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Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Patients With Gastrointestinal

Alterations III

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Continuation of Alteration in Digestion Dumping Syndrome

rapid gastric emptying happens when the lower end of the small intestine, the jejunum, fills too quickly with undigested food from the stomach Early Dumping begins during / right after 30 minutes after a meal o Clinical Manifestations: Nausea / Vomiting Bloating Cramping Diarrhea Dizziness Fatigue Abdominal failure Late Dumping happens 1 3 hours after eating o Clinical Manifestations: Weakness Sweating (Perspiration) Dizziness Hypoglycemia Pallor Drowsiness Causes

Topics Discussed Here Are: 1. Continuation of Alteration in Digestion a. Dumping Syndrome 2. Disturbance in Absorption a. Diarrhea b. Constipation c. Irritable Bowel Syndrome (IBS) 3. Structural and Obstructive Bowel Disorders a. Intestinal Obstruction b. Crohns Disease (CD) c. Ulcerative Colitis (UC)

Gastrectomy / gastric bypass surgery / Billroth I and II Esophagectomy from esophageal cancer clients Pathophysiology wala XD Management - Limit fluid intake o No fluid with meals o No salt - No CHO

Nursing Interventions
1. 2. 3. 4. Advice client to eat CHO, FAT and CHON diet ( Fiber) Instruct to eat small frequent meals, include more dry items Instruct to avoid consuming fluid with meals Instruct to LIE DOWN AFTER MEALS (OPPOSITE sa mga DATING DISORDERS) Administer antispasmodic medications to delay gastric emptying (Metoclopramide)

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Disturbance in Absorption Diarrhea


frequency of defecation and the fluidity and volume loss more than 3 times a day LARGE VOLUME DIARRHEA - Diarrhea in which VOLUME OF FECES is called LARGE VOLUME DIARRHEA - Caused by excessive amounts of water / secretions in the intestine - Painless, fluid, without mucous - Diabetic neuropathy has lesions / blockage of the nerve and it impairs autonomic control of motility SMALL VOLUME DIARRHEA - Volume of feces is not increased and is usually a result from excessive intestinal motility - Painful! - Infants and elderly = 2 3 weeks SEVERE Adults and children = 4 weeks SEVERE - Causes: o Ulcerative colitis (Mucosa and submucosa, and large colon), Crohns disease (Entire mucosa SI and LI) o Inflammation of the intestine / colon o Cramping pain o Urgency and frequency o Fecal impaction (liquid pushes impacted feces) o Secretions produced by the colon to lubricate the impacted feces o Move towards the anal canal flowing around the impaction

THREE MAJOR MECHANISMS OF DIARRHEA


1. 2. 3. Osmotic Secretory Motility

Osmotic Diarrhea
Presence of unabsorbable substance in the intestine causes it to be drawn into the lumen by OSMOSIS Pathophysiology Lactase deficiency is the most common cause of osmotic diarrhea!!
Non-absorbable substance Milk, sugar and lactose

Intestine does not produce enough lactase

Lactose remains in the intestinal lumen (Because it is not digested and absorbed)

Secretory Diarrhea
Form of large volume diarrhea caused by excessive mucosa; secretion of fluid and electrolytes due to secretions of bacterial endotoxin Some examples: o Cholera, E. coli
o Neoplasms like gastinoma/thyroid carcinoma which both can produce hormones that stimulate intestinal secretions

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Excessive motility transit timing mucosal surface contact fluid absorption Large volume of stool reaches rectum producing urgency and frequency of elimination

Motility Diarrhea
Caused by resection of small intestine Surgical bypass of an area of intestine Fistula formation between loops of intestine Causes: o Food is not mixed properly o Impaired drying o motility o Diarrhea
Frequency It is important to discover whether evacuation was stimulated by enemas / laxative Stool Constituents / Presence of Blood Blood may present as a result of bleeding, hemorrhage/neoplastic lesions of the colon Auscultate Bowel Sounds Usually hypoactive, absent

Systemic Effects of Prolonged Diarrhea


Dehydration Electrolyte Imbalance Weight loss

A. History and Physical Assessment History to document onset and frequency of diarrhea Physical examination To identify the underlying systemic disease Fecalysis / Stool Culture Abdominal X-ray Intestinal Biopsy B. Treatment Restoration of fluid and electrolyte imbalance IVF Management of distressing symptom Correction of nutritional deficiencies Administration of substances that solidify stool (Metamucil) Opium alkaloids like Lomotil which suppress motility, relieves cramping and reduce stool volume and frequency

Clinical Manifestations

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Constipation
Difficulty or infrequent defecation Clinical Manifestations: 1. Less frequent defecation 2. Difficulty of evacuating rectum 3. Feeling of bowel fullness and discomfort 4. Smaller stool volume Causes: 1. 2. 3. 4. 5. 6. 7. 8.

Abdominal distention Borborygmus Gurgling sound caused by passage of gas in the intestine Pain and pressure Indigestion Sense of vomiting emptying Straining Hard dry stool

Abdominal muscle weakness Medical Management: Painful anal lesions (hemorrhoids) - Draw habit training Residue diet Fiber and fluid intake Neurologic (Hirschsprungs Disease) Depression - Discontinue laxative abuse Sedentary lifestyle - Exercise to strengthen abdominal Opiates, anticholinergics, antacids muscles Systemic Diseases (Hypothyroidism, Diabetic Neuropathy) Megacolon (Enlarged dilated colon, complication of Crohns Disease)

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A. Assessment $ Due to different personal bowel habits, it must be individually defined $ Normal bowel habits 2 3 evacuations /day $ Cramping Symptom of bowel obstruction Palpation discloses colonic distention, masses, tenderness $ Digital Rectal Examination (DRE) Assess sphincter and detect anal lesion $ Functional Constipation Resulting from lifestyle / bowel habits, usually has a long history $ Dysfunctional Constipation More likely to be sudden, because it accompanies the development of organic lesions that require careful education B. Diagnostic Test 1. Proctosigmoidoscopy: Visualizing the lumen of the rectum 2. Barium Enema: May be required if no lesions is directly visualized and symptoms persisted often simple treatment C. Treatment Dysfunctional: Manage underlying disease / lesion Functional 1. Bowel retraining 2. Engage in moderate exercise, drink more fluid ( Fiber intake) 3. Stool softeners and laxative agents 4. Enemas 5. Avoidance of high-caloric irrigations with large volume of fluid to prevent rupture of bowel D. Complications 1. Valsalva maneuver may result to rupture of a major artery in the brain / elsewhere 2. Fecal impaction 3. Megacolon / dilated and atomic colon Cause by fecal mass that obstructs the passage of colon 4. Cathartic Colon Mucosa atrophy of the colon with muscle thickening subsequent to chronic use of laxatives Fecal Incontinence - Involves passage of stool from the rectum - Ability of the rectum to sense and accommodate stool - Amount and consistency of the stool - Integrity of the anal sphincter - Rectal motility Clinical Manifestations: Soiling Occasional urge and loss of control Complete incontinence Poor control of flatus Medical Management Biofeedback therapy Bowel training program Surgery: Reconstruction of the sphincter

Irritable Bowel Syndrome (IBS)


Functional disorder of motility in the intestines; excessive motility Causes In FAT! FRESH FRUITS! Gas forming foods Carbonated beverages Alcohol Cause is unknown Hereditary Stress, depression Smoking

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Pathophysiology Clinical Manifestations Diarrhea (Can be alternative) Constipation Lower left quadrant pain (morning after eating) Tenderness in the SIGMOID area Alteration in bowel pattern Pain, bloating and abdominal distention Pain is precipitated by eating Frequently relieved by defecation Other Signs and Symptoms Nausea Distention Dyspepsia Eructation Borborygmi Gas motility Diagnostic Tests It will usually take 3 months before it is diagnosed Sigmoidoscopy / colonoscopy Barium enema CBC / Stool examination ** No confirmatory test / histologic feature (NOTE: Explore technique that could eliminate the possibility that the patient) Health Promotion 1. Fiber diet (Millers bran, bran cereals, whole wheat and grains) FAT, avoidance of carbonated drinks 2. Encourage to stress 3. Limit / stop smoking and alcohol consumption 4. Regular exercise 5. 8 hour sleep 6. Oral fluid intake (8 glasses/day) 7. Limit milk / milk products Medications 1. Sedatives 2. Antispasmodics 3. Metamucil ( Bulk in diet)

Structural and Obstructive Bowel Disorders Intestinal Obstruction


Is an interruption of the normal flow of intestinal contents along the intestinal contents along the intestinal tract. The block may occur in the small or large intestine, may be complete / incomplete, maybe mechanical or paralytic. It may or may not compromise the blood supply

TYPES and CAUSES Mechanical Obstruction Non-Mechanical Obstruction

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Mechanical Obstruction
A physical block at the passage of intestinal contents without disturbing the blood supply of bowel Types: 1. Extrinsic Adhesions from surgery, hernia (out pouching which may lead to necrosis), masses (colorectal cancer which can obstruct colon), volvulus (twisted loop of intestine) 2. Intrinsic Fecal impaction, tumor, intussusception, stricture / stasis, congenital Atresia (telescopic appearance which occurs with mucosal inflammation and cancer), inflammatory disease (Crohns Disease)

Non-Mechanical Obstruction
Types: 1. Paralytic Ileus (Adynamic Neurogenic) Absence of peristalsis Peristalsis is ineffective (diminished motor activity perhaps because of toxic or traumatic disturbance of the ANS) There is no physical obstruction and no interrupted blood supply Disappears spontaneously after 2 3 days Causes: 1. Major traumas (Spinal cord injuries, vertebrae fractures) 2. Post-operatively after abdominal / GI surgery particularly if the bowel has been extensively manipulated 3. Peritonitis / Sepsis 4. Electrolyte imbalance Particularly hypovolemia 2. Mesenteric Vascular Occlusion / Infarction and Strangulation Compromised blood flow Mesenteric Vascular Occlusion Infarction Result from extensive atherosclerosis of the mesenteric arteries or mesenteric thrombosis creates ischemia in the bowel 15 30 minutes after eating (usually pain occurs) CANNOT BE RELIEVED BY REST! Strangulation: Prolonged mechanical obstruction 3. Volvulus A twisting of the bowel upon itself usually at least a full 180, obstructing the intestinal lumen both proximally and distally Commonly occurs in the SIGMOID COLON 4. Intussusception The bowel segments containing the mass is propelled by peristalsis on to the adjacent bowel segment There is obstruction due to change in movement Pathophysiology
Hernia Intussusceptions Volvulus Diverticulosis Tumor Paralytic Ileum Protrusion of the intrinsic through a weak abdominal muscle or through an inguinal ring Telescoping of warm part of the intestine into another usually causes strangulation of the blood supply; more common in infants than adults (muscular structure is not yet developed) 10 15 months Twisting of the intestine with occlusion of blood supply most frequently in middle aged and elderly men Inflamed saccular herniation (diverticuli) of the mucosa most common in obese individuals older than 60 years old Growth into the intestinal lumen; adenocarcinoma of the colon, rectum is the most common tumural obstruction, common in individuals older than 60 years of age Loss of peristaltic motor activities in the intestine, assocated with abdominal surgery, peritonitis, hypokalemia, ischemic bowel, spinal trauma

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Signs and Symptoms


Abdominal Pain (Colicky: Minimal diffuse tenderness) Abdominal distention Nausea / Vomiting Vomiting may be persistent Bowel Sounds Increase / Hyperactive - *HUSH* Sounds Tachycardia BP Body weakness WBC Fever Difficulty of breathing Tachypnea Dilated intestine compressing the thorax

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Some signs and symptoms may vary depending on the location of the intestinal obstruction

Diagnostic Evaluation
Abdominal and Chest X-Rays 1. May show presence and location of small or large intestinal obstruction 2. Bird beak lesion in colonic volvulus 3. Foreign body visualization Contrast Studies (Barium) 1. Barium enema may diagnose colon obstruction or intussusceptions 2. Ileus may be identified by oral barium:

Laboratory Tests
a. May show NA, K and Cl levels due to vomiting b. Elevated WBC count with necrosis, strangulation / peritonitis ENDOSCOPIC Studies / Proctosigmoidoscopy Direct visualization on a narrowed intestinal lumen

Management
Non-Surgical Correction of fluid and electrolyte imbalance with NS/LR with KCl solution is required NG Suction to decompress bowel Treatment of SHOCK and PERITONITIS TPN may be necessary to correct protein deficiency from chronic obstruction, paralytic ileus Analgesics and sedatives, avoiding opiates (Morphine) due to GI motility inhibition Antibiotics for peritonitis Surgical Management: Consists of relieving obstruction Closed Bowel Procedure Lysis of adhesion, reduction of volvulus, intussusceptions and incarcerated hernia Enterostomy (Opening) for removal of foreign bodies Resection of bowel obstruction lesions or strangulated bowel with end to end anastomosis (Removal of affected area and connection of good layers) Temporary ostomy

Complications
1. 2. 3. 4. Dehydration due to loss of water, Na and Cl Peritonitis Shock Death due to shock

Nursing Management
Achieving pain relief 1. Administer prescribed analgesics as prescribed LOL (redundant naman XD) 2. Provision of Diversional activities 3. Provide supportive care during NG insertion to assist with discomfort Maintaining Fluid and Electrolyte Balance 1. Monitor I&O, VS, drop in BP may indicate blood loss 2. Monitor serum electrolyte levels, blood cell counts and refer abdominal results 3. Administer IV fluid and parenteral nutrition as ordered Maintaining Normal Bowel Elimination 1. Collect stool samples to test for occult blood if ordered 2. Maintain adequate fluid balance 3. Record amount, consistency of stools

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4. Maintain NGT to decompress as ordered Maintain Proper Lung Ventilation 1. Keep client in fowlers position to promote ventilation 2. Monitor ABG for oxygenation levels if ordered Patient Education 1. Explain the rationale for NG suctioning, NPO status, and IV fluids, advise client to progress diet slowly as tolerated once home 2. Advise plenty of rest and slow progression of activity as directed by the surgeon 3. Teach wound care if indicated 4. Encourage client to follow up as directed and to notify the surgeon for: Abdominal pain Vomiting Fever

Crohns Disease (CD)


Also known as REGIONAL ENTERITIS Chronic, episodic, inflammatory condition of the GI tract Characterized by bowel movement: 1. Transmural Inflammation (Affecting the entire wall of the involved bowel) and; 2. Skip Lesions (Areas of inflammation with areas of normal lining in between) Cause: Unknown Genetic and environmental factors have been invoked in the pathogenesis of the disease Environmental factors such as: Diets high in sweet, fatty or refined foods Smoking Oral contraceptives Bacteria found in the colon such as mycobacterium avium sub species paratuberculosis Signs and Symptoms GI Symptoms Abdominal pain Crampy and may be relieved by defecation Often accompanied by diarrhea which may be bloody More than 20 BM/day in SEVERE CASES Bloody BM are typically intermittent and my be bright and dark red in color (+) flatus, and bloating Nausea / vomiting Abdominal distention Systemic Growth failure Weight loss (Due to oral) Fever Complications GI Symptoms Obstruction Typically occurs from strictures or adhesions which narrow the lumen, blocking the passage of the intestinal contents Fistulae Can develop between two loops of bowel, between the bowel and bladder, between the bowel and vagina and bowel and skin Abscess Are walled off collections of infection and can occur in the abdomen or in the perianal area in Crohns disease sufferers Malnutrition and Cancer Bone Complications Prolonged steroid use and menopausal women are at risk Liver and Gallbladder Effect of medications (Nephrotoxicity and hepatotoxicity)

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Assessment and Diagnostic Findings - Proctosigmoidoscopy initially - Stool examination May be (+) for occult blood and steatorrhea - Barium study of the upper GI o Is confirmatory which shows classic string on X-ray film indicating constriction of the segments involved o

Nursing Interventions
1. 2. 3. 4. 5. 6. Assess frequency and characteristics of stool to evaluate losses and effectiveness of therapy Have the client describe the location, severity and onset of abdominal cramping of pain Ask the client about weight losses and anorexia. Wight daily to monitor changes Have the client describe the food eaten to elicit dietary exacerbation Determine if the client smokes, including duration and amount Ask about family history of GI diseases

Diagnostic Tests Upper GI series (Location) Flexible Sigmoidoscopy Barium enema Biopsy Lab findings WBC Hct, Hmg, ESR Fluid and electrolyte imbalance (Due to Na, Cl, K dehydration) Treatment To treat acute disease and maintain remission Involves the use of medications to treat any infection and to reduce inflammation Usually involves the use of aminosalicylate anti-inflammatory drugs and corticosteroids and may induce antibiotics Surgery Resection and anastomosis May be required for complications such as obstruction or abscesses or if the disease does not respond to drugs within a reasonable time Diet and Lifestyle Stress management techniques (Exercise) Residue diet may reduce volume of stool per day Lactose Intolerance Avoid lactose containing foods Smoking and NSAIDS drugs should be avoided Lifestyle changes Physical rest Residue diet (To slow motility / stool) Elimination of dairy products for lactose intolerance Treatment in children: If the disease is not treated before 18, of the children have short stature or delayed growth Intervention: Aggressive nutrition therapy

Ulcerative Colitis (UC)


Spans the entire length of the colon Involves mucosa and submucosal layer More COMMON than Crohns disease

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Causes 1. History of exposure to bacteria 2. Allergic reaction 3. Altered immune status Recurrent ulcer and inflammatory condition of the mucosa and submucosal layers of the rectum The colon becomes edematous and develop bleeding ulcerations Scarring develops over time with impaired water absorption and loss of elasticity

Clinical Manifestations 1. Severe diarrhea (10 20 liquid stools/day) with rectal bleeding 2. Weight loss 3. Fever Assessment and Diagnostic Findings 4. Anorexia Assess for tachycardia, Tachypnea, hypotension, fever 5. Anemia and hypocalcemia and pallor, level of hydration and nutritional status 6. Dehydration Stool exam (+) for blood 7. LLQ Abdominal pain and cramping Hct and hmg and albumin 8. Tenesmus Straining on defecation WBC Nursing Diagnoses - Altered nutrition: less than body requirements related to pain, nausea - Fluid volume deficit related to diarrhea - Pain related to inflammatory disease of the small intestine
Sigmoidoscopy, colonoscopy Barium Enema MRI and CT Scan Complication Toxic megacolon Perforation Bleeding Osteoporotic fracture

Nursing Intervention for CD and UC


1. 2. 3. 4. 5. 6. 7. 8. Maintain NPO during acute Monitor for complications like severe bleeding, dehydration, electrolyte imbalance Monitor bowel sounds, stool and blood studies Restrict activity = Rest and comfort Administer IVF, electrolytes, TPN if prescribed (Monitor complications of diarrhea) Instruct the client to avoid gas forming foods, milk products such as wheat grains, nuts, RAW fruits and vegetables, especially spinach, pepper, alcohol and Diet Progressive = Clear liquid Residue, CHON diet Administer drugs Anti-inflammatory, antibiotics, steroids, bulk forming agents (Metamucil) vitamins / iron supplements

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