peritonitis and other git complications
TRANSCRIPT
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.
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(39) Pancreas: Acute hemorrhagic pancreatitis.
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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
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