Althea NCM 116a

CARE OF CLIENTS WITH
METABOLIC &
ENDOCRINE DISORDER:
Part II
Althea A. Alejano, RN, MAN
02 March 2021
Intended Learning Outcomes
• After taking this lesson, the learners shall:
1. Relate clinical manifestations to the anatomy and
physiology of organs affected among patients with
metabolic and endocrine disorders;
2. Identify medical, surgical and nursing management
to patients with metabolic and endocrine disorders;
3. Use the nursing process as a framework for care of
the patient with metabolic and endocrine disorders.
HEPATIC ENCEPHALOPATHY
AND COMA
• a life-threatening complication of liver

disease
• occurs with profound liver failure
• may result from the accumulation of
ammonia and other toxic metabolites in the
blood
• Hepatic coma - most advanced stage of
hepatic encephalopathy
Stages of Hepatic Encephalopathy and
Possible Nursing Diagnosis
Clinical
Pathophysiology
Manifestations
Ammonia accumulates and enters  minor mental changes and motor
disturbances
the bloodstream
 slightly confused, has alterations in
mood, becomes unkempt, and has
Increased ammonia concentration in altered sleep patterns
the bloodstream  tends to sleep during the day and
have restlessness and insomnia at
night.
Ammonia enters the brain causing
 Asterixis
dysfunction and damage
 constructional apraxia
Assessment and Diagnostic
Findings
• ECG
• Fetor Hepaticus
Medical Management
 Lactulose (Cephulac)
 intravenous administration of glucose to
minimize protein breakdown
 administration of vitamins to correct deficiencies
 correction of electrolyte imbalances (especially
potassium)
What are the possible
NURSING DIAGNOSIS for
patients with hepatic
encephalopathy?
Nursing Management
 maintaining a safe environment to prevent
injury, bleeding, and infection
administers the prescribed treatments and
monitors the patient for the many potential
complications
communicates with the patient’s family to
keep them informed about the patient’s
status, and supports them by explaining
the procedures and treatments that are
part of the patient’s care
OTHER MANIFESTATIONS OF LIVER DYSFUNCTION
• Edema and • Vitamin Deficiency Metabolic Abnormalities Pruritus and Other

Bleeding  Vitamin A deficiency: night blindness and eye o Abnormalities of glucose Skin Changes
 and skin changes metabolism
 Thiamine deficiency: beriberi, polyneuritis, and o Many endocrine abnormalities
Wernicke-Korsakoff psychosis
Gynecomastia
 Riboflavin deficiency: characteristic skin and
amenorrhea
 mucous membrane lesions
 Pyridoxine deficiency: skin and mucous testicular atrophy
membrane lesions and neurologic changes loss of pubic hair in the
 Vitamin C deficiency: hemorrhagic lesions mal
 of scurvy  menstrual irregularities in
 Vitamin K deficiency: hypoprothrombinemia, the female
 characterized by spontaneous bleeding and other disturbances of
ecchymoses
sexual function and sex
 Folic acid deficiency: macrocytic anemia
characteristics
VIRAL HEPATIC DISORDER
Viral Hepatitis
• a systemic, viral infection in which

necrosis and inflammation of liver
cells produce a characteristic
cluster of clinical, biochemical,
and cellular changes
Comparison
of Major
Forms of
Viral
Hepatitis
Risk Factors for Hepatitis B
What should I Do?
1. PREVENTING
TRANSMISSION
2. ACTIVE IMMUNIZATION:
HEPATITIS B VACCINE
3. PASSIVE IMMUNITY:
HEPATITIS B IMMUNE
GLOBULIN
Medical Management for HBV
• alpha interferon: for chronic type B viral hepatitis but has significant
side effects such as bone marrow suppression, thyroid dysfunction,
alopecia, and bacterial infections.
• Antiviral agents (lamivudine [Epvir] and adefovir [Hepsera]) oral nucleoside
analogs: approved for use
• Bed rest to gradual activity as tolerated
• Adequate nutrition should be maintained
NON-VIRAL HEPATIC
DISORDERS
TOXIC HEPATITIS
• exposure to hepatotoxic chemicals, • Management
medications, or other agents
1. Client may die of fulminant hepatic
• Recovery is rapid if the hepatotoxin is failure unless receives a liver transplant.
identified early and removed
2. Therapy is directed toward
• no effective antidotes
• restoring and maintaining fluid and electrolyte
• Manifestations balance
• Anorexia • blood replacement
• Nausea • comfort and supportive measures
• vomiting
• jaundice and hepatomegaly
DRUG-INDUCED HEPATITIS
• onset is abrupt, with chills, fever, rash, pruritus, arthralgia, anorexia, and nausea
• jaundice and dark urine and an enlarged and tender liver
• . If fever, rash, or pruritus occurs from any medication, its use should be stopped
immediately
• Common medications
• anesthetic agents (Halothane) : Isoflurane is the anesthetic of choice for those
with liver disease
• medications used to treat rheumatic and musculoskeletal disease
• Antidepressants
• psychotropic medications
• Anticonvulsants
• anti-tuberculosis agents (Isoniazid)
• Acetaminophen
• certain antibiotics
• Antimetabolites
FULMINANT HEPATIC FAILURE
• the clinical syndrome of sudden and severely impaired liver function in a previously
healthy person • Manifestations
• 3 Categories 1. Jaundice and profound
1. hyperacute liver failure-the duration of jaundice before the onset of anorexia
encephalopathy is 0 to 7 days 2. coagulation defects
2. acute liver failure-8 to 28 days
3. renal failure and
3. subacute liver failure - 28 to 72 days
electrolyte disturbances
• prognosis for fulminant hepatic failure is much worse than for chronic liver failure
• Common causes: 4. infection
• toxic medications (eg, acetaminophen) 5. Hypoglycemia
• chemicals (eg, carbon tetrachloride) 6. encephalopathy
• metabolic disturbances (Wilson’s disease, a hereditary syndrome with 7. cerebral edema
deposition of copper in the liver)
• structural changes (Budd-Chiari syndrome, an obstruction to outflow in major
hepatic veins).
Management of Fulminant Hepatic Failure
• Liver transplant – treatment of choice

• plasma exchanges (plasmapheresis) or charcoal
hemoperfusion for the removal (theoretically) of
potentially harmful metabolites
• Temporary devices until transplant
• ELAD (extracorporeal liver assist devices)
• BAL (bioartificial liver)
• Mortality is high
HEPATIC CIRRHOSIS
• a chronic disease characterized by replacement of normal liver tissue
with diffuse fibrosis that disrupts the structure and function of the liver
• 3 TYPES
1. Alcoholic cirrhosis
- scar tissue characteristically surrounds the portal areas
-most frequently due to chronic alcoholism and
-most common type of cirrhosis.
2. Postnecrotic cirrhosis
- there are broad bands of scar tissue as a late result of a
previous bout of acute viral hepatitis
3. Biliary cirrhosis
- scarring occurs in the liver around the bile ducts
- result of chronic biliary obstruction and infection (cholangitis)
- much less common than the other two types.
Medical
Diagnostic Findings Management
• severe parenchymal liver dysfunction • Supportive management
• serum albumin level tends to decrease • antacids - to decrease gastric distress
• serum globulin level rises.
and minimize the possibility of GI
• Enzyme tests indicate liver cell damage
• serum alkaline phosphatase, AST, ALT, and GGT levels bleeding
increase, • Vitamins and nutritional supplements
• serum cholinesterase level may decrease. promote healing of damaged liver cells
• Bilirubin tests - to measure bile excretion or bile retention and improve the general nutritional status
• Prothrombin time – prolonged • Potassium-sparing diuretics
• Ultrasound scanning - to measure the difference in density (spironolactone [Aldactone], triamterene
of parenchymal cells and scar tissue [Dyrenium]) - to decrease ascites
• CT, MRI, and radioisotope liver scans - liver size and • Colchicine- used for mild to moderate
hepatic blood flow and obstruction cirrhosis
• Liver Biopsy - confirmatory
As a NURSE, What will you do?
ASSESS
DIAGNOSE
PLAN
INTERVENE
EVALUATE
Cancer of the Liver
• PRIMARY LIVER TUMORS • LIVER METASTASES
• associated with chronic liver disease, • 50% of all advanced cancer cases
hepatitis B and C infections, and cirrhosis
• Hepatocellular carcinoma (HCC) – most
• Malignant tumors are likely to
common reach the liver eventually, by way
• Other types: cholangiocellular carcinoma of the portal system or lymphatic
and combined hepatocellular and channels, or by direct extension
cholangiocellular carcinoma from an abdominal tumor
• Risk factor • The liver apparently is an ideal
• Cigarette smoking + alcohol
place for these malignant cells to
• aflatoxin, a metabolite of the fungus
Aspergillus flavus thrive
Clinical Assessment & Medical
Manifestations Diagnostic Findings Management
• pain, a continuous dull ache • History & PE • RADIATION THERAPY &

in the right upper quadrant, CHEMOTHERAPY – palliative
epigastrium, or back. • laboratory and x-ray studies
• PERCUTANEOUS BILIARY
• Weight loss • serum level of alpha- DRAINAGE or transhepatic
• loss of strength fetoprotein (AFP) – tumor drainage
• anorexia marker • OTHER NONSURGICAL

TREATMENTS
• Anemia • carcinoembryonic antigen • Laser hyperthermia
• Hepatomegaly (CEA) – marker of • radiofrequency thermal
advanced CA of the GI tract ablation
• Jaundice • Immunotherapy
• Ascites • Positive emission • Transcatheter arterial
tomograms (PET scans) embolization
Surgical Nursing
Management Management
• Surgical resection • constant infusion of

• Lobectomy - Removal of 10% glucose may be
a lobe of the liver required in the first 48
• Cryosurgery hours to prevent a
(cryoablation) - tumors precipitous fall in the
are destroyed by liquid blood glucose level
nitrogen at −196° C resulting from
• Liver Transplantation -
decreased
Removing the liver and gluconeogenesis.
replacing it with a healthy • BT and IVF due to
donor organ extensive blood loss
Liver Transplantation
• used to treat life-threatening, end-stage liver disease for
which no other form of treatment is available
• total removal of the diseased liver and its replacement
with a healthy liver in the same anatomic location
(orthotopic liver transplantation [OLT])
• Immunosuppressants: reduce incidence of rejection
COMPLICATIONS
• cyclosporine (Neoral)
1. Bleeding
• Corticosteroids
• azathioprine (Imuran)
2. Infection
• mycophenolate mofetil (CellCept)
3. Rejection
• OKT3 (a monoclonal antibody)
• tacrolimus (FK506, Prograf)
• sirolimus (formerly known as rapamycin [Rapamune])
• antithymocyte globulin
WHAT ARE YOUR
NURSING
RESPONSIBILITIES IF
PATIENT IS FOR LIVER
TRANSPLANT?
Liver
Pathophysiology
Abscesses
• amebic (Entamoeba histolytica) and Infection in biliary or GI tract
pyogenic Organisms enter liver through the biliary
• Manifestations system, portal venous system, or hepatic
arterial or lymphatic system
• Fever with chills and diaphoresis
bacterial toxins destroy the neighboring
• Malaise liver cells, and the resulting necrotic
• Anorexia tissue
• nausea, vomiting, and weight loss leukocytes migrate into the infected area
• dull abdominal pain and tenderness
abscess cavity full of a liquid containing
on RUQ living and dead
• Hepatomegaly, jaundice, anemia, and leukocytes, liquefied liver cells, and
bacteria
pleural effusion
Assessment and
Medical Nursing
Diagnostic
Findings Management Management
• Blood cultures • IV antibiotic therapy • monitoring of the

drainage and skin care
• Aspiration of the liver • Continuous
abscess, guided by supportive care • Vital signs are monitored
ultrasound to detect changes
• Open surgical
• CT or MRI • administers IV antibiotic
drainage
therapy as prescribed
• Percutaneous • percutaneous
• Discharge instructions
drainage of pyogenic drainage
abscesses
BILIARY DISORDERS
Anatomy & Physiology
• Gallbladder
• Pancreas
• Exocrine: secretion of
pancreatic enzymes into the
gastrointestinal tract through
the pancreatic duct
• Endocrine: secretion of
insulin, glucagon, and
somatostatin directly into the
bloodstream
Disorders of the Gallbladder
CHOLECYSTITIS CHOLELITHIASIS
• Acute inflammation of the gallbladder • Calculi, or gallstones, usually form in the

gallbladder from the solid constituents of bile
• Manifestation • Types
• pain, tenderness, and rigidity of the RUQ
1. those composed predominantly of pigment
that may radiate to the midsternal area
- unconjugated pigments in the bile
or right shoulder a
precipitate to form stones
• nausea, vomiting, and the usual signs of
an acute inflammation 2. those composed primarily of cholesterol -
decreased bile acid synthesis and
• Empyema-purulent fluid
increased cholesterol synthesis in the liver,
• Calculous cholecystitis 90% resulting in bile supersaturated with
cholesterol
• Acalculous cholecystitis
Clinical Assessment and
Manifestations Diagnostic Findings
• PAIN AND BILIARY COLIC • ABDOMINAL X-RAY

• ULTRASONOGRAPHY
• JAUNDICE
• RADIONUCLIDE IMAGING OR
• CHANGES IN URINE AND CHOLESCINTIGRAPHY
STOOL COLOR • CHOLECYSTOGRAPHY
• With contrast: What are your nursing implications?
• VITAMIN DEFICIENCY • NO to jaundice – cannot excrete dye
• ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY
• PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY
Medical
Management
• Removal of the gallbladder (cholecystectomy)
• laparoscopic cholecystectomy
• NUTRITIONAL AND SUPPORTIVE THERAPY
• PHARMACOLOGIC THERAPY
• Ursodeoxycholic acid (UDCA)
• chenodeoxycholic acid (chenodiol or
CDCA)
• NONSURGICAL REMOVAL OF GALLSTONES
• Dissolving Gallstones - infusion of a solvent
(mono-octanoin or methyl tertiary butyl ether
[MTBE]) into the gallbladder
• ERCP
• Extracorporeal Shock-Wave Lithotripsy (ESWL)
Disorders of the Pancreas
ACUTE PANCREATITIS • Clinical Manifestations
• Severe abdominal pain
• ranges from a mild, self-limiting disorder to a
severe, rapidly fatal disease that does not • Pain is frequently acute in onset,
occurring 24 to 48 hours after a very
respond to any treatment.
heavy meal or alcohol ingestion
• Mild acute pancreatitis is characterized by • Ecchymosis (bruising) in the flank or
edema and inflammation confined to the around the umbilicus : severe pancreatitis
pancreas: risk for hypovolemic shock, fluid
• Nausea and vomiting
and electrolyte disturbances, and sepsis
• Fever, jaundice, mental confusion, and
• severe acute pancreatitis: systemic agitation
complications; increased mortality
• Hypotension is typical and reflects
• CAUSE: Self-digestion of the pancreas by its hypovolemia and shock
own proteolytic enzymes, principally trypsin • Respiratory distress and hypoxia
Assessment and
Medical Management
Diagnostic Findings
• a history of abdominal • Pain Management

pain, the presence of
known risk factors & • Intensive Care
physical examination • Respiratory Care
findings
• Biliary Drainage
• Increased Serum amylase
and lipase • Surgical Intervention
• Ultrasound
• CT Scan
As a NURSE, What will you do?
ASSESS
DIAGNOSE
PLAN
INTERVENE
EVALUATE
Disorders of the Pancreas
CHRONIC • Clinical Manifestations
• recurring attacks of severe upper
PANCREATITIS abdominal and back pain,
• an inflammatory disorder characterized accompanied by vomiting
by progressive anatomic and functional • Pain not relieved by opioids
destruction of the pancreas
• Steatorrhea
• Cells are replaced by fibrous tissues due
to pancreatitis – mechanical obstruction • Diagnostic: ERCP
• Cause: long-term alcohol consumption
Surgical
Medical Management
Management
• Endoscopy to remove • Pancreaticojejunostomy

pancreatic duct stones (Roux-en-Y) with a side-
and stent strictures to-side anastomosis or
• Use of non-opioid joining of the pancreatic
analgesics duct to the jejunum
allows drainage of the
• No alcohol intake
pancreatic secretions
into the jejunum
PANCREATIC CANCER OF THE
CYSTS PANCREAS
• result of the local necrosis that • Factors: Cigarette smoking, exposure to industrial
occurs at the time of acute chemicals or toxins in the environment, and a diet high
pancreatitis, collections of fluid in fat, meat
may form in the vicinity of the • Manifestations: Pain, jaundice, or both along with
pancreas weight loss
• pancreatic pseudocysts – most • diabetes may be an early sign of carcinoma of the
common pancreas
• Diagnostics: MRI, CT Scan, ERCP
• Diagnostics: ultrasound, computed
tomography, and ERCP • Management:
• Resection of tumor (if localized)
• Management: Drainage into the GI • Total resection not possible due to metastasis
tract
• Nursing Care? Supportive due to poor prognosis
TUMORS OF THE HEAD OF THE
PANCREAS
• obstruct the common bile
duct where the duct
passes through the head of
the pancreas to join the
pancreatic duct and empty
at the ampulla of Vater into
the duodenum
Clinical
Diagnostic Findings
Manifestations
• jaundice, clay-colored • duodenography,

stools, and dark urine angiography by hepatic or
celiac artery
• Abdominal discomfort or
catheterization, pancreatic
pain and pruritus with scanning, percutaneous
anorexia, weight loss, transhepatic
and malaise cholangiography, ERCP,
and percutaneous needle
biopsy of the pancreas
Medical Management
• long period of preparation
• diet high in protein along with pancreatic enzymes
• adequate hydration
• correction of prothrombin deficiency with vitamin K
• treatment of anemia to minimize postoperative complications
• Parenteral nutrition
• Surgical Management
• Total pancreatectomy (removal of the pancreas) may be
performed if there is no evidence of direct extension of the
tumor to adjacent tissues or regional lymph nodes
• pancreaticoduodenectomy (Whipple’s procedure or
resection) is used for potentially resectable cancer of the
head of the pancreas
• Cholecystojejunostomy – to relieve jaundice if tumor cannot
be excised
As a NURSE, What will be your focus?
ASSESS Preoperative care

DIAGNOSE
PLAN
INTERVENE
Postoperative care EVALUATE

PANCREATIC ISLET TUMORS
• The pancreas contains the islets (islands) of Langerhans, small nests of cells that
secrete directly into the bloodstream and therefore are part of the endocrine system
• two types of tumors of the pancreatic islet cells are known:
1. those that secrete insulin (insulinoma)
2. those in which insulin secretion is not increased (“nonfunctioning” islet cell cancer)
• . Insulinomas produce hypersecretion of insulin and cause an excessive rate of
glucose metabolism – hypoglycemia - f weakness, mental confusion, and seizures
• Surgical Management
• removal of the tumor
• partial pancreatectomy (tail or body)
ULCEROGENIC
HYPERINSULINISM
TUMORS
• overproduction of insulin • hypersecretion of gastric

by the pancreatic islets acid that produces ulcers
• Manifestations: hunger, in the stomach,
nervousness, sweating, duodenum, and jejunum
headache, and faintness; • Zollinger Ellison
in severe cases, seizures
syndrome
and episodes of
unconsciousness • Total gastrectomy-to
• Management: Surgical reduce the secretion of
removal of the hyperplastic gastric acid sufficiently to
or neoplastic tissue prevent further ulceration
DIABETES MELLITUS
DIABETES MELLITUS (DM)
• a group of metabolic diseases characterized by Classifications
elevated levels of glucose in the blood (hyperglycemia) 1. Type 1 diabetes(insulin-dependent
resulting from defects in insulin secretion, insulin action, diabetes mellitus)
or both
2. Type 2 diabetes (non-insulin
• Insulin, a hormone produced by the pancreas, controls
dependent diabetes mellitus)
the level of glucose in the blood by regulating the
production and storage of glucose 3. Gestational diabetes mellitus
• Metabolic Complications 4. Diabetes mellitus associated with

• diabetic ketoacidosis(DKA) other conditions or syndromes
• hyperglycemic hyperosmolar nonketotic syndrome (HHNS
Type I DM Type II DM
• characterized by destruction of the pancreatic beta
cells
• Problem: insulin resistance and
• genetic, immunologic, and possibly environmental (eg, impaired insulin secretion
viral) factors
• genetic tendency has been found in people with
• beta cells cannot keep up with the
certain HLA (human leukocyte antigen) increased demand for insulin, the
• the destruction of the beta cells results in decreased glucose level rises, and type 2 diabetes
insulin production, unchecked glucose production by
the liver, and fasting hyperglycemia develops
• Glucose > 180 to 200 mg/dL (9.9 to 11.1 mmol/L)
• Uncontrolled - HHNS
• Glycosuria
• fat breakdown - increased production of ketone bodies
- DKA
GESTATIONAL DIABETES
• any degree of glucose
intolerance with its onset during
pregnancy
• May return to normal after
delivery of develop into type II
DM
• Manifestations: “three Ps”:
polyuria, polydipsia, and
polyphagia
Management
• Monitor complications
• retinopathy, nephropathy, and neuropathy
• Monitor hypoglycemia – coma or
seizure
• Management
• Nutritional management
• Exercise
• Monitoring - SMBG
• Pharmacologic therapy
• Education
Insulin Therapy
End of Presentation
CARE OF CLIENTS
WITH METABOLISM &
ENDOCRINE
DISORDER: HEPATIC
Part I
Althea A. Alejano, MAN, RN
23 February 2021
• After taking this lesson, the learners shall:
1. Identify the metabolic functions of the liver and the
alterations in these functions that occur with liver
disease;
2. Describe the medical, surgical, and nursing
management of patients with hepatic disorders;
the patient with hepatic disorders
Anatomic and Physiologic
Overview
largest gland of the body
considered a chemical factory that
manufactures, stores, alters, and excretes
a large number of substances involved in
metabolism
located behind the ribs in the upper right
portion of the abdominal cavity
75% of the blood supply comes from the
portal vein
remainder of the blood supply enters by
way of the hepatic artery and is rich in
oxygen
Functions of
the Liver
Glucose Metabolism
Ammonia Conversion
Protein Metabolism
Fat Metabolism
Vitamin and Iron Storage
Drug Metabolism
Bile Formation
• Bilirubin Excretion
Assessment
1. Health History
Exposure to hepatotoxic substance
Exposure to hepatotoxins (industrial
chemicals)
Lifestyle
Family History
Medical and Surgical history
2. Physical Assessment
Diagnostic
Evaluation
1. Liver Function Tests
 Serum aminotransferases
(transaminases)
 Alanine aminotransferase (ALT) -
serum glutamic-pyruvic
transaminase [SGPT]
 aspartate aminotransferase (AST)
- serum glutamic-oxaloacetic
transaminase [SGOT]
 gamma glutamyl transferase
(GGT) - G-glutamyl transpeptidase
2. Liver Biopsy
3. Others
 UTZ
 CT scan
 MRI
 Laparoscopy
Other Diagnostic Tests
HEPATIC
DYSFUNCTION
JAUNDICE
• bilirubin concentration in the blood
is abnormally elevated, all the body
tissues, including the sclerae and
the skin, become yellow-tinged or
greenish-yellow
• clinically evident when the serum

bilirubin level exceeds 2.5 mg/dL
(43 fmol/L)
Types of Jaundice
• Hemolytic Jaundice • Hepatocellular • Obstructive • Hereditary
 result of an Jaundice Jaundice Hyperbilirubinemia
increased destruction  caused by the inability  results from several
of the red blood cells,  caused by inherited disorders
of damaged liver cells occlusion of the
the effect of which is  Gilbert’s syndrome -
to flood the plasma to clear normal bile duct by a
amounts of bilirubin familial disorder
with bilirubin so gallstone, an characterized by an
rapidly that the liver, from the blood
inflammatory increased level of
although functioning  causes of damage: unconjugated bilirubin
normally, cannot infection, medication, process, a tumor,
 inborn errors of biliary
excrete the bilirubin alcohol or pressure from metabolism :
as quickly as it is
 Cirrhosis of the liver is
an enlarged organ  Dubin–Johnson
formed
a form of  May be caused by syndrome (chronic
 hemolytic transfusion hepatocellular disease intrahepatic or idiopathic jaundice,
reactions and other with pigment in the
hemolytic disorders  lack of appetite, extrahepatic liver)
nausea, malaise, obstruction  Rotor’s syndrome
 Risk for brain stem
damage
fatigue, weakness,  Light /clay-colored (chronic familial
and possible weight conjugated
loss
stools; dyspepsia, hyperbilirubinemia
intolerance to fatty without pigment in
the liver)
foods
PORTAL
HYPERTENSION
• Obstructed blood flow through the
damaged liver results in increased blood
pressure (portal hypertension) throughout
the portal venous system
• Common manifestation: splenomegaly
(enlarged spleen) with possible
hypersplenism
• Major consequences:
• ASCITES: fluid accumulates in the abdominal
cavity
• VARICES: develop from elevated pressures
transmitted to all of the veins that drain into
the portal system
ASCITES
• Clinical Manifestations
• Increased abdominal girth
and rapid weight gain
• Shortness of breath
• striae and distended veins
• Fluid and electrolyte
imbalances
• Assessment and
Diagnostic Evaluation
• percussing for shifting
dullness or by detecting a
fluid wave
• Daily measurement and
recording of abdominal
girth and body weight
ASCITES: Management
• DIETARY MODIFICATION
• strict sodium restriction
• DIURETICS
• Spironolactone (Aldactone)
• Furosemide (Lasix)
• BED REST
• PARACENTESIS
Nursing Management
• Admitted
• assessment and documentation of intake and
output
• abdominal girth, and daily weight to assess fluid
status
• monitors serum ammonia and electrolyte levels to
assess electrolyte balance, response to therapy,
and indicators of encephalopathy
• Home Care
• Lifestyle modification
• Adherence to prescribed medication
• Self-monitoring
• Regular consultation
ESOPHAGEAL
VARICES
• Clinical Manifestations
• Hematemesis
• Melena
• general deterioration in mental or physical
status
• often has a history of alcohol abuse
• symptoms of shock (cool clammy skin,
hypotension, tachycardia)
• Assessment and Diagnostic Findings
• Endoscopy
• PORTAL HYPERTENSION
MEASUREMENTS
• Laboratory Tests
ESOPHAGEAL VARICES: Medical
Management
• PHARMACOLOGIC THERAPY
• Vasopressin (Pitressin) – vasoconstriction
• combination of vasopressin and nitroglycerin (administered by the
intravenous, sublingual, or transdermal route)
• Somatostatin and octreotide (Sandostatin) – decrease bleeding
• Propranolol (Inderal) and nadolol (Corgard) - beta-blocking agents
that decrease portal pressure
• Nitrates such as isosorbide (Isordil) - lower portal pressure by
venodilation and decreased cardiac output
BALLOON TAMPONADE
• To control hemorrhage
• pressure is exerted on the
cardia (upper orifice of the
stomach) and against the
bleeding varices by a
double-balloon tamponade
(Sengstaken-Blakemore
tube)
ENDOSCOPIC SCLEROTHERAPY
• a sclerosing agent is
injected through a fiberoptic
endoscope into the bleeding
esophageal varices to
promote thrombosis and
eventual sclerosis.
ESOPHAGEAL BANDING THERAPY
(VARICEAL BAND LIGATION)
• a modified endoscope
loaded with an elastic
rubber band is passed
through an overtube
directly onto the varix (or
varices) to be banded
TRANSJUGULAR INTRAHEPATIC
PORTOSYSTEMIC SHUNTING
• a method of treating
esophageal varices in
which a cannula is
threaded into the portal
vein by the transjugular
route
SURGICAL MANAGEMENT
• Surgical Bypass Procedures
• Surgical decompression of the portal circulation
can prevent variceal bleeding if the shunt remains
patent
• distal splenorenal shunt made between the splenic
vein and the left renal vein after splenectomy
• mesocaval shunt is created by anastomosing the
superior mesenteric vein to the proximal end of the
vena cava or to the side of the vena cava using
grafting material
• Portacaval shunts divert all portal flow to the vena
cava via end-to-side or side-to-side approaches, so
they are considered nonselective shunts
• If the cause of portal hypertension is the rare Budd-
Chiari syndrome or other venous obstructive disease,
a portacaval or a mesoatrial shunt may be performed
ESOPHAGEAL VARICES: Nursing
Management
• Monitor physical condition
• evaluate emotional responses and cognitive status
• vital signs
• nutritional and neurologic status
• Complete rest of the esophagus – parenteral nutrition
• Gastric suction
• Frequent oral hygiene and moist sponges to the lips
• monitors the blood pressure
• Vitamin K therapy and multiple blood transfusions
• Provision of quiet environment
• Provides support and explanations regarding medical and nursing interventions
Summary of
Management
End of Presentation
INTESTINAL AND RECTAL
DISORDERS
23 February 2021
After taking this lesson, the learners shall:
1. Compare small bowel and large bowel obstruction
with regard to their pathophysiology, clinical
manifestations and management;
2. Describe colorectal and anorectal disorders in
terms of its pathophysiology, clinical
manifestations and management;
3. Identify health care teaching needs of clients with
intestinal disorders;
4. Utilize the nursing process in the care of clients
with intestinal disorders.
Where does obstruction commonly occurs? Is it in
the small bowel? Or in the large bowel?
INTESTINAL DISORDERS
Intestinal Obstruction
• Presence of blockage
• Types of blockage:
Mechanical Obstruction Functional Obstruction
intraluminal obstruction or a mural intestinal musculature cannot propel the

obstruction from pressure on the contents along the bowel.
intestinal walls occurs.
 Intussusception  Amyloidosis
 polypoid tumors and neoplasms  muscular dystrophy
 stenosis,  endocrine disorders (DM)
 Strictures  neurologic disorders (Parkinson’s
 Adhesions disease)
 Hernias
 abscesses
Mechanical Obstruction
Small Bowel Large Bowel
Pathophysiology Accumulation of intestinal contents, fluid, and gas results in an accumulation of intestinal contents, fluid, and
gas proximal to the obstruction
Increase in the intestinal lumen –decrease in
venous and arteriolar capillary pressure can lead to severe distention and perforation unless some
gas and fluid can flow back through the ileal valve.
edema, congestion, necrosis, and eventual
rupture or perforation of the intestinal wall blood supply is cut off; however, intestinal strangulation and
necrosis (ie, tissue death) occur; this condition is life
threatening
Clinical  crampy pain that is wavelike and colicky  Constipation

Manifestations  pass blood and mucus, but no fecal matter and  Abdominal distention
no flatus  Crampy lower abdominal pain
 Vomiting
 intense thirst
 drowsiness
 generalized malaise
 parched tongue
 abdominal distention
 hypovolemic shock
Assessment & • Abdominal x-ray • Abdominal x-ray
Diagnostic Findings • Laboratory tests (CBC, electrolytes) to • Barium studies – Contraindicated
detect dehydration, plasma volume
depletion and infection
Medical • Decompression of the bowel through a • colonoscopy - to untwist and decompress the
Management nasogastric or small bowel tube bowel
• Surgical Intervention • Surgical intervention
• repairing the hernia or dividing • Cecostomy - for patients who are poor
the adhesion surgical risks and urgently need relief from
• removal of affected bowel with the obstruction
anastomosis • surgical resection to remove the
obstructing lesion
• temporary or permanent colostomy
• Ileoanal anastomosis
Nursing • Non-surgical • Non-surgical

Management • maintaining the function of the • monitor for symptoms that indicate that the
nasogastric tube intestinal obstruction is worsening
• assessing and measuring the • provide emotional support and comfort
nasogastric output • administers intravenous fluids and electrolytes
• assessing for fluid and electrolyte as prescribed
imbalance • Surgical
• monitoring nutritional status • prepares the patient for surgery
and assessing improvement • general abdominal wound care and routine
• reports discrepancies in intake and postoperative nursing care
output, worsening of pain or
abdominal distention, and increased
nasogastric output
• Surgical
• Prepare patient for surgery
• Care for patient post abdominal
surgery
COLORECTAL AND
ANORECTAL DISORDERS
Colorectal Cancer
• Tumors of the colon and rectum
Pathophysiology predominantly (95%) adenocarcinoma (ie, arising from the
epithelial lining of the intestine)
start as a benign polyp but may become malignant, invade and

destroy normal tissues, and extend into surrounding structures
Cancer cells may break away from the primary tumor and spread
to other parts of the body (most often to the liver)
Clinical Most common:
• change in bowel habits
Manifestations • passage of blood in the stools
• passage of blood in the stools
• unexplained anemia, anorexia, weight loss, and fatigue
• right-sided lesions
• dull abdominal pain
• melena (ie, black, tarry stools)
• left-sided lesions
• associated with obstruction (ie, abdominal pain and cramping, narrowing
stools, constipation, and distention)
• bright red blood in the stool.
• rectal lesions
• tenesmus (ie, ineffective, painful straining at stool)
• rectal pain
• feeling of incomplete evacuation after a bowel movement
• alternating constipation and diarrhea
• bloody stool
Assessment & • Abdominal and rectal examination
Diagnostic Findings • fecal occult blood testing, barium enema,
proctosigmoidoscopy, and colonoscopy
• sigmoidoscopy with biopsy or cytology smears
• Carcinoembryonic antigen (CEA)
Complications • partial or complete bowel obstruction
• Hemorrhage
• Perforation, abscess formation, peritonitis, sepsis,
and shock
Medical ADJUVANT THERAPY: chemotherapy, radiation
Management therapy, immunotherapy, or multimodality therapy
(Depends on stage) • Dukes’ class C colon cancer is the 5-
fluorouracil plus levamisole regimen
• Dukes’ class B or C rectal cancer are given 5-
fluorouracil and high doses of pelvic
irradiation.
• Radiation therapy is used before, during,
and after surgery
• Irradiation for inoperative or unresectable
tumors (Intracavity and implantable devices
to deliver radiation)
Surgical Interventions
Surgery: Primary Treatment

- Curative or palliative
• Segmental resection with

anastomosis
• Abdominoperineal resection with
permanent sigmoid colostomy
• Temporary colostomy followed by
segmental resection and
anastomosis and subsequent
reanastomosis of the colostomy
• Permanent colostomy or ileostomy
• Construction of a coloanal reservoir
called a colonic J pouch
Nursing Interventions
1. Prepare patient for surgery
2. Providing emotional support
3. Providing post-operative care
4. Maintaining optimal nutrition
5. Providing wound care
6. Monitoring and managing complications
7. Removing and applying colostomy appliance
8. Irrigating a colostomy
9. Supporting a positive body image
10. Discussing sexuality issues
11. Promote home care/self-care
Polyps of the Colon and Rectum
• a mass of tissue that protrudes into

the lumen of the bowel
• Classifications
• neoplastic
• adenomas
• carcinomas
• non-neoplastic - benign epithelial
growths
• mucosal a
• Hyperplastic
Clinical Manifestation Rectal bleeding
Symptoms of obstruction
Assessment and Diagnostic Findings history and digital rectal examination

barium enema studies
Sigmoidoscopy
Colonoscopy
Medical Management Removal through:

• colonoscopy with the use of special equipment (ie, biopsy forceps and
snares)
• Laparoscopy
• colonoscopic excision with laparoscopic visualization.
Diseases of the Anorectum
Anorectal Abscess Clinical Manifestations Foul-smelling pus
• Superficial
- caused by obstruction of an anal gland, • swelling
resulting in retrograde infection • Redness
- High risk: immunocompromised • Tenderness
(AIDS); regional enteritis • deeper abscess
• toxic symptoms
• lower abdominal pain
• fever
Management Palliative: sitz baths and analgesics
Treatment of Choice: Incision and drainage
Anal Fistula Clinical Manifestation Pus or stool may leak

- tiny, tubular, fibrous tract that extends passage of flatus or feces from the vagina or
into the anal canal from an opening bladder, depending on the fistula tract
located beside the anus
- Result from infection Management fistulectomy (ie, excision of the fistulous tract)
Diseases of the Anorectum
Anal Fissure Clinical Extremely painful defecation, burning, and bleeding
- a longitudinal tear or ulceration Manifestations
in the lining of the anal canal
- caused by the trauma of passing Management conservative measures
a large, firm stool or from • stool softeners and bulk agents
persistent tightening of the anal • an increase in water intake
canal because of stress and • sitz baths
anxiety (leading to constipation) • emollient suppositories
- Other cause: childbirth • anal dilation under anesthesia
Hemorrhoids Clinical Itching and painful - bright red bleeding with defecation
- dilated portions of veins in the Manifestation
anal canal Management  good personal hygiene and by avoiding excessive straining during
- Increased pressure in the defecation
hemorrhoidal tissue  high-residue diet that contains fruit and bran along with an increased
- Classified as INTERNAL and fluid intake
EXTERNAL  Warm compresses, sitz baths, analgesic ointments and suppositories,
astringents (eg, witch hazel), and bed rest
 Surgical Interventions
 rubber-band ligation procedure
 Cryosurgical hemorrhoidectomy
 Hemorrhoidectomy, or surgical excision
Anal Lesions
Sexually Transmitted Anorectal Disease
• Proctitis • Proctocolitis • Enteritis
• recent anal-receptive • rectum and lowest • involves more of the
intercourse with an portion of the descending colon
infected partner descending colon • Manifestations:
• Manifestations: • Manifestations: watery, bloody
mucopurulent include watery or diarrhea; abdominal
discharge or bleeding, bloody diarrhea, pain; and weight loss
pain in the area, and cramps, pain, and • Causes: E. histolytica,
diarrhea bloating Giardia lamblia,
• Causes: Neisseria Shigella, and
gonorrheae, Campylobacter
Chlamydia, herpes
simplex virus, and
Treponema pallidium
Sexually Transmitted Anorectal Disease
• Diagnostic Findings • Management
• Sigmoidoscopy • Treatment of choice: antibiotics (ie, cefixime,
• rectal swabs, and doxycycline, and penicillin)
cultures • Acyclovir – viral infections
• Antiamebic (Metronidazole) - E. histolytica and G.
lamblia
• Ciprofloxacin – Shigella
• Erythromycin and ciprofloxacin - Campylobacter
Pilonidal Sinus or Cyst
• found in the intergluteal cleft on the

posterior surface of the lower sacrum
• results from local trauma that causes the
penetration of hairs into the epithelium and
subcutaneous tissue
• may be formed congenitally by an infolding
of epithelial tissue beneath the skin, which
may communicate with the skin surface
through one or several small sinus opening
• may be controlled by antibiotic therapy at
early stage
• Surgery: Incision and drainage
Management of Patients
with Gastric and
Duodenal Disorders
February 2021
1. Compare the clinical manifestations of acute gastritis, chronic gastritis, and

peptic ulcer;
2. Discuss the medical and surgical management of the different disorders;
3. Enumerate the nursing responsibilities in the care of patients with gastric and
duodenal disorders
4. Integrate the nursing process in the care of patients with gastric and duodenal
disorders.
GASTRITIS: inflammation of the gastric or stomach mucosa
 Acute Gastritis  Chronic Gastritis

o often caused by dietary indiscretion o caused by either benign or malignant ulcers of
o eats food that is contaminated with disease- the stomach or by the bacteria Helicobacter
causing microorganisms or that is irritating or pylori
too highly seasoned
o associated with autoimmune diseases such as
o overuse of aspirin and other nonsteroidal anti- pernicious anemia; dietary factors such as
inflammatory drugs (NSAIDs), excessive alcohol caffeine; the use of medications, especially
intake, bile reflux, and radiation therapy
NSAIDs; alcohol; smoking; or reflux of intestinal
o ingestion of strong acid or alkali contents into the stomach
o Clinical Manifestations
o Clinical Manifestations
 abdominal discomfort
 Anorexia
 headache
 heartburn after eating
 lassitude
 belching
 nausea
 a sour taste in the mouth
 anorexia
 vomiting  nausea and vomiting
 hiccupping
 Assessment and Diagnostic
Findings
o Endoscopy
o upper GI radiographic studies
o histologic examination of a
tissue specimen obtained by
biopsy
o H. pylori test
 Serologic
 Breath test
Medical Management
o Acute Gastritis o Chronic gastritis

 refrain from alcohol and food until  modifying the patient’s diet
symptoms subside
 promoting rest
 nonirritating diet is recommended
 reducing stress
 fluids may need to be administered
parenterally  initiating pharmacotherapy
 If gastritis is caused by ingestion of  antibiotics for H. pylori (eg,
strong acids or alkalis tetracycline or amoxicillin,
 diluting and neutralizing the combined with
offending agent clarithromycin)
 neutralize acids, common antacids  proton pump inhibitor (eg,
(eg, aluminum hydroxide) lansoprazole [Prevacid])
 to neutralize an alkali, diluted
lemon juice or diluted vinegar
 If corrosion is extensive or severe,
emetics and lavage are avoided
because of the danger of perforation
and damage to the esophagus
GASTRIC AND DUODENAL ULCERS
 peptic ulcer is an excavation (hollowed-out area) that forms in the mucosal wall of the stomach,
in the pylorus (opening between stomach and duodenum), in the duodenum (first part of small
intestine), or in the esophagus
 frequently referred to as a gastric, duodenal, or esophageal ulcer, depending on its location, or
as peptic ulcer disease
• Zollinger-Ellison syndrome (ZES) - caused by excessive amounts of the hormone gastrin,

produced by tumors
 Stress ulcers - ulcerations in the mucosa that can occur in the gastroduodenal area
o may occur in patients who are exposed to stressful conditions
 Esophageal ulcers - result of the backward flow of HCl from the stomach into the esophagus
 Cushing’s ulcers - common in patients with trauma to the brain

o occur in the esophagus, stomach, or duodenum and are usually deeper and more
penetrating than stress ulcers
 Curling’s ulcer - frequently observed about 72 hours after extensive burns and involves the
antrum of the stomach or the duodenum
 Clinical Manifestations
o 20% to 30% perforation or hemorrhage may
occur without any preceding manifestations
o dull, gnawing pain or a burning sensation in the
midepigastrium or in the back
o Pain is usually relieved by eating but returns
o localized tenderness
o pyrosis (heartburn), vomiting, constipation or
diarrhea, and bleeding
o sour eructation, or burping
o bloating
 Assessment and Diagnostic Findings
o physical examination
o barium study of the upper GI tract
o endoscopy
Medical Management: Pharmacologic Therapy
Medical & Surgical Management
o STRESS REDUCTION AND REST
o SMOKING CESSATION
o DIETARY MODIFICATION
o avoiding extremes of
temperature and
overstimulation from
consumption of meat extracts,
alcohol, coffee (including
decaffeinated coffee, which also
stimulates acid secretion) and
other caffeinated beverages,
and diets rich in milk and cream
(which stimulate acid secretion)
o SURGICAL MANAGEMENT
o vagotomy, with or without
pyloroplasty
o Billroth I and Billroth II
procedures
MORBID OBESITY
 people who are more than two times their ideal body
weight or whose body mass index (BMI) exceeds 30
kg/m2.
 body weight that is more than 100 pounds greater than the
ideal body weight
 frequently suffer from low self-esteem, impaired body
image, and depression
 higher risk for health complications, such as cardiovascular

disease, arthritis, asthma, bronchitis, and diabetes
 Medical Management
o weight loss diet in conjunction with behavioral
modification and exercise
o PHARMACOLOGIC MANAGEMENT
 sibutramine HCl (Meridia) and orlistat (Xenical)
 jejunoileal bypass
 Gastric bypass and vertical banded gastroplasty
– operations of choice
 Roux-en-Y gastric bypass - recommended
procedure for long-term weight loss
 Nursing Management
o care of the patient after surgery
 monitor for complications: peritonitis, stomal obstruction, stomal ulcers,
atelectasis and pneumonia, thromboembolism, and metabolic imbalances
resulting from prolonged vomiting and diarrhea
 small feedings consisting of a total of 600 to 800 calories per day
 encourages fluid intake to prevent dehydration
 instructs patients to report excessive thirst or concentrated urine, both of
which are indications of dehydration
o Psychosocial interventions
 modify their eating behaviors
 cope with changes in body image
GASTRIC CANCER
 diet high in smoked foods and low in fruits and vegetables may
increase the risk
 Other factors: e chronic inflammation of the stomach, pernicious
anemia, achlorhydria, gastric ulcers, H. pylori infection, and genetics
o Asymptomatic at early stage
o Progressive stage: anorexia, dyspepsia (indigestion), weight
loss, abdominal pain, constipation, anemia, and nausea and
vomiting
o Endoscopy for biopsy and cytologic washings
o barium x-ray examination of the upper GI tract
o computed tomography (CT) scan, bone scan, and liver scan – to
determine metastasis
 Medical Management
o No successful treatment
o tumor can be removed while it is still localized to the stomach
o Palliative care
DISORDERS O F THE
ESOPHAGUS
February 2021
Let Us Review:
• When is the perfect time to collect specimen for fecalysis?
• What are your nursing interventions after the patient had undergone barium
swallow?
• What are your nursing responsibilities if the patient is for CT scan whole
abdomen?
Intended Learning Outcomes:
•
1. Identify physical and psychosocial needs of patients with esophageal disorders and
corresponding nursing management;
2. Utilize the nursing care process as a framework for care of patients with esophageal
disorders.
Disorders of the Esophagus
- begins at the base of the pharynx and ends about 4 cm below the diaphragm
1. DYSPHAGIA
 most common symptom of esophageal disease
 an uncomfortable feeling that a bolus of food is caught in the upper esophagus (before it
eventually passes into the stomach)
 acute pain on swallowing (odynophagia)
 pathologic conditions of the esophagus, including motility disorders (achalasia, diffuse
spasm), gastroesophageal reflux, hiatal hernias, diverticula, perforation, foreign bodies,
chemical burns, benign tumors, and carcinoma
2. ACHALASIA
 absent or ineffective peristalsis of the  Assessment and Diagnostic Findings
distal esophagus, accompanied by failure o Barium Swallow
of the esophageal sphincter to relax in
o CT of esophagus
response to swallowing
o Endoscopy
 occurs most often in people 40 years of
age or older
 Management
 Clinical Manifestations o eat slowly and to drink fluids with meals
o difficulty in swallowing both liquids and solids o calcium channel blockers and nitrates have been used to
o sensation of food sticking in the lower portion of decrease esophageal pressure and improve swallowing
the esophagus o Injection of botulinum toxin (Botox) to quadrants of the
o chest pain and heartburn (pyrosis) esophagus via endoscopy has been helpful because it
inhibits the contraction of smooth muscle
o secondary pulmonary complications from
o treated conservatively by pneumatic dilation to stretch the
aspiration of gastric contents
narrowed area of the esophagus
o esophagomyotomy – surgery
3. DIFFUSE SPASM: motor disorder of the esophagus
 Cause: unknown  Management

 Associated factor: stress o Conservative therapy
 Symptoms  administration of sedatives
o Dysphagia  long-acting nitrates to relieve pain
o Odynophagia o Calcium channel blockers
 Assessment and Diagnostic Findings o Small, frequent feedings and a soft diet
o Esophageal manometry o Dilation performed by bougienage (use of progressively
sized flexible dilators), pneumatic dilation
o Diagnostic x-ray studies after
ingestion of barium show separate o Esophagomyotomy may be necessary if the pain becomes
areas of spasm intolerable
4. HIATAL HERNIA
 Management
 the opening in the diaphragm through which the
esophagus passes becomes enlarged, and part of
o Frequent, small feedings
the upper stomach tends to move up into the lower o Instruct patient not to recline for 1
portion of the thorax
hour after eating, to prevent reflux or
 Types movement of the hernia, and to
o Sliding, or type I, hiatal hernia - the upper elevate the head of the bed on 4- to
stomach and the gastroesophageal junction 8-inch (10- to 20-cm) blocks to
(GEJ) are displaced upward and slide in and
out of the thorax
prevent the hernia from sliding
upward
o Paraesophageal hernia - all or part of the
stomach pushes through the diaphragm beside o Paraesophageal hernia – emergency
the esophagus surgery to correct torsion of the
 Assessment and Diagnostic Findings Diagnosis stomach
o x-ray studies, barium swallow, and fluoroscopy.
5. DIVERTICULUM

 an outpouching of mucosa and submucosa that protrudes
through a weak portion of the musculature
o barium swallow
 Areas o Manometric studies
o the pharyngoesophageal or upper area of the esophagus
o the midesophageal area o Esophagoscopy
o the epiphrenic or lower area of the esophagus
o along the border of the esophagus intramurally  Management
 Zenker’s diverticulum – most common o Diverticulectomy - pharyngoesophageal
o also known as pharyngoesophageal pulsion diverticulum or pulsion diverticulum
a pharyngeal pouch
o Myotomy of the cricopharyngeal muscle -
 Clinical Manifestations to relieve spasticity of the musculature
o difficulty swallowing/dysphagia
o fullness in the neck o Postoperative: NGT is inserted
o belching
o regurgitation of undigested food
o gurgling noises after eating
o Halitosis and a sour taste in the mouth
6. PERFORATION
 Management
 may result from stab or bullet wounds of the neck or o broad-spectrum antibiotic therapy
chest, trauma from motor vehicle crash, caustic injury
from a chemical burn (described later), or inadvertent o nasogastric tube is inserted
puncture by a surgical instrument during examination or
dilation
o Parenteral nutrition is preferred to
gastrostomy
o Surgery may be necessary to close the
o Dysphagia
wound
o Fever
o Leukocytosis
o severe hypotension
o Diagnostic x-ray studies and fluoroscopy
7. FOREIGN BODIES
 swallowed foreign bodies (eg, dentures, fish  Management

bones, pins, small batteries, items
containing mercury or lead) may injure the o Glucagon IM
esophagus or obstruct its lumen o Endoscopy: extraction f foreign
 Clinical Manifestations body
o Pain o mixture consisting of sodium
o Dysphagia bicarbonate and tartaric acid may
be used to increase intraluminal
o Dyspnea
pressure by the formation of a gas
 Diagnostics: X-ray
8. CHEMICAL BURNS
 caused by:  Management

o undissolved medications in the o Management shock
esophagus (elderly) o Management for pain
o Relieve respiratory distress
o swallowing of a battery o NPO
o swallowing a strong acid or o IV Fluids
base (eg, lye) o nasogastric tube may be inserted
o Vomiting and gastric lavage are avoided to prevent further exposure of
 Clinical Manifestations the esophagus to the caustic agent
o burns of the lips, mouth, and o Questionable but still prescribed
pharynx, with pain on  Use of corticosteroids
swallowing  Prophylactic use of antibiotics
o nutritional support via enteral or parenteral feedings
o difficulty in breathing o Dilation by bougienage
o febrile and in shock o For strictures that do not respond to dilation: Reconstruction may be
accomplished by esophagectomy and colon interposition to replace the
 Diagnostics portion of esophagus removed
o Esophagoscopy and barium
swallow
9. GASTROESOPHAGEAL REFLUX DISEASE (GERD)
 back-flow of gastric or duodenal contents into the esophagus
 Causes:
o incompetent lower esophageal sphincter
o pyloric stenosis
o motility disorder
o aging
 Clinical Manifestations (mimics heart attack)
o pyrosis (burning sensation in the esophagus)
o dyspepsia (indigestion)
o regurgitation
o dysphagia or odynophagia (difficulty swallowing, pain on swallowing)
o hypersalivation
o esophagitis
o endoscopy or barium swallow
o Bilirubin monitoring
 Management
o instructed to eat a low-fat diet; to avoid caffeine, tobacco, beer, milk, foods containing peppermint or
spearmint, and carbonated beverages
o avoid eating or drinking 2 hours before bedtime
o maintain normal body weight; to avoid tight-fitting clothes
o elevate the head of the bed on 6- to 8-inch (15- to 20-cm) blocks or elevate the upper body on pillows
o medications such as antacids or histamine receptor blockers
o Proton pump inhibitors (medications that decrease the release of gastric acid, such as lansoprazole [Prevacid]
or rabeprazole [Aciphex]) may be used; however, there is concern that these products may increase
intragastric bacterial growth and the risk for infection
o prokinetic agents - accelerate gastric emptying; bethanechol (Urecholine), domperidone (Motilium), and
metoclopramide (Reglan)
o Metoclopramide has central nervous system complications with long-term use
o Surgical management involves a fundoplication (wrapping of a portion of the gastric fundus around the
sphincter area of the esophagus). Fundoplication may be performed by laparoscopy
10. BARRETT’S ESOPHAGUS: 11. BENIGN TUMORS OF THE
long-standing untreated GERD ESOPHAGUS
 a precancerous condition that, if left untreated, can  arise anywhere along the esophagus
result in adenocarcinoma of the esophagus, which
has a poor prognosis  Leiomyoma (tumor of the smooth muscle) –
most common lesion; can occlude the lumen of
the esophagus
o Symptoms of GERD with notably frequent
heartburn  Asymptomatic
 Assessment and Diagnostic Findings  Management:
o esophagogastroduodenoscopy (EGD) with o Small lesions are excised during
biopsy esophagoscopy
 Management o lesions that occur within the wall of the
o repeat EGD in 6 to 12 months if with cell esophagus may require treatment via a
changes thoracotomy
o Medical and surgical management is similar to
that for GERD
12. CANCER OF THE ESOPHAGUS
 Risk factor: Chronic irritation  Assessment and Diagnostic Findings

 associated with ingestion of alcohol and with the use of tobacco o EGD with biopsy
 Clinical Manifestations o Bronchoscopy usually is performed, especially in
tumors of the middle and the upper third of the
o dysphagia, initially with solid foods and eventually with
esophagus, to determine whether the trachea has
liquid
been affected and to help determine whether the
o a sensation of a mass in the throat lesion can be removed
o painful swallowing o Endoscopic ultrasound or mediastinoscopy is used
to determine whether the cancer has spread to the
o substernal pain or fullness nodes and other mediastinal structures
o later, regurgitation of undigested food with foul breath and
hiccups
o hemorrhage may take place, and progressive loss of
weight and strength occurs from starvation
o respiratory difficulty
 Medical Management  Nursing Management
o Nutrition
o surgery, radiation, chemotherapy, or a combination  promote weight gain based on a high-calorie and high-
of these modalities, depending on the extent of the protein diet, in liquid or soft form
disease  initiate parenteral or enteral nutrition
o Standard surgical management includes a total
resection of the esophagus (esophagectomy) with
o Postoperative Care
 patient is placed in a low Fowler’s position, and later in a
removal of the tumor plus a wide tumor-free margin
Fowler’s position, to assist in preventing reflux of gastric
of the esophagus and the lymph nodes in the area secretions
o Surgical resection of the esophagus has a  observed carefully for regurgitation and dyspnea
relatively high mortality rate because of infection,  temperature is monitored to detect any elevation that may
pulmonary complications, or leakage through the indicate aspiration or seepage of fluid through the operative
site into the mediastinum
anastomosis
o Postoperative Management o Post jejunal grafting
 checks for graft viability hourly for at least the first 12 hours
 nasogastric tube in place that should not be  gauze is removed briefly to assess the graft for color and to
manipulated assess for the presence of a pulse by means of Doppler
 NPO until x-ray studies confirm that the ultrasonography
anastomosis is secure and not leaking
o Home Care
o Palliative treatment may be necessary to keep the  How to promote nutrition
esophagus open, to assist with nutrition, and to  what observations to make
control saliva  what measures to take if complications occur
 how to keep the patient comfortable
 how to obtain needed physical and emotional support
End of Presentation.
LESSON 4: Management of Patients with Intestinal and
Rectal Disorders

1. Compare the conditions of malabsorption with regard to
their pathophysiology, clinical manifestations, and
management.
2. Identify the health care teaching needs of patients with
constipation or diarrhea.
patients with intestinal and rectal disorders
Introduction
In all age groups, a fast-paced lifestyle, high levels of stress,
irregular eating habits, insufficient intake of fiber and
water, and lack of daily exercise contribute to GI problems.
Nurses can have an impact on these chronic problems by
identifying behavior patterns that put patients at risk, by
educating the public about prevention and management,
and by helping those affected to improve their condition
and prevent complications.
Abnormalities of Fecal Elimination
CONSTIPATION
➢ an abnormal infrequency or irregularity of defecation
➢ abnormal hardening of stools that makes their passage difficult and sometimes painful
➢ a decrease in stool volume
➢ retention of stool in the rectum for a prolonged period
➢ Other causes
CAUSES: ▪ Weakness
1. certain medications ▪ Immobility
a. tranquilizer ▪ Debility
b. anticholinergics ▪ Fatigue
▪ inability to increase intra-abdominal pressure to
c. antidepressants
facilitate the passage of stools, as occurs with
d. antihypertensives emphysema
e. opioids ▪ dietary habits (ie, low consumption of fiber and
f. antacids with aluminum inadequate fluid intake)
g. iron ▪ lack of regular exercise
2. rectal or anal disorders ▪ stress-filled life
a. hemorrhoids ➢ Pathophysiology
b. fissures ▪ interference with one of three major functions of
3. obstruction the colon
a. cancer of the bowel • mucosal transport (ie, mucosal
4. metabolic, neurologic, and secretions facilitate the movement of
neuromuscular conditions colon contents)
a. diabetes mellitus • myoelectric activity (ie, mixing of the
rectal mass and propulsive actions)
b. Hirschsprung’s disease
• the processes of defecation
c. Parkinson’s disease
d. multiple sclerosis ➢ Clinical Manifestations
5. endocrine disorders ▪ abdominal distention
a. hypothyroidism ▪ borborygmus (gurgling or rumbling sound
b. pheochromocytoma caused by passage of gas through the intestine)
▪ pain and pressure
6. lead poisoning
▪ decreased appetite
7. connective tissue disorders ▪ headache
a. scleroderma ▪ fatigue
b. lupus erythematosus ▪ indigestion
▪ a sensation of incomplete emptying
▪ straining at stool
▪ elimination of small-volume, hard, dry stools
➢ Assessment and Diagnostic Findings
o patient’s history
o physical examination
o possibly a barium enema or sigmoidoscopy
o stool testing for occult blood
➢ Complications
o Hypertension
o fecal impaction
o hemorrhoids and fissures
o megacolon
➢ Medical Management
o Education
o bowel habit training
o increased fiber and fluid intake
o judicious use of laxatives
o Routine exercise
o addition to the diet of 6 to 12 teaspoonfuls of unprocessed bran is recommended
o Enemas and rectal suppositories are generally not recommended
➢ Nursing Management
o Gather pertinent data through
health history interview
➢ onset and duration of
constipation
➢ current and past elimination
patterns
➢ patient’s expectation of
normal bowel elimination
➢ lifestyle information
o exercise and
activity level
o Occupation
o food and fluid intake
o stress level
➢ Past medical and surgical
history
➢ current medications
➢ laxative and enema use
o Patient education and health
promotion
➢ Nursing Goals
o restoring or maintaining a regular pattern of elimination
o ensuring adequate intake of fluids and high-fiber foods
o learning about methods to avoid constipation
o relieving anxiety about bowel elimination patterns
o avoiding complications
DIARRHEA
➢ increased frequency of bowel movements (more than three per day), increased amount of
stool (more than 200 g per day), and altered consistency (ie, looseness) of stool
➢ associated with urgency, perianal discomfort, incontinence, or a combination of these
factors
➢ CAUSES
o Any condition that causes increased
intestinal secretions, decreased mucosal
absorption, or altered motility can produce
diarrhea
▪Irritable bowel syndrome (IBS)
▪inflammatory bowel disease (IBD)
▪lactose intolerance
o certain medications
▪ thyroid hormone replacement
▪ stool softeners and laxatives
▪ antibiotics
▪ chemotherapy
▪ antacids
o certain tube feeding formulas
o metabolic and endocrine disorders
▪ diabetes
▪ Addison’s disease
▪ thyrotoxicosis
o viral or bacterial infectious processes
▪ dysentery
▪ shigellosis
▪ food poisoning
o nutritional and malabsorptive disorders
▪ Celiac disease
▪ celiac disease
o anal sphincter defect
o Zollinger-Ellison syndrome
o paralytic ileus
o intestinal obstruction
o acquired immunodeficiency syndrome
(AIDS)
➢ may be ACUTE or CHRONIC
➢ Pathophysiology
o Secretory diarrhea
▪ usually high-volume diarrhea
▪ caused by increased production and secretion of water and
electrolytes by the intestinal mucosa into the intestinal lumen
o Osmotic diarrhea
▪ occurs when water is pulled into the intestines by the osmotic
pressure of unabsorbed particles, slowing the reabsorption of water
o Mixed diarrhea
▪ caused by increased peristalsis (usually from IBD)
▪ a combination of increased secretion and decreased absorption in
the bowel
➢ Clinical Manifestations
o increased frequency and fluid content of stools
o abdominal cramps
o distention
o intestinal rumbling (ie, borborygmus)
o anorexia
o thirst
o Painful spasmodic contractions of the anus and ineffectual straining
o Stool characteristics
▪ small bowel disease: Watery stools
▪ disorders of the colon: loose, semisolid stools
▪ intestinal malabsorption: Voluminous, greasy stools
▪ inflammatory enteritis or colitis: presence of mucus and pus in the stools
▪ diagnostic of pancreatic insufficiency: Oil droplets on the toilet water
o complete blood cell count
o chemical profile
o urinalysis
o routine stool examination
o stool examinations for infectious or parasitic organisms, bacterial toxins, blood,
fat, and electrolytes
o Endoscopy or barium enema
➢ Complications
o potential for cardiac dysrhythmias
▪ significant fluid and electrolyte loss (especially loss of potassium)
o Urinary output of less than 30 mL per hour for 2 to 3 consecutive hours
o muscle weakness
o paresthesia
ohypotension
oanorexia
odrowsiness with a potassium level of less than 3.0 mEq/L (3 mmol/L)
oDecreased potassium levels cause cardiac dysrhythmias that can lead to death
▪ atrial and ventricular tachycardia
▪ ventricular fibrillation
▪ premature ventricular contractions
o controlling symptoms
o preventing complications
o eliminating or treating the underlying disease
o assessing and monitoring the characteristics and pattern of diarrhea
o health history addresses the patient’s medication therapy, medical and surgical
history, and dietary patterns and intake, exposure to acute illness, and travel
o Assessment includes abdominal auscultation and palpation for abdominal
tenderness
o Inspection of the abdomen and mucous membranes and skin
o Obtain stool samples for testing
o encourages bed rest and intake of liquids and foods low in bulk until the acute
attack subsides
o recommends a bland diet of semisolid and solid foods
o avoid caffeine, carbonated beverages, and very hot and very cold foods, because
they stimulate intestinal motility
o restrict milk products, fat, whole-grain products, fresh fruits, and vegetables for
several days
o administers antidiarrheal medications such as diphenoxylate (Lomotil) and
loperamide (Imodium) as prescribed
o Intravenous fluid therapy
o closely monitor serum electrolyte levels
o immediately reports evidence of dysrhythmias or a change in the level of
consciousness
o follow a perianal skin care routine to decrease irritation and excoriation
FECAL INCONTINENCE
➢ involuntary passage of stool from the rectum
➢ factors influencing fecal continence
o the ability of the rectum to sense and accommodate stool
o the amount and consistency of stool
o the integrity of the anal sphincters and musculature
o rectal motility
➢ Pathophysiology
o trauma
▪ after surgical procedures involving the rectum
o a neurologic disorder
▪ stroke
▪ multiple sclerosis
▪ diabetic neuropathy
▪ dementia
o inflammation
o infection
o radiation treatment
o fecal impaction
➢ pelvic floor relaxation
o laxative abuse
o Medications
o advancing age
▪ weakness or loss of anal or rectal muscle tone
o occasional urgency and loss of control, or complete incontinence
o poor control of flatus
o diarrhea
o constipation

o rectal examination
o endoscopic examinations
▪ sigmoidoscopy
o X-ray studies such as barium enema
o computed tomography (CT) scans
o anorectal manometry
o Depends on identified cause
o Biofeedback therapy
o Bowel training programs
o Surgical procedures
▪ surgical reconstruction
▪ sphincter repair
▪ fecal diversion
o health history
o examination of the rectal area.
o initiates a bowel-training program that involves setting a schedule to establish
bowel regularity
o use suppositories to stimulate the anal reflex
o Maintaining skin integrity (perianal area)
o assists the patient and family to accept and cope with this chronic situation
IRRITABLE BOWEL SYNDROME (IBS)

➢ results from a functional disorder of
intestinal motility
➢ Factors:
o Heredity
o psychological stress or conditions
such as depression and anxiety
o a diet high in fat
o stimulating or irritating foods
o alcohol consumption
o smoking
➢ Pathophysiology
o Related factors
▪ neurologic regulatory
system
▪ infection or irritation
▪ vascular or metabolic
disturbance
o alteration in bowel patterns—constipation, diarrhea, or a combination of both
o Pain, bloating, and abdominal distention
o abdominal pain precipitated by eating and relieved by defecation

o tests that prove the absence of structural or other disorders
o Stool studies, contrast x-ray studies, and proctoscopy – to rule out colon disease
o Barium enema and colonoscopy – to reveal spasm
o Manometry and electromyography – intraluminal pressure changes
o Goals
▪ relieving abdominal pain
▪ controlling the diarrhea or constipation
▪ reducing stress
o Food restrictions (beans, caffeinated products, fried foods, alcohol, spicy foods)
o healthy, high-fiber diet
o Exercise
o stress reduction or behavior-modification program
o Pharmacotherapy
▪ Hydrophilic colloids (ie, bulk)
▪ antidiarrheal agents (eg, loperamide)
▪ Antidepressants
▪ Anticholinergics and calcium channel blockers
o provide patient and family education
o emphasizes teaching and reinforces good dietary habits
o encouraged to eat at regular times and to chew food slowly and thoroughly
o adequate fluid intake
▪ fluid should not be taken with meals because this results in abdominal
distention
o Discourage alcohol use and cigarette smoking
CONDITIONS OF MALABSORPTION
➢ inability of the digestive system to absorb one or more of the major vitamins
(especially vitamin B12), minerals (ie, iron and calcium), and nutrients (ie,
carbohydrates, fats, and proteins)
➢ Common cause: Diseases of the small intestine
➢ Pathophysiology
o Mucosal (transport) disorders causing generalized malabsorption (eg, celiac
sprue, regional enteritis, radiation enteritis)
o Infectious diseases causing generalized malabsorption (eg, small bowel
bacterial overgrowth, tropical sprue, Whipple’s disease)
o Luminal problems causing malabsorption (eg, bile acid deficiency, Zollinger-
Ellison syndrome, pancreatic insufficiency)
o Postoperative malabsorption (eg, after gastric or intestinal resection)
o Disorders that cause malabsorption of specific nutrients (eg, disaccharidase
deficiency leading to lactose intolerance)
o hallmarks of malabsorption syndrome: diarrhea or frequent, loose, bulky, foul-
smelling stools that have increased fat content and are often grayish
o abdominal distention
o pain
o increased flatus
o weakness
o weight loss,
o decreased sense of well-being
o Chief result: malnutrition, manifested by weight loss and other signs of
vitamin and mineral deficiency (eg, easy bruising, osteoporosis, anemia)
o If untreated: weak and emaciated because of starvation and dehydration
o Failure to absorb the fat-soluble vitamins A, D, and K causes a corresponding
avitaminosis

o stool studies for quantitative and qualitative fat analysis, lactose tolerance
tests, D-xylose absorption tests, and Schilling tests
o hydrogen breath test – carbohydrate absorption
o Endoscopy with biopsy of the mucosa – BEST diagnostic tool
o Biopsy of the small intestine
o Ultrasound studies, CT scans, and x-ray
o Pancreatic function tests
o CBC to detect anemia
o avoiding dietary substances that aggravate malabsorption and at
supplementing nutrients that have been lost
o Commons supplements
▪ water-soluble vitamins (eg, B12, folic acid)
▪ fat-soluble vitamins (ie, A, D, and K)
▪ minerals (eg, calcium, iron)
o Dietary therapy
▪ reducing gluten intake for celiac sprue
▪ Folic acid supplements for tropical sprue
o Pharmacologic Therapy
▪ Antibiotics (tetracycline, ampicillin ) treatment of tropical sprue and
bacterial overgrowth syndromes
▪ Antidiarrheal agents - decrease intestinal spasms
▪ Parenteral fluids - treat dehydration
o provides patient and family education regarding diet and the use of nutritional
supplements
▪ risk of osteoporosis related to malabsorption of calcium
o monitor fluid and electrolyte imbalances.
o conducts ongoing assessments
Acute Inflammatory Intestinal Disorders
➢ Any part of the lower GI tract is susceptible to acute inflammation caused by
bacterial, viral, or fungal infection. Two such situations are appendicitis and
diverticulitis. These two conditions can lead to peritonitis, an inflammatory
process within the abdomen.
APPENDICITIS
➢ appendix becomes inflamed and edematous as a result of either becoming kinked or
occluded by a fecalith (ie, hardened mass of stool), tumor, or foreign body)
➢ inflammation increases intraluminal pressure, initiating a progressively severe,
generalized or upper abdominal pain that becomes localized in the right lower quadrant
of the abdomen within a few hours. Eventually, the inflamed appendix fills with pus
o Vague epigastric or
periumbilical pain
progresses to RLQ
pain and is usually
accompanied by a
low-grade fever and
nausea and
sometimes by
vomiting
o Loss of appetite
o Local tenderness is
elicited at
McBurney’s point
o Rebound tenderness
o Rovsing’s sign -
elicited by palpating
the left lower
quadrant; this
paradoxically causes
pain to be felt in the
right lower quadrant
o complete physical examination and on laboratory and x-ray findings
o CBC
▪ elevated white blood cell count
▪ leukocytes exceed 10,000 cells/mm3, and the neutrophil count may exceed
75%.
o Abdominal x-ray films, ultrasound studies, and CT scans
➢ Complications
o perforation of the appendix
▪ peritonitis or an abscess
▪ Symptoms
• fever of 37.7°C (100°F) or higher
• a toxic appearance
• continued abdominal pain or tenderness.
o Surgery: Appendectomy - low abdominal incision or by laparoscopy
o antibiotics
o intravenous fluids
o Analgesics – given after diagnosis has been made
o Goals
▪ relieving pain
▪ preventing fluid volume deficit
▪ reducing anxiety
▪ eliminating infection from the potential or actual disruption of the GI tract
▪ maintaining skin integrity
▪ attaining optimal nutrition
o prepares the patient for surgery
▪ NO ENEMA – it can lead to perforation
▪ Insert NGT if with likelihood of paralytic ileus
o After surgery
▪ semi-Fowler position
▪ administer opioid (morphine sulphate)
▪ oral fluids once indicated
▪ instructs the patient to make an appointment to have the surgeon remove
the sutures
▪ Incision care and activity guidelines
o If with peritonitis
▪ Left with drain
▪monitored carefully for signs of intestinal obstruction or secondary
hemorrhage
o home care
▪ teaches the patient and family to care for the incision and perform dressing
changes and irrigations
▪ monitor for potential complications
DIVERTICULAR DISEASE
➢ Diverticulum (Diverticula)
o saclike outpouching of the lining of the bowel that extends through a
defect in the muscle layer
o may occur anywhere along the GI tract
➢ Diverticulosis
o multiple diverticula are present without inflammation or symptoms
➢ Diverticulitis
o results when food and bacteria retained in a diverticulum produce
infection and inflammation that can impede drainage and lead to
perforation or abscess formation
➢ Pathophysiology
o Causes
▪ forms when the mucosa and submucosal layers of the colon herniate
through the muscular wall because of:
• high intraluminal pressure
• low volume in the colon (ie, fiber-deficient contents)
• decreased muscle strength in the colon wall (ie, muscular
hypertrophy from hardened fecal masses)
o potential complications (symptoms)—abscesses, fistulas, obstruction, and
hemorrhage
o bowel irregularity and intervals of diarrhea
o abrupt onset of crampy pain in the left lower quadrant of the abdomen
o a low-grade fever
o nausea and anorexia
o bloating or abdominal distention
o Weakness, fatigue, and anorexia
o Mild to severe pain

o CT Scan : procedure of choice
o DIETARY AND MEDICATION
MANAGEMENT
▪ rest, analgesics (opioid), and
antispasmodics (propantheline
bromide)
▪ diet is clear liquid until the
inflammation subsides
▪ a high-fiber, low-fat diet is
recommended
▪ Antibiotics are prescribed for
7 to 10 days
▪ Bulk-forming laxative
▪ One-stage resection - inflamed area is removed and a primary end-to-end
anastomosis is completed
▪ Multiple-staged procedures for complications such as obstruction or
perforation
PERITONITIS
➢ inflammation of the peritoneum, the serous
membrane lining the abdominal cavity a nd
covering the viscera
➢ CAUSES
o bacterial infection (Escherichia coli,
Klebsiella, Proteus, and Pseudomonas)
o external sources such as injury or trauma
(eg, gunshot wound, stab wound)
o an inflammation that extends from an
organ outside the peritoneal area
o appendicitis
o perforated ulcer
o diverticulitis
o bowel perforation
o associated with abdominal surgical
procedures and peritoneal dialysis.
➢ Pathophysiology
o leakage of contents from abdominal organs into the abdominal cavity, usually as a
result of inflammation, infection, ischemia, trauma, or tumor perforation
o Abdominal tenderness and distended, and the muscles become rigid
o Rebound tenderness and paralytic ileus
o nausea and vomiting
o leukocyte count is elevated
o abdominal x-ray is obtained
o CT scan of the abdomen
o Peritoneal aspiration and culture and sensitivity
➢ Complications
o Sepsis is the major cause of death from peritonitis
o Shock may result from septicemia or hypovolemia
o postoperative complications: wound evisceration and abscess formation
o Fluid, colloid, and electrolyte replacement
o isotonic solution
o Analgesics
o Antiemetics
o Massive antibiotic therapy
o Surgical treatment
▪ excision (ie, appendix)
▪ resection with or without anastomosis (ie, intestine)
▪ repair (ie, perforation)
▪ drainage (ie, abscess)
o Ongoing assessment of pain, vital signs, GI function, and fluid and electrolyte
balance
o Administering analgesic medication and positioning the patient for comfort are
helpful in decreasing pain
o placed on the side with knees flexed
o Accurate recording of all intake and output
o administers and monitors closely intravenous fluids
o increases fluid and food intake gradually and reduces parenteral fluids as
prescribed
o Post-operative Care
▪ observe and record the character of the drainage postoperatively
▪ be cautious when moving and turning the patient to prevent the drains
from being dislodged
▪ prepare the patient and family for discharge by teaching the patient to care
for the incision and drains if the patient will be sent home with the drains
still in place
Inflammatory Bowel Disease
➢ regional enteritis (ie, Crohn’s disease or granulomatous colitis)
➢ ulcerative colitis
REGIONAL ENTERITIS (CROHN’S DISEASE)
➢ a subacute and chronic inflammation that extends through all layers (ie, transmural
lesion) of the bowel wall from the intestinal mucosa
➢ characterized by periods of remissions and exacerbations
o prominent lower right quadrant abdominal pain and diarrhea unrelieved by
defecation
o crampy abdominal pains
o diarrhea
o steatorrhea
o anorexia
o weight loss
o nutritional deficiencies
o barium study of the upper GI tract – most conclusive
o proctosigmoidoscopic examination
o stool examination
➢ Complications
o intestinal obstruction or stricture formation
o perianal disease
o fluid and electrolyte imbalances
o malnutrition from malabsorption
o fistula and abscess formation
ULCERATIVE COLITIS
➢ a recurrent ulcerative and inflammatory disease of the mucosal and submucosal layers of
the colon and rectum
➢ characterized by multiple ulcerations, diffuse inflammations, and desquamation or
shedding of the colonic epithelium
o Diarrhea
o lower left quadrant abdominal pain
o intermittent tenesmus
o rectal bleeding
o anorexia
o weight loss
o fever
o vomiting
o dehydration
o feeling of an urgent need to defecate
o passage of 10 to 20 liquid stools each day

o stool is positive for blood
o laboratory test results
▪ low hematocrit and hemoglobin concentration
▪ elevated white blood cell count
▪ low albumin levels
▪ electrolyte imbalance
o Abdominal x-ray studies
o Sigmoidoscopy or colonoscopy
o barium enema
o CT scanning, magnetic resonance imaging, and ultrasound
➢ Complications
o toxic megacolon
o perforation
o bleeding as a result of ulceration
o vascular engorgement
o highly vascular granulation tissue
Medical Management of Chronic Inflammatory Bowel Disease
➢ Goals
o reducing inflammation
o suppressing inappropriate immune responses
o providing rest for a diseased bowel so that healing may take place
o improving quality of life
o preventing or minimizing complications
➢ NUTRITIONAL THERAPY
o Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental
vitamin therapy and iron replacement
o intravenous therapy
o Cold foods and smoking
o Parenteral nutrition as indicated
➢ PHARMACOLOGIC THERAPY
o Sedatives and antidiarrheal and antiperistaltic medications
o Aminosalicylate formulations: sulfasalazine (Azulfidine)
o sulfa-free aminosalicylates (eg, mesalamine [Asacol, Pentasa])
o corticosteroids (eg, prednisone)
o Immunomodulators (eg, azathioprene [Imuran], 6-mercaptopurine, methotrexate,
cyclosporin)
➢ SURGICAL MANAGEMENT
o total colectomy and ileostomy – procedure of choice for regional enteritis
o intestinal transplant
o Proctocolectomy with ileostomy (ie, complete excision of colon, rectum, and
anus) is recommended when the rectum is severely involved.
o Strictureplasty - the blocked or narrowed section of the bowel is widened, leaving
the bowel intact
o Total Colectomy with Ileostomy
▪ Ileostomy - surgical creation of an opening into the ileum or small
intestine (usually by means of an ileal stoma on the abdominal wall)
▪ allows for drainage of fecal matter (ie, effluent) from the ileum to the
outside of the body
▪ drainage is very mushy and occurs at frequent intervals.
o Total Colectomy with Continent Ileostomy.
▪ removal of the entire colon and creation of the continent ileal reservoir (ie,
Kock pouch)
▪ eliminates the need for an
external fecal collection
bag
▪ Approximately 30 cm of
the distal ileum is
reconstructed to form a
reservoir with a nipple
valve that is created by
pulling a portion of the
terminal ileal loop back
into the ileum.
▪ GI effluent can
accumulate in the pouch
for several hours and then
be removed by means of a
catheter inserted through
the nipple valve
o Total Colectomy with Ileoanal
Anastomosis
▪ A total colectomy with
ileoanal anastomosis is
another surgical
procedure that eliminates the need for a permanent ileostomy
▪ establishes an ileal reservoir, and anal sphincter control of elimination is
retained
▪ connecting a portion of the ileum to the anus (ie, ileoanal anastomosis) in
conjunction with removal of the colon and the rectal mucosa (ie, total
abdominal colectomy and mucosal proctectomy)
▪ the diseased colon and rectum are removed, voluntary defecation is
maintained, and anal continence is preserved
o education about diet and medications and referral to support groups
o careful monitoring, parenteral nutrition, fluid replacement, and possibly emergent
surgery
o needs for physical care, emotional support, and extensive teaching about
management of the ostomy
MANAGEMENT OF PATIENTS WITH DIGESTIVE AND GASTROINTESTINAL
DISORDERS
LESSON 1: Assessment of Digestive and Gastrointestinal Function

After taking this lesson, the learner shall:
1. Describe the structure and function of the organs of the

gastrointestinal tract.
2. Describe the mechanical and chemical processes involved in
digesting and absorbing foods and eliminating waste
products.
3. Use assessment parameters appropriate for determining the
status of gastrointestinal function.
4. Describe the appropriate preparation, teaching, and follow-
up care for patients who are undergoing diagnostic testing of
the gastrointestinal tract.
Kicking it Off!
OVERVIEW: Assessment of Digestive and

Gastrointestinal Function
I. Anatomy of the
Gastrointestinal Tract
II. Functions
a. To break down food
particles into the
molecular form for
digestion
b. To absorb into the
bloodstream the small
molecules produced by
digestion
c. To eliminate undigested
and unabsorbed
foodstuffs and other
waste products from the
body
CHEWING AND SWALLOWING
• Chewing - food is broken down into small particles that can
be swallowed and mixed with digestive enzymes
• Swallowing
o begins as a voluntary act that is regulated by a swallowing
center in the medulla oblongata of the central nervous system.
o the epiglottis moves to cover the tracheal opening and prevent
aspiration of food into the lungs
o The smooth muscle in the wall of the esophagus contracts in a
rhythmic sequence from the upper esophagus toward the
stomach to propel the bolus of food along the tract
GASTRIC FUNCTION
• Ingestion of food
• The stomach can produce about 2.4 L per day of these
gastric secretions.
Gastric secretions also contain the enzyme pepsin, which
is important for initiating protein digestion
• Intrinsic factor is also secreted by the gastric mucosa.
This compound combines with dietary vitamin B12 so that
the vitamin can be absorbed in the
ileum. In the absence of intrinsic factor, vitamin B12
cannot be absorbed and pernicious anemia results.
• Food mixed with gastric secretions is called chyme.
• Hormones, neuroregulators, and local regulators found in
the gastric secretions control the rate of gastric secretions
and influence gastric motility
SMALL INTESTINE FUNCTION

• The digestive process continues in the duodenum.
• Secretions in the duodenum come from the accessory
digestive organs—the pancreas, liver, and gallbladder—
and the glands in the wall of the intestine itself.
• Pancreatic secretions have an alkaline pH because of
high concentrations of bicarbonate.
• Digestive enzymes secreted by the Pancreas
o Trypsin - aids in digesting protein
o Amylase - aids in digesting starch
o Lipase - aids in digesting fats
• Bile (secreted by the liver and stored in the gallbladder)
aids in emulsifying ingested fats, making them easier to
digest and absorb.
COLONIC FUNCTION
• Within 4 hours after eating, residual waste material passes into
the terminal ileum and passes slowly into the proximal portion
of the colon through the ileocecal valve
• The waste materials from a meal eventually reach and distend
the rectum, usually in about 12 hours.
• As much as one fourth of the waste materials from a meal may
still be in the rectum 3 days after the meal was ingested.
WASTE PRODUCTS OF DIGESTION
• Fecal matter is about 75% fluid and 25% solid material.
• Large portion of the fecal mass is of nondietary origin,
derived from the secretions of the GI tract.
• The brown color of the feces results from the breakdown of
bile by the intestinal bacteria. Chemicals formed by intestinal
bacteria (especially indole and skatole) are responsible in
large part for the fecal odor.
• Gases formed contain methane, hydrogen sulfide, and
ammonia, among others.
• The GI tract normally contains approximately 150 mL of
these gases, which are either absorbed into the portal
circulation and detoxified by the liver or expelled from the
rectum as flatus.
• Elimination of stool begins with distention of the rectum,
which reflexively initiates contractions of the rectal
musculature and relaxes the normally closed internal anal
sphincter.
• The internal sphincter is controlled by the autonomic nervous
system; the external sphincter is under the conscious control
of the cerebral cortex.
• During defecation, the external anal sphincter voluntarily
relaxes to allow colonic contents to be expelled.
• Normally, the external anal sphincter is maintained in a state
of tonic contraction. Thus, defecation is seen to be a spinal
reflex (involving the parasympathetic nerve fibers) that can
be inhibited voluntarily by keeping the external anal
sphincter closed.
• Contracting the abdominal muscles (straining) facilitates
emptying of the colon. The average frequency of defecation
in humans is once daily, but the frequency varies among
individuals.
LET’S START THE NURSING PROCESS!
ASSESSMENT
HEALTH HISTORY AND CLINICAL MANIFESTATIONS
Activity 1: Taking History
What are the symptoms common to GI dysfunction?

___________________ _______________________
___________________ _______________________
___________________ _______________________
___________________ _______________________
What are the relevant questions to ask?
1. _______________________________________________________
2. _______________________________________________________
3. _______________________________________________________
4. _______________________________________________________
5. _______________________________________________________
Let us EXPLORE YOUR ANSWERS!
PAIN
What to ask?
• Character
• Duration
• Pattern
• Frequency
• Location
• Distribution of referred pain
• Time of the pain
What are the factors:
• Meals
• Rest
• Defecation
• Vascular disorders
INDIGESTION
• Upper abdominal discomfort or distress associated with
eating
• Basis: gastric peristaltic movements
• Bowel movements may or may not relieve the pain
• Causes: disturbed nervous system control of the stomach or
disorder in the GI tract or elsewhere in the body
o Fatty foods tend to cause the most discomfort, because
they remain in the stomach longer than proteins or
carbohydrates do.
o Coarse vegetables and highly seasoned foods can
also cause considerable distress.
INTESTINAL GAS
• accumulation of gas in the GI tract may result in:
o belching - the expulsion of gas from the stomach
through the mouth
o flatulence - the expulsion of gas from the rectum
• Excessive flatulence may be a symptom of gallbladder
disease or food intolerance.
NAUSEA and VOMITING

• Vomiting is usually preceded by nausea, which can be
triggered by odors, activity, or food intake.
• The emesis, or vomitus, may vary in color and content. It
may contain undigested food particles or blood
(hematemesis).
o When vomiting occurs soon after hemorrhage, the
emesis is bright red.
o If blood has been retained in the stomach, it takes on a
coffee-ground appearance because of the action of the
digestive enzymes.
CHANGE IN BOWEL HABITS & STOOL CHARACTERISTICS

• Changes in bowel habits may signal colon disease.
• Diarrhea - an abnormal increase in the frequency and
liquidity of the stool or in daily stool weight or volume
o the contents move so rapidly through the intestine and
colon that there is inadequate time for the GI secretions
to be absorbed
o sometimes associated with abdominal pain or cramping
and nausea or vomiting
• Constipation - a decrease
in the frequency of stool,
or stools that are hard,
dry, and of smaller
volume than normal
o may be associated
with anal discomfort
and rectal bleeding.
• Factors affecting stool color
o Certain foods
o Medications
• Other common abnormalities in stool characteristics:
o Bulky, greasy, foamy stools that are foul in odor; stool
color is gray, with a silvery sheen
o Light gray or clay-colored stool, caused by the absence
of urobilin
o Stool with mucus threads or pus that may be visible on
gross inspection of the stool
o Small, dry, rock-hard masses called scybala;
sometimes streaked with blood from rectal trauma as
they pass through the rectum
o Loose, watery stool that may or may not be streaked
with blood
PHYSICAL ASSESSMENT
Activity 2: The I-P-P-A
What is the order of performing physical assessment of the

abdomen?
1. ________________________
2. ________________________
3. ________________________
4. ________________________
What to inspect on the upper GI? How to assess the abdomen?
• Mouth 1. Inspect
• Tongue a. noting skin changes and scars from previous surgery
• buccal mucosa b. note the contour and symmetry of the abdomen
• teeth 2. Auscultate
• gums a. note the character, location, and frequency of bowel
What to note? sounds
• Ulcers b. assesses bowel sounds in all four quadrants using the
• Nodules diaphragm of the stethoscope
• Swelling c. document the frequency of the sounds
• Discoloration • normal (sounds heard about every 5 to 20
• inflammation seconds),
NOTE: Remove dentures when • hypoactive (one or two sounds in 2 minutes)
inspecting • hyperactive (5 to 6 sounds heard in less than 30
seconds)
• absent (no sounds in 3 to 5 minutes).
Inspection of the anal and perineal What sounds will you hear during percussion?
area • tympany
• inspect and palpate areas • dullness
of excoriation or rash,
fissures or fistula How to palpate?
openings, or external light palpation - identifying areas of tenderness or swelling
hemorrhoids deep palpation - identify masses in any of the four quadrants.
• digital rectal examination How to assess rabound tenderness?

can be performed to note 1. exert pressure over the area and then releases it quickly
any areas of tenderness or 2. note any pain experienced on withdrawal of the pressure
mass
Inspection-Auscultation-Palpation-
Percussion
DIAGNOSTIC EVALUATION
1. Blood Tests - may reveal alterations in basal metabolic

function and may indicate the severity of a disorder
• complete blood count (CBC)
• carcinoembryonic antigen (CEA)
• liver function tests
• serum cholesterol
• triglycerides
2. Ultrasound and Endoscopy

• Nursing Responsibilities:
• Instruct time of fasting
• Administer laxatives or enemas, and ingestion
• Injection of a contrast agent or a radiopaque dye
Health Education for Patients who will undergo GI diagnostic
procedure
✓ Providing general information about a healthy diet and the
nutritional factors that can cause GI disturbances; after a
diagnosis has been confirmed, the nurse provides
information about specific nutrients that should be included
in the diet
✓ Providing needed information about the test and the
activities required of the patient
✓ Providing instructions about post procedure care and activity
restrictions
✓ Alleviating anxiety
✓ Helping the patient cope with discomfort
✓ Encouraging family members or others to offer emotional
support to the patient during the diagnostic testing
✓ Assessing for adequate hydration before, during, and
immediately after the procedure, and providing education
about maintenance of hydration
3. Stool Tests
• Stool Exam/Fecalysis
• Occult Blood
• Specific Tests
• Urobilinogen
• Fat
• Nitrogen
• Parasites
• Pathogens
• food residues
• other substances
• Nursing Responsibilities
• Stool Samples
• randomly collected unless for quantitative study
(fat, urobilinogen)
• quantitative 24- to 72-hour collections must
be kept refrigerated until they are taken to the
laboratory
• Some stool collections require the patient to
follow a special diet or to refrain from taking
certain medications before the collection. It is
important to follow test guidelines closely for
accurate results.
• Fecal occult blood testing- tests for heme, the iron-
containing portion of the hemoglobin molecule that
is altered during transit through the intestines.
• NOT performed when there is hemorrhoidal
bleeding.
• Serial 3- to 6-day testing is recommended.
• False-positive results may occur if the patient
has eaten rare meat, liver, poultry, turnips,
broccoli, cauliflower, melons, salmon,
sardines, or horseradish within 7 days before
testing.
• Medications that can cause gastric irritation,
such as aspirin, ibuprofen, indomethacin,
colchicine, corticosteroids, cancer
chemotherapeutic agents, and
anticoagulants, may also cause false-positive
results.
• Ingestion of vitamin C from supplements or
foods can cause false-negative results.
4. Breath Tests
• hydrogen breath test
• evaluate carbohydrate absorption
• used to aid in the diagnosis of bacterial
overgrowth in the intestine and short bowel
syndrome.
• determines the amount of hydrogen expelled in
the breath after it has been produced in the colon
(on contact of galactose with fermenting bacteria)
and absorbed into the blood
• Urea breath tests
• detect the presence of Helicobacter pylori
• patient takes a capsule of carbon-labeled urea and
then provides a breath sample 10 to 20 minutes
later
• What to avoid?
• antibiotics or loperamide (Pepto-Bismol) for
1 month before the test
• sucralfate (Carafate) and omeprazole
(Prilosec) for 1 week before the test
• cimetidine (Tagamet), famotidine (Pepcid),
ranitidine (Zantac), and nizatidine (Axid) for
24 hours before urea breath testing
5. ABDOMINAL ULTRASONOGRAPHY
• noninvasive diagnostic technique
• used to indicate the size and configuration of abdominal
structures
• useful in the detection of cholelithiasis, cholecystitis,
and appendicitis
• useful in diagnosing acute colonic diverticulitis
• no ionizing radiation, there are no noticeable side
effects, and it is relatively inexpensive
• it cannot be used to examine structures that lie behind
bony tissue
• Gas and fluid in the abdomen or air in the lungs also
prevent transmission of ultrasound
• Endoscopic ultrasonography (EUS) is a specialized
enteroscopic procedure that aids in the diagnosis of GI
disorders by providing direct imaging of a target area
• better quality resolution and definition than regular
ultrasound imaging
• helps in staging of a tumor, including size, spread,
and whether the tumor is operable
• useful in evaluating transmural changes in the
bowel wall that occur in ulcerative colitis
• Nursing Interventions
• fasts for 8 to 12 hours before the test
• If gallbladder studies are being performed, the
patient should eat a fat-free meal the evening
before the test
• If barium studies are to be performed, the nurse
should make sure they are scheduled after the
ultrasound
6. DNA TESTING
• genetic risk assessment, preclinical diagnosis, and
prenatal diagnosis
• DNA testing allows practitioners to prevent (or
minimize) disease, by intervening before its onset, and
to improve therapy
7. IMAGING STUDIES: x-ray and contrast studies, computed

tomography (CT) scans, magnetic resonance imaging (MRI),
and scintigraphy (radionuclide imaging)
• Upper Gastrointestinal Tract Study
• X-ray: upper GI series or barium swallow
• enables the examiner to detect or exclude
anatomic or functional derangement of the
upper GI organs or sphincters
• aids in the diagnosis of ulcers, varices,
tumors, regional enteritis, and malabsorption
syndromes
• may be extended to examine the duodenum
and small bowel (small bowel follow-through)
• NURSING INTERVENTIONS
a. patient may need to maintain a low-
residue diet for several days before the
test
b. receive nothing by mouth after midnight
before the test
c. physician may prescribe a laxative to
clean out the intestinal tract
d. nurse discourages the patient from
smoking on the morning before the
examination
e. nurse withholds all medications
f. After the procedure: Fluids must be
increased to facilitate evacuation of
stool and barium
g. nurse monitors the patient’s stools until
they return to their normal color
h. laxative or enema may be needed
• Lower Gastrointestinal Tract Study
• barium enema
• to detect the presence of polyps, tumors, and
other lesions of the large intestine and to
demonstrate any abnormal anatomy or
malfunction of the bowel
a. emptying and cleansing the lower bowel
b. low-residue diet 1 to 2 days before the
test
c. clear liquid diet and a laxative the
evening before; nothing by mouth after
midnight; and cleansing enemas until
returns are clear the following morning
d. If the patient has active inflammatory
disease of the colon, enemas are
contraindicated
e. Barium enema also is contraindicated in
patients with signs of perforation or
obstruction; instead, a water-soluble
contrast study may be performed in
these situations.
f. Active GI bleeding may prohibit the use
of laxatives and enemas
g. nurse administers an enema or laxative
after these tests to facilitate barium
removal
h. Increasing fluid intake also will assist in
eliminating the barium.
i. As with any barium study, the nurse
monitors the patient for complete
elimination of the barium
• Computed Tomography
• provides cross-sectional images of abdominal
organs and structures
• valuable tool for detecting and localizing many
inflammatory conditions in the colon, such as
appendicitis, diverticulitis, regional enteritis, and
ulcerative colitis
• patient should not eat or drink for 6 to 8 hours
before the test.
• practitioner may prescribe an intravenous or
oral contrast agent
• nurse should question the patient about
contrast dye allergies
• If barium studies are to be performed, it is
important to schedule them after CT
scanning, so as not to interfere with imaging.
• Magnetic Resonance Imaging

• used in gastroenterology to supplement
ultrasonography and CT scanning
• a noninvasive technique that uses magnetic fields
and radio waves to produce an image of the area
being studied.
• useful in evaluating abdominal soft tissues as well
as blood vessels, abscesses, fistulas, neoplasms,
and other sources of bleeding
• contraindicated for patients with permanent
pacemakers, artificial heart valves and
defibrillators, implanted insulin pumps, or
implanted transcutaneous electrical nerve
stimulation devices, because the magnetic field
could cause malfunction. MRI is also
contraindicated for patients with internal metal
devices (eg, aneurysm clips) or intraocular metallic
fragments
before the test
• patient must remove all jewelry and other
metals
• entire procedure takes 30 to 90 minutes
• warn patients that the close-fitting scanners
used in many MRI facilities may induce
feelings of claustrophobia and that the
machine will make a knocking sound during
the procedure
• Scintigraphy
• (radionuclide testing) relies on the use of
radioactive isotopes (ie, technetium, iodine, and
indium) to reveal displaced anatomic structures,
changes in organ size, and the presence of
neoplasms or other focal lesions, such as cysts or
abscesses
• Scintigraphic scanning is also used to measure
the uptake of tagged red blood cells and
leukocytes
• Gastrointestinal Motility Studies

• Radionuclide testing also is used to assess gastric
emptying and colonic transit time
• liquid and solid components of a meal are tagged
with radionuclide markers. After the patient ingests
the meal, the patient is positioned under a
scintiscanner, which measures the rate of passage
of the radioactive substance out of the stomach
• Colonic transit studies are used to evaluate
colonic motility instances of chronic constipation
and obstructive defecation syndromes
8. ENDOSCOPIC PROCEDURES:
fibroscopy/esophagogastroduodenoscopy, anoscopy,
proctoscopy, sigmoidoscopy, colonoscopy, small-bowel
enteroscopy, and endoscopy through ostomy
• Upper Gastrointestinal Fibroscopy/

Esophagogastroduodenoscopy (EGD)
• especially valuable when esophageal, gastric, or
duodenal abnormalities or inflammatory,
neoplastic, or infectious processes are suspected
• endoscopic retrograde cholangiopancreatography
(ERCP)
• uses the endoscope in combination with
radiographic techniques to view the ductal
structures of the biliary tract
• helpful in evaluating jaundice, pancreatitis,
pancreatic tumors, common duct stones, and
biliary tract disease
• Nursing Interventions
before the examination
• Patient Preparation:
• helping the patient spray or gargle with a
local anesthetic
• administering midazolam (Versed)
intravenously just before the scope is
introduced
• nurse also may administer atropine to reduce
secretions, and may give glucagon, if needed
and prescribed, to relax smooth muscle.
• nurse positions the patient on the left side to
facilitate saliva drainage and to provide easy
access for the endoscope
• patient may experience nausea, gagging, or
choking. Use of topical anesthetics and moderate
sedation makes it important to monitor and
maintain the oral airway during and after the
procedure.
• Finger or ear oximeters are used to monitor
oxygen saturation, and supplemental oxygen may
be used if needed
• Emergency equipment must be readily available.
• Precautions must be taken to protect the scope,
because the fiberoptic bundles can be broken if
the scope is bent at an acute angle.
• The patient wears a mouth guard to keep from
biting the scope.
• After the procedure:
• nurse instructs the patient not to eat or drink
until the gag reflex returns (in 1 to 2 hours), to
prevent aspiration of food or fluids into the
lungs.
• nurse places the patient in the Simms
position until he or she is awake and then
places the patient in the semi-Fowler’s
position until ready for discharge.
• nurse includes observing for signs of
perforation, such as pain, bleeding, unusual
difficulty swallowing, and an elevated
temperature
• nurse monitors the pulse and blood pressure
for changes that can occur with sedation
• nurse can test the gag reflex by placing a
tongue blade onto the back of the throat to
see whether gagging occurs
• nurse can offer lozenges, saline gargle, and
oral analgesics to relieve minor throat
discomfort
• Patients who were sedated for the procedure
must stay on bed rest until fully alert
• Anoscopy, Proctoscopy, and Sigmoidoscopy

o lower portion of the colon also can be viewed directly
to evaluate rectal bleeding, acute or chronic diarrhea,
or change in bowel patterns and to observe for
ulceration, fissures, abscesses, tumors, polyps, or
other pathologic processes
o Nursing interventions
▪ patient assumes a comfortable position on the
left side with the right leg bent and placed
anteriorly
▪ explain the sensations associated with the
examination
▪ examinations require only limited bowel
preparation, including a warm tap water or
Fleet’s enema until returns are clear
▪ During the procedure: nurse monitors vital
signs, skin color and temperature, pain
tolerance, and vagal response
▪ After the procedure: nurse monitors the patient
for rectal bleeding and signs of intestinal
perforation
• Fiberoptic Colonoscopy
o Direct visual inspection of the colon to the cecum is
possible by means of a flexible fiberoptic
colonoscope
o most frequently used for cancer screening
o tissue biopsies can be obtained as needed, and
polyps can be removed and evaluated
o Nursing Interventions
▪ patient should limit the intake of liquids for 24 to
72 hours before the examination
▪ laxative for two nights before the examination
and a Fleet’s or saline enema until the return
runs clear the morning of the test
▪ polyethylene glycol electrolyte lavage solutions
(Golytely, Colyte, NuLytely) are used as
intestinal lavages for effective cleansing of the
bowel
▪ Informed consent is obtained before the test.
▪ NPO
▪ performed while the patient is lying on the left
side with the legs drawn up toward the chest
▪ monitor the patient’s cardiac and respiratory
function continuously
▪ Oxygen saturation is monitored; Supplement as
needed
• Small-Bowel Enteroscopy
o “pull” endoscope - balloon tip advances the scope by
peristalsis through the small intestine
o “Push” endoscopes - smaller in caliber and longer in
length, while still allowing the use of biopsy forceps
and probes
o useful in the evaluation of patients who have
continued bleeding even after extensive diagnostic
testing has identified no other problem area
o can also be used when biopsy of the small bowel is
needed to diagnose malabsorption syndromes.
• Endoscopy Through Ostomy

o Endoscopy using a flexible endoscope through an
ostomy stoma is useful for visualizing a segment of
the small or large intestine.
o It may be indicated to evaluate an anastomosis, to
screen for recurrent disease, or to visualize and treat
bleeding in a segment of the bowel
LESSON 2: Nursing Care and Management of patients with Oral and
Esophageal Disorders
After taking this lesson, the learner shall:
1. Identify physical and psychosocial needs of patients with oral

and esophageal disorders and corresponding nursing
management;
2. Utilize the nursing care process as a framework for care of
patients with oral and esophageal disorders.
Dental Health Diseases

DENTAL PLAQUE AND CARIES
➢ Tooth decay is an erosive process that begins with the action of
bacteria on fermentable carbohydrates in the mouth, which produces
acids that dissolve tooth enamel.
➢ Dental plaque is a gluey, gelatin-like substance that adheres to
the teeth.
➢ Dental decay begins with a small hole, usually in a fissure (a
break in the tooth’s enamel) or in an area that is hard to clean.
➢ Prevention:
o Mouth Care
o Diet
o Fluoridation
o Pit ad Fissure Sealants
DENTOALVEOLAR ABSCESS OR PERIAPICAL ABSCESS
➢ Periapical abscess, more commonly referred to as an
abscessed
tooth, involves the collection of pus in the apical dental
periosteum (fibrous membrane supporting the tooth structure)
and the tissue surrounding the apex of the tooth (where it is
suspended in the jaw bone).
➢ Acute periapical abscess is usually secondary to a suppurative
pulpitis (a pus-producing inflammation of the dental pulp) that
arises from an infection extending from dental caries.
➢ Chronic dentoalveolar abscess is a slowly progressive
infectious process. It differs from the acute form in that the
process may progress to a fully formed abscess without the
patient’s knowing it.
o dull, gnawing, continuous pain, often with a surrounding
cellulitis
o edema of the adjacent facial structures
o mobility of the involved tooth
o systemic reaction, fever, and malaise
➢ Management
o Early stage: a needle aspiration or drill an opening into
the pulp chamber to relieve tension and pain and to
provide drainage done by dentist or dental surgeon
o After the inflammatory reaction has subsided, the tooth
may be extracted or root canal therapy performed.
o Antibiotics may be prescribed.
➢ Nursing Responsibilities
o Assess for bleeding post treatment
o Instruct to use a warm saline or warm water mouth rinse
to keep the area clean.
o Instruct to take antibiotics and analgesics as prescribed,
to advance from a liquid diet to a soft diet as tolerated,
and to keep follow-up appointments.
MALOCCLUSION
➢ Malocclusion is a misalignment of the teeth of the upper and lower
dental arcs when the jaws are closed.
➢ Malocclusion can be inherited or acquired (from thumb-sucking,
trauma, or some medical conditions).
➢ Correction of malocclusion requires an orthodontist with special
training, a patient who is motivated and cooperative, and adequate
time.
➢ Most treatments begin when the patient has shed the last primary
tooth and the last permanent successor has erupted, usually at
about 12 or 13 years of age, but treatment may occur in
adulthood.
➢ Management
• Braces
• Retaining device
➢ Nursing Responsibilities
• Instruct to practice meticulous oral hygiene
• Encourages to persist in this important part of the treatment.
• Remind to continue wearing the retainer
Disorders of the Lips, Mouth and Gums
-
Disorders of the Jaw
➢ congenital malformation, fracture, chronic dislocation, cancer, and
syndromes characterized by pain and limited motion
TEMPOROMANDIBULAR DISORDERS
➢ Categories:
o Myofascial pain—a discomfort in the muscles controlling jaw
function and in neck and shoulder muscles
o Internal derangement of the joint—a dislocated jaw, a displaced
disc, or an injured condyle
o Degenerative joint disease—rheumatoid arthritis or
osteoarthritis in the jaw joint
o pain ranging from a dull ache to throbbing, debilitating pain that
can radiate to the ears, teeth, neck muscles, and facial sinuses
o often have restricted jaw motion and locking of the jaw.
o may hear clicking and grating noises, and chewing and
swallowing may be difficult
o Depression may occur in response to these symptoms
➢ Assessment
o based on subjective symptoms of pain, limitations in range of
motion, dysphagia, difficulty chewing, difficulty with speech, or
hearing difficulties
➢ Diagnostics
o MRI
o X-ray
➢ Management
o patient education in stress management may be helpful (to
reduce grinding and clenching of teeth)
o range-of-motion exercises
o Pain management measures
▪ nonsteroidal anti-inflammatory drugs (NSAIDs), with the
possible addition of opioids, muscle relaxants, or mild
antidepressants
o bite plate or splint (plastic guard worn over the upper and lower
teeth) may be worn to protect teeth from grinding
o Surgical Management
▪ repositioning or reconstruction of the jaw
▪ Rigid plate fixation (insertion of metal plates and screws
into the bone to approximate and stabilize the bone)
▪ Bone grafting
o Nursing Management
▪ Instruct not to chew food in the first 1 to 4 weeks after
surgery
▪ A liquid diet is recommended, and dietary counseling
should be obtained to ensure optimal caloric and protein
intake
▪ Promoting home and community-based care
• mouth care and feeding
• Consultation with a dietitian
• Nutritional supplements
Disorder of the Salivary Glands

➢ consist of the parotid glands, one on each side of the face
below the ear; the submandibular and sublingual glands,
both in the floor of the mouth; and the buccal gland, beneath
the lips.
PAROTITIS
➢ inflammation of the parotid gland
➢ most common inflammatory condition of the salivary glands
➢ Mumps (epidemic parotitis), a communicable disease
caused by viral infection and most commonly affecting
children, is an inflammation of a salivary gland, usually the
parotid
➢ High Risk
o Elderly
o acutely ill
o debilitated people with decreased salivary flow from
general dehydration or medications
➢ Cause: Staphylococcus aureus (except in mumps)
➢ Signs and Symptoms:
o Fever
o gland swells and becomes tense and tender
o pain in the ear
o swollen glands interfere with swallowing
➢ Management
o Antibiotics
o Analgesics
o Parotidectomy – to drain gland; for chronic parotitis
SIALADENITIS
➢ inflammation of the salivary glands
➢ caused by dehydration, radiation therapy, stress,
malnutrition, salivary gland calculi (stones), or improper
oral hygiene
➢ Cause of infection: S. aureus, Streptococcus viridans, or
pneumococcus
➢ Symptoms include pain, swelling, and purulent discharge
➢ Management:
o Antibiotics
o Massage, hydration, and corticosteroids
o surgical drainage of the gland or excision of the
gland and its duct
SALIVARY CALCULUS (SIALOLITHIASIS)
➢ stones; formed mainly from calcium phosphate
➢ usually occurs in the submandibular gland
➢ Symptoms:
o cause no symptoms unless infection arises;
however, a calculus that obstructs the gland’s duct
causes sudden, local, and often colicky pain, which is
abruptly relieved by a gush of saliva
o stone itself can be palpable, and its shadow may be
seen on x-ray films
➢ Management
o Extraction
o lithotripsy, a procedure that uses shock waves to
disintegrate the stone, may be used instead of
surgical extraction for parotid stones and smaller
submandibular stones
o Surgery may be necessary to remove the gland if
symptoms and calculi recur repeatedly
NEOPLASMS (tumors/growth)
➢ Tumors occur more often in the parotid gland
➢ Risk factors include prior exposure to radiation to the head
and neck
➢ Management:
o Partial excision – preserve 7th CN
o For malignant tumor
▪ Radiation Therapy
▪ Chemotherapy
Cancer of the Oral Cavity and Pharynx

➢ occur in any part of the mouth or throat, are curable if
discovered early
➢ associated with the use of alcohol and tobacco
➢ Malignancies: squamous cell cancers
➢ Common areas: lips, the lateral aspects of the tongue,
and the floor of the mouth
➢ Clinical Manifestations:
o few or no symptoms in the early stages
o painless sore or mass that will not heal
o typical lesion in oral cancer is a painless indurated
(hardened) ulcer with raised edges
o Tissue from any ulcer of the oral cavity that does not
heal in 2 weeks should be examined through biopsy
o Progression: tenderness; difficulty in chewing,
swallowing, or speaking; coughing of blood-tinged
sputum; or enlarged cervical lymph nodes
o Physical exam
▪ Oral examination
▪ Cervical lymph
nodes
o Biopsy
o Surgical resection,
radiation therapy,
chemotherapy, or a
combination of these
therapies
o assesses the patient’s
nutritional status
preoperatively, and a dietary consultation may be
necessary
o patient may require enteral (through the intestine) or
parenteral (intravenous) feedings before and after
surgery to maintain adequate nutrition
o Postoperatively, the nurse assesses for a patent
airway
o patient may be unable to manage oral secretions,
making suctioning necessary

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CARE OF CLIENTS WITH

• a life-threatening complication of liver

• Edema and • Vitamin Deficiency Metabolic Abnormalities Pruritus and Other

• a systemic, viral infection in which

• Liver transplant – treatment of choice

• pain, a continuous dull ache • History & PE • RADIATION THERAPY &

• anorexia marker • OTHER NONSURGICAL

• Surgical resection • constant infusion of

• Blood cultures • IV antibiotic therapy • monitoring of the

• Acute inflammation of the gallbladder • Calculi, or gallstones, usually form in the

• PAIN AND BILIARY COLIC • ABDOMINAL X-RAY

• a history of abdominal • Pain Management

• Endoscopy to remove • Pancreaticojejunostomy

• jaundice, clay-colored • duodenography,

ASSESS Preoperative care

Postoperative care EVALUATE

• overproduction of insulin • hypersecretion of gastric

• Metabolic Complications 4. Diabetes mellitus associated with

• clinically evident when the serum

intraluminal obstruction or a mural intestinal musculature cannot propel the

Clinical  crampy pain that is wavelike and colicky  Constipation

Nursing • Non-surgical • Non-surgical

start as a benign polyp but may become malignant, invade and

Surgery: Primary Treatment

• Segmental resection with

• a mass of tissue that protrudes into

Assessment and Diagnostic Findings history and digital rectal examination

Medical Management Removal through:

Anal Fistula Clinical Manifestation Pus or stool may leak

• found in the intergluteal cleft on the

After taking this lesson, the learners shall:

1. Compare the clinical manifestations of acute gastritis, chronic gastritis, and

 Acute Gastritis  Chronic Gastritis

o Acute Gastritis o Chronic gastritis

• Zollinger-Ellison syndrome (ZES) - caused by excessive amounts of the hormone gastrin,

 Cushing’s ulcers - common in patients with trauma to the brain

 higher risk for health complications, such as cardiovascular

 Cause: unknown  Management

 Assessment and Diagnostic Findings

 swallowed foreign bodies (eg, dentures, fish  Management

 caused by:  Management

 Risk factor: Chronic irritation  Assessment and Diagnostic Findings

Intended Learning Outcomes

➢ Assessment and Diagnostic Findings

IRRITABLE BOWEL SYNDROME (IBS)

➢ Assessment and Diagnostic Findings

➢ Assessment and Diagnostic Findings

➢ Assessment and Diagnostic Findings

➢ Assessment and Diagnostic Findings

LESSON 1: Assessment of Digestive and Gastrointestinal Function

After taking this lesson, the learner shall:

1. Describe the structure and function of the organs of the

OVERVIEW: Assessment of Digestive and

SMALL INTESTINE FUNCTION

digest and absorb.

What are the symptoms common to GI dysfunction?

Let us EXPLORE YOUR ANSWERS!

NAUSEA and VOMITING