Uploaded by solomon marfo

Digestive Track Disorders 2015

The GI tract begins in the mouth and extends through the pharynx, esophagus, stomach,
small intestine, large intestine to the anus.
Accessory organs include the salivary glands, liver, gall bladder and pancreas.
Nursing Assessment of the GI Tract
 Assessment of the GI tract follows the 4 basic assessment skills and techniques
 Inspection
 Auscultation
 Palpation
 Percussion
Diagnostic Test
 History and physical exams
 Chemistries
 Coagulating factors
 Radiological studies
 X-ray (abdominal)
 CT scan
 Endoscopy
 Gastric analysis
 Fecal fat study
 Occult blood test
Occult blood Test
Is done when bleeding is suspected, samples can be tested for occult blood.
Specimens most often tested for occult blood are vomitus, gastric secretions and stool
Stool samples can be tested for occult blood. A series of three tests are usually collected
to increase the chances of detecting blood in the stool and also helps presents false –
positive results.
False positive results usually occur:
 following dental procedures
 Ingestion of meat (iron-liver meats)
 Ingestion of beats
 Medications (ASA, colchicines (gout medication), NSAIDS, steroids)
Upper GI series/study
Also called a Barium Swallow
This is an X-Ray examination of the mouth, esophagus, stomach and small intestines
(duodenum, jejunum) using an oral liquid radiopaque contrast medium
Preoperative Nursing
 Explain the procedure to the pt-inform the patient that during the procedure he/she
will be asked to drink a thick chalky white substance called barium while standing
in front of a fluoroscopy tube.
 X-Rays will be taken at specific intervals to visualize the outline of the organs
and note the passage of the barium through the GI tract
 Pt needs to be NPO for 6-8 hours before the procedure- should eat a light meal the
night before the test
 Pt is discouraged from smoking the evening before the procedure or the day of the
procedure (because smoking increase gastric motility or stimulates gastric
 Assess for allergies to barium – not to iodine because iodine is not used
 Pt does not require informed consent for barium swallow
Postoperative Nursing
 Patient is instructed to increase fluid intake to 3-3 ½ L unless contraindicated
Encourage the pt to ambulate as soon as possible after procedure to help excrete
barium from barium
 A laxative
 Assess abdominal girth, abdominal tenderness, abdominal distention, abdominal
firmness/board like abdomen and nausea and vomiting-the presence of the
following may indicate barium impaction
 Assess the stool to determine if the barium is completely eliminated from the
body stool would be white or clay
 –If the pt is ordered a barium swallow, gallbladder sonogram, barium enema the
tests should be done in this order:
 gallbladder sonogram
 barium enema
 barium swallow
Barium enema (lower GI series)
Barium enema is done to visualize the position, movement and filling of the colon.
Preoperative Nursing
 pt does not need an informed consent
 pt placed on a low residue diet, or clear liquid diet at least 2 days before the procedure
and then NPO after midnight
 laxative or bowel cleansing agents or solution (golytely) and enemas may be given
the evening before the procedure
no barium enema is done when a pt has an obstruction or suspected obstruction,
perforation, active GI bleeding, diarrhea, inflammation of the colon
Assess for electrolyte imbalances
increase fluid intake
apply lubricant to the rectal area because loose stools may cause irritation
Uses a rigid or flexible tube to observe a hollow organ or cavity
o Upper GI Endoscopy
o Lower GI endoscopy
Upper GI Endoscopy
EGD – Esophagogastroduodenoscopy
This procedure visualizes the esophagus, stomach and the duodenum
Usually done to diagnose inflammation, cancer, trauma, bleeding or obstruction
Preoperative Nursing
 Explain procedure to the patient
 Informed consent
 NPO after midnight to prevent aspiration of stomach contents in the lungs if
vomiting occurs
 Local anesthesia is usually used to depress the gag or cough reflex
 Baseline vital signs
 Mild sedative is usually given before the procedure to calm the pt
Postoperative Nursing
 maintain patent airway-place patient on the side to prevent aspiration until gag
reflex return
 assess respiratory pattern, rate and effort after the procedure
 check vital signs and level of consciousness
 Keep patient NPO until gag reflex returns
 Nurse should assess for bleeding- small bright red bleeding or blood streak is
expected after the procedure
 Nurse should assess for S/S of bowel perforation
o Fever 101-103oF
o Abdominal cramps
o Abdominal distention
o Board like abdomen
o Absent or diminished bowel signs
o Abdominal pain
o Malaise
o Change in VS
o Referred pain – shoulder and back/flank pain
Signs and symptoms of esophageal perforation
o Dysphagia
o Hematoma
o Cyanosis
o Epigastric pain
o Sore throat for few days
o Dyspnea
o Chest pain
Lower GI endoscopy (colonoscopy and proctosigmoidoscopy)
Colonoscopy-Visualization of the colon
Proctosigmoidoscopy-visualization of the distal sigmoid colon, the rectum and the anal
wall using a rigid or flexible endoscope.
Preoperative Nursing
 Informed consent
 pt needs to be NPO after midnight
 prepare the bowel by ensuring that the bowel cleansing agent (golytely) is
completely taken by the pt
 a mild laxative or enema can also be given with the bowel cleansing agent
 a mild sedative is usually given to calm the pt
 VS taken before and during the procedure-Especially the pulse –because vagal
stimulation increase which has the potential of causing bradycardia
 Coagulation studies –PT,PTT,INR are done before the test
Postoperative Nursing
 Vital signs are checked frequently after the test
 Asses for bleeding-small bleeding is expected
 excessive bleeding should be reported to MD
 Explain to the pt that cramping or flatulence are common after the procedure
 pt should not drive immediately after the procedure
 Pt should also not make any important or major decisions 24hours after the
 Keep pt NPO until bowel sounds return or able to pass gas
Gastric Analysis
Measure the amount of hydrochloric acid in gastric fluid
Diagnose pyloric or duodenal obstruction or pernicious anemia (B12 deficiency)
Gastric analysis is done in two ways:
o basal cell secretion test
o gastric acid stimulations test
Basal Cell Secretion Test
 The pt is advised to avoid drugs that could interfere with gastric acid secretion
o antacids
o cholinergic
pt is asked to be NPO after midnight
No smoking on the day of the test stimulate reduction of gastric acid
A nasal gastric tube is inserted and the contents of the stomach is aspirated
through the tube using a syringe
gastric contents is withdrawn or aspirated every 15minutes for 1 hour
If too much HCL acid is found on the gastric content the pt is said to have peptic
ulcer disease (PUD)
If there is too little or no HCL – pernicious anemia is diagnosed
Gastric Acid Stimulation Test
Measures the amount of gastric acid for one hour after subcutaneous injection of
histamine drugs
A stimulus in the form of carbohydrate like a dry toast or caffeinated product or
medication like histamine is given to produce more secretion.
Common Therapeutic Measures
Gastrointestinal intubation
This refers to an insertion of a tube into the stomach or small intestines.
Purpose of GI intubation
 diagnostic purposes
 Gastric Decompression - Remove gas or fluid from the stomach or intestine
 relieve or treat obstruction or bleeding within the GI tract
 means of nutrition, hydration or administering medications when PO is not
 To promote healing after esophageal, gastric or intestinal surgery by preventing
distention of the GI tract and strain on the suture line.
GI intubation can be temporary or permanent
Tube Feeding
Tube feeding is initiated when the patient is unable to eat or swallow. Tube feeding
requires an MD order
Tube feeding can be administered through a
 Nasogastric Tube
 Orogastric Tube
 Jejunostomy Tube
 Gastrostomy Tube
Tube feeding administered either via gravity or by a pump
Nasogastric Tubes
Levin-Single lumen stomach tube used to remove stomach contents or provide tube
Salem-Sump-Double lumen stomach tube;most frequently used tube for decompression
with suction
Measurement of NG Tube
The nurse should measure from the tip of the nose to the tip of the auricle and to the
xiphoid process
Add 5 cm to the above measurement if the tube has to enter into the intestine
Placement of NGT
Before the nurse administers anything into a tube he/she needs to check for placement
Check for placement:
 Abdominal X-ray
 Aspiration of gastric content and checking the pH
Tube feedings are delivered intermittently, continuously or by a bolus
Care of the patient with enteral feeding–
 Assist pt to semi-fowler’s position when receiving tube feeding at all times
 Good mouth care
 Lubricate tube around nares with water-soluble jelly
 Check for placement before administering tube feeding
 Check bowel sounds every 4 hours and before each feeding
 Check the stoma site for redness, exudates, irritation and granuloma etc.
 Check for residual – nurse should check the residual anytime the feeding is
administered to the pt and if the patient is receiving continuous feeding residual
is checked every 4 hours–
 Check for patency of the tube before administering anything into a tube
 Nurse needs 5cc of water to check for patency
 When administration medication into a tube request liquid form if possible, if not
the tablets should be crushed thoroughly
 Check with the pharmacy to determine which medications are not to be crushed
 The nurse should not crush –enteric coated, sustained release or capsules
TPN (Total Parenteral Nutrition)
Also referred to as intravenous hyper alimentation
TPN contains protein, fat, CHO, vitamins, minerals, water and trace element
TPN is used when the pts nutritional needs can not be met satisfactory by the GI Tract
 Hyperemesis gravidarium
 Extensive burns
 Trauma
 Cancer
 Pancreatitis
Inflammatory bowel disease
Following extensive bowel surgery
Acute renal failure
Nursing care of a patient on TPN
 Follow doctor’s order
 A registered nurse is responsible for administering TPN
 TPN should be started slowly to allow the pancreas to adjust to the high glucose
 The nurse should check the patency of the central catheter before resuming the
 TPN should only be administered via sterile technique
 TPN orders should be renewed everyday
 Nurse should monitor the following when the pt is on TPN
 Weight
 Intake and output
 Check fluid and electrolyte status
 Check albumin levels
 Nurse should check blood glucose every 4 hours and continuously while
receiving TPN
 Nurse should monitor for complications of TPN
 Infection
 Septicemia
 Hyperglycemia
 Depression
 Fluid overload
Gastrointestinal Surgery
A laparotomy is the surgical opening of the abdomen
Surgery can be done for bleeding ulcers, cancers, hernia’s (abdominal or umbilical),
appendicitis or for obstruction.
Gastrectomy is the surgical excision of the stomach
Billroth I-Pyloric portion is removed and the remaining stomach is joined to the
Billroth II- The pylorus is removed, the proximal end of the duodenum is sutured and the
remaining portion of the stomach is joined to the jejunum
Clear Liquid
Apple juice
Full Liquid
All clear liquid
Soft Diet
All full liquids
Pureed foods
Cranberry juice
Ice cream
Poached eggs
Broth (soup)
Creamed soup
Mashed potatoes
Jello (gelatin)
Cooked cereal
Meat (tender puree)
Ginger ale
Fruit juices
Tea with lemon
Bland diet- A diet without spices
GI Medications
These drugs are used in the treatment of GERD and gastric ulcers.
They inhibit histamine release in the gastric parietal cells, therefore gastric acids. H2
blocks – reduce the acidity of gastric juices by blocking the ability of histamine to
stimulate gastric acid secretion
Cimetidine (Tagamet)
Famotidine ( Pepcid)
Ranitidine (Zantac)
Nizatidine (Axid)
Nursing consideration for H2 Antagonists
 Monitor kidney function-BUN, creatinine
 Administer with meals
 Take antacids one hour before or after taking these drugs
 Monitor gastric Ph- should be checked periodically
 Cimetidine may be prescribed in one large dose at bedtime
 Sucralfate decreases the effects of histamine 2 receptor blockers
 Avoid smoking because it interferes or impairs the effect of H2 blockers
 H2 blockers should be used cautiously in the elderly
Suppress gastric secretions- inhibiting the hydrogen/potassium ATPase enzyme system.
Lansoprazole (Prevacid)
Pantoprazole (Protonix)
Rabeprazole (Aciphex)
Esomeprazole (Nexium)
Nursing considerations
 Monitor liver function
 Take medications before meals
 Inform the patient not to crush pantoprazole (protonix)
Act by elevating the pH of the gastric contents, thereby deactivating pepsin.
They are inadequate for the control of symptoms because their duration of action is too
short and their nighttime effectiveness is minimal.
Aluminum or magnesium salts (Mylanta, Maalox)
Aluminum hydroxide (Amphogel)
Magnesium carbonate (Gaviscon)
Calcium carbonates (Tums)
Nursing consideration for antacids
 Give after meals and at bedtime
 Observe the client for constipation or diarrhea
 Absorption of tetracyclines, phenothiazides, Isoniazid and ferrous sulfate reduced
when given with antacids
 Effectives of oral contraceptives and salicylates may decrease when giving with
 Do not administer antacids with ferrous sulfate, histamine 2 blockers and other
 Use medication with sodium content cautiously for clients with cardiac and
renal disease
Disorders of the GI tract
Oral Cancers
Oral cancer comprises of any cancer in the mouth or the throat. It also affects the tongue,
lips, roof of mouth etc.
It is life threatening because of the possibility of obstructing the airway
Highest incidence of oral cancer is found in the pharynx (throat)
Risk Factor
Hiatal Hernia
In hiatal hernia there is a protrusion of part of the stomach into the thoracic cavity
through the opening in the diaphragm where the esophagus passes.
Common in women than in men
Two types of Hiatal Hernia
 Sliding hiatal hernia
 Rolling hiatal hernia
Sliding Hiatal Hernia
90% of hiatel hernias are sliding
In sliding hiatal hernia the top of the stomach enters the thoracic cavity when the pt is in a
supine position – but slides back in the abdomen when a pt assumes a vertical (reclining)
position (associated with GERD)
Rolling Hiatal Hernia
In a rolling hiatal hernia also referred to as a Paraesophageal hernia – the
gastroesophageal junction remains in place but a portion of the stomach protrudes or
herniates into the thoracic cavity through a secondary opening.
Risk Factors
Weakness of the muscles of the diaphragm in the lower esophageal sphincter (LES)
 Aging
 Obesity
 Surgery
 Genetics/hereditary
 Stress
 Trauma
 Straining or lifting heavy objects
 Pregnancy
 Increased intraabdominal or thoracic pressure-from bending, coughing or
 Prolonged bed rest in a reclining position
Signs and Symptoms
 most pts are asymptomatic
 heartburn
 belching
 gas (flatulence)
 abdominal distention
 abdominal fullness
 bloating
 Chest pain
 Increase pulse
 Difficulty swallowing (dysphagia)
Nursing Intervention
 Nurse should instruct the pt to avoid alcohol – because alcohol increase the
pressure in the LES (lower esophageal sphincter)
 Patient should also avoid activities or conditions that increase intraabdominal pressure. These activities or conditions include:
 bending
 straining
 lifting
 carrying heavy objects
 coughing
 vomiting
 pregnancy
 sneezing
 obesity
 eating a large meal
 wearing constrictive clothing
Inform the patient that prolong bed-rest can also cause hiatal hernia –because it
decrease LES pressure
Avoid smoking (increase gastric acid secretion)
If obese – counsel the patient to decrease weight
Serve the pt small –frequent meals instead of 3 large meals
Eat slowly and chew food well
Inform pt to avoid foods that are known to decrease LES pressure
Caffeinated products
carbonated drinks
Instruct pt to avoid spicy or acid foods
Give antacids- should be given after meals
Encourage pt to sit up at least (30-45 degrees) for at least 2-3 hours after
HOB should always be elevated when sleeping
Instruct the client to keep a diary of the foods that seem to increase the signs and
symptoms and avoid these foods
Reduce stress and encourage relaxation techniques
Assess patient general nutritional needs and identify dietary changes
Surgery may be done-fundoplication
Gastroesophageal Reflux Disease (GERD)
Backflow of gastric content from the stomach into the esophagus
GERD also referred to as heartburn or esophagitis
Normally the LES remains closed except during swallowing
When a pt has GERD the LES remains open even after the pt has swallowed
When a pt has GERD – gastric content are regurgitated into the esophagus, these
gastric contents contains gastric acid, pepsin, bile and corrosive substances which
may irritate the lining of the esophagus causing ulcerations.
 High fat diet
 Hiatal hernia
 Duodenal or gastric ulcers
 Obesity
Conditions that reduce LES pressure-excessive caffeine intake, smoking and
Congenital defects
GI intubation
Signs and Symptoms of GERD
 Heartburn
 Pain 1-2 hours after eating –or when lying down
 Bloating
 Frequent belching with a sour taste
 Abdominal distention
 Sore throat
 Hoarseness
 Symptoms occur after activity that increase intra-abdominal pressure such as
lifting, straining and lying supine position
Nursing Intervention
Peptic Ulcer Disease
Loss of tissue or break in the mucous lining of the GI tract
hydrochloric acid (HCL), pepsin, bile and other corrosive substances may cause injury to
unprotected tissue
Ulcers may occur in different areas
 Lower end of the esophagus
 Stomach
 Duodenum
Most ulcers occur in the stomach or the duodenum
Gastric Ulcers
Often occur often in men and in the elderly. Gastric ulcers are usually small and located
in the lesser curvature of the stomach
Causes include:
 Ingestion of medications-aspirin, NSAIDS, steroids
 Coffee or caffeinated products
 Smoking
 Alcohol
 Stress
 Helicobacter pylori
Duodenal Ulcers
Occur in the beginning area of the duodenum close to the pyloric sphincter
Usually caused by secondary factors or problems:
 Cirrhosis of the liver
 Hyperthyroidism
 Alcoholism
 Chronic pancreatitis
 Smoking
 H. pylori
Stress Ulcer (Curling’s)
Usually result from prolong illness or after surgery
Usually related to inadequate blood flow to the lining of the GI tract
Signs and Symptoms of Gastric Ulcers
 Severe epigastric pain or heartburn that occurs immediately or 1-2 hours
after or during meals or at bedtime
 Pain may radiate to the lower back or flank area
 Weight loss
 N/V
 Anorexia
 Feeling fullness after eating
 Abdominal distention
 Bloating
 Hematemesis
 Melena
Signs and Symptoms Duodenal Ulcers
 Patient may have no pain-if pain is present it is normally relieved by food
 Abdominal distention
 N/V
 Melena
 Hematemesis
 Weight gain
 Feeling of fullness
 Bloating
Complication of Ulcers
Major complication of an ulcer is
 Hemorrhage
 Perforation of the stomach or small intestine –Peritonitis
 Pyloric obstruction
 Find cause and treat the underlying cause
 Relieve signs and symptoms
 Promote healing
 Prevent recurrence
 Drug therapy
 antacids
 H2 blockers
 Protein Pump Inhibitors (PPI’s)
 Mucosal barrier (Sulcrafate)
 Antibiotic therapy
 Flagyl
 Tetracycline
 Pepto-bismuth – is given with antibiotic to kill the H. pylori- Pepto-bismuth
makes stool to be tarry (black)
Nursing Interventions for Ulcers
 Inform pt to avoid alcohol and smoking
 Inform the pt to eat small frequent meals rather than 3 large ones
 The pt needs to be weigh periodically ( increase or decrease of more that 5 lbs in
1 month -report to MD)
 Inform pt to avoid meds know to exacerbate ulcers
 Give meds on time and as prescribed to relieve pain from local irritation of the
intestinal mucosa
 Have patient rest because physical activity stimulates gastric secretions
 Increase fluid intake 2-3 liters unless contraindicated
 Nurse should closely monitor pt for complications of an ulcer
 Signs and Symptoms of Hemorrhagic Shock
 _______________
 _______________
 _______________
 _______________
 _______________
 _______________
 _______________
 _______________
 Signs and Symptoms of Perforation
 Sudden severe sharp pain in the upper abdomen- pain may radiate
to the mid epigastric area or to the shoulders or lower back
 N/V
 Increase temperature
 __________________
 __________________
 Malaise
 ___________________
Gastrectomy (partial or total)
Complications of gastrectomy
Pernicious anemia – lack of intrinsic factor –Vitamin B12
Dumping syndrome
Nutritional imbalance
Dumping Syndrome
Rapid passage of large amounts of food and fluids through the remaining portion of the
stomach into the intestines
Rapid emptying of food and fluids from the stomach into the jejunum. When a pt has
dumping syndrome-there is inabsorption of nutrients in the body
Signs and Symptoms of Dumping Syndrome
 Nausea and Vomiting
 Abdominal pain/tenderness
 Diarrhea
 Decrease blood sugar
 Diaphoresis
 Feeling of dizziness/fainting
 Palpitations
 Hyperactive bowel sounds
 Weakness
 Pallor
 Decrease blood pressure
 Increase pulse
Nursing Interventions for Dumping Syndrome
 Lie down flat for 30 minutes to 1 hour after a meal
 Make sure pt eats small frequent meals
 Avoid drinking fluids in between meals
 Diet : low in CHO, high fiber, moderate in fat and high in protein
 Stress the need for reducing stress
 Check blood sugar every 4 hours-if pt has decrease blood sugar- encourage
pt to eat a candy or drink fluids that contain glucose
 Absorption of vitamins and minerals-iron, folic acid, calcium, vitamin D may be
impaired so encourage the intake of these nutrients
 Give medications on time
 Antispasmodic – Probanthine
- Bentyl
 Sedatives are usually given as well
Inflammation of the appendix
Any obstruction of the appendix makes it more susceptible to an infection
Appendix can be obstructed by the following:
 Feces (stool)
 Helminths (worm)
 Bacteria
 Dead particles
 Undissolved substances (seeds, nuts)
Rupturing of the appendix allows the digestive juices or contents to enter the
abdominal cavity causing peritonitis or hemorrhage
Signs and Symptoms of appendicitis
 Pain in the epigastric region around the umbilicus which shifts to the Right
lower Quadrant (RLQ)
 Pain at the Mcburney’s point located midway between the umbilicus and the
iliac crest
 Increased temperature 100o-103o
 Increase WBC
 Increase ESR
 Nausea and Vomiting
 Normal bowel sounds
 Guarding position or assume a position of hip flexion Pain in the RLQ when LLQ is palpated – this is referred to as the Rovsing
 Rebound tenderness –severe pain over the tender area when pressure is
applied quickly and released
Nursing Intervention for appendicitis
 Monitor VS
 Place patient in a semi-fowlers’ s position
 Keep pt NPO until diagnosis is made
 Assess the pt for pain-onset, location, severity, frequency and type
 Avoid giving narcotics –
 Avoid laxatives
 No enemas
 No heat-apply cold packs if needed
 No palpation of the stomach because this may cause a perforation of appendix
 If appendix has ruptured it is a medical emergency, however, surgery will be
delayed for 6-8 hours after the ruptures because high doses of antibiotic are
needed to diffuse the infection.
 Give IV fluids
The nurse should obtain a consent – because surgery is imminent
Postoperative Nursing care for Appendectomy
Abdominal Hernia
Hernias are caused be a weakness in the wall of the cavity
Hernias are classified into two
 Reducible
 Irreducible
Reducible Hernia
A reducible hernia means the protruding organ can be retuned to its proper place when
the pt lies supine or when there is a gentle pressure placed on the protruding organ
Irreducible Hernia (Strangulated)
Means that the protruding part of the organ cannot be returned back to its proper place
when pt lies supine or when gentle pressure is applied because the protruding organ is
tightly wedged outside the cavity and cannot be pushed back through the opening
Risk Factors
 Stress
 Obesity
 Straining
 Bending
 Carrying heavy objects
 Pregnancy
 Trauma
 Aging
 Wearing constrictive clothing
Medical Treatment
Surgery is warranted even for reducible hernia
Hernias can also be treated without surgery. The patient is asked to wear a binder or a
A Truss is an external restraining device that is held in place with a belt.
Inguinal Hernia
Scrotal support and elevate the scrotum with a towel/wash cloth
Ice pack can greatly reduce the painful swelling
Inflammatory Bowel Syndrome (IBD)
Refers to any inflammation or infection of the intestine
IBD refers to both ulcerative colitis and crohn’s disease
Ulcerative Colitis
Eroded areas of the mucous membrane and tissues beneath it
Inflammation of the superficial mucosa of the colon causing the bowel to eventually
narrow, thicken and shortens due to the muscular hypertrophy
Ulcerative colitis usually affects the large bowel-colon and the rectum
Crohn’s Disease
Crohn’s disease can affect any part of the intestines. It is a sub acute, chronic
inflammation extending throughout the entire intestinal mucosa. Crohn’s disease can
involve any part of the intestine but most commonly occur in the terminal portion of
the ileum.
The inflammation extends through the intestinal mucosa which leads to the formation of
abscesses, fistulas and fissures.
Causes of IBD
 Exact cause is unknown but there is a strong familiar tendency
 Autoimmune process
 Environmental
 Immunologic process
 Infectious agents-Bacteria, virus, mycobacterium
 Chemicals (pesticides)
 Stress
 Dietary - especially in people who eat decrease fiber diet
IBD is characterized by a period of remission and exacerbation.
Usual age of onset
Fatty stool
Rectal bleeding
Abdominal pain
Nutritional deficit,
weight loss, anemia,
Anal abscess
Crohns’s disease versus Ulcerative Colitis
Crohn’s Disease
Ulcerative Colitis
20-30 and 50-80 years
Young adult to middle age (30-50)
Occasional: mucus, pus, fat Common: blood, pus, mucus in
in stool
After meals
Less severe
10-20 liquid stools per day
Complications for IBD
 Hemorrhage
 Fissures or fistula
 Malnutrition and nutritional deficiency
 Perforation or obstruction of the colon
 Enlargement of the colon-megacolon
 Fissures
 Fistulas
Diagnosis of IBD
 Biopsy of colon
 Sigmoidoscopy or colonoscopy
 Occult stool test
 Serum albumin
 Antibody test (IGg) autoimmune
Treatment of IBS
 Give anti inflammatory drugs : Sulfasalazine (Azulfidine) and oral steroids like
budesonide (entocort EC)
 Give antibiotics
 Immunosuppressive meds
 Surgery if obstruction, stricture of fistula or abscess
 Surgical procedures include resection of the affected area with anastomosis.
Nursing Intervention for IBS
 Promote rest
 Relieve rest
 Weigh pt periodically
 Monitor Intake and output
 Assess for pain and give pain meds
 If patient complain of pain in the rectal area sitz baths may be used
 Apply skin Protectants to the rectal area after cleaning gently and pat dry
 Increase fluid intake 2-3L unless contraindicated
 Monitor electrolytes periodically
 Assess signs and symptoms of dehydration
 The nurse should encourage the pt foods that are low in bulk- decrease fiber
 Offer nutritional supplement
 Offer psychological and emotional support
 Diet
 High calorie
 Low fat
 Low fiber
 May require TPN to rest bowel
Diverticular Disease
Manifested in 2 clinical ways (forms)
o diverticulitis
o diverticulosis
Inflammation or infection of the diverticulum within the intestinal tract
Diverticulosis outpouching of the walls of the colon
Diverticular disease usually occurs due to a weakness in the wall of the intestine
Most diverticulosis are found in the sigmoid colon
More common in individuals above 60 years old with a long history of low residue diet
 Constipation
 Associated with deficiency in dietary fiber diet
 Obesity
 Lack of blood supply to the intestine
 Mega colon (enlarged colon)
Signs and Symptoms of Diverticular Disease
 Constipation alternating with diarrhea
 N/V
 Cramping pain in left lower quadrant of abdomen relieved by passage of
stool or flatus
 Rectal bleeding
 Anorexia
 Abdominal distention/cramps
 Low grade fever
 Increased flatulence
 Increase white blood cell count
Diagnostic Test
 History and physical exam
 Colonoscopy
 Sigmoidoscopy
 guaiac stool test (occult test)
Medical Treatment
 Antispasmodics-Belladonna Tincture (Donnatal) is used for spastic colon. It is
the drug of choice for diverticulosis
 Stool softeners
 Laxatives-bulk forming
 Antidiarrheal
 Analgesics
 Antipyretics
Nursing Intervention for Diverticular Disease
 Provide a well balanced diet- A diet high in fiber is recommended unless
inflammation is present at which time client is NPO followed by a residue or
bland diet.
 Increase fluids
 In the acute phase patient is usually on
 Bedrest
 IV fluids
 NG tube
 Antibiotics
 Surgery
 Encourage fluid intake 2-3 liters per day unless contraindicated
 Avoid small poorly digested foods or foods that contain seeds, nuts etc.
 Popcorn
 Peanuts
 Cucumbers
 Watermelon
 Strawberries
 Grapes
 Guava
Disorders of the Liver, Gallbladder and Pancreas
Functions of the Liver
 a major role in digestion, absorption, metabolism and storage of nutrients
 converts excess glucose to glycogen and glycogen to glucose
 stores glycogen, fat soluble vitamins, iron and copper
 break down of fats, CHO and proteins
 the blood by removing foreign particles or substances from the blood
 produces and secretes bile needed for fat digestion
 helps detoxify drugs, toxins and other substances
 helps produces coagulating factors
 synthesize Vitamin K
 helps produce and store cholesterol
Nursing Assessment of Liver Disease
The liver performs many functions in the body so any alterations or dysfunction of the
liver may lead to systemic effects
Diagnostic Tests
 Electrolytes
 Albumin level
Bilirubin levels
ammonia will be high
check Liver enzymes
CT Scan
Liver biopsy is done to diagnose cirrhosis, hepatitis or other related diseases like cancer
open biopsy or needle biopsy
Open Biopsy- incision made into the abdominal cavity under general anesthesia
Needle Biopsy- needle inserted through the abdominal wall to obtain the specimen
Liver biopsy - high risk for bleeding because the liver is very vascular and because
many patients with liver disease also have faulty clotting ability this also increases the
chances of bleeding.
Preoperative Nursing Care
 Explain procedure to pt
 Inform consent needed
 Keep pt NPO for 6-8 hours
 Obtain base line V/S
 Check CBC
 Check coagulating factors before the procedure
 Give preoperative sedative to calm and relax pt
 Ask the pt to empty the bladder
 Place the pt in a proper position with the right arm behind the head and ask the pt
to remain still
 Patient is usually placed on the left side during the procedure
 Instruct pt to take a deep breath and hold it while the needle is being inserted to
prevent accidental puncturing of the lung
Post Operative Nursing care
 pt should remain on bed rest for 24 hours
 Assess V/S
 place pt on Right side for the first 2 hours after procedure (this prevent the
possibility of bleeding)-a small pillow or small towel may be rolled under the
biopsy site
 nurse should apply a pressure dressing over the puncture site and check the
dressing frequently
 pt is advised to avoid coughing, straining or sneezing for the first couple of hours
after procedure
 assess for pain and give pain medications
 assess for signs and symptoms of infection at the puncture site
 monitor for complications after liver biopsy
o hemorrhage
o pneumothorax
o puncturing of the bladder
X-ray visualization of the gallbladder
Can visualize gallstones
ingest a radio opaque dye that collects in the gallbladder.
The patient is also asked to eat a high fat diet 2 days before the procedure and then a low
or no fat diet on the day before the procedure and then the pt is asked to be NPO after
Before the pt is NPO the pt should take 6 radio opaque tablets called telepaque 5 minutes
apart with water.
These tablets contain iodine-so ask the pt if he or she has any allergies to iodine or
Side Effects of telepaque
o N/V
o Abdominal pain/cramps
o Dysuria
o Diarrhea
ERCP (Endoscopic Retrograde Choliangiopancreatography)
Endoscopic study of the gallbladder, liver and pancreas
Dye is injected into the gallbladder, liver and pancreas and a scope is inserted through the
esophagus in to the duodenum to help visualize the bile duct, pancreatic duct and
common bile duct.
Common therapeutic measures
Usually done in pt with liver disease who has ascites. Abdominal paracentesis may be
indicated if dietary restrictions and drug administration fail to control ascites and dyspnea
is present. The procedure is performed at the bedside
Preoperative Nursing Care
 ___________________________
 Informed consent
 _____________________________
 ask pt to void before procedure
 Pt is asked to be in an up right position in a chair or the side of the bed or can be
lying down with feet and back supported
 Strict aseptic technique
 Fluid needs to be removed slowly to prevent shock or to prevent circulatory
Postoperative Nursing Care
 Monitor V/S
Position the client in bed with the head of the bed elevated
Maintain bed rest
Weigh the client after the paracentesis
Apply a pressure dressing at puncture site
Monitor the amount, color and consistency of fluid being removed
Disorders of the Liver
Inflammation of the cells of the liver usually caused by a virus.
When a pt has hepatitis there are local or systemic effects that occurs in the liver
Liver becomes swollen due to the inflammatory response. If the swelling is profound 2
things happen
 The bile channels are compressed-damaging the cells of the liver that produces
the bile
 Impaired blood flow to the liver causing the pressure to rise in the portal
Systemic Effects
Are related to altered metabolic functions normally performed by the liver
Hepatitis A, B, C, D, and E,
Hepatitis A
Also called infectious hepatitis and epidemic hepatitis. Hepatitis A is primarily
transmitted by the oral-fecal route.
Signs and Symptoms of Hepatitis A
 Chills
 muscle weakness
Abdominal pain in the RUQ
 Abdominal cramps
 Jaundice
 High bilirubin levels
 Clay colored stools
 Bleeding
 Liver enlarged and tender
Nursing Intervention for hepatitis A
 Identify individuals that are at high risk of hepatitis A
 Individuals living in poor sanitation conditions
Individuals in the military
Food handlers
Day care centers
Individuals that are institutionalized
 Prisons
 Schools
 Nursing homes
Wash hands thoroughly after eating and toileting
Use clean water and food supplies
Follow standard precautions when handling pt’s stool and urine
Pt should receive immunoglobulin A before or within 48 hours after
All individuals with close contact with the pt must also receive the vaccine
Hepatitis B
Hepatitis B is also called serum hepatitis caused by HBV. Transmitted by parenteral
routes and is present in all body fluids and stools
 Saliva
 Tears
 Semen
 Blood
 Urine
 Sweat
 Stool
 Breast milk
Hepatitis B mostly transmitted by contaminated needles, sexual contact and contaminated
Incubation period for Hepatitis B is 2-5 months
Signs and Symptoms
 No early signs and symptoms or only flu-like signs and symptoms
 Fatigue
 anorexia
 Malaise
 Low grade fever
 Nausea and vomiting
 Headaches
 Muscle aches
 Abdominal pain and cramps
 Chills
 If not treated jaundice like symptoms may result
Nursing Intervention for Hepatitis B
 Nurse should identify individuals that are high risk for Hepatitis B
 I V drug users
 Health care workers
 Homosexuals
 Prostitutes
 Hemodialysis
 blood donors
 blood transfusion
 pts who receive transplant
 Give Hepatitis B vaccine to high risk groups – immunoglobulin B vaccine
 Screen blood donors
 Dispose contaminated sharps appropriately
 Follow standard precautions
 Inform individuals to practice safe sex
Hepatitis D
Caused by the Delta Agent-the Delta agent is a defective RNA virus that survives only in
the company of the HBV
Coinfection with HBV
Signs and Symptoms-same as Hepatitis B
Hepatitis E
Similar to Hepatitis A-very rare in the U.S. Mostly found in travelers in endemic areas.
Poor sanitation
No vaccine
Cirrhosis of the Liver
Is scarring or fibrosis of the liver resulting in the distortion of the liver structure and
vessels or scarring of liver tissue which interferes with normal liver function and results
in structural changes.
Four types of cirrhosis of the liver
 Laenecc (alcoholic) cirrhosis
 Post necrotic cirrhosis resulting from previous acute viral hepatitis that produces
scar tissue
 Biliary cirrhosis – chronic biliary obstruction and infection-scar tissue around the
bile duct
 Cardiac cirrhosis – right heart failure (hepatomegaly)
There are many causes for cirrhosis- the major course is unknown. Other possible causes
 Chronic alcoholic use
 Viral hepatitis
Exposure to hepatotoxins
Infection-autoimmune disease
Chronic biliary tree obstruction
Chronic severe right heart failure
Signs and Symptoms of cirrhosis
In the early stages signs and symptoms are subtle
 Weakness
 Fatigue
 Fever
pain in the RUQ
 Weight loss
enlarged spleen
 Change in LOC
spider angiomas
 Nausea and vomiting
palmer erythema
 Diarrhea
 Constipation
 Dark colored urine
Fetor hepaticus
 Increased ammonia levels
 Sodium and water retention
 Peripheral neuropathy
 Lack of vitamin B12, thiamine and folic acid
 Decreased blood volume
Loss of libido
muscle wasting
Complications of Liver Disease
There are many complications that may result from liver disease. The student should
familiarize themselves with the acronym CHEAP
 Coagulations disorder
 Hepatorenal syndrome
 Encephalopathy
 Ascitis
 Portal HTN
Coagulation Disorders
Disseminated Intravascular Coagulation (DIC)
Portal Hypertension
A persistent increase in blood pressure within the portal vein.
The portal vein delivers blood from the intestine to the liver.
The liver damage causes a blockage of blood flow in the portal vein which allows the
back up of in the portal system.
The blood meets resistance to flow and seeks collateral venous channels around the high
pressure area.
This obstruction causes the back up of blood into the spleen, the veins in the esophagus,
stomach, intestines, abdomen and the rectum. These veins become engorged and dilated
causing varices.
Bleeding Esophageal varices
Esophageal varices represent a life threatening medical emergency because of the
potential of rupture causing massive hemorrhage.
Esophageal bleeding can occur spontaneously with no precipitating factors; however any
activity that increases intraabdominal pressure may increase the likelihood of bleeding.
Esophageal varices can also be caused by coughing forcefully, straining or lifting heavy
object, or by spicy food or acidic GI content.
Is the accumulation of fluid within the peritoneal cavity.
Ascites may be caused by the following:
 Increased hydrostatic pressure from portal hypertension
 Accumulation of plasma protein primarily albumin
 Inability of the liver to synthesize albumin
Treatment of ascites
 Low sodium diet as an initial means of controlling fluid accumulation in the
abdominal cavity
 Advise the client to read sodium content labels and to adhere to the sodium
 Limit fluid intake
 Give vitamin supplements such as thiamine, folate, zinc
 Administer diuretic to reduce fluid accumulation and to prevent cardiac and
respiratory impairment
 Monitor intake and output
 Weigh daily
 Measure abdominal girth every 4 hours
 Prepare the patient for paracentesis
 Plasma expanders to help push fluid back into the circulation
Hepatic Encephalopathy
Also referred to as portal-systemic encephalopathy
Caused by the accumulation of ammonia or other chemical or noxious substances in the
brain or in the systemic circulation.
The failing liver is unable to metabolize or detoxify ammonia, a waste product of protein
Signs and Symptoms of Hepatic Encephalopathy
Neurologic symptoms and is characterized by an altered level of consciousness, impaired
thinking processes and neuromuscular disturbances
Early signs and symptoms
 Restlessness
 Changes in LOC or diminished responsiveness
 Confusion
 Lethargy
 Irritability
 Apprehension
 Drowsiness
 Inability to concentrate
 Forgetfulness
Late signs and symptoms
 Muscle twitching (facial twitching and fasciculation)
 Asterixis –flapping tremors of the hands when extending the arms
 Stuporous
 Hyperreflexia
 Marked mental confusion
 Positive babinski sign
 seizures
 Somnolence
 Fetor hepaticus-Fruity and musty breath
 Coma
 Seizures
Treatment of hepatic Encephalopathy
 Assess level of consciousness frequently
 Identify factors that may precipitate hepatic encephalopathy:
 High protein diet
 Infections
 Hypovolemia
 Constipation
 Drugs-opoids, hypnotics, sedatives, analgesics and diuretics
 GI bleeding
 Administer lactulose to promote the excretion of ammonia in the stool
 give antibiotic – Neomycin is usually ordered to decrease colonic bacteria that
breaks down protein and prevents the formation of ammonia
 reduce protein and fat intake and give simple carbohydrates
 restrict foods high in ammonia levels
 chicken
 egg yolk
 ham
 bacon
 butter milk
 cheddar cheese
 peanut butter
 onions
Nursing Intervention for Cirrhosis
Goal of treatment is to prevent complications of liver disease
The nurse should identify the cause and eliminate the cause
 In the acute phase of the cirrhosis the pt should be on bed rest
 Nurse should space nursing care because this allows the liver to regenerate
 Assess the pts neurological status every hour
 Give IV fluid to hydrate patient and correct electrolyte imbalances except if
pt has ascites
 If ascites is present the pts fluid intake should be restricted to 1-1 ½ L
 Monitor I & O daily
 Weigh daily
 Measure abdominal girth every 4 hours
 Assess pt for peripheral edema or sacral area
 Give vitamin high in thiamine, pyridoxine and B12,folic acid, iron and zinc
 Avoid foods that produce high ammonia levels (chicken, ground beef, ham,
bacon, peanut butter, egg yolk, cheese)
 offer small frequent meals
 give neomycin an antibiotic to reduce the bacterial count in the intestines
 To lower ammonia levels give lactulose a laxative that binds to ammonia and
help excrete ammonia though the stool
 Inspect the skin daily
 Apply lotion on the skin to prevent dryness of the skin-if the skin is too dry
this may cause pruritis
 If pt has pruritis advice the pt not to scratch the area this may cause
bleeding. The Pt may apply pressure on the area or use a hair dryer set on
 Make sure pt wears gloves/ mittens to avoid scratching the area
 Avoid cold/hot water – use warm water while bathing.
 Institute bleeding precautions
 Give vitamin K (to promote coagulation)
 Inform pt to avoid alcohol or medications that are known to be hepatotoxic–
Tylenol, INH, oral contraceptive, antipsychotics, sedatives, opoids
The Biliary Tract
Includes the gall bladder and the bile duct
The gall bladder stores bile which emulsifies fat, stimulates pancreatic secretion and
activates pancreatic lipase.
Nursing Assessment of the Biliary System
 Assess past medical history
 Assess for indigestion
 Assess for weight loss/ weight gain
 Assess patient stool (color, amount and consistency
 Assess vital signs
 Assess drug history
Disorders of the Biliary Tract
Gallbladder disease is the most common health problem in the U.S.
The two most common disorders of the gallbladder are
 Cholecystitis
 Cholelithiasis
Risk Factor for Gallbladder Disease
 obesity
 familiar predisposition
 sedentary lifestyle
 use of estrogen (or oral contraception)
More common in women than in men -think about 5Fs
 Female
 Fat
 Fair
 Forty
 Fertile
Cholecystitis and Cholelithiasis
Cholecystitis is an acute inflammation of the gallbladder or the cystic duct caused by the
lodging of a gallstone in the duct.
Cholecystitis can also be caused by bacteria or toxic chemicals, anesthesia, starvation,
trauma, medications (opiods), surgery, TPN (hyperalimentation) (no fat)
Signs and Symptoms
Pt may be asymptomatic
In the early phase of the disease the signs and symptoms include:
 Intolerance to fatty or spicy foods
 N/V
 Abdominal cramps
 Severe abdominal pain in the RUQ that radiates to the right shoulder and back
 Abdominal tenderness
 Abdominal guarding
 Fever
 Heartburn
 Diaphoresis
As the condition progresses patient may start to have jaundice like symptoms
 Jaundice
 high bilirubin level
 high ammonia levels
 Dark colored urine
 fat in the stool (steatorrhea)
 White or clay colored stool
Biliary colic pain-spasmodic pain due to the obstruction of the duct and occurs
when due to an attempt to move the stone
Petechiae or ecchymosis
Medical Treatment
The goal of treatment depends on the condition, if the patient has cholecystitis supportive
treatment is done
 Rest
 Keep pt NPO
 Give IV fluids
 Medications –antibiotics and analgesic
 Reduce fever
 Promote nutrition
Dissolution therapy-administration of bile salts
Nursing Intervention (Lithotripsy)
 Coagulation study-PT, PTT, platelet, fibrinogen
 Empty bladder before the procedure
 Relieve anxiety
 After the procedure monitor for complications
 Increase the pt’s fluid intake 3-3 ½ L unless contraindicated-fluid intake
helps to push the crushed stone out of the body
 Assess for pain and medicate appropriately
 Inform the patient that small bright red tinged blood is normal after the procedure;
excessive amount of blood in the urine should be reported to MD
 Give prophylactic antibiotic after the procedure to prevent infection
Open cholecystectomy.
To prevent this obstruction a T-tube is inserted. The T-tube is placed to maintain the
flow of bile from the liver to the small intestine.
Postoperative Nursing Intervention for Cholecystectomy
 Avoid fried, spicy or fatty foods
 Encourage low fat, high carbohydrate, high protein diet
 Low fat diet-Inform the patient to consume skim milk, cooked fruits, rice,
lean meats, mashed potatoes, non gas forming vegetables, bread
 Patients should avoid eggs, cream, pork, fried foods, cheese and rich dressings
 Reduce weight
 Assess for pruritis due to the blockage of bile ducts. This blockage would cause
the accumulation of bile salts under the skin-give cool baths and apply lanolin
lotion, reduce room temperature, trim nails, have the patient wear mittens or
gloves and administer cholestyramine (Questran)
Notify physician if patient has clay colored stools, dark urine, jaundice and
pruritis because this mean bile is obstructed
Check liver function
Inform patient on oral contraceptives to seek alternative birth control
measures if taking bile salts
Reduce patient anxiety and encourage patient to verbalize fears and concerns
Monitor T-Tube if present for amount, color and odor of drainage
T-Tube inserted to ensure drainage of bile from common bile duct until edema
Place the pt in a semi fowlers position
Follow MD orders when to clamp the T-tube-The T-tube may be clamped 12hrs before meals this allow bile to flow in the duodenum
Observe for jaundice-yellow sclera, stool that does not slowly progress from light
to dark color after removal of tube
 Fat – lipase
 Protein – trypsin
 Carbohydrate – amylase
Is an inflammation of the pancreas, it can be acute or chronic
Acute Pancreatitis
Caused by autodigestion, it occurs when there is digestion of the pancreas by its own
enzymes primarily trypsin. Other causes include
 Alcohol abuse-excessive use of alcohol
 Diuretics (thiazide)
 Steroids
 Oral contraceptives
 Tylenol
 Cholecystitis
 Increase calcium
 High cholesterol diet
 High triglyceride levels
 Infection
 Gallstones
Chronic Pancreatitis
 Prolong alcohol use
 Cholelithiasis (Gall Stones)-stone lodge in the pancreatic duct
 Surgery on or near the pancreas
Signs and Symptoms of Pancreatitis
Severe mid epigastric or left upper quadrant pain-this pain may radiate to the back
of shoulders
The pain is aggravated by alcohol or eating a fatty meal
The intensity of the pain when the patient assumes a lying position
Abdominal distention
Firm board like or rigid abdomen
Bowel sounds are absent
Nausea and Vomiting
Flushing of the skin
Increase temperature
Decrease BP
Increase Pulse
Cool/clammy skin
Grey Turner sign-bluish discoloration of the flank area
Cullen sign-bluish discoloration of the periumbilical area
Weight loss
Dark concentrated urine
High bilirubin levels
Increase blood sugar in the urine and blood
Diagnostic (Pancreatitis)
 Pancreatic enzymes
 Amylase 60-160 (normal) with pancreatitis
 Lipase 0-160
 Trypsin
 Increase blood sugar
 Liver function test
bilirubin levels
 Ammonia
 Check kidney function
 X-Ray
 24 hour urine test
Treatment for Pancreatitis
 Keep pt NPO-prevent visualization of food since gastric secretions are
stimulated by the sight or smell of food
 Insert NG tube
 Maintain bed rest
 Assess for pain and give pain meds – No morphine
 Assess for the location, radiation, character, intensity and duration
 Instruct the patient to sit up and lean forward to reduce the pain knees bent
 Control the pts fever by giving antipyretics
Monitor I&O
Weight pt daily
Stress the importance of stopping alcohol
Avoid caffeinated, spicy or fatty foods-these foods stimulate gastric and
pancreatic secretions and may precipitate pain
Place pt in a semi fowler position or side lying position with knees flexed
Give pancreatic enzymes with meals or snacks. They should be swallow whole or
sprinkle on food
Encourage small frequent meals
Check pt albumin levels
Monitor the amount, color and consistency of the stool
Individuals that have pancreatitis- color of stool is white or clay colored and
contains fat
Check bowel sounds q4hrs – if bowel sounds are present the NG tube may be
Check blood sugar q4hrs if high – insulin may be administered
Give antianxiety medications because anxiety increase pancreatic secretion
by stimulating the autonomic nervous system
Administer antiemetic if patient has nausea and vomiting
Administer antispasmodic-Bentyl to relieve spasms
Assess for signs and symptoms of infection