Adult GI Disorders Lower GI Disorders

Appendicitis inflammation of vermiforn appendix d/t infection Assessment –Progressive, severe, RLQ or periumbilical area pain –Pain localized in RLQ(McBurney’s point) worse with movement, coughing, sneezing –anorexia, constipation –nausea, vomiting –rebound tenderness –slight temperature –moderate leukocytosis

Nursing Plan of Care –Assist with diagnostics, ie UA, IVP, Rectal –NPO, narcotics after cause of pain determined, maintain bedrest –Pre op: keep in high fowlers –NO CATHARTICS or ENEMAS –Monitor vital signs

Goals Recognize and treat symptoms Prevent death from complications Re-establish normal bowel function

Nursing Care: Post Op Maintain fowlers Care of nasogastric tube, suction prn Check for return of peristalsis May need enema, 3 rd -4 th day post-op Health education (review signs/symptoms) Discharge instruction –monitor incision, watch for infection, return of bowel function, return of symptoms

Hemorrhoids Pathophysiology –congestion of the veins of the hemorrhoidal plexus –leads to varicosities of rectum and anus d.t. elevated intra-abd pressure from constipation, straining when defecating, pregnancy –Heredity,obesity,long standing/sitting occupations –also with cirrhosis and portal hypertension Assessment Data –Internal: painless, bleeding with defecation –External: apparent outside anal sphincter inflammation & pain if ruptures w/subsequent thrombosis itching Goal –alleviate symptoms –Provide pre/post-op care for hemorrrhoidectomy –Health education to prevent occurence

Interventions Medical –analgesic ointment:Nupercaine –ice or warm compresses –sitz baths –stool softeners –local sclerosing may be done, R.N. assists with procedure Surgical: post op –watch hemorrhage (1st 24 hr and 7-10 days post-op) –promote comfort: ice or warm compresses –watch infection –bulk laxatives(promote B.M) –education: sitz bath, bulk in diet(to prevent constipation) encourage fluid, daily BM, stool softeners, laxatives

Evaluation Verbalizes plan for bowel elimination Verbalizes signs and symptoms of recurrence Verbalizes signs and symptoms of complications, i.e. bleeding, pain, constipation, etc. Recovers without complications from the surgery

Diverticulosis, Diverticulitis Outpouching of mucosa through a weak point in muscle layer of bowel wall that: gets impacted with feces(Diverticulosis) or gets inflammed(Diverticulitis) Causes are unknown Goal: relieve pain & restore normal bowel function

Nursing Plan of Care Administer medications –Narcotics (Demerol) antispasmodics, bulk laxatives(Metamucil) antibiotics Assess bowel sounds, report changes(increase or decrease) Observe type, color, frequency of stool Intake and output(record) Observe for complications –peritonitis, obstruction, hemorrhage Dietary education –high fiber, bran, lots of fluid(8 glasses per day), bulk laxatives

Evaluation Patient establishes regular bowel habits without pain Patient follows diet principles Verbalizes understanding of medications Patient verbalizes signs/symptoms of complications

Ulcerative colitis Inflammatory and ulcerative disease of colon Superficial ulcers seen in mucosa that –bleed –become edematous –become abscessed causing reduced absorbive surface of the bowel Cause unknown(auto-immune) May be seen more with certain personalities – Independent exterior but dependent interior –Structured persons who tend to be perfectionistic

Ulcerative colitis Assessment(Physical) –frequent diarrhea –stool with mucus, blood, pus –colicky abdominal cramps, distention –low grade fever –fluid and electrolyte imbalance –wt loss, anorexia –weakness cachexia Psychosocial/Cultural Occurs most often in Adolescents Young adults Jewish descent –causes depression, anger, frustration –stress may cause exacerbation

Goals Restore nutrition/ F&E balance Combat infection Promote comfort Decrease bowel motility Assist patient to cope with Alteration in body image Psychological problems

Nursing Plan of Care Antibiotics to prevent or treat secondary infections ACTH or adrenal steroids(decrease inflammation) Bedrest, as needed Sitz bath, prn Lomotil to decrease GI motility Emotional support Protect perineum, buttock and anal area –Wash –Lubricants to prevent skin breakdown –Ointments to relieve discomfort

Nursing Care continued... Weight, q.d. Assess nutritional status (anemia, vitamin K deficiency, dehydration) High protein, high calorie diet, TPN Record type, amount, character of stools Education if surgery indicated

Ileostomy Pre op –prepare for bowel surgery –no enemas –watch fluid and electrolyte status Post Op –care of skin and stoma –observe for peritonitis –maintain high protein, high calorie, high vitamins –Teaching rehabilitation principles –Referrals(to community health nurse) –discharge planning(social worker for financial, etc.)

Evaluation Patient has less diarrhea and is able to control or manage other signs and symptoms Patient maintains their nutritional status Patient verbalizes knowledge of the disease Patient follows up on their outpatient appointments

Regional enteritis (Crohn’s Disease) Chronic inflammatory disease of small intestine affecting the terminal ileum. Results in chronic diarrhea Causes are unknown

Crohn’s Physical –crampy pain after meals –chronic diarrhea, melena –low grade fever –abd tenderness –lymphadenitis –UGI> string sign present, suggests a constriction of a segment of intestine Psychosocial –more common in Jews of European ancestry –familial tendency –Age, years Goals –promote comfort –adequate hydration and nutrition

Nursing Plan of Care Diet low in residue, roughage and fat, high in calories, protein, vitamins Rest periods Antimicrobials to control inflammation Assess F & E status May need colon resection Evaluation –maintains F & E status, free of symptoms understands diet

Intestinal Obstruction Blockage of intestinal tract that inhibits passage of fluid, gas, feces Caused by –mechanical obstruction (strangulated hernia, adhesion, cancer, volvulus, intussusception) –neurogenic obstruction (paralytic ileus, uremia, electrolyte imbalance(low K), spinal cord lesion) –Vascular disease (occlusion of superior mesentery vessels)

Intestinal Obstruction Physical –loud frequent bowel sounds above obstruction –intermittent & cramping pain –vomiting (fecal) –distention, no stool or gas passage –severe F & E imbalance –shock Goal –relieve discomfort –return of normal bowel peristalsis and function

Nursing Plan of Care Administer intravenous fluid, electrolytes Administer pain medication (avoid morphine: d/t effect on respiratory system) Maintain intestinal decompression using a Miller Abbott tube, (see nursing care in textbook) Skin/mouth care Watch respiration's, abd. distension may cause resp. distress, V.S. Check abdomen q2h for changes(distension, rigidity, or pain)

Nursing Care cont.…. Assess for return of peristalsis –listen for bowel sounds, check abdominal girth, passage of stool If no resolution, may need surgery Maintain diet according to disease that caused problem Teach good bowel habits –avoid harsh laxatives drink fluid stool softeners, regular exercise

Evaluation Patient remains free of pain Patient experiences normal bowel elimination Patient normalizes their fluid and electrolyte balance Patient verbalizes correctly diet changes