NCM 116: Care for Clients with Problem in Nutrients and Gastrointestinal Metabolism and Endocrine,
Perception and Coordination
 Infection
Chapter 1: Care for Clients with Nutritional
 Hemorrhage or burns
Problem
 failure of protein synthesis, as in chronic
Malnutrition according to WHO
liver diseases
 Malnutrition, in all its forms, includes
MARASMUS
undernutrition
(wasting,
stunting,
 (Infantile Atrophy, energy-deficiency or
underweight), inadequate vitamins or
energy-protein deficiency; a protein-energy
minerals, overweight, obesity, and resulting
malnutrition
diet-related noncommunicable diseases.
 1.9 billion adults are overweight or obese,
ETIOLOGY
while 462 million are underweight.
 Inadequate caloric intake insufficiency of
 Around 45% of deaths among children
diet, improper feeding habits
under 5 years of age are linked to
 Metabolic abnormalities or congenital
undernutrition. These mostly occur in lowmalformations
and middle-income countries. At the same
 Severe impairment of any body system may
time, in these same countries, rates of
result in malnutrition
childhood overweight and obesity are rising.
 The developmental, economic, social, and
CLINICAL MANIFESTATION
medical impacts of the global burden of
 Failure to gain weight followed by loss of
malnutrition are serious and lasting, for
weight until emaciation results.
individuals and their families, for
 Loss of turgor in skin which becomes
communities and for countries.
wrinkled and loose as subcutaneous fat
MALNUTRITION
disappears
 from a worldwide perspective, is one of the
 Edema
leading causes of morbidity and mortality in
 Low temperature and slow pulse
childhood due to:
 Reduced basal metabolic rate
1. improper and / or inadequate food intake
 Fretful or listless
2. inadequate absorption of food Causes
 Diminished appetite and constipation
are:
followed by the so-called starvation type of
1. poor dietary habits
diarrhea, with frequent, small stools
2. food faddism
containing mucus
3. diseases
 Skin wrinkled
4. deficient supply of food
 Subcutaneous fat, disappears from abdomen
5. metabolic abnormalities
first, then extremities, and finally face
6. emotional factors
KWASHIORKOR
 a clinical syndrome resulted from a severe
PROTEIN MALNUTRITION
deficiency of protein inadequate caloric
 (PCM or PEM, Protein-Calorie (Energy)
intake
Malnutrition, Kwashiorkor)
 The most serious and prevalent form in
ETIOLOGY
industrially underdeveloped areas
 deficient intake of protein of good biologic
 Deposed child may become evident from
value
early infancy to 5 year of age, usually after
weaning
 Impaired absorption of protein, as in chronic
 height and weight are accelerated with
diarrheal states
treatment but never equal those of
 abnormal losses of protein in proteinuria
consistently well-nourished children.
CLINICAL MANIFESTATION
 Early clinical evidence----vague, including
lethargy, apathy, and irritability
 Inadequate growth, lack of stamina, loss of
muscular tissue, increased susceptibility to
infections, and edema
 Dermatitis and dyspigmentation
 Secondary immunodeficiency
 Anorexia, flabbiness of subcutaneous
tissues, and loss of muscle tone
LABORATORY DATA
 Concentration of serum albumin decreased
 Aminoaciduria
 Ketonuria in the early stage
 Low blood glucose values
 Potassium and magnesium deficiencies
 Amylase, esterase, transaminase, lipase,
alkaline phosphatase, pancreatic enzymes
decreased
 normocytic, microcytic, or macrocytic
 Anemia
 Bone growth delayed
PREVENTION
 Diet containing an adequate quantity of
protein of good biologic quality
 Adequate dietary instruction and food
distribution
 Treatment of diseases:
o Immediate management of any acute
problems such as those of severe
diarrhea, renal failure, and shock and,
ultimately, the replacement of missing
nutrients is essential.
TREATMENT AND MANAGEMENT FOR
DEHYDRATION
 For mild to moderate dehydration, feedings
are administered orally or by nasogastric tube,
when culturally appropriate, to prevent
aspiration.
 A breasted infant should be nursed as often
as he or she wants.
 For severe dehydration, intravenous (IV)
fluids are necessary
 MILK:
 When dehydration is corrected, oral or
nasogastric feeding starts with small,
frequent feeds of dilute milk (66 kcal
and
1.0g
protein/100
ml
at
120/ml/kg/24 hour) with nutrient
supplementation.
 ANTIBIOTICS:
o The routine administration of
antibiotics
such
as
Cotrimoxazolehas also been advocated.
o Other antimicrobials are used only to
treat overt infection because of
concerns about emergence of
microbial resistance.
 VITAMINS AND MINERALS:
o Vitamins and minerals, especially
vitamin
A,
potassium,
and
magnesium, are necessary from the
outset of treatment.
o Iron and folic acid usually correct the
anemia.
NUTRITIONAL ANEMIAS
 Deficiency of: Iron, Folate, B12, Protein
corrected
by
supplementation
Iron
Deficiency Anemia (IDA)
Iron deficiency (ID)
 is one of the most frequent, nutrition
deficiency all round the world.
 Its prevalence is higher in children and
childbearing age women.
 Iron deficiency anemia (IDA)
o mainly affects child behavior and
development, work performance and
immunity.
CAUSES OF IRON DEFICIENCY ANEMIA
 Diminished stores-Preterm small for date
babies, Twins, Early cord clamping (100ml
of blood)
 Diminished intake-Not breast feeding,
Cows milk feeding, Iron poor diet
 Diminished
absorption-Malabsorption,
Low level of enhancers, High level of
inhibitors
 Increased demands-Rapid catch up growth
in preterm and SFD, Infancy puberty,
Pregnancy and Lactation.
 Defective
metabolism-Idiopathic
pulmonary Hemosiderosis, Sideroblastic
anemia, Congenital transferrin deficiency
CLINICAL FEAUTURES
 Pallor, pica, dull, irritable, poor appetite
 Failure to thrive, easily fatigued
 Frequent infections
 Splenomegaly
 Tongue papillae are atrophied
 Malabsorption
and
protein
losing
enteropathy
 Nails-flat, thin, brittle, spoon shaped
(koilonychia)
 Decreased attention span, poor school
performance, cognitive impairment
 Severe cardiomegaly, Congestive Heart
Failure (CCF)
Assessment of Iron-Deficiency Anemia:
 Clinical and Laboratory indices.
 Laboratory indices - are the most common
methods used to assess iron nutrition status.
 Having low hemoglobin, low hematocrit
HYPOCHROMIC MICROCYTIC ANEMIA
 The most common cause for a hypochromic
microcytic anemia is iron deficiency.
 The most common nutritional deficiency is
lack of dietary iron.
 Thus, iron deficiency anemia is common.
 Persons most at risk are children and women
in reproductive years (from menstrual blood
loss and from pregnancy. Clinical Indices:
o Pallor of the conjunctiva, tongue,
nail bed and palm
TREATMENT OF IRON DEFICIENCY ANEMIA
Treat underlying cause:
 Oral iron therapy
 3-6mg/kg in 3 divided doses (Hb rises by
0.4g/day)
 Vit C, empty stomach or in between meals
for 6-8 weeks after Hb is normal:
 Parental iron therapy
 Blood transfusion rarely when severe
infection with poor iron utilization
PREVENTION FOR IRON DEFICIENCY
ANEMIA
 Dietary modification
 Breast feeding and appropriate weaning diet
 Iron rich food
 Increase ascorbic acid
 Food fortification
 Iron supplementation
 Deworming
MEGALOBLASTIC ANEMIA
 Also known as Vitamin B-12/Folate
Deficiency Anemia, Macrocytic Anemia, or
Megaloblastic Anemia
 Caused when RBC’s aren’t produced
properly Due to:
 Drinking goats milk- is poor source
 Cooking- destroys folic acid
 Chronic diarrhea, malabsorption and
recurrent infections -are prone
 In hemolytic anemias- due to increased
erythropoiesis
 Treatment: phenytoin / antimetabolites
CLINICAL FEAUTURES
 Pale
 Very sick
 Irritable
 Severe anorexia
 Failure to thrive
 Knuckle pigmentation (hands and nose)
 Tremor and developmental regression
TREATMENT
 Can be treated with oral or intravenous folic
acid supplements.
 Dietary changes also help boost folate
levels.
NUTRITIONAL
MANAGEMENT
AND
PARENTERAL NUTRITION
 It is an intravenous administration of
nutrition, which may include protein,
carbohydrate, fat, minerals, and electrolytes,
vitamins, and other trace elements for
patients who cannot eat or absorb enough
food through tube feeding formula or by
mouth to maintain good nutrition status.
NURSING DIAGNOSIS
 Imbalanced nutrition: less than body
requirements related to inability to ingest
food due to physiologic and/or psychologic
factors as evidenced by body weight 20% or
more below ideal weight range, pale
conjunctivae and mucous membranes, poor
muscle tone
 Risk for aspiration related to gastrointestinal
tubes and tube feedings
 Risk for deficient fluid volume related to
diarrhea and/or inadequate water intake
Chapter 2: Care for clients with Gastrointestinal
Problems
ANATOMY OF GASTROINTESTINAL TRACT
 The GI tract is a 23- to 26-foot-long
pathway that extends from the mouth
through the esophagus, stomach, and
intestines to the anus.
 The esophagus is located in the mediastinum
in the thoracic cavity, anterior to the spine
and posterior to the trachea and heart.
 The stomach is situated in the upper portion
of the abdomen to the left of the midline,
just under the left diaphragm. It is a
distensible pouch with a capacity of
approximately 1500 mL.
 The small intestine is the longest segment of
the GI tract, accounting for about two thirds
of the total length. It folds back and forth on
itself, providing approximately 7000 cm of
surface area for secretion and absorption, the
process by which nutrients enter the
bloodstream through the intestinal walls.
 The large intestine consists of an ascending
segment on the right side of the abdomen.
The terminal portion of the large intestine
consists of two parts: the sigmoid colon and
the rectum. The rectum is continuous with
the anus.
FUNCTION OF THE DIGESTIVE SYSTEM
The primary digestive functions of the GI tract are
the following:
 To break down food particles into the
molecular form for digestion.
 To absorb into the bloodstream the small
molecules produced by digestion
 To eliminate undigested and unabsorbed
food stuffs and other waste products from
the body
Health History and Clinical Manifestations:
 Pain- can be a major symptom of GI disease.
 Indigestion- most common symptom of
patients with GI dysfunction
 Intestinal Gas-accumulation of gas in the GI
tract
 Nausea and Vomiting-another major
symptom of GI disease
 Change in Bowel
Characteristics
Habits
and
Stool
PHYSICAL ASSESSMENT
 The
physical
examination
includes
assessment of the mouth, abdomen, and
rectum.
 The mouth, tongue, buccal mucosa, teeth,
and gums are inspected, and ulcers, nodules,
swelling, discoloration, and inflammation
are noted.
 People with dentures should remove them
during this part of the examination to allow
good visualization.
DIAGNOSTIC EVALUATION
 Stool tests
 Breath tests
 Abdominal Ultrasonography
 DNA Testing
 Imaging
Studies-Upper
and
Lower
Gastrointestinal Tract Study (X-ray with
barium), Computed Tomography, Magnetic
Resonance
Imaging,
Gastrointestinal
Motility Studies (Radionuclide testing also
is used to assess gastric emptying and
colonic transit time), endoscopic procedures,
 gastric analysis, gastric acid stimulation test,
and
pH
monitoring,
laparoscopy
(peritoneoscopy)
DIFFERENT DISORDERS FOR TEETH, JAW
AND SALIVARY GLANDS
 Dentoalveolar Abscess or Periapical Abscess
o abscessed tooth, involves the
collection of pus
 Malocclusion
o misalignment of the teeth
 Dental plaque and caries
o Tooth decay
 PAROTITIS
o Inflammation of the parotid gland
 Sialadenitis
inflammation of the salivary glands
 Salivary Calculus (Sialolithiasis)
o stones, usually occurs in the
submandibular gland
Neoplasms
 tumors or growths
 Cancer of the Oral Cavity associated with
the use of alcohol and tobacco.
 Predisposing factors ingestion of alcohol,
dietary deficiency, and ingestion of smoked
meats.
PATHOPHYSIOLOGY
 Malignancies of the oral cavity are usually
squamous cell cancers.
 Any area of the oropharynx can be a site for
malignant growths, but the lips, the lateral
aspects of the tongue, and the floor of the
mouth are most commonly affected
CLINICAL MANIFESTATION
 Many oral cancers produce few or no
symptoms in the early stages.
 Later, the most frequent symptom is a
painless sore or mass that will not heal. A
typical lesion in oral cancer is a painless
indurated (hardened) ulcer with raised
edges. Tissue from any ulcer of the oral
cavity that does not heal in 2 weeks should
be examined through biopsy. As the cancer
progresses, the patient may complain of
tenderness;
difficulty
in
chewing,
swallowing, or speaking; coughing of bloodtinged sputum; or enlarged cervical lymph
nodes.
MEDICAL MANAGEMENT
 Management varies with the nature of
the lesion, the preference of the
physician, and patient choice.
 Surgical resection, radiation therapy,
chemotherapy, or a combination of these
therapies may be effective.
NURSING MANAGEMENT
 The nurse assesses the patient’s nutritional
status preoperatively, and a dietary
consultation may be necessary. The patient
may require enteral (through the intestine) or
parenteral (intravenous) feedings before and
after surgery to maintain adequate nutrition.
 Promoting Mouth Care
Ensuring Adequate Food and Fluid Intake
Supporting A Positive Self-Image
Minimizing Pain and Discomfort
Promoting Effective Communication
Preventing Infection
Promoting Home and Community-Based
Care
 Teaching Patients Self-Care, Continuing
Care
 The patient should be instructed to eat
slowly and to drink fluids with meals. As a
temporary measure, calcium channel
blockers and nitrates have been used to
decrease esophageal pressure and improve
swallowing.
 Achalasia may be treated surgically
esophagomyotomy. The procedure usually is
performed laparoscopically.
DISORDERS OF THE ESOPHAGUS
 DYSPHAGIA- (difficulty swallowing) is the
most common symptom of esophageal
disease.
 ACHALASIA-absent
or
ineffective
peristalsis of the distal esophagus,
accompanied by failure of the esophageal
sphincter to relax in response to swallowing.
HIATAL HERNIA
 In a condition known as hiatus (or hiatal)
hernia, the opening in the diaphragm
through which the esophagus passes become
enlarged, and part of the upper stomach
tends to move up into the lower portion of
the thorax.
 Hiatal hernia occurs more often in women
than men. There are two types of hiatal
hernias: sliding and paraoesophageal.






CLINICAL MANIFESTATION
 The primary symptom of achalasia is
difficulty in swallowing both liquids and
solids. The patient has a sensation of food
sticking in the lower portion of the
esophagus. As the condition progresses,
food is commonly regurgitated, either
spontaneously or intentionally by the patient
to relieve the discomfort produced by
prolonged distention of the esophagus by
food that will not pass into the stomach. The
patient may also complain of chest pain and
heartburn (pyrosis). Pain may or may not be
associated with eating. There may be
secondary pulmonary complications from
aspiration of gastric contents.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 X-ray studies show esophageal dilation
above the narrowing at the gastroesophageal
junction. Barium swallow, computed
tomography (CT) of the esophagus, and
endoscopy may be used for diagnosis;
however, the diagnosis is confirmed by
manometry, a process in which the
esophageal pressure is measured by a
radiologist or gastroenterologist.
MANAGEMENT
CLINICAL MANIFESTATION
 Heartburn, regurgitation, and dysphagia, but
at least 50% of patients are asymptomatic.
 Sliding hiatal hernia is often implicated in
reflux.
 The patient with a paraoesophageal hernia
usually feels a sense of fullness after eating
or may be asymptomatic.
 The
complications
of
hemorrhage,
obstruction, and strangulation can occur
with any type of hernia.
 Assessment and Diagnostic Findings:
Diagnosis is confirmed by x-ray studies,
barium swallow, and fluoroscopy.
MANAGEMENT
 Frequent, small feedings that can pass easily
through the esophagus.
 The patient is advised not to recline for 1
hour after eating, to prevent reflux or
movement of the hernia, and to elevate the
head of the bed to prevent the hernia from
sliding upward.
 Surgery is indicated in about 15% of
patients.
 Medical and surgical management: surgery
to correct torsion (twisting) of the stomach
or other body organ that leads to restriction
of blood flow to that area.
DIVERTICULUM
 A diverticulum is an outpouching of mucosa
and submucosa that protrudes through a
weak portion of the musculature.
 The most common type of diverticulum is
Zenker’s diverticulum (also known as
pharyngoesophageal pulsion diverticulum or
a pharyngeal pouch).
DIVERTICULITIS
 Common development with advancing
years, associated with diets low in fiber
 Diverticulitis Is Inflammation of Diverticula
 Signs and symptoms: Fever, anorexia,
nausea, lower left sided pain, bright-red
rectal bleeding
 Complications: Hypovolemic shock, Sepsis
 The most common type of diverticulum is
Zenker’s diverticulum (also known as
pharyngoesophageal pulsion diverticulum or
a pharyngeal pouch).
CLINICAL MANIFESTATION
 Symptoms experienced by the patient with a
pharyngoesophageal pulsion diverticulum
include difficulty swallowing, fullness in the
neck, belching, regurgitation of undigested
food, and gurgling noises after eating.
 Dysphagia is the most common complaint of
patients.
 Assessment and Diagnostic Findings:
Barium Swallow, Esophagoscopy
MANAGEMENT
 Because
pharyngoesophageal
pulsion
diverticulum is progressive, the only means
of cure is surgical removal of the
diverticulum.
 Postoperatively, the patient may have a
nasogastric tube inserted at the time of
surgery.
PERFORATION
 Perforation may result from stab or bullet
wounds of the neck or chest, trauma from
motor vehicle crash, caustic injury from a
chemical burn or inadvertent puncture by a
surgical instrument during examination or
dilation.
CLINICAL MANIFESTATIONS
 The patient has persistent pain followed by
dysphagia. Infection, fever, leukocytosis,
and severe hypotension may be noted.
 Pneumothorax are observed.
GASTROINTESTINAL REFLUX DISEASE
 Gastroesophageal reflux (back-flow of
gastric or duodenal contents into the
esophagus)
CLINICAL MANIFESTATIONS
 pyrosis (burning sensation in the
esophagus),
dyspepsia
(indigestion),
regurgitation, dysphagia or odynophagia
(difficulty swallowing, pain on swallowing),
hypersalivation, and esophagitis.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 endoscopy or barium swallow to evaluate
damage to the esophageal mucosa
MANAGEMENT
 The patient is instructed to eat a low-fat diet;
 Avoid caffeine, tobacco, beer, milk, foods
containing peppermint or spearmint, and
carbonated beverages;
 Avoid eating or drinking 2 hours before
bedtime
 Elevate the head of the bed on 6- to 8-inch
(15- to 20-cm) blocks
 Elevate the upper body on pillows
 If reflux persists, the patient may be given
medications such as antacids or histamine
receptor blockers
CELIAC DISEASE
 Celiac disease is a digestive disorder caused
by an abnormal immune reaction to gluten.
Celiac disease is also known as:sprue,
nontropical
sprue,
gluten-sensitive
enteropathy
 Gluten is a protein found in foods made with
wheat, barley,rye,oats,triticale and other
grains.
 Some people with gluten intolerance have a
mild sensitivity to gluten, while others have
celiac disease which is an autoimmune
disorder.
SIGNS AND SYMPTOMS
 weight loss
 vomiting
 abdominal bloating
 abdominal pain
 persistent diarrhea or constipation
 pale, fatty, foul-smelling stooL
COMMON BLOOD TEST
 complete blood count (CBC)
 liver function tests
 cholesterol test
 alkaline phosphatase level test
 Serum albumin test
CLINICAL MANAGEMENT
 Eat only gluten-free products
Risk Factors for Digestive and Gastrointestinal
System Disease (Usually Self-Induced)
 Excessive alcohol consumption
 Excessive smoking
 Increased stress
 Ingestion of caustic substances
 Poor bowel habits
 Pain is the hallmark of acute abdominal
problems
o Visceral, Somatic, or Referred pain
VISCERAL PAIN
 Caused by inflammation, distention
(inflation of the organ), or ischemia
(inadequate blood flow)
 Pain vague, dull, or crampy
 Is generally diffuse and difficult to localize
 Examples (most often hollow organs)
o gallbladder (cholecystitis)
o appendix (appendicitis)
 Presentation (from sympathetic stimulation)
o nausea and vomiting
o diaphoresis
o tachycardia
SOMATIC PAIN
 Produced by bacterial or chemical irritation
of nerve fibers in the peritoneum
(peritonitis)
 Is usually constant and localized to a
specific area
 Often described as sharp or stabbing
 Examples
o ruptured appendix
o perforated ulcer
o inflamed pancreas
o Peritonitis can lead to sepsis death
 Presentation
o Patient often hesitant to move
o Lies on their back or side with legs
flexed to prevent additional pain
from stimulation of the peritoneal
area
o Often exhibits involuntary guarding
of the abdomen
o Rebound tenderness often noted
during the physical examination
REFFERED PAIN
 Pain in a part of the body considerably
removed from the tissues that cause the pain
 Results from neural pathways from various
organs passing thru or over a region where
the organ was initially formed in the fetal
stage
 Examples
o Diaphragm injury- refers pain to
neck or shoulders
o Appendicitisrefers
pain
to
periumbilical area
o Gallbladder disorder- refers pain to
right shoulder
DISEASE ENTITIES
 Upper GI Disease
o Gastroenteritis
o Gastritis
o Peptic ulcer disease
 Lower GI Disease
o Colitis
o Crohn’s disease
o Diverticulitis
o Bowel obstruction
 Other Organ Disease
o Appendicitis
o Cholecystitis
o Pancreatitis
o Acute hepatitis
GASTROENTERITIS
 Inflammation of the stomach and intestines
that accompanies numerous GI disorders
 Causes
o bacteria or viral infections, chemical
toxins, and other conditions
 Signs and symptoms
o anorexia (loss of appetite),
o nausea,
o vomiting,
o abdominal pain
 Management:
o emergency management,
o supportive therapy
GASTRITIS
 An acute or chronic inflammation of the
gastric mucosa
 Causes:
o hyperacidity
o alcohol or drug ingestion
o infection
 Signs and symptoms
o epigastric pain
o nausea and vomiting
o bleeding
PEPTIC ULCER DISEASE
 Erosions in the GI tract from gastric acid
 Duodenal ulcers
o most
frequently
in
proximal
duodenum
o most common 25-50 years old in
those under stress
o pain at night when the stomach is
empty
 Gastric ulcers
o in the stomach
o more common over 50 years of age
in jobs requiring physical activity
o usually no pain at night pain on full
stomach
 Causes of peptic ulcer disease
o H. pylori infection (treated with
antibiotics)
o Non-steroidal
anti-inflammatory
drug use
o aspirin, Motrin, Advil
o Acid stimulating products like
alcohol, nicotine
o Acid secreting tumor (ZollingerEllison syndrome)
o * Zollinger-Ellison syndrome - is a
rare condition in which one or more
tumors form in the pancreas or upper
part of the small intestine. This
tumor is called gastrinomas.
COLITIS
 An inflammatory condition of the large
intestine characterized by severe diarrhea
and ulceration of the mucosa of the intestine
(ulcerative colitis)
 Incidence - most often 20-40-year old
 Cause is unknown
 Signs and symptoms
o Nausea, vomiting, weight loss
o Significant pain
o cramping colicky
o Grossly bloody stools or stool
containing mucus
CROHNS DISEASE
 A chronic, inflammatory bowel disease
thought to be of autoimmune etiology,
usually affecting the ileum, the colon, or
both structures  Exact cause unknown
 Most prevalent in white females, those
under stress, and in the Jewish population
 The diseased segments associated with
Crohns disease may be separated by normal
bowel segments or skip areas
 Formation of fistulas from the diseased
bowel to the anus, vagina, skin surface, or to
other loops of bowel are common
BOWEL OBSTRUCTION
 A partial or complete blockage of the large
or small intestines
 Causes:
o Adhesions
o Hernias
o fecal impaction
o polyps
o tumors
 Signs and symptoms –
o decreased appetite,
o nausea and vomiting
o diffuse abdominal pain
o constipation, and
o abdominal distention
 Bowel obstruction, if untreated can lead to
death
APPENDICITIS
 A common abdominal emergency that
occurs when the opening between the lumen
of the appendix and the cecum is obstructed
by fecal material or from inflammation from
viral or bacterial infection
 Signs and symptoms:
o early abdominal pain is diffuse
o colicky
o in periumbilical area (later RLQ),
abdominal tenderness guarding
o nausea
o vomiting, chills
o low-grade fever
o anorexia
 If ruptured, increased risk of inflammation
of peritoneum (Peritonitis)
PERITONITIS
 It is inflammation of the peritoneum, the
serous membrane lining the abdominal
cavity and covering the viscera.
 Usually, it is a result of bacterial infection
the organisms come from diseases of the GI
tract or, in women, from the internal
reproductive organs
 Peritonitis can also result from external
sources such as injury or trauma (eg,
gunshot wound, stab wound) or an
inflammation that extends from an organ
outside the peritoneal area, such as the
kidney.
 The most common bacteria implicated are
Escherichia coli, Klebsiella, Proteus, and
Pseudomonas,
 Other common causes of peritonitis are
appendicitis, perforated ulcer, diverticulitis,
and bowel perforation. Peritonitis may also
be associated with abdominal surgical
procedures and peritoneal dialysis.
 Clinical Manifestations
o At first, a diffuse type of pain is felt.
The pain tends to become constant,
localized, and more intense near the
site of the inflammation. Movement
usually aggravates it.
 The affected area of the abdomen becomes
extremely tender and distended, and the
muscles become rigid. Rebound tenderness
and paralytic ileus may be present. Usually,
nausea and vomiting occur and peristalsis is
diminished, temperature and pulse rate
increase, and elevation of the leukocyte
count.
 Management:
o Fluid, colloid, and electrolyte
replacement (isotonic solution),
o Analgesics,
o Antiemetics,
o Surgical treatment is directed toward
excision (ie, appendix), resection
with or without anastomosis
(surgical connection between two
structures)
CHOLECYSTITIS
 Inflammation of the gallbladder, most often
associated with the presence of gallstones
 Incidence: -more common in women 30-50
years old
 Signs symptoms
o pain, often colicky,
o in RUQ with referral to right
shoulder
o pain often after high fat content meal
o nausea, vomiting common
o pale, cool, clammy skin (sympathetic
response)
o giving Morphine may increase
spasms
PANCREATITIS
 Inflammation of the pancreas
 Alcoholism causes 80 of cases in the USA
 Signs and symptoms
o severe abdominal pain
o localized to LUQ or referred to back
or epigastric area
o nausea and uncontrolled vomiting
retching
o abdominal tenderness and distention
o fever,
o tachycardia,
o diaphoresis
o sepsis shock possible
ACUTE HEPATITIS
 Inflammation of the liver
 Signs symptoms related to severity of
disease
o Associated with the sudden onset of
malaise,
weakness,
anorexia,
intermittent nausea and vomiting,
and dull right upper quadrant pain or
referral to right shoulder
 Usually followed within 1 week by the onset
of jaundice of skin sclera, dark urine, claycolored stool
RISK FACTORS OF HEPATITIS A
 Spread by fecal-oral route
 Health care practice without BSI (body
substance isolation) or infection control
precautions
 Household or sexual contact with an
infected person
 Living in an area with HIV outbreak
 Traveling to developing countries
 Poor handwashing hygiene practice
especially after toileting
 Disease often self-limiting, lasts 2-8 weeks,
low mortality rate
RISK FACTORS OF HEPATITIS B
 Serum hepatitis transmitted as blood born
pathogen can stay active in body fluids
outside body for days
 Health care practice without infection
control precautions
 Infant born to Hepatitis B virus (HBV)
infected mother
 Engaging in sex with infected partners
and/or multiple partners
 Drug use by injection
 Patients receiving hemodialysis
RISK FAVTOR OF HEPATITIS C
 Health care practice without infection
control precautions
 Blood transfusion recipients
 Engaging in sex with infected partners
and/or multiple partners
 Drug use by injection
 Patients receiving hemodialysis
GASTRIC CANCER
 This type of cancer is more common among
middle-aged males.
 Predisposing factors:
o lifestyle related and history of cancer
in the family
 Clinical manifestations:
o progressive loss of appetite,
o gastric fullness,
o dyspepsia or indigestion,
o hematemesis,
o melena,
o weight loss,
o anemia,
o fatigues
 Collaborative surgery:
o Total gastrectomy,
o Chemotherapy,
o Radiation
HIATAL HERNIA OR DIAPHRAGMATIC
HERNIA
 Two types:
o sliding hiatal hernia;
o paraesophagealrolling hernia
 Sliding hiatal Hernia
o protrusion of the esophagogastric
junction into the thoracic cavity and
back into abdominal cavity
 Paraesophageal Hernia
o protrusion of the fundus of the
stomach and the greater curvature
into the stomach and esophagus.
 Clinical Manifestations:
o heartburn,
dysphagia,
dyspnea,
nausea and vomiting, gastric
distention
 Collaborative Management
o Medications:
antacids to relieve
heartburns, antiemetics to relieve
nausea and vomiting
 Nursing Interventions:
o Modify diet: high protein diet, small
frequent feedings, avoid foods and
beverages that can cause too much
acidity,avoid
evening
snacks,
promote lifestyle changes
 Management:
o Surgery-Nissenfundoplicationor
gastric wrap-around
ASSESSING ABDOMINAL PAIN
 Onset - when did it begin?
 Provocation/palliation - what makes the pain
worse/better?
 Quality - described in the patients own
words
 Region/radiation - if the patient can use one
finger the pain is localized if the patient rubs
their hands over the general entire abdomen
it is diffuse
 Severity - on a scale of 0-10 (0 being no
pain and 10 being the worse)
 Time - how long has the pain been present?
DIAGNOSTIC PROCEDURE
 RADIOLOGIC
o The digestive tract can be outlined
by x-rays by utilizing the
administration of a contrast medium.
The contrast medium is swallowed
by the patient in order to visualize
the upper GI tract. These procedures
are referred to as “Barium Swallow,"
or “Small Bowel Follow-Through."
To visualize the lower GI tract,the
contrast
medium
is
instilled
rectally.This
procedureis called
a“Barium Enema."
 GASTRIC ANALYSIS
o Examination of gastric contents and
gastric juice provides information
used in diagnosis. For example, the
following may be determined:
(1) The presence, amount, or
absence of hydrochloric
acid.
(2) The presenceof cancercells.
(3) The types and amounts of
enzymes present.
 STOOL EXAM
o Stool samples can be examined on
the ward and in the laboratory to
determine the presence of substances
that aid in diagnosis.
o For example:
(1) On the ward, nursing
personnel can determine the
color,
consistency,
and
amount of stool. The
presence of unseen blood
(occult) can be determined
with a simple test.
(2) In the laboratory,tests can be
performed to determine the
presence of fat, urobilinogen,
ova,
parasites,bacteria,and
other substances.
 ENDOSCOPY
o is a visual examination of the interior
through the use of special
instruments called endoscopes. In
relation to the digestive system, the
term endoscopy is used to describe
visual examination of the inside of
the GI tract.
o There are many different types of
endoscopes, each designed for a
specific use. Generally, the scope
consists of a hollow tube with a
lighted lens system that permits
multi-directional viewing. The scope
has
a
power
source
and
accessoriesthat permitboth biopsy
and suction.
 BLOOD TESTS
o There are many blood tests that can
be used to assist in the identification
and measurement of gastrointestinal
disorders.
Impaired
glucose
utilization may be detected by
abnormal blood glucose levels.
MANAGEMENT OF GASTROINTESTINAL
PROBLEMS
 Majority of care is supportive and aimed at
treating signs and symptoms presented
 Position of comfort with ability to protect
airway in the case of vomiting
 Abdominal pain control - EMS needs to
contact medical control for medication
orders (Morphine 2mg IVP every 2 minutes,
max 10 mg)
 IV to replace fluid loss (vomiting, diarrhea,
internal hemorrhage)
 Shock (hypovolemic, septic) possible and
then aggressive care required
COLOSTOMY
 A colostomy is a surgically created, artificial
opening (stoma) into the colon through the
abdomen. It may be temporary or
permanent. Fecal diversion is utilized in
order to rest a portion of the colon following
intestinal surgery, in preparation for further
surgery, or in cases of severe inflammatory
disease (such as Diverticulitis).
.
Chapter 3: Care for Clients with Anorectal
Disorder
Anorectal disorders
 are a group ofmedicaldisorders that occur at
the junction of the anal canal and the
rectum.
 Wide range of disorders of the rectum
including diarrhea, hemorrhoids, abscesses,
fistula, fissures,anal itching, warts and rectal
prolapse.
Anal Fistula
 An anal fistula is a small tunnel that
develops between the end of the bowel and
the skin near the anus (where poo leaves the
body).
 They're usually the result of an infection
near the anus causing a collection of pus
(abscess) in the nearby tissue.
 When the pus drains away, it can leave a
small channel behind. Anal fistulas can
cause unpleasant symptoms, such as
discomfort and skin irritation, and will not
usually get better on their own. Surgery is
recommended in most cases.
 Symptoms of Anal Fistula
o skin irritation around the anus
o a constant, throbbing pain that may
be worse when you sit down, move
around,poo or cough
o smelly discharge from near your
anus
o passing pus or blood when you poo
o swelling and redness around your
anus
ANAL FISSURES
 An anal fissureis a small tear in the thin,
moist tissue (mucosa) that lines the anus. An
anal fissuremay occur when you pass hard
or large stools during a bowel
movement.Anal fissures typically cause pain
and bleeding with bowel movements.
 Common symptom: bleeding
HEMORRHOIDS
 Hemorrhoids are swollen veins in your
lower rectum. Internal hemorrhoids are
usually painless, but tend to bleed. External
hemorrhoids may cause pain.
 Hemorrhoids, also called piles, are swollen
veins in your anus and lower rectum, similar
to varicose veins.
 Hemorrhoids are one of the most common
causes of rectal bleeding.
 Cinical manifestations:
o pain, bleeding, itching, swelling
 Assessment:
o Digital Exam, Visual inspection
 Management:
o Hemmorrhoidectomy(if bleeding)
PILONIDAL SINUS
 A pilonidal sinus (PNS) is a small hole or
tunnel in the skin. It may fill with fluid or
pus, causing the formation of a cyst or
abscess. It occurs in the cleft at the top of
the buttocks.
 A pilonidal cyst usually contains hair, dirt,
and debris. It can cause severe pain and can
often become infected.
 No exact cause but believed to be a
combination of changing hormones (because
it occurs after puberty), hair growth, and
friction from clothes or from spending a
long time sitting.
 The signs of an infection include:
o pain when sitting or standing
o swelling of the cyst
o reddened, sore skin around the area
o pus or blood draining from the
abscess, causing a foul odor
o hair protruding from the lesion
o formation of more than one sinus
tract, or holes in the skin
TREATMENT AND MANAGEMENT
 For Anal Fistula:
o Fistulotomy – a procedure that
involves cutting open the whole
length of the fistula so it heals into a
flat scar;
o Seton procedures – where a piece of
surgical thread called a seton is
placed in the fistula and left there for
several weeks to help it heal before a
further procedure is carried out to
treat it
 For Anal Fissures: Laxatives, topical
analgesics, Glyceryl trinitrate; Surgery:
lateral sphincterotomy
 For Hemorrhoids: Over-the-counter creams,
ointments,
suppositories
or
pads,
hydrocortisone and lidocaine, which can
temporarily relieve pain and itching.
 Surgical procedure: External hemorrhoid
thrombectomy
 For Pilonidal Sinus: broad-spectrum
antibiotic, surgery using local anesthesia
NURSING MANAGEMENT
 Relieving Constipation-adequate hydration
and high fiber foods
 Reducing
Anxiety-maintains
patients’
privacy, individualizes plan of care
 Relieving Pain-provide comfort measures,
hot sitz bath, warm compress, analgesics
 Promoting Urinary Elimination-encourage
voluntary voiding, before resorting to
catheterization if indicated
 Health Education