NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V.

. Velasco, RN MN NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Nanette V. Velasco, RN MN Evaluation 50-40-10 Update (something we did not know yet) with Reaction 5% Summary and Reaction with Source Clarity of thought 40% Relevance 40% Sentence Construction 20% Anatomy and Physiology 1. Mouth - Teeth, cheek, tongue, pharynx; chewing, mastication, break down food - 2-3 Liters of saliva if properly hydrated - produced by glands a. Parotid b. Submaxillary c. Sublingual - Contains amylase for breaking down of starchy substances - Saliva contains antibodies responsible in minimizing the level of bacteria in the mouth 2. Esophagus - Made of muscle, capable of peristalsis-wavelike motion, responsible for the movement of bolus (semi digested food) from the mouth to the stomach - 2-3 seconds to travel the entire length of the esophagus - 10inches or 25cm - Esophagectomy removal of the esophagus 3. Stomach - Cardioesophageal sphincter - Bolus will turn to chyme almost digested with mixture of gastric secretions - Pouch like organ that is covered with muscle - Responsible for storing food and mixing it with gastric juices (hydrochloric acid, water, pepsin for breaking down protein; mucus has mucin to coat the inner lining of the stomach to prevent ulceration) - pH is 2-3 - 3 parts a. Fundus b. Body c. Antrum most common site of ulceration, site commonly removed (antrectomy or partial gastrectomy), acid pools in this area - Food stays for 2-4 hours before transported to the duodenum - Further digestion of starches and protein (pepsin) - Pyloric sphincter, between stomach and small intestine

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NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN 2 Phases of Digestion 1. Cephalic Phase of Digestion o Digestion is stimulated by the smell, sight and thought food 2. Gastric Phase o Stimulated by the presence of food in the stomach o Actual phase of digestion 4. Small Intestine - For absorption and to further digest food - Approximately 20ft long - 3 Parts a. Duodenum o no absorption, just digestion o has Sphincter of Oddi connected to pancreas (produces lipase), liver, and gall bladder (stores the bile); Cholecystokinin produced by the duodenum that stimulates the gall bladder to release bile to emulsify the fat content of the food; pancreozymin stimulates the pancreas to release the pancreatic lipase, to breakdown fat to release fatty acid for absorption o Most sterile part b. Jejunum o Also for absorption c. Ileum o Highly active for absorption 5. Large intestine - For absorption of water and formation of stool - 4 Divisions a. Cecum (Ascending Colon) o Stool is watery b. Transverse Colon o Mushy c. Descending o Semi formed d. Sigmoid o Formed - Colectomy removal of the colon - Total Proctocolectomy client will excrete through ileostomy 6. Rectum - Reservoir or storage of stool 7. Anus - Passageways of stool - Has anal sphincter Accessory Organs 1. Liver - The largest organ internal organ of the human body - Produces bile 111

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN - Metabolic processes of Vit A, B, D and Iron, and other fat soluble vitamins (ADEK) - Storage of glucose in the form of glycogen - Production of coagulants low platelet count if having kidney trouble thrombocytopenia - Liver transplant is possible 2. Gall Bladder - Storage of Bile - Maximum of 60mL of bile - Cholecystectomy removal of gall bladder - Cholelithiasis gall stones 3. Pancreas - Just beneath the stomach - 2 Functions a. Endocrine produces insulin b. Exocrine produces pancreatic lipase (break down fats), amylase, trypsin (for protein substances) - Can be entirely removed 4. Appendix - No known function but highly linked to the immune system Gastrointestinal Tract or Alimentary Canal Function: 1. Absorption 2. Digestion 3. Secretion 4. Motility NGT landmarks NEX; Nose to Ears to the Xiphoid Process History - To determine the direction and focus of the physical examination and the required diagnostic 1. Family History - Question related to history of GI - Vomiting diarrhea, constipation, reflux 2. Past abdominal history and current problems 3. Eating Habits most GI problems are linked to GI pattern - Recall previous 24 hours, unusual eating requirement a. Appetite b. Food intolerance c. Bowel habits number of times defecate per week, less than 3 times a week constipation; normal is everyday 4. Nutritional Assessment a. Basis is the food pyramid 5. Dysphagia or Heartburn (substernal chest pain d/t reflux of acid usually after meals) 6. Nausea and Vomiting HCl is high every morning 7. Abdominal Pain using the pain scale; pinpoint precise area of pain 8. Medications Aspirin, antibiotics, NSAIDS, Anti-Psychotic Drugs are gastric irritants 112

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN GI Symptom Assessment 1. Pyrosis substernal pain, may be due to hot food 2. Odynophagia 3. Dysphagia 4. Dyspepsia indigestion, common for those veracious eaters 5. Queasiness (the stomach feels ill), nausea, regurgitation (common in those with esophageal CA), and vomiting (involuntary passing of gastric contents) 6. Hiccups (Hicoughs) involuntary contraction of the diaphragm can be stimulated by suddenly drinking cold, especially carbonated liquids; self limiting 7. GI Gas eating gas forming food and bacteria in the stomach 8. Diarrhea watery, loose stool 3 or more times per day 9. Constipation passing of stool less than 3 times in a week 10. Abdominal Pain mild, moderate to severe abdominal pain; Buscopan is given, anticholinergic, relaxes muscles Physical Assessment: GI System Body Mass Index good indicator of taking food normally based on the height and weight Formula: ((weight in lbs/height in inches)/height in inches)x703 = BMI Examples: 120lbs, Height is 60 inches BMI is 24.43 Interpretation Less than is 18.5 = underweight 19-24.9 = normal 25-30 = overweight 30 or greater = obese Abdomen IAPP inspection, Auscultation, Percussion, Palpation I. Inspection a. Condition of the skin and contour b. Distention or irregular contour c. Rashes, discoloration ,scars, petechiae (small red spots), striae and dilated veins (usually with those with cirrhosis) II. Auscultation a. Beginning from the lower quadrant. Continue in clockwise fashion. b. Normal bowel sounds 5-35 sounds per minutes c. Borborygmi hyperactivity; loud high pitched sound d/t hyperactivity of the bowel; heard if hungry, or if having diarrhea III. Percussion a. Size and location of abdominal organs and to detect fluids, air, or masses b. Tympanic loud high pitch sound heard over gaseous area. c. Thud-like or dull sounds mass like organ such as the liver 113

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN Palpation exert pressure, best method for presence of pain a. Palpate quadrant to quadrant b. Involuntary abdominal rigidity or guarding Diagnostic Tests/ Laboratory Test: 1. Gastric Analysis - Measure secretion of HCl and pepsin the stomach - For gastritis and peptic ulcer diseases - Through NGT lavage Nursing Care: Pretest a. NPO 12 hours to get the acidity of HCl on an empty stomach; may sip water b. Insert NGT c. Do not administer drugs that interfere with gastric acid levels (anticholinergic, antacids, antispasmodic) Nursing Care: Post-test a. Record amount and color of drainage (usually greenish in color) b. Assess for signs of bowel perforation (fresh blood may mean bleeding in the ulcer or perfoaration) 2. Fecalysis - Form, consistency, color are notes - Mucus, blood, pus, parasites, and fat content - Guaiac test, Hemocult, Hematest for occult blood in the stool (melena) - No special preparation 3. Endoscopy - Direct visualization of the GI system by means of lighted, flexible tube - Can reach up to the duodenum 3.1 Gastroscopy an instrument passed through the mouth and used to examine the stomach 3.2 Esophagogastroduodenoscopy direct visualization of the esophagus, stomach, and duodenum, nyy insertion of a lighted fiber scope. Nursing Care: Pretest a. NPO for 6-8 hours b. Consent signed (this is an invasive procedure) c. Explain that local anesthetic will be used lidocaine spray d. Speaking during the procedure will not be possible may cause spasms or displace the tube. Discomfort will be felt. Provide piece of paper and a pen. Nursing Care: Post-test a. NPO until gag reflex will return get a padded tongue depressor and place at the back of the tongue b. Assess V/S, pain, dysphagia (give a glass of water) and bleeding c. Administer warn NSS gargles 4. Colonoscopy - The visual examination of the lining of the entire colon with a flexible fiberoptic endoscope; client is sedated part of the info given to the client prior to the test - May be performed OPD Nursing Care: Pre-test a. NPO for 8 hours and sedated b. Position patient on the left side; left side lying with the legs flexed toward the chest 114 IV.

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN c. Administer laxatives for 1-3 days before the exam; or enema until return flow is clear d. Consent signed e. Explain a feeling of pressure might be experienced into the rectum Nursing Care: Post-test a. Observe for signs of perforation and rectal bleeding Acid Perfusion Test (Bernsteins Test) - Used for client with CA of esophagus - To determined whether the clients chest pain is related to acid perfusion across the esophageal mucosa. - Uses PNSS or HCl Proctosigmoidoscopy (Rectosigmoidoscopy) - Examination of the lining if the distal sigmoid colon, the rectum, and the anal canal - Diverticula sac like outpouching portion of the large intestine - Client is not sedated Nursing Resp i. Enema giving before ad morning of the procedure ii. Clear liquids iii. Knee chest position fetal position iv. Deep breathing during insertion of the scope, facilitates insertion of the tube and relaxes the sphincter, and prevents unnecessary entrance of air Liver Biopsy (closed needle) - Needle is inserted into the liver to remove a small piece of tissue for study - Percutaneous puncturing the abdomen - Liver has a tendency to bleed Nursing Care: Pre-test a. Refrain from ingesting ASA, NSAIDS or anticoagulants 2 weeks pre-test b. NPO for 6h pretest c. Hold breath during the biopsy d. Blood clotting test ( PT prothrombin time, PTT partial thromboplastin time, bleeding time, platelet, Hct) e. Left side lying Nursing Care: Post-test a. Assess V/S b. Right side for 1-2 hours with a pillow against the abdomen c. Obs for hemorrhage d. Assess for complication of shock and pneumothorax (may compress the lung producing DOB) e. Bed rest for 24 hours Nasogastric and Nasointestinal Intubation Ultrasonography - High frequency sound waves over an abdominal organ to obtain an image of the structure - Generally no preparation unless prescribed by MD Nursing Care: 115

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NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN 1. Special diet (High fat for gall bladder visualization), laxative or other medication to cleanse the bowel and decrease gas. 2. NPO for 8-12 h Computed Tomography Scan (CT Scan) - An x-ray technique that provide excellent anatomic definition and is used to detect tumors, cyst, and abscesses - 30-35 minutes - Advise client to remove jewelry - Contraindication: pregnant and obese Nursing Care: 1. NPO for 6-12 hours 2. Check of pregnant 3. Supine position Upper GI Series (Ba Swallow) - Fluoroscopic examination of upper GI tract to determine structural problems and gastric emptying time - Ba looks like flour and should be mixed with a little water, can be mixed with sprite Nursing Care: Pre-test a. NPO 6-8 hours b. Expla9in that Ba will taste chalky c. Avoid smoking smoke will create cloudy appearance; chewing gum is not advised Nursing Care: Post Test a. Administer laxative and force fluids: b. Assess abdomen for distention Ba will clump together and clump together if not removed immediately c. Instruct patient that within 72 hours, stool will be whitish in color d. No food restriction after the procedure Lower GI Series (Ba Enema) - Ba is instill in to the colon by enema Nursing Care: Pre-test a. NPO for 8h b. Give enemas until clear in AM of the test c. Administer laxative or suppository d. Explain that cramping may be experienced during the procedure Nursing Care: Post-test a. Administer laxatives and fluids to eliminate the Ba; maximum of 3 days that the stool may be white Oral Cholecystogram - An x-ray test for gall bladder or cystic duct disease - Viewing of gall bladder emptying capacity Nursing Care: Pre-test a. Radiopaque dye 6 tablets will be given i. Iopodate Na ii. Iopanoic Acid best given if dinner is high fat if not prepared b. Feed client high fat diet the day before (egg, cheese); 2 hours before the test, low fat meal 116

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NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN Nursing Care: Post-test a. Obs for S/E of the dye: allergies, report if symptoms are found Benadryl for allergy Pharmacologic Management 1. Antacid neutralizes the acidic environment of the stomach; ideally given after meal E.g. Na Bicarbonate; Calcium containing meds; Mg(OH)2or Gaviscon, Maalox; Al(OH)3 or Alu-cap, Gaviscon 2. Antispasmodic stops muscular contraction 3. H2 Blocker (Cemitidine, Famotidine, Ranitidine) block histamine that stimulates parietal cells to produce HCl; decreases HCl production 4. Anticholinergics (Antispasmodic) directly act is the ANS (involuntary) by blocking the effect of involuntary contractions E.g. Buscopan (relaxes the cervix cervical dilatation, 3 doses every 2 hours) Bentyl Pro-Banthene 5. Cytoprotective Agent coats the inner lining of the stomach esp if with ulcer to cover it to prevent further damage E.g. Sucralfate/Carafate 6. Anti-inflammatory 7. Antimicrobials 8. Antidiarrheals 9. Antiemetics 10. Laxatives Surgical Interventions 1. Partial Gastrectomy certain portion of the stomach is surgically removed Bariatric Surgery 2. Gastrostomy surgical opening of the stomach a. Billroth I (Gastroduodenostomy) portion of the stomach is anastomosed to the duodenum b. Billroth II (Gastrojejunostomy) c. Roux-en-y gastric bypass; portion of the stomach will not be used Dumping syndrome food is dumped from the stomach to the small intestine 3. Vagotomy surgical cutting of the cranial (vagus) nerves; responsible for production of HCl; to dec secretions 4. Appendectomy surgical removal of the appendix; McBurneys point; if ruptured, ExLap 5. Total Proctocolectomy with permanent Ileostomy (In RLQ) removal of the colon, rectum, and anus with the closure of the anus; Stoma 6. Total Proctocolectomy with continent Ileostomy Kock pouch is the continent ileostomy; no external pouch Problem is nutrition soft or low residue diet 7. Total Colectomy and Ileal Reservoir total removal of colon and ileoanal anastomosis with the formation of ileal reservoir. 8. Cholecystectomy and Choledocholithotomy - removal of the gall bladder 117

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN - incision into common bile duct for removal of duct Nissen Fundoplication (Gastric Wrap Around) stomach is sutured around the esophagus in cases of hiatal hernia NCM of Patents with Digestive System Diseases The Nursing Process Approach 1. Infections of the Mouth A. Stomatitis (no scar formation) - Inflammation of the Buccal mucosa a. Primary i. Aphthous Stomatitis o canker sore o caused by biting cheeks and caused by virus that infiltrate o stress releases cortisol which balances hormones and immune system o virus can remain active for years o may last for 2-3 weeks Causes o Herpes Simples o Allergies o Stress o Trauma (Chemical or Mechanical Trauma) o Vitamin deficiency Treatment o Topical anesthetic (EMLA) o Topical or systemic steroid if problem is due to allergy (under strict prescription) o Tetracycline for severe pain Herpes Simplex o Inflammation of the mouth with vesicle formation o Cold sores o Vesicle formation o Around the lips or upper part of nose Treatment a. Oral and topical analgesics b. Acyclovir Zovirax (IVTT) Denavir (Caplet) Vincents Angina o Aka oral thrush o Acute bacterial infection of the pain o Painful swallowing that might be mistaken as chest pain o Bacterial infection 118

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NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN Treatment o Removal of devitalized tissues o Improve oral hygiene o Bland diet o Vitamins o Analgesics o Saline mouth rinses (mouth wash should be mix with water) b. Secondary Stomatitis 1. Allergies 2. Bone marrow disorders 3. Nutritional disorders 4. Chemotherapy, radiation, immunosuppressive therapy 5. Immunodeficiency disorders Precipitating Factors Poor hygiene Increased age (increased bacteria in mouth) Malnutrition Lack of rest and sleep Debilitating disease Local tissue damage B. Parotitis - Inflammation of the parotid glands - May cause sterility in males if not immune after puberty (has affinity to testacles) - May be prevented by MMR Causes: a. Inactivity of the gland causes caused by medication (anticholinergic drugs) b. Prolonged NG intubation (client cannot taste food) c. Lack of oral intake d. DHN (when you feel that you are not producing saliva) Nursing Intervention a. Sialogogues any substance that can trigger salivation (E.g. Candy) b. Keep client well hydrated c. Warm compress (because it is swollen) Medical Management a. Antibiotic b. Stop taking anticholinergic medications (stop it momentarily! For healing purposes) c. Analgesics C. Candidiasis - Caused by C. albicans - Secondary infection by an overgrowth of an organism Candida albicans 119

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN Yeast infection

S/S: a. b. c. d.

milk curd appearance Dry and hot lesions Frequent sore throat Difficulty in swallowing

Precipitating Factors Immunosuppressed clients GM Pregnant (caused by GDM) Stress Long term or high does antibiotic or steroid-based therapy Smoking may predispose Management Monitor client closely Antifungal agents Analgesics Cotrimoxazole, Miconazole nitrate, Haloprogin creams for denture wearers 2. Cancer of the Mouth - Primarily in clients who smoke and drink alcoholic beverages in large quantities Signs and Symptoms (Progressive) Pain (localized pain in the mouth) Alteration in taste sensation Leukoplakia (pre-cancerous yellow or white patch in the mouth, any part of Buccal lining) Ulcerated area (burrowing of affected area) Difficulty chewing/speaking, dysphagia Treatment Reconstructive surgery Radiation then Chemotherapy Nursing Care Fluid and electrolyte balance Provide a means of communication (piece of paper and a pen) Relieve dryness of the mouth (cotton balls with water) 3. Cancer of the Esophagus - Cause: Smoking and Drinking alcohol - Predisposing Factors: Habitual ingestion of alcohol Heavy smoking Nutritional deficiencies 120

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN Poor oral hygiene Spicy foods Obesity (fat deposits may result to mutation process)

Signs and Symptoms (Progressive) Progressive Dysphagia Odynophagia Substernal pain Substernal burning after drinking hot liquids Regurgitation Irregularities in the lumen of the esophagus Hoarseness of voice, choking sensation Weight loss Management surgical removal of the esophagus a. Esophagogastrostomy (Gastrostomy feeding) b. Esophagectomy c. Gastrostomy d. Radiation and/or chemotherapy Nursing Care Emotional support (Emotional Support therapeutic silence or providing the need of the client) Observe for respiratory distress caused by pressures on the trachea Semi-fowlers or high fowlers position Monitor V/S esp. RR Maintain nutritional status Client teaching (avoid drinking alcoholic beverages and stopping smoking) NDx: Imbalanced nutrition: less than body requirements 4. Gastritis - Inflammation of the gastric mucosa (the stomach lining) a. Acute Gastritis - Produces mucosal reddening (tissue is inflamed), edema, hemorrhage (ruptured blood vessels), and erosion uppermost layer is stripped off (ulceration is burrowing) b. Chronic Gastritis - Common among elderly people - Present as chronic atrophic gastritis (decrease in the size of the cell), all stomach mucosal layers are inflamed. - Layers of the stomach are mucosal, sub-mucosal, muscles Possible Causes Acute Gastritis Irritating foods, spicy foods Drugs (ASA, NSAIDS, antibiotics, antipsychotics) 121

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN Poisons and corrosive substances Endotoxins (substance released by an infecting bacteria) Pathophysiology Causative agent Penetrates mucosal barrier Results to injury to the mucosa Injury to small vessels with edema, hemorrhage, ulceration HCl comes in contract with injured mucosa Chronic Gastritis 1. Alcohol ingestion 2. Cigarette smoking 3. Environmental irritants (CO) 4. Peptic Ulcer Disease (PUD) Assessment Findings 1. Abdominal discomfort (Queasiness) - Cramping, reflux 2. Epigastric discomfort - Burning or aching 3. Hematemesis - Blood together with the vomitus 4. Indigestion 5. Belching (caused by acid and bacteria) 6. N and V Diagnosis - CBC, SE, Gastric analysis, Ba swallow, Endoscopy Treatment 1. Blood transfusion PRBC 2. IVF Therapy 3. NG Lavage drain out stomach irritants 4. O2 therapy low Hgb count; max of 6lpm via nasal cath 5. Partial or total gastrectomy 6. Vagotomy and pyloroplasty (mucin is produced somewhere in the pylorus) Nursing Management Implementation 1. Give antiemetics and IV Fluids to prevent DHN and electrolyte imbalance. 2. MIO and electrolyte levels (through blood chemistry, Se Na, Se K, as often as 6h). 3. Bland diet 122

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN 4. 5. 6. 7. If surgery is necessary, prepare the client preop and provide appropriate postop care. Administer antacids and other prescribed medications Take prophylactic medications as prescribed Provide emotional support.

NDx: Ineffective tissue perfusion, Alteration in comfort: pain, Anxiety, Knowledge deficit 5. Peptic Ulcer Disease - Ulceration of the mucosal wall, pylorus, duodenum, esophagus - H. pylori one of the causative agent of PUD - 90% of PUD are caused by H. pylori - Helivax vaccination for H. pylori a. Gastric ulcers - Extends to the submucosal layer of the stomach - Incompetent pylorus produces less mucus (mucin) Predisposing Factors Stress (cortisol) Smoking (can increase HCl and poor O2 supply) Drugs (NSAIDS, ASA, Antibiotics, Antipsychotics) Hx of gastritis b. Duodenal Ulcer - Mucosa of the duodenum - High acid secretion Risk factors o Alcohol intake, smoking o Stress, caffeine o Drugs Gastric Ulcer Duodenal Ulcer 1. Weight loss (foods stimulates pain) 1. Weight gain (pain 2-4 hours after meal, 2. Left Epigastric pain eating decreases pain) 3. N and V 2. Mid epigastric pain (burning and cramping), Epigastric pain at HS 3. N and V Diagnostic Tests - Gastric acid analysis, UTZ, UGI series, LGI series, SE (for presence of H. pylori), Complications 1. Hemorrhage (ruptured capillaries) anemia (pallor conjunctiva and Buccal mucosa), peripheral pulses, dizziness, cold clammy skin, orthostatic hypotension (dizziness upon sudden change of position) 2. Perforation submucosal layers become ulcerated/GIT contents empty into the peritoneum (may lead to peritonitis) S/Sx: Sever sharp abdominal pain, vomiting/collapse, signs of shock, and boardlike abdomen

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NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN 3. Pyloric Obstruction S/Sx: epigastric fullness, anorexia, nausea, projectile vomiting 4. Intractability you can no longer manipulate the abdomen; most common indication for surgery Management (Goal: provide stomach rest) A. Pharmacology 1. Antacid o Al containing antacids o Mg containing antacid (milk of magnesia) 2. H2 Receptor Blocker 3. Anticholinergics 4. Cytoprotective B. Surgical Interventions o Gastrectomy o (Billroth 1) o Billroth 2 o Roux-en-y modified o Vagotomy Complication of Surgery 1. Dumping Syndrome S/Sx: Epigastric fullness, distention, abdominal cramping, N and V, occasionally diarrhea 15-30 min. pc and last for 20-60 minutes Nursing Responsibilities 1. Small frequent meals (avoid heavy carbohydrate meals bread, rice, pasta) 2. Do not take fluids while eating 3. Lie down, left side lying after eating to prolong stay of food in stomach 2. Pernicious Anemia upon ingestion of Vit B12, covered by intrinsic factor (produced in the pylorus) and delivered to ileum, intrinsic factor fades and Vit B12 is absorbed; Vit B12 is needed in RBC synthesis; IV or IM B12 supplements 3. Steatorrhea foul, frothy, fatty (FFF) stool; high fat diet 6. Appendicitis - Causes: o Fecalith (small hard stool) o Kinking if the intestine o Swelling o Fibrous condition o External occlusion of the bowel adhesion - Assessment o RLQ pain, McBurneys point (steady dull pain) o Rovsings sign flex the opposite area o Low grade fever o Increased WBC 5000-10000mm3 o Rebound tenderness 124

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN Do not give analgesics, pre diagnosis; give analgesics after diagnosis, absence of pain may mean rupture of appendix - Treatment o Appendectomy o Management of peritonitis, shock, dehydration, and infection - Nursing Care o Avoid: Enemas or laxatives Hot compress o If perforated/ruptures Penrose drains are in place, position in semi-Fowlers or on the right side with legs flexed post-op 7. Diverticular Disease a. Diverticulosis - Presence of non-inflamed Diverticula - Asymptomatic Diverticula - Common Sites: Sigmoid and Descending colon b. Diverticulitis - An inflammation of Diverticula - Possible causes: o Age (weakening of colon wall) o Chronic constipation o Congenital weakening of the intestinal wall o Low intake of roughage and fiber o Straining during defecation o Stress - Assessment Findings o Anorexia o Stool with blood and mucus o Constipation and diarrhea o Fever o Flatulence o Intermittent LLQ pain or midabdominal pain that radiates to the back o Nausea o Rectal bleeding Management - Generally no treatment for asymptomatic Diverticulosis - Colon resection - High residue diet with no seeds for diverticulosis (high fiber) to prevent further outpouching; Green leafy vegetable, oatmeal - Low residue diet with diverticulitis to prevent further inflammation; refined wheat; fruit juice - Temporary colostomy 125 o

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN 8. Ulcerative Colitis - Chronic inflammation limited to the mucosal and submucosal layers of the colon and rectum - Possible Causes o Genetics o Idiopathic o Allergies o Infection o Abnormal immune response - Assessment Findings o Abdominal cramping, urgency, distention, and tenderness o Anorexia o Severe diarrhea (20 or more per day) Pathognomonic sign leading to DHN in the interstitial fluid compartment o Bloody, purulent, mucoid, watery stools o DHN (confusion, poor skin turgor) and electrolyte imbalance o Fever o Hyperactive bowel sounds (Borborygmus) o Weakness o Weight loss - Diagnostic Tests o Ba enema, Colonoscopy, Rectosigmoidoscopy, UTZ, CT scan, MRI, blood chemistry - Surgical Management Colectomy, Total Proctocolectomy with ileostomy - Nursing Management o V/S, MIO, Laboratory values, WODAC, feed client with Bland diet right after surgery o Amount of stool and frequency o NDx: Fluid and electrolyte imbalance r/t sever bloody stool as evidenced by poor skin turgor, sunken eyeballs, and lab values dec Se Na and Se K. |Risk for injury related to body weakness/dec Se K and Se Na | Alteration in tissue perfusion related to ulceration in the colon as evidenced by [lab values] 9. Intestinal Obstructions READ about this in MedSurg books - Partial or complete impairment of the forward flow of intestinal contents - 90% occurs in the small intestine - Bowel Obstructions o Strangulated Hiatal Hernia o Ileocecal Intussusception o Intussusception from polyps o Volvulous - twisting o Neoplasms 80% of clients with intestinal obstruction has neoplasms o Adhesions o Mesenteric occlusion 10. Hemorrhoids READ about this in MedSurg - Perianal varicose veins 126

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN Internal or External Ages 20-50 Predisposing factors o Constipation o Straining during defecation o Pregnancy (pressure of the uterus to the perianal area) o Obese o Those who are always carrying heavy objects (more than 10lbs everyday) o Prolonged standing o Prolonged standing - Signs and Symptoms o Bright red bleeding with defecation o Pain when the client sits, stands or walks o Protrusion of an enlarged mass at the anus (external hemorrhoid) - Diagnostic Test o DRE o Proctoscopy o Hgb/Hct Count - Management o Hemorrhoidectomy o Rubber band ligation (8-10 days, the hemorrhoid will slough off) o Laser therapy o Analgesic for pain - Nursing Management o Hot sitz bath 12h post-op o Flotation pad if client is lying or sitting down o Stool softeners o Diet modification (High Fiber, High in Protein for tissue repair-not meat products) o Force fluids of 2.5-3L/day o Use an antiseptic solution after defecation 11. Hepatic Cirrhosis/Liver Cirrhosis - A chronic, progressive disease characterized by widespread fibrosis and nodule formation - Liver has nodular formation - Client has Ascites - Causes o Excessive alcohol consumption o Genetic o Hypersensitivity to alcohol - Types READ about this in MedSurg books regarding on what is most common 1. Laennecs (alcoholic cirrhosis) 2. Post necrotic cirrhosis 3. Biliary cirrhosis 4. Cardiac cirrhosis 127 -

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN Incidence is higher in Alcoholics Malnourished Hx of hepatitis As liver failure progresses: Inc secretion of aldosterone (has capacity to retain fluids) Dec absorption and utilization of the fat soluble vitamins (ADEK) supplement is given to client Ineffective detoxification of CHON wastes ammonia (CNS depressant-client will have cognitive deficiency) is never excreted, but processed by liver to produce urea Signs and Symptoms o Early Signs General body malaise RUQ discomfort GI disturbances such as lack of appetite (anorexia), indigestion, bowel habit changes o Late Signs Jaundice nodular formation makes secretion of bile difficult, blood vessels will absorb the bile Conjugated indirect-cannot be excreted by the body further converted by the liver to direct bilirubin for defecation or urination Unconjugated direct Esophageal varices (portal vein is blocked, causes pressure on the veins) Spider angiomas face, neck, shoulders Anemia-Thrombocytopenia-coagulation disorders liver is responsible for synthesis of blood coagulants Ascites albumin is synthesized in the liver, keeps fluid in intravascular space; feed client with egg whites Collateral veins visible on abdominal wall d/t ascites Hemorrhoids d/t pressure of ascites Sexual characteristics changes Males: decreased in libido; decrease in size of testacles, gynecomastia Female: Amenorrhea Hepatomegaly and Spleenomegaly Edema d/t high amount of aldosterone Changes in mental responsiveness and memory caused by ammonia Palmar Erythema d/t presence of jaundice Peripheral Neuropathy lack of sensation due to poor circulation; usually in the lower extremities/feet Complications 1. Portal HTN o Persistent inc in B in the portal venous system caused by an obstruction to blood flow which causes a rise in portal venous pressure 2. Hepatic Encephalopathy/Coma o The livers inability to metabolize ammonia to form urea 3. Ascites o Accumulation of fluid within the peritoneal cavity 128

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN 4. Bleeding esophageal varices o Fragile, thin-walled, distended esophageal veins that become irritated and rupture - Interventions 1. Rest 2. Restriction of alcohol, hepatotoxic drugs 3. Vitamin therapy: especially the fat soluble vitamins and Vit B (Thiamine chloride and nicotinic acid) increase nerve transmission 4. Diuretics 5. Neomycin (the greater the bacteria, the greater the ammonia level) and Lactulose (has special affinity to ammonia) 6. Paracentesis aspiration of fluid from the peritoneal cavity 7. Surgical Intervention (to decrease portal hypertension): shunt 8. Esophageal varices management Sengstaken-Blakemore tube lavage and inflates balloon to exert pressure on the bleeding esophageal varices 9. Dietary Modification a. Cirrhosis 1. CHON as tolerated (80-100g) 2. Inc CHO, mod fat; vitamin, mineral, and electrolyte supplements 3. Dec Na (500-1000mg daily) 4. Soft foods if esophageal varices are present 5. Alcohol is contraindicated - Diagnostic Test o Liver biopsy o SGPT/SGOT o MRI o CT Scan o Hgb/Hct o Abdominal UTZ o Se Bilirubin level and Se Albumin 12. Hepatitis See Daniels book Unit 2 - Inflammation of the liver - ABCDE - A food born, oral-fecal route - B Serum; STD - C virus; serum - D virus; serum - E water born 13. Cholelithiasis/Cholecystitis - 5 Fs Fat, Female, Forty and above, Fertile, Fair skinned - Made up of Ca, bile pigments, cholesterol - Etiology and Phatophysiology 1. Presence of stones (cholesterol, bile, pigments, and Ca 129

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN 2. Unable to contract in response to fatty foods 3. Bile is unable to pass into the duodenum and is absorbed into the blood 4. Obese women Signs and Symptoms 1. Fever and Leukocytosis inc in WBC 2. Jaundice bile in the gall bladder is absorbed by the blood vessels 3. N and V 4. RUQ Pain or epigastric pain may radiate to back, inc pain with deep breath 5. Steatorrhea fat indigestion/intolerance 6. Feeling of fullness/abdominal distention Diagnostic Tests 1. Inc serum bilirubin 2. UTZ 3. ERCP (Endoscopic Retrograde Cholangiopancreatography) 4. X-ray of gall bladder with stones Nursing Care o Teach dietary modification (low cholesterol, low fat), Inc OFI o Relieve pain both preoperatively and postoperatively o Observe for sings of bleeding (stones may cause abrasions), administer vitamin K preparation as ordered o Provide care following a Cholecystectomy: surgical/laparoscopic laser o Monitor NGT attached to suction 1. Maintain patency 2. Assess and measure drainage o Provide fluid and electrolyte via IV route o Low Fowlers position o Cough and deep breath Treatment of Stones: o Cholesterol Dissolvement Moctanin Nasal biliary catheter 1-3 weeks o Oral Bile Acids: Chenodiol (chenix) ursodiol (actigall) Dissolve small stones 6 months and 2 years Success rate is only 30% o Shockwave Lithotripsy Small number of stones and mild to moderate symptoms. Patient will be immersed in a pool of water, there will be a current that will dissolve the gall stones 1-2 hours Candidates must have no cardiac problems 130

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN After the procedure, tell the px to return to MD if there is presence of hematuria, hematoma, nausea, biliary colic

14. Pancreatitis - Types Acute pancreatitis o Autodigestion of the pancreas by its own enzymes Chronic pancreatitis o Progressive inflammatory destructive disease of the pancreas - Causes Acute o Alcoholism o Cholelithiasis o Abdominal trauma o Metabolic factors Chronic o Idiopathic o Hereditary o Chronic alcoholism - Symptoms o Pain (aching, burning, stabbing) in the LUQ or mid epigastric area o Weight loss o Increase Se Amylase, lipase and trypsin o Cullens sign bluish discoloration in the periumbilical area o Grey Turner bluish discoloration in the flank area - Therapeutic Interventions 1. Medical Management o NGT suctioning o Narcotics: avoid morphine SO4 and codeine SO4 can cause spasm of the sphincter of Oddi and the movement causes pain o Give antispasmodic o Antibiotic therapy 2. Nursing Management 1. Avoidance of alcohol 2. NPO, TPN, Bland, dec fat, inc CHON diet, with restricted intake of caffeine, alcohol, and gas forming foods 3. Bed rest 4. IVF, BT-PRCBC, FWB 5. Surgical intervention 6. Maintain position, patency, and low suction of NG tube 7. Monitor I/O, wt OD, abdominal girth, electrolytes 8. Monitor blood glucose levels 9. Meds: meperidine, H2 blockers, anticholinergics, antacids, Ca Gluconate, pancreatic enzyme replacements (Viokase, Pancreatin, Pancrease) 131

NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN 10. Semi-Fowlers position 11. Turn patient q2h, or utilize a specialty rotation bed 12. Quiet, restful environment

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NCM 202 NCM of Clients with Disturbances in Digestion and Absorption Ms. Nanette V. Velasco, RN MN Topics for skills lab 1. 2. 3. 4. 5. 6. Administering Intravenous Hyperalimentation (TPN) 415 Inserting a Nasogastric tube 418 Assisting in gastric lavage 422 Administering gastric gavage/tube feeding -425 Caring for a colostomy 445 Manual fecal extraction

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