in stool patternPalpable abdominal mass

Necrotizing Enterocolitis

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