Nursing Management of Clients with Problems of Absorption and Elimination

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Nursing Management of Clients with Problems
ofAbsorption and Elimination

• Jayson T. Valerio RN, MSN

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Brief Review Digestive System
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Assessment- Subjective

• History
• Demographic Data
• Personal and Family History
• Diet History
• Socio-Economic Status
• Current Health Problems

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Assessment-Objective

• Remember ?????? I-A-P-P??????

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Diagnostic Assessment

• Radiographic Examinations
• Flat Plate Film of the Abdomen
• Upper GI Series (Barium Swallow)
• Lower GI Series (Barium Enema)
• CT Scan of the GI

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Diagnostic Assessment

• Other diagnostic tests Endoscopy
• Esophagogastroduodenoscopy (EGD)
• Colonoscopy
• Proctosigmoidoscopy
• Gastric Analysis
• Ultrasonography

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Acute abdomen

• Causes
  Peptic ulcer
• Abdominal penetrating trauma Peritonitis
• Acute ischemic bowel Rupture
  AAA
• Appendicitis
  Ulcerative
• Cholecystitis
  colitis
• Crohns disease
• Diveritculitis with peritonitis
• Gastritis
• Pancreatitis

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Clinical Manifestations-Acute Abdomen

• Pain is the the most common presenting symptom
• Abdominal tenderness
• Vomiting
• Diarrhea
• Constipation
• Flatulence, fatigue
• Fever
• Increase in abdominal girth

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Diagnosis and Treatment

• CBC, ECG, Abd X-ray, UA, pregnancy test
• Exploratory Laparotomy
• Surgical repair or surgical removal

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Nursing Care

• Ensure patent airway
• Administer O2 via n/c
• Establish IV access and infuse warm normal saline
• Obtain CBC and electrolytes
• Insert foley
• Insert NGT as needed

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Ongoing Monitor

• Monitor V/S LOC O2 saturation and intake and
  output
• Assess quality of pain
• Assess amount and character of emesis
• Anticipate surgical intervention
• Keep NPO

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Post Laparotomy

• Assess for pain and medicate as necessary
• Assess bowel sounds
• Splint incision with pillows cough and deep
  breathing
• Position comfortably
• Administer anti-emetics as ordered
• Maintain patency of NG
• Keep NPO
• Ambulation

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Inflammatory Intestinal DisordersAcuteAppendicit
isPeritonitisGastroenteritisChronicUlcerative
colitisCrohn's diseaseDiverticular disease
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Appendicitis

• Inflammation of appendix
• Pain right lower quadrant and localized at Mc
  burneys point
• Rebound tenderness
• Low grade fever
• Rovsings sign palpate left quadrant pain on
  right.

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Interventions

• Keep NPO
• Apply ice bag to right lower quadrant
• Never use heat
• Post op ambulation early
• Diet is advanced as tolerated
• Discharged 1st or 2nd day.

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Peritonitis

• Results from local or generalized inflammation of
  the peritoneum
• Trauma, rupture of an organ containing chemicals
  or bacteria
• Gastric ulcer perforation
• Clinical manifestation
• Tenderness over involved site, rebound
  tenderness, muscular rigidity, spasm

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Clinical Manifestations Complications

• Abdominal distention or ascites fever,
  tachycardia, tachypnea, nausea, vomiting, and
  altered bowel habits.
• Hypovolemic shock, septicemia, intraabdominal
  abcess formation, paralytic ileus, and organ
  failure

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Interventions

• Monitor and provide relief of pain
• Keep patient NPO
• Observe for fluid volume deficit
• Provide care of NGT
• Keep patient in semi-fowlers position
• Administer IV fluids and electrolyte replacement
  as ordered
• Administer total parenteral nutrition as ordered
• Administer antibiotic treatment as ordered
• Blood transfusion as needed
• Sedatives and narcotics as needed
• Observe for potential complications

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Gastroenteritis

• Inflammation of the mucosa of the stomach and
  small intestine
• Clinical manifestations
• N/V, diarrhea , abd cramping, and distention,
  fever, leukocytosis, blood or mucus in stool
• Etiology can be bacterial, viral or parasitic

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Interventions

• Monitor Intake and output.
• Replace lost fluid
• Strict medical asepsis
• Infection control precautions
• Instruct patient on the importance of food
  handling and preparation properly
• Rest
• Care for pain
• Allay fears

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Ulcerative Colitis VS Crohns Disease

• Ulcerative colitis is inflammation and ulceration
  of the colon and rectum.

• Crohns disease is chronic nonspecific
  inflammatory bowel disorder origin may affect any
  part of the GI tract.

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Ulcerative Colitis VS Crohns Disease

• Location Begins in the rectum and proceeds in a
  continuous manner toward the cecum
• Etiology Unknown
• Peak Incidence _at_ Age 15-25 yrs and 55-65 yrs
• Stools 10-20 liquid, bloody stools per day
• Complications hemorrhage perforation fistulas
  nutritional deficiencies

• Most often in the terminal ileum with patchy
  involvement through all layers of the bowel
• Unknown
• 15-40 yrs
• 5-6 soft, loose stools/day, rarely bloody
• Fistulas and nutritional deficiencies

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The types of fistulas that are complications of
Crohns disease
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Diagnostics

• Colonoscopy
• Sigmoidoscopy
• Barium enema
• CBC
• Stool for blood, culture and sensitivity

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Nursing Diagnoses (for both)

• Diarrhea
• Acute and chronic pain
• Imbalanced nutrition
• Disturbed body image
• Activity intolerance
• Ineffective coping

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Interventions

• Low roughage diet and no milk and milk products
• Antibiotics
• Corticosteriods
• Anticholinergics
• Antidiarrheals agents
• Total proctocolectomy with permanent ileostomy
• Total protocolectomy with continent ileostomy
• Total colectomy with ileal reservoir.

• High calorie, high vitamin,high protein, low
  residue, milk free diet
• Antibiotics
• Corticosteriods
• TPN
• Physical and emotional rest
• Surgery controversial

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Nursing Goals Teaching

• Experience a decrease in number and severity of
  acute exacerbations
• Maintain normal fluid and electrolyte balance
• Be free of pain
• Comply with medical regimen
• Maintain nutritional balance

• Importance of rest and diet
• Perianal care
• Action and side effects of medications
• Symptoms of recurrence of disease
• When to seek medical care
• Use of diversional activities to reduce stress.
• Stoma care

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Total proctocolectomy with a permanent ileostomy
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The creation of a Kock (continent) ileostomy
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The creation of an ileoanal reservoir
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Diverticular Disease

• Diverticula
• Congenital/acquired pouchlike herniations
• Occur in small intestine/colon
• Usually there is no discomfort and the problem
  goes unnoticed unless seen on x-ray examination
• Diverticulitis
• Perforated diverticulum with formation of local
  abscess
• Minor bleeding to massive hemorrhage
• Retained undigested food bacterial invasion of
  sac

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Nursing Assessment

• Left lower quadrant pain
• Increased flatus
• Rectal bleeding
• Signs of intestinal obstruction
• constipation alternating with diarrhea
• abdominal distention
• anorexia
• low-grade fever
• Barium enema positive for diverticular disease

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Nursing Plans Interventions

• Nonsurgical Management
• Drug therapy Broad spectrum Abx Analgesics
• IV fluids
• Anticholinergics
• NCLEX!!!! Provide a well balanced and high fiber
  diet unless inflammation is PRESENT
• Rest

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Nursing Plans Interventions

• Diet Therapy NCLEX!!!!
• Acute Phase NPO graduating to liquids
• Recovery Phase no fiber or foods that irritate
  the bowel
• Maintenance Phase high-fiber diet with
  bulk-forming laxatives to prevent pooling of
  foods in the pouches where they can become
  inflamed
• Surgical Management Colon Resection with or
  without a colostomy

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Intestinal Obstruction

• Partial or complete
• Mechanical
• Outside the intestine
• Blockage of lumen
• Nonmechanical
• Neuromuscular disturbances
• Decreased peristalsis slowing/backup of
  intestinal contents
• Paralytic (adynamic) ileus

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Etiology and Pathophysiology

• Fluid and gas accumulate proximal to obstruction
  causing distention and distal bowel collapses.
• Distention reduces absorption of fluids.
• Pressure in abdomen increases.
• Increase capillary permeability and extravasation
  into peritoneal cavity.

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Clinical Manifestations

• Nausea and vomiting
• Abdominal pain
• Distention
• Inability to pass flatus
• Projectile vomiting
• Colicky pain
• High pitched bowel sounds

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Examples of Mechanical Obstruction
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Diagnostic Assessment

• CBC
• Abdominal x-ray
• Barium enema
• GI series
• Sigmoidoscopy
• Electrolytes, amylase
• HH
• BUN

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Interventions

• Decompression of intestine and removal of gas and
  fluid
• NGT to low suction
• Maintenance of electrolytes
• Monitor intake and output
• IV infusions
• Pain relief

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CANCER OF THE COLON AND RECTUM

• SECOND MOST COMMON CAUSE OF CANCER DEATH IN US
• 16.5/100,000 MALES AND 11/100,000 FEMALES
• 56,500 DEATHS.
• 131,600 NEW CASES IN 1998 IN US
• 5 YEAR SURVIVAL RATE IS 91

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Incidence of Colorectal Cancer
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Etiology

• Genetic predisposition
• Personal factors
• Age
• Polyps
• Dietary factors
• Decreased bowel transit time
• High-fat diet
• Refined carbohydrates
• Inflammatory bowel disease

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Risk Factors

• Age
• Familial polyposis
• Colorectal polyps
• Family Hx of colorectal cancer
• Previous Hx of colorectal Ca
• History of genital or Breast Ca(women)
• High fat/low fiber diet.

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Diagnostic Assessment

• History
• Physical exam
• Fecal occult blood
• Sigmoidoscopy
• CT scan
• CBC
• CEA

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Clinical Manifestations

• Rectal bleeding
• Anemia
• Changes in stool
• Symptoms of obstruction
• Gas pains, cramping, incomplete evacuation
• Hematochezia
• Straining to pass stools/narrowing of stools
• Mass lower right quadrant
• Changes in bowel sounds

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Interventions

• REMOVAL OF POLYP
• LASER SURGERY
• NONINVASIVE
• SURGERY IS THE ONLY CURATIVE TX
• RIGHT HEMICOLECTOMY IF IN CECUM, ASCENDING COLON
  TRANSVERSE COLON.

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Interventions

• LEFT HEMICOLECTOMY
• RADIATION AS PALLATIVE MEASURE TO REDUCE TUMOR
  SIZE
• CHEMOTHERAPY IF LYMPH NODE INVOLVED 5-fU
  fLUOROURCIL

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Nursing Care

• Preoperative teaching
• Ostomy care
• Wound healing
• Side-to-side positioning
• Short walks are better than sitting
• Taking sitz bath
• Phantom rectal sensation

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Ostomy Surgery

• Ostomy is a surgical procedure where an opening
  is made to allow passage of intestinal contents
  from the bowel through a stoma.
• Ileostomy is an opening from the ileum to the
  abdominal wall
• Colostomy is an opening from the colon and the
  abdominal wall

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Colostomy VS Ileostomy

• Semiliquid stool
• Increase fluid
• No bowel regulation
• Pouch and skin barrier
• No irrigation
• Perforating diverticulitis,trauma, tumors
  inoperable of colon, rectum,or pelvis

• Liquid to semiliquid
• Increased
• No
• Yes
• No
• Ulcerative colitis
• Crohns disease or injured colon, familial
  polyps,trauma, cancer

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Brief Review Normal Stoma
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Client and Family Teaching

• 1. Explain the principles of ostomy and pouch
  care
• 2. Instruct on dietary and fluid intake
• 3. Contact ostomy Association
• 4. Explain the importance of follow up care
• 5. Report fever, diarrhea,skin irritation, stoma
  problems, inversion, eversion, discoloration or
  infection

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Hernias

• Protusion of intestine through weakening of
  abdominal wall.
• Reducible if it can be placed back into abdominal
  cavity
• Irreducible if it cannot
• Strangulated if it obstructs blood supply and
  intestinal flow.

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Types of Hernias
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Clinical Manifestations

• Hernia with tension of standing or straining
• Pain with strangulation
• Vomiting
• Crampy abdominal pain
• Anal distention

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Interventions

• Herniorrhaphy
• Colon resection with colostomy-temporary
• Observe for distended bladder
• Accurate intake and output
• Scrotal edema
• Ice bag and scrotal support
• Deep breathing and turning no cough
• Restrict heavy lifting for 6-8 weeks.

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Malabsorption Syndrome

• is a condition in which the nutrients are
  ineffectively absorbed by the intestinal mucosa
  resulting in their excretion in the stool.
• Diseases of the small intestine are often
  accompanied by malabsorption.
• Examples Sprue, Crohns disease
• Regardless of the cause malabsorption syndrome is
  characterized by common manifestations.

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Clinical Manifestations

• Local (GI) diarrhea, abdominal distention,
  steatorrhea
• Systemic weight loss, weakness, maliase, anemia,
  bone pain muscle cramps, paresthesias, easy
  bruising and bleeding, glossitis, cheilosis

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Sprue

• Is a chronic primary disorder of the small
  intestine in which the absorption of nutrients,
  particularly fats, is impaired.
• Two major forms of sprue
• Celiac disease aka non tropical sprue
• Tropical sprue

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Non Tropical VS Tropical

• Is a chronic hereditary disorder characterized by
  sensitivity to the gliadin fraction of gluten
• Dietary Management
• Gluten free diet
• High caloric and protein diet low fat diet

• Is an acquired chronic disease thought to be
  cause by an infection, either bacteria or viral
• Its exact etiology is unknown
• Dietary Management
• High caloric and protein diet
• Low fat diet

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Interventions

• Antibiotics for tropical sprue
• Anti-diarrheal agents
• Steroids
• Nutritional supplements
• water-soluble vitamins, minerals, fat-soluble
  vitamins, pancreatic enzymes
• Skin care

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Lactose Intolerance

• Is a disorder characterized by lactase deficiency
• Affects 90 Asians and 75 African Americans and
  Indians
• Etiology genetic predisposition and can be
  secondary to conditions affecting intestinal
  mucosa
• Clinical Manifestations lower abdominal
  cramping, pain and explosive diarrhea after milk
  ingestion

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Interventions

• Dietary Management Lactose-free diet
• Skin care
• Nutritional supplements

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Anorectal Disroders(anorectal abscesss, anal
fissure and anal fistula

• Anorectal abscess result from obstruction of the
  ducts of glands in the anorectal region by feces,
  foreign bodies or trauma.
• Clinical Manifestions rectal pain, diarrhea as
  the 1st symptom s/s inflammation may have
  chronic discharges, bleeding fever and itchiness
• Interventions I D Abx high fiber diet
  perineal hygiene

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Anorectal Abscess and Fistula
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Anal Fissure

• Is a superficial erosion of the anal canal
• Can be primary (idiopathic) and secondary
• Clinical Manifestations pain and rectal bleeding
  after defecation are the most common symptoms
  dysuria, dyspareunia, itchiness, urinary
  retention and frequency
• Interventions
• Non-surgical Pain relief measures, perineal
  comfort, bulk-forming agents (metamucil)
• Surgical Excision of the fissure

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Anal Fissure
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Anal Fistula

• Is an abnormal tract leading from the anal canal
  to the perineal skin
• Mostly results from anorectal abscess
• Clinical Manifestations itchiness, purulent
  drainage, tenderness/pain that is worsened by
  bowel movement
• Interventions Surgery Fistulotomy