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

Alterations IV

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Continuation Appendicitis
Inflammation of the vermiform appendix, can affect many age groups, most common in males 10 30 years old Causes: o Obstruction of the intestinal lumen infection o Stricture o Fecal mass o Foreign body or tumor

Topics Discussed Here Are: 1. Continuation a. Appendicitis (Plus Peritonitis) b. Diverticular Disease 2. Anorectal Disorders a. Hemorrhoids b. Anal Fissure

Clinical Manifestations 1. General or localized abdominal pain in the epigastric or periumbilical areas and upper right abdomen within 2 12 hours, the pain localized in the RLQ and intensity increases 2. Anorexia, moderate malaise, mild fever, nausea, vomiting 3. Usually constipation occurs, occasionally diarrhea 4. Rebound tenderness, involuntary guarding, general abdominal rigidity (RUPTURED APPENDICITIS) Diagnostic Test 1. CBC will show WBC (Leukocytes) 2. Urinalysis to rule out urinary disorder 3. Abdominal X-ray may visualize shadow consistent with fecalith 4. Abdominal CTZ/CT Scan Pathophysiology
Nursing Interventions 1. PreOp! Care Monitor bowel sounds, hydration status Position of Comfort: RIGHT SIDE LYING IN A LOW FOWLERS Avoid laxatives, enemas and heating application 2. PostOp! Care Monitor VS and signs of surgical complications Maintain NPO until bowel function returns If rupture occurred, expect drain and IV antibiotic Position PostOp!: RIGHT SIDE LYING HIGH FOWLERS (To tension on incision and legs flexed to promote drainage) Administer prescribed pain medications

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Appendicitis (Mnemonics Thingy) - Rare in children < 2 years - Begins AS DULL, STEADY pain in PERIUMBILICAL AREA, progresses over 4 6 hours and localizes to RLQ - Low Grade FEVER - Nausea - Anorexia - Sudden pain relief may indicate RUPTURE of appendix which may lead to PERITONITIS - Rebound pain or tenderness DIAGNOSIS - Clinical signs and symptoms - WBC - Abdominal sonogram - Exploratory Laparoscope

PERITONITIS HOT BELLY (Mnemonics thingy din) Risk Factors Ectopic pregnancy Abdominal Surgery Perforation o Diverticulum o Appendix Nursing Care: o Ulcer Maintain F&E balance and GI distention o Trauma o NG Suction o IV Solution (NS, LR) Clinical Manifestations o Potassium Supplement with acare Pain over area o Peristalsis Bowel sounds? Presence of a CAUSE o I&O Rebound tenderness o Signs and Symptoms of Abdominal rigidity (Board like) HYPOVOLEMIA Fever Infectious process Anorexia o Antibiotics, VS, SEMI-FOWLERS N/V Prevent complications of immobility Pulse, BP Bowel sounds Dehydration Diagnostics CBC, X-ray, Paracentesis, History Treatment Identify cause Antibiotics IV Fluids Abdominal distention

Management a. Surgery (Appendectomy is indicated) a. Simple appendectomy or laparoscopic appendectomy in absence of rupture or peritonitis b. An incisional drain may be placed if an abscess or rupture occurs b. Pre-operative: Maintain bed rest, NPO status, IV hydration, possible antibiotic prophylaxis, analgesia

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Complication: 1. Perforation (95%) 2. Abscess 3. Peritonitis Nursing Assessment 1. Obtain History for local and extent of pain 2. Auscultate bowel sounds (Absent / hypoactive) 3. Palpate over McBurneys Point Rebound Tenderness? 4. Assess for Psoas Sign 5. Assess for (+) Obturator sign 6. Assess for Murphys Sign Nursing Diagnosis 1. Alteration in comfort: Pain related to inflamed appendix 2. Risk for infection related to perforation of the intestinal lumen Nursing Interventions and Patient Education 1. Monitor pain level, PQRST 2. Assist patient to comfortable position, such as Semi-fowlers and knees up 3. Restrict activity that may aggravate pain such as cough and ambulation 4. Apply ice bag to abdomen to decrease discomfort 5. Give analgesics ONLY as ordered after diagnosis is determined 6. Avoid indiscriminate palpation of the abdomen to avoid increasing patients discomfort 7. Instruct client to avoid HEAVY lifting 4 6 weeks after surgery 8. Instruct client to report symptoms of anorexia, N/V, fever, pain, incisional redness or drainage post-operative

Diverticular Disease
Diverticulum Blind out pouching or herniation of intestinal mucosa through the muscular layer coat of the large intestine Common to men and women above 45 years old (15 20%) Obese person (Increase intra-abdominal pressure) Two Forms Diverticulosis: Diverticulas are present but may cause only MILD or NO SYMPTOMS; may progress to DIVERTICULITIS Diverticulitis: Diverticulas are INFLAMED and may cause potentially FATAL OBSTRUCTION, INFECTION, HEMORRHAGE Etiology 1. Fiber Diet 2. Diminished colonic motility and Intraluminal pressure 3. Defects in wall strength (weakness) Marfans Syndrome 4. Increasing age 5. Unnatural sitting posture Diagnostic Evaluation 1. Colonoscopy Visualization of the colon 2. X-ray, rectum, MRI

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Pathophysiology

Clinical Manifestations Depends on the extent and site of occurrence Mild Diverticulitis o Moderate Left Lower Abdominal Pain (LLQ) o Low grade fever o Leukocytosis (WBC) Severe Diverticulitis o Abdominal Rigidity o Left Lower Quadrant PAIN! LLQ o High fever, chills, HTN from septic shock o Microscopic massive hemorrhage o Diminished bowel sounds o N/V

Treatment No Often Treatment is needed Hydration Fiber in diet (20 35 grams/day) Removing factors resulting in constipation If diverticulas are greater than 1 inch with other severe symptoms SURGERY is NEEDED

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Medical Management Chlordiazepoxide (Librium), Deocyclomine (Bentyl), Donnatal and Hyoscyamine (Levsin) For bloated and abdominal pain All drugs are ANTISPASMODIC Oral antibiotics Metronidazole, Ciprofloxacin, Cephalexin, Doxycycline ACUTE DIVERTICULITIS o NPO Status o NGT o Parenteral fluids o Antibiotics (Until signs and symptoms of inflammation subsides) o When acute episodes subsides More inclusive diet Health teaching about diet changes Surgical Management Surgery Indicated if such complications are present: o Hemorrhage o Obstruction o Abscess o Perforation Ligation and removal of the sac or resection of involved bowel In Abscess or Obstruction Colon resection with temporary colonostomy Vasopressin Infusion If bleeding continues Possible Nursing Diagnoses Constipation Hyperthermia Pain Diarrhea Low self-esteem Infection Risk for infection

Anorectal Disorders Hemorrhoids


Abnormal distention and weakening of the veins of the anal canal Variously classified as Internal or External, Prolapse, Thrombosed and Reducible Risk Factors Intra-abdominal pressure caused by pregnancy, constipation with prolonged straining, obesity, CHF, prolonged sitting or standing (Due to virtue of gravity), cirrhosis with portal hypertension (Damage in liver) o CHF due to decreased venous return because of congestion = VENOUS POOLING Pathophysiology HEMORRHOIDS Wala XD (Di ko nacopy) INTERNAL HEMORRHOIDS - These distended veins lie ABOVE the internal anal sphincter - Usually the condition is PAINLESS EXTERNAL HEMORRHOIDS - These lie BELOW the internal anal sphincter - Usually the condition is PAINFUL

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Assessment Findings 1. Internal Hemorrhage Cannot be seen on the perianal area 2. External Hemorrhage CAN BE SEEN! 3. Bright red bleeding with each defecation 4. Rectal / Perianal pain Nursing Interventions: 5. Rectal itching 1. Advise client to apply cold packs to the anal / 6. Skin tags rectal area 2. Hazel soaps Diagnostic Tests 3. Fiber 1. Anoscopy / Proctoscopy 4. Stool softeners as prescribed 2. Digital Rectal Examination Clinical Manifestation Enlarged mass at the anus Rectal itching Constipation Pain (Associated with thrombosis) Bright red blood in stool / tissue Surgical Management a. Sclerotherapy b. Ligation (Removing the vein) c. Cryosurgery (FREEZING!) d. Laser (Burning) e. Hemorrhoidectomy (most common) Post-Operative Complications 1. Hemorrhage 2. Urinary retention (Constipation blocks bladder!)

PostOp! Care for Hemorrhoidectomy


1. 2. 3. 4. 5. Position: PRONE / SIDE LYING! Maintain dressing over the surgical site Monitor for bleeding Administer analgesics and stool softeners Administer the use of SITZ BATH 3 4 times a day

Anal Fissure
Ulceration or tear of the lining og the anal canal Usually posterior wall Causes: 1) Excessive stretching 2) Frequent passage of hard and large stool Types: Acute Chronic Management 1. Keep the stool soft (Metamucil, Mineral Oil, Docusate Sodium) 2. Daily bowel movement 3. Clean area with WARM water after defecation (Hot SITZ BATH) Clinical Manifestations Same with Crohns Disease Predisposing is rectal bleeding Diarrhea of 20 or more stools a day Same MEDS and MANAGEMENT (Medical and Surgical) of Crohns Disease

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