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Gastrointestinal Disorders part 2

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Anthony Arciete

on 21 February 2013

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Transcript of Gastrointestinal Disorders part 2

Disorders II Gastrointestinal IRRITABLE BOWEL SYNDROME Irritable Bowel Syndrome (IBS) results from a functional disorder of intestinal motility. The change in motility may be related to neuroendocrine dysregulation, infection or irritation, or a vascular or metabolic disturbance.

Factors associated: Heredity, (women > men), psychological stress, depression and anxiety, a diet high in fat and stimulating and irritating foods, alcohol consumption, and smoking. Clinical Manifestations •constipation, diarrhea, or a combination of both.
•Abdominal distention Diagnostic Exams •Stool exams
•Contrast X-ray studies
•Barium enema
•Electromyography Assessment and Diagnostic Findings •History
•Bleeding (penetrating)
•Bruises and abrasions (Cullen’s sign and
Turner’s sign)
•Auscultation of bowel sounds
•Progressive abdominal distention Clinical Manifestations •Sigmoid colon or rectum – constipation
•Shape of stool is altered
•Blood in stool
•Weakness, weight loss, anorexia
•Marked abdominal distention
•Loops of large bowel become visibly outlined through the abdominal wall
•Crampy lower abdominal pain
•Fecal vomiting
•Shock Pathophysiology Intestinal obstruction – intestinal contents, fluid and gas accumulate above the intestinal obstruction – abdominal distention and retention – reduce absorption of fluids and stimulate gastric secretion – (distention) increased pressure within the intestinal lumen – decrease in venous and arteriolar capillary pressure – edema, congestion, necrosis and eventual rupture or perforation of the intestinal wall – peritonitis Medical Management Goal: Relieving abdominal pain, controlling the diarrhea and constipation, and reducing stress.

•Restriction and then gradual reintroduction of foods
•High fiber diet
•Stress reduction or behavior modification program.
•Hydrophilic colloids (bulk) and Antidiarrheal agents (Loperamide [Imodium])
•Anticholinergics (Propantheline [Pro-Banthine])
•Tegaserod (Zelnorm) Common Causes – Carcinoma, diverticulitis, inflammatory bowel disorders, and benign tumors, adenocarcinoid tumors INTESTINAL OBSTRUCTION Intestinal Obstruction exists when blockage prevents the normal flow of intestinal contents through the intestinal tract.
•Patient and family education Nursing Management Types

1.Mechanical Obstruction – Intraluminal or wall obstructions from pressure on the intestinal wall.

c.Volvulus - bowel twists and turns on itself
f.Strictures 2.Functional Obstruction (Paralytic ileus) – The intestinal musculature cannot propel the contents along the bowel.
a.Abdominal trauma/surgery
b.Spinal injuries
c.Peritonitis, acute appendicitis
d.Wound dehiscence (breakdown) Assessment and Diagnostic Findings •Abdominal X-ray
•CT scan
•Laboratory studies – Electrolytes and CBC, BUN
•Lower GI series/ Barium enema (contraindicated with large bowel obstruction) Small Bowel Obstruction
Common Causes – Adhesions, intussusception, volvulus and paralytics ileus. (distention) – reflux vomiting - -- loss in hydrogen ion and potassium form the stomach – reduction of chlorides and potassium in the blood – metabolic alkalosis
---- loss of water and sodium – dehydration and acidosis – hypovolemic shock Clinical Manifestation Initial symptom – crampy pain (wavelike and colicky)
May pass blood and mucus but no fecal matter and flatus (obstipation)
Nausea and vomiting
Complete obstruction – causes vigorous peristaltic waves then vomiting
Ileum – fecal vomiting
Abdominal distention
High-pitched bowel sounds and decreased or absent bowel sounds Nursing Management Medical Management Goal: Decompress intestines by removing gas and fluid; move/remove obstruction; maintain fluid and electrolyte balance Intestinal Decompression through Nasogastric Tube
oSalem sump or Levin tubes (nasogastric)
oMiller-Abbot (intestinal)
oCantor (intestinal)
IV therapy NPO •Maintaining function of nasogastric tube
•Assessing and measuring the nasogastric output
•Assessing for fluid and electrolyte imbalance
•Monitoring nutritional status
•Assessing improvement {bowel sounds, decreased abdominal distention, improvement in abdominal pain and tenderness, passage of flatus or stool}
•Assist with ADL
•Good oral and skin care
•Fowler’s position to facilitate breathing Small Bowel Obstruction Large Bowel Obstruction Pathophysiology Complete large bowel obstruction may be undramatic if the blood supply o the colon is not disturbed.If blood supply is cut off, intestinal strangulation and necrosis occur.
Dehydration occurs more slowly because the colon can absorb its fluid contents and can distend to a size considerably beyond its normal full capacity.
Most yumors occurs beyond the splenic flexure making them accessible with a flexible sigmoidoscope. ABDOMINAL TRAUMA 1.Penetrating (gunshot wounds, stabs wounds)

2.Blunt (motor vehicle crashes, falls, blows or explosions). Medical Management •Restoration of intravascular volume
•Correction of electrolyte abnormalities
•Nasogastric aspiration and decompression
•Rectal tube
•Surgical resection
•Ileoanal anastomosis Nursing Management •Patient monitoring
•Emotional support and comfort
•IV fluids and electrolytes as prescribed
•Prepares patient for surgery
•General abdominal wound care and routine postoperative nursing care Surgica Treatment Purpose: removal of diseased portion of bowel; creation of an outlet for passage of stool when there is an obstruction or nee for “bowel rest” a.Exploratory Laparotomy
b.Resection and anastomosis
c.Abdominal perineal resection
d.Intestinal ostomies •Tenderness, pain
•Muscular rigidity
•Rebound tenderness
•Nausea and vomiting
•Hypotension and shock
•Balance’s sign
•Resonance over liver •X-ray, Abdominal ultrasound
•CT scan
•Exploratory laparotomy
•Diagnostic peritoneal lavage
•Sinography (stab wounds)
•Rectal or vaginal exam{ Management •Resuscitation procedures
Direct pressure
•Place on cardiac monitor
•Monitor CVP
•IV fluid replacement and blood component therapy Immobilization
•Stomach contents aspirated and decompressed with NGT
•Indwelling catheter
•Tetanus prophylaxis and broad-spectrum antibiotics
•Administration of opioids is minimized HEPATIC FAILURE Occurs when large parts of the liver become damaged beyond repair and the liver is no longer able to function. 1. Chronic Liver Failure

2. Acute Liver Failure Acute Liver Failure Rapid deterioration of liver function results in coagulopathy and alteration in the mental status of a previously healthy individual
The development of coagulopathy, usually with an international normalized ratio (INR) of greater than 1.5, and any degree of mental alteration (encephalopathy) in a patient without preexisting cirrhosis and with an illness of less than 26 weeks' duration. Categories Hyperacute liver failure – the duration of jaundice before the onset of encephalopathy is 0 to 7 days.
Acute liver failure – 8 to 28 days
Subacute liver failure – 28 to 72 days Causes (Chronic) •Viral hepatitis
•Metabolic disturbances
•Long term alcohol consumption
•Cancer (Acute) •Acetaminophen (Tylenol)
•Viruses including hepatitis A, B, and C
•Reactions to certain prescription and herbal medications
•Ingestion of poisonous wild mushrooms Manifestations •Nausea
•Loss of appetite
•Profound anorexia
•Coagulation defects (bleeding)
•Swollen abdomen Renal failure
•Electrolyte disturbances
•Cardiovascular abnormalities
•Encephalopathy (mental confusion or disorientation) Surgical Management •Liver transplantation
•Prostaglandin therapy
•Bioartificial liver (BAL)
•Extracorporeal liver assist devices (ELAD)
Portosystemic Shunts
Peritovenous Shunts Complications •Cerebral edema
Coma •Cessation of alcohol ingestion
•Remove biliary obstructions
•Medications to be avoided
oPhenobarbital, phenytoin or chlorpromazine
oMorphine, paraldehyde, codeine Treat underlying causes Impaired Skin Integrity •Oral Cholestyramine resin
•Avoid Alkaline soap
•Application of lotion
•Soft bed linens and keep room cool
•Emotional support
Fatigue -assist with ADLs, Bed rest Altered Nutrition – modify diet, nutritious breakfast,small frequent feeding, provide vitamin supplements, antiemetics, IV therapy Altered Tissue Perfusion •Monitor for hemorrhage
•Monitor urine output
•Protect from physical injury Altered Protection - Antibiotics Fluid Volume Excess •Restrict fluids
•Monitor I and O – weigh daily, measure abdominal girth
•Albumin and Diuretics
•Avoid NSAIDs – inhibit prostaglandin synthesis and impair sodium excretion Ineffective Breathing Pattern High fowlers, DBE, Incentive spirometer, Oxygen therapy Risk for Impaired Gas Exchange •Prevent esophageal necrosis – Sengstaken-Blakemore tube
•Prevent aspiration pneumonia – Suction, NGT
•Prevent airway obstruction
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