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GASTROINTESTINAL SYSTEM
OBJECTIVES:
After this unit the student will be able to indicate the different
conditions affecting gastrointestinal system
To assist in different surgical intervention for gastrointestinal
management
To collaborate with other health providers in management of
the different conditions affecting gastrointestinal system
To provide an accurate education for client and family with
gastrointestinal conditions
To use nursing process in providing nursing intervention for a
client suffering (GIC)
To perform different nursing skills aimed to help a client
with(GIC)
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GENERAL CONDITIONS
The gastro intestinal system is mainly affected by :
DISORDERS OF ORAL BUCCO CAVITY( stomatitis, pa
rotitis,CANDIDOSIS,DENTAL ABCESS,PULPITIS)
TEMPOMENDIBULO DISORDERS
DISORDERS OF ESOPHAGUS (gastroesophageal
reflex ,motility disorder
GASTRIC AND DUODENAL (gastritis, peptic ulcer,Hiatal
hernia
INTESTINAL AND RECTAL(intestinal obstruction,
peritonitis ,Anal fistula, hemorrhoids)
DISORDER OF FECAL ELIMINATION (Constipation
and Diarrhea, Fecal incontinence)
CANCERS AND MALNUTRITION
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GENERAL MANAGEMENT
Surgical intervention:
Laparotomy
Gastrectomy
Intestinal resection
Vagotomy
Sclerotherapy
Hemorroidectomy
Apicectomy
Incision and drainage
Ileostomy
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Medical management
Spasmolytic
agents
Oral and IV antibiotic
Antifungal
Antacids
Antisecretory Drugs
Antidiarrheal
anti-inflammatory
Stool
softener
Antimotility
Peristaltic Stimulant
Antiemetic drugs
Anticholinergics
Cytoprotectives
Vitamin supplements
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1.
2.
3.
4.
5.
6.
7.
GENERAL INVESTIGATION
Other Clinical
Laboratory exam
investigations
Stool examination ( parasite
,appearance of the
Colonoscopy
stool, gravity of the stool and
Endoscopy
Full blood count ( rule out infection or
Ultrasound
inflammation
Laparoscopy
Hemoglobin levels (usually
decreased)
Biopsy
Electrolyte studies
CT scan
Albumin and protein measurement
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GI Focused Assessment
Physical
Vital
Signs
Height and Weight
Lab and diagnostic test results
Emesis ,amount, color, consistency
Stool , amount, color, consistency, odor.
Oral Assessment
Abdominal Assessment
Rectal Assessment
Anthropometric
BMI
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Pain
Indigestion
Intestinal
gas
Nausea and vomiting
Hematemesis
Changes in bowel habits
Stool characteristics
Dyspepsia
Heartburn
Regurgitation
Water brash
Nausea, vomiting
pain, cramps,
headache,
Myalgias, altered sensorium
Thirst, tachycardia,
orthostatic, decreased
urination,
Lethargy, decreased skin
turgor
Watery, bloody, mucous,
purulent, greasy stool
fever, tenesmus, blood and/or
pus in the stool)
weight gain and weigth loss
Some patients are woken at
night by choking as refluxed
fluid irritates the larynx
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CONTCLINICAL FEATURES
Hypo or hyper pigmentation
(difficulty swallowing)
Desquamation
Odynophagia (pain on swallowing)
Ulceration
Anemia
Pain with burning sensation
Chest pain
Redness and bleeding
sometimes
Signs of complication like dehydration
or shock
Bad odor
Severe palmar pallor
Swelling
Eye signs of vitamin A deficiency
Xerostomia mouth dryness
Pus
Localizing signs of infection
Sores
Fever or hypothermia
Hypersyarrhea or salivary
Mouth ulcers
gland decreased
Skin changes of kwashiorkor:
Dysphagia
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Related information
BY THIS WE NEED THE INFORMATION
ABOUT:
Previous GI disease
Past and current medication use.
Nutritional status and eating patterns or unexplained
weight gain or loss over the past year
Questioning about the use of tobacco and alcohol
The nurse records all abnormal findings and reports
them to the physician
Psychosocial, spiritual, or cultural factors that may
be affecting the patient
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Dental conditions
Dental abscess ,pulpitis ,gingivitis ,periodontitis
The most cause are inflammation that lead to
infection
Pulpitis( pus-producing inflammation of the
dental pulp) that arises from an infection
extending from dental caries
Gingivitis Painful, inflamed, swollen gums;
usually the gums bleed in response to light
contact
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Clinical manifestations
Pain
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Dental abscess
Definition
Causes(food
acute pulpitis
complications
Clinical manifestations
Medical management
Nursing management
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Dental abscess
This
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Cont
Predisposing Risk FactorsClinical manifestations
Localized, constant, deep,
Dental caries
throbbing pain
Poor dental hygiene
Pain worsens with
mastication or exposure to
Dental trauma
extreme temperatures
Tooth may be mobile
Gingival or facial swelling
and tenderness (or both) may
be present
inability to open the mouth.
Fever (rare but possible
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Medical management
Analgesics for mild to moderate pain:
(Acetaminophen, Ibuprofen
Oral antibiotic therapy: penicillin v or
amoxicillin for 60mg/kg/day in 7 days
For a client having allergic to
penicillin the Clindamycin
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Nursing management:
Nursing assessment (history taking,
physical examination)
History taking
Localized, constant, deep, throbbing pain
Pain worsens with mastication or
exposure to extreme temperatures
Tooth may be mobile
Gingival or facial swelling and
tenderness (or both) may be present
Fever (rare but possible)
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Physical Assessment
Facial swelling may be present
Carious tooth
Gingival edema and erythema
Tooth may be loose
Anterior cervical nodes enlarged and
tender
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Assess
ment
Nursing Goal/Ex
diagnosi pected
s
outcom
es
Assessm
ent:
Subjectiv
e data
Objective
data
Pain due
to
disease
process
as
manifest
ed by
facial
expressio
n
depresse
d,
inability
to talk,
inability
interven rational
tions
e
Patient
1. admin
will be
istrati
free from
on
pain in
analg
4hrs
esic
As
(aceta
evidence
minop
d bay
hen
normal
2. Oral
verbal
hygie
communi
ne
cation
with
,normal
Warm
facial
saline
expressio 5/29/16rinses
Jean bosco RN BSN
evaluati
on
Potential Complications
Cellulitis
Recurrent
abscess formation
Systemic infection
Osteomyelitis
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Surgical management
for acute Needle aspiration by a dentist surgeon
for relieving pain and for pus drainage
for chronic ,After using x-ray to discover the
blind dental abscess
extraction or root canal therapy may be used
( apicectomy )excision of the apex of the tooth
root for dentoalveolar abscess or blind dental
abscess
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Oral candidiasis
Fungal
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Clinical manifestations
Burning
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Systemic
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Cont
Candida-associated denture
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Jean bosco RN BSN
stomatitis.
Medical management
Oral
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DIAGNOSIS
After
ASSESSM
ENT d
NURSING
DIAGNOSI
S
GOAL/EXP
ECTED
OUTCOME
S
INTERVENTIONS
sores,
ce of
products that
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Jean bosco RN BSN
cream
white
oral
contain
RATION
AL
EVALU
ATION
Medical management
Antacids,
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Collaborative management
Weight
loss
Avoidance of tight-fitting garments
Avoidance of dietary items which the patient
finds worsens symptoms
Elevation of the bed-head in those who
experience nocturnal symptoms
Avoidance of late meals
Cessation of smoking
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Hiatal hernia
A part
Manifestations
Occur
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TYPES
1.
Types
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Management
Drink
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SURGICAL MANAGEMENT
All
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Peptic ulcer
A peptic
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New
Idiopathic
Stress
Smoking
Spicy food
Helicobacter Pylori
NSAID
Crohns disease
Gastronoma
Hyperparthyroidism
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Clinical manifestation
30% asymptomatic
Dyspepsia
Anaemia
Haematemesis / melaena
A dull pain or a burning sensation in the
midepigastrium or in the back.
Sharply localized Tenderness
pyrosis (heartburn),
vomiting, constipation
diarrhea and and bleeding
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complications
Bleeding:
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Management
The management is based on these following
steps
Treatment (Drugs)
Lifestyle and dietary modification
Operation
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Lifestyle change
Less
stress
Regular diet
Avoid NSAID
Quit smoking
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Drugs
Eradication
of HP
Gastric acid neutrolizers Antacids
Antisecretory
Cytoprotectives
Eradication of HP
First line treatment
Triple therapy- 2 antibiotics and 1 PPI for 1 week
Clarithromycin 500mg BD
Amoxicillin 1g BD
Nexium 20mg BD
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Cytoprotectives
Sucalfate (aluminum hydroxide + sucrose) Form a
paste to protect gastrointestinal mucosa 1 g QID
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Surgical interventions
Indications
Refractory ulcer
Complications
Bleeding
Perforation
Pyloric stenosis
Acid reduction surgery
Vagotomy
Gastrectomy
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Post-op Care
Nasogastric Gastric tube management
patency, position (co2, pH paper)
Bright
& stability observe, record and
report output
red/24
Dark red/ PO Day
Fluid replacement
1
IV fluids
Red/green PO Day
2
blood products
Bile color PO Day
Pain management
3
Cough, Deep Breathe, Ambulate
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Assessm Nursin
ent
g
diagno
sis
Goal
/expec
ted
outco
mes
Subjecti
ve and
objectiv
e data
Dyspep
sia
signs
of
Anaemi
a
Haema
temesi
s/
melaen
Patient
will
gain
the
normal
nutritio
n
status
as
evidenc
ed by
normal
Imbalan
ced
nutritio
n less
than
body
require
ment
related
to
changes
in diet
intake
As
Nursi Ration
ng
ale
interv
ention
s
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evaluation
Diagnosis
Analysis of cues or data as obtained from history and
physical examination
To obtain the priority nursing diagnosis
Epigastric pain
Electrolyte and fluid imbalance
Planning(care Plan)
Acute pain related to the effect of gastric acid secretion on
damaged tissue
Anxiety related to coping with an acute disease
Imbalanced nutrition related to changes in diet
Deficient knowledge about prevention of symptoms and
management of the condition
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GASTRITIS
Inflammation of the gastric or stomach mucosa) is a common GI
problem it may be acute or chronic
Causes and risk factors
Exposure to irritating agents
Hypochlorhydria(absence or low levels of hydrochloric acid [hcl]) or
with hyperchlorhydria(high levels of hcl)
Excessive alcohol intake
Bile reflux and radiation therapy
Acute systemic infection
Ingestion of strong acid or alkali
NB: chronic
Autoimmune diseases such as pernicious anemia;
Dietary factors ( caffeine; the use of medications nsaids; alcohol;
smoking; or reflux of intestinal contents)
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it involve autoimmune
activity against parietal cells
Type B (bacterial infection) :it provokes an
acute inflammatory response
Type C (reflux gastritis): the regurgitation of
duodenal contents into the stomach through the
pylorus
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COLLABORATIVE MANAGEMENT
Treatment
Assess
ment
Nursing Goal/ex
diagnosi pected
s
outcom
es
Subjectiv
e
objective
data
abdomin
al
discomfo
rt
headach
e
Lassitude
nausea
anorexia
vomiting
Anxiety
related
to coping
with an
acute
disease
Nursing rational
interven e
tions
1. Asses
s
what
patien
t
wants
to
know
about
the
diseas
e,
ande
valuat
e Jean bosco RN BSN
5/29/16
Evaluati
on
Peritonitis
Peritonitis
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Causes
Primary
of GIT wall
ruptured appendix
perforations the stomach( ulcers) and gallbladder
Pelvic inflammatory disease in sexually active women
after surgery
Peritoneal dialysis
Diagnostic studies
using X-rays or a CT scan (the presence of fluid,
accumulation of pus or infected organs in the abdomen.
samples of blood or abdominal fluid (causative
microorganism)
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Collaborative Management
Fluid and Electrolyte
Replace
Elimination
NG
Protection
Incision
& Drainage
Wound Care w/ irrigations
wound drainage
Antibiotic Therapy
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Medical management
Antibiotic
administration(ampicilline)
Analgesic (morphine)
Immediate surgery to wash the pertonial cavity
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Nursing Priorities
Assessment
Pain
Bowel sounds
Wound Care
Post-op
ARDS
Sepsis Septic Shock
IV fluids & antibiotic therapy
Teaching Wound Care
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Comparison
Crohns Disease
Ulcerative Colitis
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Crohns
Ulcerative
Colitis
Distributio
n
Inflammati
on
Common
CMs
Blood in
stool
Visible w/colon
involved
Carcinogene
Mild Risk
Discontinuous
Transmural
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Continuous
Mucosa & submucosa
Usually visible
Risk after 10
Hemodynamic
stability
Restore/maintain fluid & electrolyte balance
Nutritional support
Parenteral Nutrition (PN) bowel rest
Elemental or low residue diet
Decrease immune response
Immuno-suppressants : Azathioprine (Imuran)
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Medical management
Diarrhea if severe(npo
Antidiarrheal(lomotil, imodium)
Aminosalicylates (anti-inflam. Prostaglandin
synthesis)
Corticosteroids
Immunosuppressives
Remicade blocks action of TNF
Anticholinergics
Anti-infectives
Sulfonamides
Flagyl
Cipro
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Nursing Interventions
Diarrhea
Bowel rest
Help patient determine causative foods (caffeine, spicy)
Skin integrity
Encourage protein intake
Cleanse well, Sitz bath, moisturizer & barrier creams
Acute Pain r/t inflamed bowel mucosa
Assess, alert to complications
Use narcotics as needed (PRN)
Teach cancer screening (ulcerative colitis)
Ineffective coping
Identify ineffective coping behaviors
Include family, other staff in plan
Encourage expression of feelings
Stress reduction techniques
Referrals as necessary
Counseling, dietician
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Surgical Management
Crohns Disease
Surgery not usually indicated except for
complications
Perforation
Hemorrhage
Obstruction
Ulcerative colitis
25-40% eventually will need surgery.
Permanent ileostomy
Continent ileostomy
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Intestinal obstruction
A blockage
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Clinical Manifestations
High
Low
Gradual onset
Vomitus orange brown & foul smelling
d/t overgrowth of bacteria
Distention
Metabolic Acidosis
No fecal nor flatus that pass only blood
and mucus
Signs of shock
Rapid onset
Projectile vomitus of bile
Vomiting relieves pain
Distention minimal or absent
Large Bowel
Metabolic alkalosis
Bowel Sounds
Vomiting may be absent with ileocecal
valve competent or fecal vomiting signs
of constipation
high pitched
Lower abdominal clumpy pain
over area of obstruction Incompetent valve vomits fecal material
Loop of large intestine may be seen on
the outline of the abdominal wall
audible
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Collaborative Management
Decompression(
NG tubes- Intestinal tubes (controversial)
Sigmoid tubes to reduce volvulus
Correct & maintain fluid balance
(IV normal saline w/ K+
TPN to correct nutritional deficiencies
Relief or removal of obstruction
(surgery
colonoscopy then cecostomy
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Hemorrhoids
condition in which the portion of the anal became
dilated including the vascular tissue(veins) ,this
can occur on the internal or external sphincter and
it can result the sliding of the whole anal wall
including the vascular tissue in the(lumen) of anal
cavity
TYPES:
the hemorrhoid can be categorized into 2 mains
types: internal hemorrhoid (internal sphincter) anal
and external hemorrhoid(external sphincter) depend
on the location where the veins were dilated
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Clinical manifestations
Itch
Causes
Constipation.
Hold
Complications
Ischemia
Hemorrhage
Anal
stenosis
Thrombos
Rectal obstruction
constipation
impactation
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Nursing Management
Good
personal hygiene
Sitting for few minutes warm water a few times
a day may help(sitz baths)
Avoiding excessive strain during defecation.
Consume diet that contains fruit
Avoid intraobdomonial pressure
Increase fluid intake
Warm compresses
Bed rest allow the engorgement to subside..
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Pharmacological interventions
Corticosteroid
creams
Nitroglycerin ointment
Analgesic ointment( Nupercainal)
Calcium dobisilate
The addition of hydrophilic agents psyllium
and mucilloid
Analgesic ointments or suppositories,
Astringents (eg, witch hazel),
Injecting sclerosing solutions
Stool softener
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Surgical management
With
Diarrhea
Frequent
Types
how?
Osmotic
diarrhea
Secretory diarrhea
Infectious diarrhea
The aim of management :
To correct dehydration and electrolyte deficits.
By fluids replacement orally or intravenously
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Risk factors
Consumption
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General manifestations
Nausea,
vomiting
Abdominal pain, cramps, headache,
Myalgias, altered sensorium
Thirst, tachycardia, orthostatic, decreased
urination,
Lethargy, decreased skin turgor
Watery, bloody, mucous, purulent, greasy stool
Signs of dysentery(fever, tenesmus, blood and/or
pus in the stool)
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MANAGEMENT
The
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What to assess
When
and how the illness began (e.G., Abrupt or gradual onset and
duration of symptoms);
Stool characteristics (watery, bloody, mucous, purulent, greasy, etc.);
Frequency of bowel movements and relative quantity of stool
produced;
Presence of dysenteric symptoms (fever, tenesmus, blood and/or pus
in the stool);
Symptoms of volume depletion (thirst, tachycardia, or thostasis,
decreased urination, lethargy, decreased skin turgor); and
associated symptoms and their frequency and intensity (nausea,
vomiting, abdominal pain, cramps, headache, myalgias, altered
sensorium).
Risk factors
Observe for abnormal vital signs or other signs of volume depletion
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Constipation
The difficult or unduly infrequent passage of
faeces or abnormal infrequency or irregularity
of defecation.
Abnormal hardening of stools ( difficult and
sometimes painful, a decrease in stool volume, or
retention of stool in the rectum for a prolonged
period)
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Causes
Rectal
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Complication
Abdominal
distension/pain;
Anorexia, nausea and/or vomiting
Faecal overflow incontinence
Hemorrhoids/anal fissure
Urinary retention/infection
Faecal impaction (that can lead to bowel
obstruction)
Agitated delirium.
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Management
Goals
of Management
The main goal is to prevent the consequences of
constipation, or treat them if they have occurred.
Identify and treat any reversible causes if appropriate.
Proactive management with prophylactic laxatives in
patients at high risk of constipation (e.g. commencing
opioid).
Education of patient and carers about the importance of
close vigilance of bowel pattern, early intervention and
ongoing management of constipation.
Aggressive intervention to reverse severe
constipation/faecal impaction and to prevent recurrence.
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Medical management
First
Second line
When
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CONT
Quality
What does it feel like?
Is using your bowels painful?
Is there a feeling of incomplete evacuation?
What do the stools look like?
Where do you most feel it? (abdomen? ano-rectal area?)
Severity
How bad is the constipation (on a scale of 0 to 10 with 0 being none
and 10 being
worst possible)? Right now? At best? At worst? On average?
How bothered are you by it?
Are there any other symptoms that accompany the constipation e.g.
anorexia,nausea, vomiting, abdominal pain, pain on defecation,
bloating
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Colaborative management
The
Cont
Fluid intake should be between 2 and 3 L/day unless
contraindicated. Prune juice or fig juice (120 mL)
taken 30 minutes before a meal once daily is helpful to
some cases
when constipation is a problem. Physical activity and
exercise are encouraged, as is self-care in toileting.
The patient is encouraged to respond to the natural urge
to defecate.
Privacy during toileting is provided.
Stool softeners, bulk-forming agents, mild stimulants and
suppositories may be prescribed to stimulate defecation
and to prevent constipation.
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Malnutrition
a condition in which a client show poor nutrition due to
insufficient or excessive or imbalanced diet or from inability to
absorb foods.
RISK FACTORS OF MALNUTRITION
Elderly people
Hospitalized people for long time
Poor people (People with low income)
People with chronic eating disorder
People convalescing after serious illness such as measles,
pneumonia and diarrhea
Medications side effects can reduce dietary intake (proton
pump inhibitor)
Dysphagia
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Types of malnutrition
Acute
malnutrition
Marasmus (wasting)
Kwashiorkor (oedematous)
Chronic malnutrition
Stunting
Growth faltering (underweight)
Composite of acute & chronic malnutrition
Specific nutrient deficiency
Anaemia, Iodine etc
Malnutrition secondary to disease
HIV / TB
Any illness
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Management
It start with initial assessment
History taking that include :
Recent intake of food and fluids
Diet
Duration and frequency of diarrhea and vomiting
history of diarrhea
Family circumstances
Chronic cough
Contact with TB
Known or suspected HIV infection
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On physical Examination
Assessment
of Anthropometry:
(Age,Sex,Weight,Height,Bilateral edema,MUAC) Mid Upper
Arm Circumference ,BMI
Signs of complication like dehydration or shock
Severe palmar pallor
Eye signs of vitamin A deficiency
Localizing signs of infection
Fever or hypothermia
Mouth ulcers
Skin changes of kwashiorkor:
Hypo or hyper pigmentation
Desquamation
Ulceration
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Management of complications
Hypoglycemia:
Hypothermia(<35C):
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Electrolyte imbalance:
Extra potassium should be added to the feeds during
their preparation.
All severely malnourished children have deficiencies of
potassium and magnesium which may take 2 weeks or
more to correct.
Infection:
In severe malnutrition, the usual signs of infection such
as fever are often absent, yet multiple infections are
common.
Therefore, assume all malnourished children have an
infection on their arrival at the hospital and treat with
broad spectrum antibiotics straight away
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Micronutrient deficiencies:
CONT
Eye
problems:
If the child has eye signs of vitamin A deficiency (dry
conjunctiva or cornea, corneal ulceration, keratomalacia):
Give vitamin A orally on day 1,2 and 14 (aged <6
months5, 0000 IU; aged 6-12 months, 100000 IU; older
children, 200000 IU)
If the eyes shows signs of inflammation or ulceration
Instill Chloramphenicol or tetracycline eye drops, 3
hourly for 7-10 days.
Instill atropine eye drop.
Cover with saline-soaked eye pads.
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Daily diet
Frequent
1.
2.
3.
4.