GASTROINTESTINAL DISEASES
(PUD, GERD, GASTROENTERITIS, CROHN’S, ULCERATIVE COLITIS, HEMORRHOIDS)
_______________________________________
A Seminar Manuscript Presented To
the Faculty of the Nursing Department
Mrs. Jocelyn A. Cataraja, RN, MN
_______________________________________
In Partial Fulfillment of
The requirements in SEM - 101
SEMINAR IN NURSING
By
Angkang, Gene Anthony
Balug, Nova Mae
Banasig, Trisha Mae
Banggo, Farisa Jane
Bangonon, Angel Shane
Caburnay, Mylah Marie
Caiña, Thea Marie
Calipusan, Xylen May
Casiple, Xynna
Confesor, Gerald Vonn
Coronel, Elmer Jr.
BSN 4K - Group 1
March 07, 2023
TABLE OF CONTENTS
INTRODUCTION…………………………………………………….…………………….………4
GOALS AND OBJECTIVES………………………………………….…………………..………5
I.
PUD
DEFINITION OF CASE………………………………………….………………………..………6
ANATOMY AND PHYSIOLOGY………………………………………….………………...……6
PATHOPHYSIOLOGY………………………………………….…………………………………10
SYMPTOMATOLOGY…………………………….………………………………......…10
ETIOLOGY………………………………………….…………………………………….11
SCHEMATIC DIAGRAM…………………………….…………………………….….…13
NARRATIVE…………………………….……………………………………………..…15
MANAGEMENT……………….………………………………………….……………………....16
DIAGNOSTIC EXAM………………………….…………………………………………16
MEDS…….………………………………………….……………………………..…..…20
TREATMENT…………………………………….…………………………………..…...31
SURGICAL MANAGEMENT…….………………………………………….………..…33
NURSING MANAGEMENT…….………………………………………….…..………..35
REVIEW OF RELATED LITERATURE…….………………………………………….……..…46
II.
GERD
DEFINITION OF CASE………………………………………….……………………….………50
ANATOMY AND PHYSIOLOGY………………………………………….………………..……50
PATHOPHYSIOLOGY………………………………………….……………………………...…53
SYMPTOMATOLOGY…………………………….……………………………………..53
ETIOLOGY………………………………………….………………………………...…..55
SCHEMATIC DIAGRAM…………………………….………………………………..…58
NARRATIVE…………………………….……………………………………………...…60
MANAGEMENT……………….………………………………………….…………………….…61
DIAGNOSTIC EXAM………………………….……………………………………….…61
MEDS…….………………………………………….………………………………….…66
TREATMENT…………………………………….……………………………………….81
SURGICAL MANAGEMENT…….………………………………………….………..…83
NURSING MANAGEMENT…….………………………………………….……………85
REVIEW OF RELATED LITERATURE…….………………………………………….…..……92
III.
GASTROENTERITIS
DEFINITION OF CASE………………………………………….………………………………95
ANATOMY AND PHYSIOLOGY………………………………………….………………….…95
PATHOPHYSIOLOGY………………………………………….……………………………..…97
SYMPTOMATOLOGY…………………………….………………………………….…97
1
ETIOLOGY………………………………………….…………………………………...99
SCHEMATIC DIAGRAM…………………………….…………………………………100
NARRATIVE…………………………….…………………………………………….…101
MANAGEMENT……………….………………………………………….…………………...…102
DIAGNOSTIC EXAM………………………….…………………………………..……102
MEDS…….………………………………………….……………………………...……104
TREATMENT…………………………………….……………………………………...115
SURGICAL MANAGEMENT…….………………………………………….…………117
NURSING MANAGEMENT…….………………………………………….…………..117
REVIEW OF RELATED LITERATURE…….…………………………………………….……125
IV.
CROHN’S DISEASE
DEFINITION OF CASE……………….………………………………………….………....…..127
ANATOMY AND PHYSIOLOGY……………….………………………………………………127
PATHOPHYSIOLOGY………………………………………….…………………………..…..128
SYMPTOMATOLOGY…………………………….……………………………………128
ETIOLOGY………………………………………….……………………………….….129
SCHEMATIC DIAGRAM…………………………….…………………………………132
NARRATIVE…………………………….……………………………………………….134
MANAGEMENT……………….………………………………………….………………..……136
DIAGNOSTIC EXAM………………………….……………………………….………136
MEDS…….………………………………………….………………………..…………146
TREATMENT…………………………………….………………………….………….162
SURGICAL MANAGEMENT…….………………………………………..………..…165
NURSING MANAGEMENT…….………………………………………..……………168
REVIEW OF RELATED LITERATURE…….………………………………….…….……..…176
V.
ULCERATIVE COLITIS
DEFINITION OF CASE……………….………………………………………….………...…..180
ANATOMY AND PHYSIOLOGY……………….………………………………………………180
PATHOPHYSIOLOGY………………………………………….…………………………..…..183
SYMPTOMATOLOGY…………………………….……………………………………183
ETIOLOGY………………………………………….……………………………….….185
SCHEMATIC DIAGRAM…………………………….…………………………………188
NARRATIVE…………………………….……………………………………………….191
MANAGEMENT……………….………………………………………….……...………………192
DIAGNOSTIC EXAM………………………….………………………...………………192
MEDS…….………………………………………….……………………………………204
TREATMENT…………………………………….……………………………………….232
SURGICAL MANAGEMENT…….………………………………………….………..…240
NURSING MANAGEMENT…….………………………………………….……………246
2
REVIEW OF RELATED LITERATURE…….………………………………………….……..…253
VI.
HEMORRHOIDS
DEFINITION OF CASE……………….………………………………………….………...…..256
ANATOMY AND PHYSIOLOGY……………….………………………………………………256
PATHOPHYSIOLOGY………………………………………….…………………………..…..257
SYMPTOMATOLOGY…………………………….……………………………………257
ETIOLOGY………………………………………….……………………………….….258
SCHEMATIC DIAGRAM…………………………….…………………………………260
NARRATIVE…………………………….……………………………………………….261
MANAGEMENT……………….………………………………………….……..………………262
DIAGNOSTIC EXAM………………………….…………………….…………………262
MEDS…….………………………………………….……………..……………………263
TREATMENT…………………………………….………………..…………………….277
SURGICAL MANAGEMENT…….……………………………..………….………..…282
NURSING MANAGEMENT…….…………………………..…………….……………283
REVIEW OF RELATED LITERATURE…….………………………..……………….……..…294
REFERENCES……………………………………………………….………………………….297
3
INTRODUCTION
Digestion is essential for breaking down food into nutrients, which our body uses for
energy, growth, and cell repair. The esophagus, stomach, large and small intestines, liver,
pancreas, and gallbladder are all parts of the digestive tract, and disorders of the digestive tract,
often known as the gastrointestinal (GI) tract, are known as digestive illnesses. Any health
problem that occurs on it has a condition that may range from mild to severe. There are two types:
functional and structural. Functional diseases are when the GI tract is checked, it appears normal,
but it doesn't function as it should. They are the GI tract's most frequent health issues, including
GERD. Structural gastrointestinal diseases are when your bowel looks abnormal upon
examination and doesn't work properly, including hemorrhoids and diverticulitis. Sometimes
surgery is required to repair the structural defect.
In everyone's life, a little digestive distress will occur. Whether it's a meal that doesn't agree
with us or a lingering gastrointestinal ailment requiring lifestyle changes and treatment, digestive
problems are prevalent. The first sign of problems in the digestive tract often includes bleeding,
bloating, constipation, diarrhea, heartburn, nausea and vomiting, pain in the belly, and weight loss
or gain. Some digestive diseases include Peptic Ulcer disease, GERD, Gastroenteritis, Crohn's
disease, Ulcerative Colitis, and Hemorrhoids.
According to the National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK), over 60 to 70 million people worldwide suffer from the digestive disorder. It is estimated
that 11% of the population in the United States suffers from a chronic digestive disease, with a
prevalence rate as high as 35% of those 65 years and over. In a report published by the Philippine
Statistics Authority in 2021, infections or complications of the digestive tract are among the top
causes of death in the Philippines. The most common, among others, are liver cancer, colorectal
cancer, peptic ulcer disease, diarrhea, and stomach ulcer. According to the latest WHO data
published in 2020 Peptic Ulcer Disease Deaths in the Philippines reached 6,865 or 1.02% of total
deaths. The age adjusted Death Rate is 9.95 per 100,000 of population ranks Philippines #12 in
the world and as Peptic ulcer disease ranks 17th in leading cause of death in the philippines. With
that, it was proclaimed under Proclamation 930 issued in 2020; President Rodrigo Roa Duterte
declared the second week of March of every year as the "Philippine Digestive Health Week."
This topic plays a significant role in nursing practice, research, and education, which are
necessary to help the patient achieve holistic care. For nursing education, student nurses may
acquire information about the condition and the process of learning about Gastrointestinal
4
disease. In addition, this could help health workers and medical students to obtain data and
enhance their nursing and medical skills for a patient who has gastrointestinal problems. The data
contributed can also be used to provide effective sufficient care; the study can also serve as
related literature for further studies that could improve to impart more factual information about
Gastrointestinal Disease. Moreover, it will benefit future nursing students encountering patients
with similar cases. Furthermore, it could also impart data and recent updates regarding the said
disease.
Objectives
At the end of the seminar conducted by the BSN 4K Group 1, the BSN participants will be able to
acquire sufficient knowledge according to research-based information that can contribute to skill
development; develop a positive attitude conducive to learning on providing holistic nursing care
for patients suffering with gastrointestinal diseases.
Specifically, the proponents aim to:
a. discuss an overview about gastrointestinal disease and provide relevant statistic data;
b. explain what is peptic ulcer disease, GERD, gastroenteritis, crohn's disease, ulcerative
colitis, and hemorrhoids;
c. indicate the anatomical structures that is correlated with the disease;
d.
discuss the predisposing and precipitating factors that contribute to the onset of the
disease;
e. identify the signs and symptoms of the disease;
f.
trace the pathophysiology of the disease through a schematic diagram;
g. list the possible medical, surgical, and nursing management, including diagnostic,
laboratory examinations, and interventions;
h. present a summary on a related literature published not earlier than 5 years from conduct
of this study;
i.
arrange an alphabetical list of references used in the study using APA format.
5
PEPTIC ULCER DISEASE
I.
DEFINITION
A discontinuity characterizes peptic ulcer disease in the GI tract's inner lining due to pepsin
or gastric acid secretion. Usually, the stomach and proximal duodenum are affected. It may
involve the lower esophagus, distal duodenum, or jejunum. Patients with gastric ulcers typically
have epigastric pain 15 to 30 minutes after eating; in contrast, patients with duodenal ulcers
typically experience pain 2 to 3 hours after eating. (Malik et al., 2022). The two major causes of
peptic ulcer disease are bacteria which are called helicobacter pylori (H.pylori). This can
aggravate the digestive tract, increase acid production, and damage the mucus lining. While
certain pain relievers, such as taking aspirin often and for a long time. NSAIDs prevent the body
from producing a chemical that aids in protecting the interior walls of the stomach and small
intestine from stomach acid. (Pathak, 2021).
II.
ANATOMY/ PHYSIOLOGY
Mouth
The digestive process starts in your mouth when you chew. Your salivary glands make
saliva, a digestive juice, which moistens food so it moves more easily through your esophagus
into your stomach. Saliva also has an enzyme that begins to break down starches in your food.
The lips and cheeks help hold food in the mouth and keep it in place for chewing. They
are also used in the formation of words for speech. The lips contain numerous sensory receptors
that are useful for judging the temperature and texture of foods.
The palate is the roof of the oral cavity. It separates the oral cavity from the nasal cavity.
The anterior portion, the hard palate, is supported by bone. The posterior portion, the soft palate,
is skeletal muscle and connective tissue. Posteriorly, the soft palate ends in a projection called
the uvula. During swallowing, the soft palate and uvula move upward to direct food away from the
nasal cavity and into the oropharynx.
6
The tongue manipulates food in the mouth and is used in speech. The surface is covered
with papillae that provide friction and contain the taste buds. A complete set of deciduous (primary)
teeth contains 20 teeth. There are 32 teeth in a complete permanent (secondary) set. The shape
of each tooth type corresponds to the way it handles food.
Pharynx & Esophagus
Food is forced into the pharynx by the tongue. When food reaches the opening, sensory
receptors around the fauces respond and initiate an involuntary swallowing reflex. This reflex
action has several parts. The uvula is elevated to prevent food from entering the nasopharynx.
The epiglottis drops downward to prevent food from entering the larynx and trachea in order to
direct the food into the esophagus. Peristaltic movements propel the food from the pharynx into
the esophagus.
The Stomach
The stomach is located in the upper part of the abdomen, just beneath the diaphragm. The
stomach is distensible and on a free mesentery; therefore, the size, shape, and position may vary
with posture and content. An empty stomach is roughly the size of an open hand and, when
distended with food, can fill much of the upper abdomen and may descend into the lower abdomen
or pelvis on standing.
7
The duodenum extends from the pylorus to the ligament of Treitz in a sharp curve that
almost completes a circle. It is so named because it is about equal in length to the breadth of 12
fingers, or about 25 cm. It is mainly retroperitoneal, and its position is relatively fixed. The stomach
and duodenum are closely related in function, pathogenesis, and disease manifestation.
It takes in food from the esophagus (gullet or food pipe), mixes it, breaks it down, and then
passes it on to the small intestine in small portions. It has three functions; to temporarily store
food, contract and relax to mix and break down food, and produce enzymes and other specialized
cells to digest food. In addition, it has a protective function because of the highly acidic medium
due to the presence of HCl. Many of the micro-organisms die. Thereby it protects the GI tract from
getting invaded by microorganisms.
Structures
Several layers of muscle and other tissues make up the stomach.
8
●
Mucosa is your stomach’s inner lining. When your stomach is empty, the mucosa has
small ridges (rugae). When your stomach is full, the mucosa expands, and the ridges
flatten.
●
Submucosa contains connective tissue, blood vessels, lymph vessels (part of your
lymphatic system) and nerve cells. It covers and protects the mucosa.
●
Muscularis externa is the primary muscle of your stomach. It has three layers that
contract and relax to break down food.
●
Serosa is a layer of membrane that covers your stomach.
5 Distinct Sections
The stomach may be divided into five major sections. The cardia is a 1–2 cm segment
distal to the esophagogastric junction. The fundus refers to the superior portion of the stomach
that lies above an imaginary horizontal plane that passes through the esophagogastric junction.
The antrum is the smaller distal one-fourth to one-third of the stomach. The narrow 1–2 cm
channel that connects the stomach and duodenum is the pylorus. The lesser curve refers to the
medial shorter border of the stomach, whereas the opposite surface is the greater curve. The
angularis is along the lesser curve of the stomach where the body and antrum meet, and is
accentuated during peristalsis. The duodenum extends from the pylorus to the ligament of Treitz
in a circle-like curve and is divided into four portions.
The superior portion is approximately 5 cm in length, beginning at the pylorus, and passes
beneath the liver to the neck of the gallbladder. The first part of the superior portion (2–3 cm) is
the duodenal bulb. The descending or second part of the duodenum takes a sharp curve and goes
down along the right margin of the head of the pancreas. The common bile duct and the pancreatic
9
duct enter the medial aspect of this portion of the duodenum at the major papilla either separately
or together. The duodenum turns medially, becoming the horizontal portion, and passes across
the spinal column, inclining upward for 5–8 cm. The ascending portion begins at the left of the
spinal column, ascending left of the aorta for 2–3 cm, and ends at the ligament of Treitz, where
the intestine angles forward and downward to become the jejunum.
III.
SIGNS AND SYMPTOMS
SIGNS & SYMPTOMS
RATIONALE
Burning stomach pain
The acid eats away the inner surface of the stomach
or small intestine in the digestive system. It causes a
painful open sore that can sometimes be alleviated
by taking acid-reducing medicine or eating particular
foods that buffer stomach acid, but it may return.
(Mayo Clinic, 2022)
Pain radiating at the back
Pain radiating to the back may suggest that an ulcer
has penetrated posteriorly, or the pain may be
pancreatic in origin. (Malik et al., 2022)
Feeling of fullness/bloating
The infection is brought on by H infection. pylori, a
common yet potentially harmful bacterium. Bloating
from too much gas production might result from
having too many bacteria in the small intestine.
(Bakshis, 2021)
Heartburn
It occurs when stomach acid flows up into your
esophagus. This leads to a burning discomfort below
your breastbone or in your upper belly. (Digestive
Health Associates Endoscopy, 2020)
Nausea & Vomiting
Peptic Ulcer can block the passage of food through
the digestive tract, causing you to feel nauseous and
10
vomit. (Mayo Clinic, 2022)
Appetite Change/Weight Loss
Blockage in the digestive system caused by
inflammation can prevent food from moving through
the stomach, leading to weight loss and a decrease
in appetite. (Prima Medicine, 2021)
Dark Stool
Dark stools and tarry may also result from unusual
blood vessels or veins break in the esophagus,
stomach, or duodenum. (Phillips & Dugdale, 2022)
IV.
ETIOLOGY
Predisposing factors
Age
Rationale
Age-related
increases
in
Helicobacter
pylori
prevalence can have a significant impact on ulcer
formation. Aging skin is more prone to pressure sores
for a number of reasons. The skin loses some
elasticity (stretchiness) in the elderly, making it more
susceptible to damage.
Blood Type
According to a study, people with blood type O are
more susceptible than people with other blood types
to develop peptic and duodenal ulcers. Due to an
increased epithelial cell colonization density and
elevated inflammatory reactions to H. pylori.
Precipitating factors
Rationale
Helicobacter Pylori infection
A gram-negative bacillus called pylorus is present in
the gastric epithelial cells. 90% of duodenal ulcers and
70% to 90% of stomach ulcers are brought on by this
bacterium. The pylori bacteria destroy the stomach
and duodenum protective mucous lining, allowing acid
11
to enter the delicate lining underneath. The bacteria
and the acid irritate the lining, leading to an ulcer or
sore.
NSAIDs
The
stomach
prostaglandin
mucosa
is
secretion.
often
protected
by
prevent
the
NSAIDs
production of prostaglandins by inhibiting the COX-1
enzyme,
which
lowers
the
production
of
gastrointestinal mucus, bicarbonate, and mucosal
blood flow.
Smoking
This increases the chance of Helicobacter pylori
infection.
Nicotine
reduces
the
production
of
prostaglandins in a smoker's stomach mucosa,
making the mucosa more sensitive to ulceration.
Alcohol
Excess take of alcohol can weaken and irritate the
stomach lining, which can lead to inflammation. Also,
this inflammation can exacerbate ulcers already
present and inhibit the healing process.
Zollinger-Ellison Syndrome
Peptic ulcer disease can develop in people also with
the
rare
disorder
Zollinger-Ellison
syndrome
(gastrinoma). This disease forms a tumor of cells that
produce acid in the digestive tract. These tumors may
or may not be malignant. The acid that is produced
excessively harms stomach tissue.
12
V.
PATHOPHYSIOLOGY
13
14
Narrative
Peptic ulcer is where the lining of the stomach, intestine, or esophagus develops sores.
Predisposing factors such as age, blood type O, and precipitating factors like Helicobacter Pylori
Infection, NSAIDs, Smoking, Alcohol, and Zollinger- Ellison Syndrome contribute to the
development of peptic ulcer disease. The ingestion of infected utensils, food, and water in our
mouth can eventually increase the spread of Helicobacter Pylori Infection in our body, it can bind
to the mucosa, especially the foveolar cells, due to its adhesive capability. This would then
stimulate the release of an enzyme called protease, which will then break down stomach tissues
and also causes the release of more gastrin and a reduction in the generation of somatostatin.
Together, they may induce burning stomach pain and bloating, in addition to gradually damaging
the mucosal cells.
Continuous intake or use of Alcohol, cigarette, and NSAIDs are the other factors that cause
mucosal disruption. Nonsteroidal anti-inflammatory medications (NSAIDs) used over an extended
period of time can harm the stomach mucosa. NSAIDs function by preventing the formation of
inflammatory prostaglandins by the enzyme cyclooxygenase. The prostaglandin increases the
production of mucus and the synthesis of bicarbonate, protecting the mucosa from gastric acid. A
poor barrier to protect the mucosa layer from hydrochloric acid contact results from low mucus
and bicarbonate synthesis. HCL irritates the mucosal layer because it is known for digesting or
breaking down protein. Also, vagal stimulation stimulates the release of acid and pepsinogen,
which increases gastric production and stimulates the production of gastric acid. This results in
signs and symptoms like abdominal pain and heartburn. Those three factors irritate the mucosal
layer and will lead to further damage and weakening of the mucosal barrier. Excessive production
of stomach acid can irritate the mucosal layer and eventually lead to ulcerations as hyperacidity
progresses. Ulcerations then progress to Peptic Ulcer Disease.
When the breakdown of the mucosal barrier will then lead to painful sores appearing on
the lower esophageal lining, which results in Esophageal Ulcers. Another type of peptic ulcer
happens when there is a decline in the function of the stomach mucus and results in the formation
of open sores in the stomach lining which will then lead to a Gastric Ulcer. Lastly, when the
duodenum's surface mucosa is disrupted, duodenal lesions develop in the surface part of the
duodenum lining, which results in what is known as a duodenal ulcer. Peptic ulcer disease is made
up of duodenal, esophageal, and stomach ulcers. As these ulcers worsen, they gradually cause
bleeding and hemorrhage, which lowers hemoglobin levels and the body's ability to carry oxygen.
These combine to create generalized, distinctive signs and symptoms. The person will experience
15
pain when they have ulcers, which are characterized by epigastric or abdominal pain. Melena and
hematemesis arise as a result of bleeding when the ulceration spreads to the layer of the stomach
called the muscularis, which contains blood vessels and muscle tissues. Moreover, progressive
bleeding leads to loss of appetite, a feeling of fullness, and unexplained weight loss. Scarring
arises from tissues recovering from ulcerations; whether this scarring thickens, particularly on the
pyloric sphincter, it may result in a blockage. If treated with certain medical management and
complying with medication the tissue in the lining of the stomach, esophagus, or duodenum that
causes peptic ulcers will restore and contributes to a good prognosis. However, if it is not treated
immediately this will eventually progress to hemorrhage and further ulcerations which will then
causes inflammation which decreases the tissue perfusion and leads to hypovolemic shock which
will cause death to the patient and contributes to a bad prognosis.
VI.
MEDICAL MANAGEMENT
A. DIAGNOSTIC EXAMS
TEST
RATIONALE
NURSING
RESPONSIBILITIES
Esophagogastroduoden
Upper GI Endoscopy is the golden Before the procedure:
●
oscopy
standard and remains the most
(Upper Gastrointestinal
accurate diagnostic test for PUD. A
fast and restrict fluids
Endoscopy)
test to observe the lining of the
for 6 to 8 hr prior to the
esophagus,
and
procedure to reduce
permits
the risk of aspiration
biopsies and cytology brushings in
related to nausea and
the presence of a gastric ulcer to
vomiting.
duodenum.
stomach,
This
also
distinguish a benign ulcer from a
●
Instruct the patient to
Instruct that the patient
malignant one. Through this exam,
may be required to be
gastric ulcers can be seen as
NPO after midnight.
discrete mucosal holes with a
●
The patient may be
punched-out regular ulcer base,
instructed to take a
often covered with whitish fibrinoid
laxative, an enema, or
exudate. (Cleveland Clinic, 2021)
a
rectal
laxative
suppository.
16
●
Instruct to avoid taking
natural products and
medications
with
known anticoagulant,
antiplatelet,
or
thrombolytic
properties or to reduce
dosage, as ordered,
prior to the procedure.
After the procedure:
●
Observe the patient's
vital
signs
for
any
unusualities.
●
If sedated, advise to
drink plenty of water to
help
eliminate
sedative
the
more
efficiently.
●
Instruct to ingest soft
foods and liquids such
as broth can enable
recovery with minimal
soreness and easier
swallowing.
Barium Contrast
Radiography
Barium X-rays are used to diagnose Before the procedure:
abnormalities of the GI tract, such
as
tumors,
ulcers
and
●
Instruct the patient to
other
eat a low-residue diet
inflammatory conditions, polyps,
for several days before
hernias, and strictures. Barium is a
the
dry, white, chalky powder that is
consume only clear
mixed with water to make barium
liquids during the 24 hr
procedure
and
17
liquid. It is an X-ray absorber and
appears white on X-ray film. When
before the procedure.
●
Advise
to
take
instilled into the GI tract, barium
laxative
coats
the
before the exam to
large
excrete excess waste
the
inside
esophagus,
wall
of
stomach,
intestine, and/or small intestine so
the
a
night
before the procedure.
that the inside wall lining, size,
shape, contour, and patency are After the procedure:
visible on X-ray. (John Hopkins
●
Medicine, 2023)
Advise to drink water
to cleanse the body
after undergoing the
procedure.
●
Monitor
for
any
casualties such as a
sudden drop in blood
pressure
and
fast
respiratory rate.
Testing for Helicobacter
pylori:
Stool antigen test
Helicobacter pylori are a common
cause of Peptic Ulcers. In this test, Before the procedure:
a stool sample is collected from the
●
patient to determine if H. pylori
antigens are present in the GI
Assess patient’s level
of comfort to defecate.
●
Encourage
to
drink
system. The sample is sent to the
plenty of liquids to
laboratory and added with a specific
facilitate
chemical and color developer. A
excretion.
presence of a blue color indicates
●
the presence of H. pylori antigens.
easier
Instruct to avoid eating
red meat and having a
diet high in residue.
The breath test is a simple and safe
test that detects active H. pylori
infection
Urea breath test
enzymatic
by
testing
activity
of
for
the
bacterial
●
Instruct
to
maintain
NPO at least 3 hours
18
urease. The test is done by drinking
a special liquid substance called
before the test.
●
Advise that they may
urea. The patient will be breathing
brush their teeth and
or exhaling into a bag and will be
rinse,
sent to the laboratory for testing.
swallow water.
but
do
not
The rapid urease test (RUT), also
known
as
the
CLO
test
(Campylobacter-like organism test),
is a popular diagnostic test that
Rapid urease test
●
Advise to not have a
detects the presence of urease in or
second
on the gastric mucosa. Through
breath test within 2
endoscopic
days of your first test.
mucosal
biopsy,
14C
urea
presence of H. pylori may be
obtained;
the
test
involves After the procedures:
incubating a gastric biopsy sample
●
Encourage patient to
in a urea broth that contains pH
maintain
indicator phenol red
hygiene such as hand
(Cleveland Clinic, 2021)
washing.
●
proper
Drink plenty of water
every
after
the
procedure to replenish
the body’s loss.
Serology
Serologic tests are blood tests that After the procedure:
look for antibodies in the blood. The
●
Advice
to
increase
test has a high specificity and
fluid
intake
sensitivity. The test relating to
rehydrate the body.
to
peptic ulcer disease is useful in
detecting a newly infected patient
but not a reliable test for a follow-up
test of treated patients because
19
results may not indicate recent
infection of the bacteria. (Mayo
Clinic, 2023)
B. MEDS
1. Proton pump inhibitors (PPIs)
-
PPIs directly suppress gastric acid production by blocking the proton pumps of the gastric
parietal cell that is responsible for acid secretion, and thereby promoting the ulcer healing.
Their effect on suppressing gastric acid production is stronger than that of Histamine-2
receptor antagonists.
GENERIC NAME
Esomeprazole
BRAND NAME
Nexium, Prosome, Esoget, Esotaz-40
DRUG CLASSIFICATION
Proton pump inhibitors, Anti-ulcers
SUGGESTED DOSE
Peptic Ulcer Disease (Helicobacter pylori)
PO: Adult 40 mg b.i.d. for 2 wk in combination
therapy for 10-14 d
Duodenal Ulcer
PO: Adult 15 mg/d for 4 wk
ROUTE OF
PO
ADMINISTRATION
MODE OF ACTION
Esomeprazole works by binding irreversibly to the H+/K+
ATPase in the proton pump. Because the proton pump is the
20
final pathway for secretion of hydrochloric acid by the parietal
cells in the stomach, its inhibition dramatically decreases the
secretion of hydrochloric acid into the stomach and alters gastric
pH.
INDICATION
Esomeprazole is indicated for the treatment of acid reflux
disorders including healing and maintenance of erosive
esophagitis, and symptomatic gastroesophageal reflux disease
(GERD), peptic ulcer disease, and duodenal ulcer
CONTRAINDICATION
- Hypersensitive to esomeprazole magnesium or other protonpump inhibitors
- Gastric Malignancy
- Pregnant (Category B)
- Lactating Mothers
SIDE EFFECTS
-
Dry
mouth
and
thirst,
Nausea,
Hiccups,
Diarrhea,
Constipation, Rash, Headache, Dizziness, Blurred vision,
Fatigue
ADVERSE EFFECTS
- CNS: Headache, dizziness, vertigo, insomnia
- GI: Nausea, vomiting, diarrhea, constipation, abdominal pain,
flatulence, dry mouth.
- Respiratory: Upper Respiratory Tract Infections, Cough
- Others: Elevated AST, ALT
DRUG INTERACTIONS
Drug-Drug
- May decrease theophylline levels; sucralfate decreases
lansoprazole bioavailability; may interfere with absorption of
ampicillin, ketoconazole, digoxin.
Drug-Food
- Food decreases peak levels (decreased absorption by up to
35%)
NURSING
RESPONSIBILITIES
1.
Assess for the mentioned contraindications to this drug
R: To prevent potential adverse effects.
21
2.
Before
initiating
comprehensive
pharmacological
physical
therapy,
a
should
be
examination
performed.
R: To determine effectiveness of therapy, and evaluate potential
adverse effects.
3. Assess for the patients’ neurological status
R: To determine potential CNS effects.
4. Assess for the cardiac status attentively
R: To determine whether change in drug dose is essential
5. Monitor laboratory test results including complete
blood count, renal and liver function tests
R: Some medications such as digoxin can interfere the
liver metabolism of esomeprazole.
6. Inspect and palpate the abdomen to determine potential
underlying medical conditions; assess for changes in
bowel elimination and GI upset
R: To decrease the risk of developing GI adverse effects
7. Administer the drug before meals. Ensure that the
patient swallows whole as indicated.
R: To ensure the therapeutic effectiveness of the drug.
8. Provide comfort and safety measures
R: To aid in patient’s well-being
9. Have emergency medications and equipment
at the bedside
R: To promote prompt treatment in cases of severe toxicity.
10. Monitor the patient for diarrhea or constipation
R: To administer proper bowel interventions as needed
2. Antacids
-
Antacids are drugs that relieve heartburn and indigestion by reducing the amount of acid
in your stomach. Antacids neutralize the acid in your stomach by stopping an enzyme that
creates acid to break down food for digestion (pepsin). This drug can also help lessen the
22
symptoms of stomach lining infection or gastritis and help lessen the appearance of
stomach ulcers.
GENERIC NAME
Aluminum Hydroxide
BRAND NAME
AlternaGEL, Amphojel, and Nephrox
DRUG CLASSIFICATION
Antacids
SUGGESTED DOSE
Oral suspension:
5-30 mL between meals and at bedtime or as directed
Peptic Ulcer Disease
5-30 mL between meals and at bedtime or as directed
Hyperphosphatemia
Adult: 300-600 mg orally 3 times/day between meals and at
bedtime
ROUTE
OF PO
ADMINISTRATION
MODE OF ACTION
Acts by neutralizing hydrochloric acid in gastric secretions.
Aluminum hydroxide is slowly solubilized in the stomach and
reacts with hydrochloric acid to form aluminum chloride and
water. It also inhibits the action of pepsin by increasing the pH
and via adsorption.
INDICATION
- Relieves heartburn, acid indigestion, and upset stomach. They
may be used to treat these symptoms in patients with peptic
ulcer, gastritis, esophagitis, hiatal hernia, or too much acid in the
stomach (gastric hyperacidity).
23
CONTRAINDICATION
- Hypophosphatemia, Diarrhea, Neonates, renal disease, renal
failure, renal impairment, Ascites, heart failure, hepatic disease,
Geriatric, Pregnancy
SIDE EFFECTS
-
Nausea,
Vomiting,
Rebound
hyperacidity,
Aluminum-
intoxication, Hypophosphatemia, Chalky taste, Constipation
(this could lead to hemorrhoids or bowel obstruction), Stomach
cramps
ADVERSE EFFECTS
- Black/tarry stools, Mental/mood changes (e.g., confusion,
deep sleep), Pain with urination, Stomach/abdominal pain,
Vomit that looks like coffee grounds
DRUG INTERACTIONS
Drug-drug
-
Acetaminophen: Antacids can delay the oral absorption
of acetaminophen
-
Allopurinol: Aluminum hydroxide decreases the oral
bioavailability of allopurinol
-
Captopril: Antacids can decrease the GI absorption of
captopril if administered simultaneously
NURSING
RESPONSIBILITIES
1. Assess vital signs before and after drug administration
R: This is to watch out for any adverse effects that may occur
2. Educate to shake the suspension well before use
R: To ensure proper dosage is administered
3. Advise to take medication after meals and at bedtime
R: Intake on an empty stomach may cause stomach cramps
4. Encourage to intake drug with water
R: To avoid the the chalky taste of the drug
5. Advise to not Aluminium Hydroxide drug along with other
drugs
R: This to ensure adequate absorption of other medications
6. Monitor periodic serum calcium and phosphorus levels
R: Prolonged use may cause impaired renal function
7. Advise to increase phosphorus in diet if prolonged use
24
of drug occurs
R: Hypophosphatemia can develop within 2 weeks of
continuous use of these antacids.
8. Monitor number and consistency of stools.
R: Constipation is common and dose related. Intestinal
obstruction from fecal concretions may occur
9. Administer an appropriate bowel program
R: Constipation and speckled or whitish stools may appear
10. Provide comfort measures and safety
R: To ensure patient’s well-being
3. Histamine-2 receptor antagonists
-
Histamine-2 receptor antagonists, also known as H2-blockers, suppress the secretion of
gastric acid by blocking the actions of histamine, a protein produced by the body that
stimulates gastric acid secretion. They are also used to treat gastric ulcers and for some
conditions, such as Zollinger-Ellison disease, in which the stomach produces too much
acid.
GENERIC NAME
Ranitidine
BRAND NAME
Zantac
DRUG CLASSIFICATION
Antiulcer, Histamine H2 antagonists
SUGGESTED DOSE
Gastric Ulcer
- Treatment: 150 mg orally every 6 hours or 50 mg
intramuscular/intravenously every 6-8
hours intermittent bolus or infusion;
25
alternatively, 6.25 mg/hours intravenously by continuous
infusion
- Maintenance of healing: 150 mg orally every
12 hours
ROUTE
OF PO
ADMINISTRATION
MODE OF ACTION
Inhibits the action of histamine at the H2 receptor site located
primarily in gastric parietal cells resulting in inhibition of gastric
acid secretion. In addition, healing and prevention of ulcers.
INDICATION
- Short term treatment of active duodenal ulcers
and benign gastric ulcers.
- Management of GERD
- Treatment and prevention of heartburn, acid
indigestion, and sour stomach
- Management of gastric hypersecretory states
CONTRAINDICATION
- Hypersensitivity to ranitidine or other components of the drug.
- Some products contain aspartame and should be avoided in
patients with phenylketonuria.
SIDE EFFECTS
- Nausea, headache, abdominal pain, diarrhea, dizziness, hair
loss, confusion, constipation, vomiting, anemia
ADVERSE EFFECTS
- CNS: drowsiness and hallucinations
- CV: arrhythmias
- GU: decreased sperm count, impotence
- ENDO: gynecomastia
- HEMATO: agranulocytosis, aplastic anemia,
neutropenia, thrombocytopenia
- LOCAL: Pain at IM site
- Hypersensitivity reactions, vasculitis
DRUG INTERACTIONS
Drug-Drug
26
- Atazanavir and Delavirdine Drug absorption may be impaired
- Gefitinib: Gefitinib exposure is reduced when used with
ranitidine
- Midazolam: Oral midazolam increases when
used with ranitidine and may cause excessive
and prolonged sedation.
- Procainamide: Higher doses of ranitidine (>
300 milligrams/day) may increase plasma
levels of this drug and in rare cases may
cause toxicity.
- Triazolam: Oral triazolam increases when
used with ranitidine and may cause excessive
or prolonged sedation.
- Warfarin: Ranitidine may affect warfarin’s
effectiveness.
NURSING
RESPONSIBILITIES
1. Assess heart rate, ECG, and heart sounds
R: Any rhythm disturbances or symptoms of
increased arrhythmias, should be reported right away
2. Monitor signs of hypersensitivity reactions, including
pulmonary symptoms or skin reactions
R: Notify the doctor immediately
3. Assess for side effects such as fatigue, weakness,
muscle pain, numbness, fever, loss of appetite, and
weight loss
R: These could be adverse effects of the drug
4. Assess dizziness and drowsiness that might affect gait,
balance, and other functional activities
R: Report balance problems and functional
limitations to the physician and nursing staff
5.
Monitor other CNS symptoms such as confusion,
hallucinations, and headache
R: Excessive or prolonged CNS symptoms
27
may require a reduction in dose
6. Encourage adequate fluid intake
R: Increased fluid intake helps improve bowel function
7. Advise increase in fiber intake
R: Fiber intake helps with constipation
8. Advise patients to avoid alcohol.
R: Alcohol in ranitidine may be contraindicated to some patients
and may increase GI irritation.
9. Advise patient to avoid smoking or any exposure to
tobacco chemicals
R: Smoking interferes with the action of
histamine antagonists
10. Educate family member to report any side effects
immediately
R: Immediate interventions helps reduce the risk for further
complications
4. Cytoprotective agents
-
Cytoprotective agents stimulate mucus production and enhance blood flow throughout the
lining of the gastrointestinal tract. These agents also work by forming a coating that
protects the ulcerated tissue. Cytoprotective agents help protect the tissues that line your
stomach and small intestine.
GENERIC NAME
Misoprostol
BRAND NAME
Cytotec
DRUG CLASSIFICATION
Prostaglandin, Antisecretory, gastric protectant
28
SUGGESTED DOSE
For prophylaxis of NSAID-induced ulcers
Adults: 200 mcg PO 2 to 4 times a day with
food; if not tolerated, decrease to 100mcg PO
q.i.d.
For gastric and duodenal ulcers, NSAID associated
ulceration
Adults: 800mg daily in 2 to 4 divided
doses for at least four weeks even if
symptoms are relieved sooner.
ROUTE
OF PO
ADMINISTRATION
MODE OF ACTION
Misoprostol is a synthetic prostaglandin E1 analog that inhibits
basal and nocturnal gastric acid secretion through direct
stimulation of prostaglandin E1 receptors on parietal cells in the
stomach
INDICATION
- Ulcer
- Prevents NSAID-induced gastric ulcer
- For those at high risk for developing gastric
ulcer/ gastric complications
- Medical termination of intrauterine pregnancy
- Cervical ripening
- Labor induction
- Treatment/prevention of postpartum
hemorrhage
- Treatment of incomplete or missed abortion
CONTRAINDICATION
- Hypersensitivity to prostaglandin
- Pregnancy when used to reduce NSAID induced ulcers
- Inflammatory bowel disease
SIDE EFFECTS
- Diarrhea, abdominal pain, vomiting, constipation, headache,
nausea, flatulence, dyspepsia
29
ADVERSE EFFECTS
- Tremor, seizures, dyspnea, palpitations,
hypotension, bradycardia
DRUG INTERACTIONS
Drug-Drug
- Antacids may increase concentration
Drug-Food
- Any food: May decrease the absorption rate of drug
NURSING
1. Assess vital signs especially blood pressure for
RESPONSIBILITIES
hypotension
R: When hypotension is severe, it may cause
severe symptoms when taking the drug
2. Assess the female patient if pregnant or has plans to
become pregnant.
R:
R: The drug induces uterine contractions, It may cause
miscarriage, premature birth, or congenital disabilities if it is
taken during pregnancy
3. Administer drug with or after meals.
R: Intake with food will help prevent loose
stools, diarrhea, and abdominal cramping, which is a
common side effect of misoprostol
4. Advise to advise administering with magnesiumcontaining antacids
R: This is to minimize the potential for diarrhea
5. Inform patient of taking the drug at the same time with
NSAID
R: To prevent NSAID-induced gastric ulcers, the drug must be
continued as long as NSAIDs are taken
6. Inform the client about the common side effects of the
medicine
R: This is for the patient to anticipate the untoward symptoms
and provide assurance
7. Monitor improvement of Gastrointestinal symptoms
R: This is to know and help document if the drug effectively
30
prevents gastric damage or duodenal
ulcers
8. Educate about using caution to the patient with
kidney disease
R: Since the effects may increase because of the slower
removal of the medicine from the body
9. Instruct patient to avoid intake of alcohol.
R: Some drinks and food may increase gastric irritation,
worsening symptoms
10. Educate the patient about not taking for a longer
time intended by the physician
R: This is to achieve a safe and maximum effect of the medicine.
Also, long term use of the drug may increase unwanted effects
C. TREATMENT
THERAPY
Medications
RATIONALE
NURSING RESPONSIBILITIES
Treatment will depend on the Before the procedure:
underlying cause of your ulcer.
●
Instruct patient to take the
Several different medication
proper dosage, and process
therapies are available to help
of
reduce gastric acid and coat
prescribed by their doctor or
the ulcers. If tests show that
physician.
you have an H. pylori infection,
●
the
medications
Educate to not take drugs all
your doctor will prescribe a
at once or together with
combination
other drugs as this may
The
of
medication.
medications
include
lessen the effect of the
antibiotics to help kill infections
prescribed drug or it may
and
cause
proton
pump
inhibitors(PPIs) to help reduce
stomach
acid.
Another
severe
adverse
effects.
is
31
Bismuth,
this
medication After the procedure:
covers the ulcer and protects it
●
Advice on proper bed rest
from stomach acid. It can also
after
intake
of
help kill H. pylori infections
medications
(Rogers, 2020)
proper absorption of the
to
the
facilitate
drug.
Antisecretory therapy
with a proton pump
inhibitor (PPI)
Proton pump inhibitors (PPIs) Before the procedure:
effectively block gastric acid
secretion
by
●
Instruct to take medication
irreversibly
before meals to ensure that
binding to and inhibiting the
the patient does not open,
hydrogen-potassium ATPase
chew, or crush capsules;
pump that resides on the
they should be swallowed
luminal surface of the parietal
whole
cell membrane. PPIs are first-
therapeutic effectiveness of
line antisecretory therapy in
the drug.
to
ensure
the
the treatment of peptic ulcer
disease. (UpToDate, 2023)
After the procedure:
●
Monitor
Vital
signs
especially cardiac rate for
tachycardia
and
other
unusualities.
VII.
SURGICAL MANAGEMENT
PROCEDURE
Vagotomy
RATIONALE
This
surgical
NURSING RESPONSIBILITIES
procedure Before the procedure:
requires removing a part or all of
●
Educate
client
on
the
the vagus nerve. This is used to
procedure itself to lessen
aid in treating stomach ulcers
anxiety and uncertainty.
due to H. pylori infection and
32
erosion from stomach acid. The
●
Instruct that abdominal hair
procedure is usually done in
is removed with clippers in
conjunction
the preoperative area.
with
procedures
other
such
as
pyloroplasty, where the pylorus After the procedure:
is widened to help control the
●
Keep the wound clean and
movement of partially digested
dry. The dressing should
food and juiced into the small
be removed and wounds
intestine.
covered
(Cleveland
Clinic,
2023)
with
adhesive
bandages on the first or
second day after surgery.
Do not remove the paper
strips or cut any of the
visible sutures.
●
Administer
pain
medications as ordered by
the physician.
●
Monitor patients vital signs
for any unusualities
Gastrectomy
Gastrectomy may come in two Before the procedure:
kinds:
total
and
partial
●
Advise to not eat or drink
gastrectomy. Both gastrectomy
anything after midnight the
procedures are indicated for
night before your surgery.
patients
with
peptic
ulcer
●
Advise to not ingest any
disease that have failed to
drugs that make it difficult
respond
or
for your blood to clot (ex.
with
gastric
aspirin, ibuprofen, vitamin
A
partial
E, warfarin.
to
individuals
malignancies.
therapy
gastrectomy is mainly done
since a small region of the After the procedure:
stomach will be resected to
remove the gastric ulcer. On the
●
Administer
killers
until
regular
the
pain
patient
33
other hand, total gastrectomy is
recovers
the procedure where the entire
discharged.
stomach is removed, and the
●
and
will
be
Advise patients that they
esophagus is directly connected
are allowed to drink water 6
to the small intestine to continue
hours after surgery.
digestion.
(Penn
Medicine,
●
2023)
Provide a relaxing and
noise-free environment to
aid in uninterrupted rest.
Graham’s Omental
Patch
Graham patch is a technique Before the procedure:
where a patch of omentum, a
●
Educate the client on the
fatty tissue that normally covers
process of the surgery to
the stomach and intestines, is
lessen
used to cover the perforation.
uncertainty.
The technique can be done with
an
open
laparotomy
●
their
fear
and
Advice to maintain an NPO
or
after midnight before the
laparoscopically. Three or four
surgery to avoid any gastric
interrupted sutures are inserted
complications during the
through and through the axis.
procedure.
Both approaches are within the
standard of care, yet it still After the procedure:
depends on the experience of
●
Assess the operation site
the surgeon and the condition of
for any unusualities such
the patient. (Cleveland Clinic,
as swelling and pus.
2023)
●
Instruct patient to take a
few sips of water from time
to time to replenish fluids
lost during the surgery.
●
Monitor for any adverse
effects
and
and
unusualities
administer
pain
medication as prescribed
VIII.
NURSING MANAGEMENT
34
NURSING DIAGNOSIS
GOAL
INTERVENTION
Acute pain related to the effect Within 1 hour of nursing
1. Administer prescribed
of gastric acid secretion on intervention the patient will
medications
damaged tissue as evidenced demonstrate relief of pain as
alleviate the symptoms
by pain score of 8 out of 10, evidenced by:
of heartburn/ stomach
verbalization of chest pain or
heartburn
guarding
after
sign
eating,
on
the
abdomen.
a. verbalization
comfort
decrease
of
and
that
pain.
a Rationale: Antibiotics such as
in
the amoxicillin can kill H pylori.
intensity level of pain Antacids
are
helpful
in
less than 2 to 4 on a neutralizing stomach acid. H2Rationale:
occur
Peptic
when
acid
ulcers
in
inner
surface
receptor blockers reduce the
the
digestive tract eats away at
the
scale of 0 to 10.
of
the
stomach or small intestine.
production of stomach acid.
b. Exhibit
stable
vital Proton- pump inhibitors work
signs, and absence of by reducing the amount of
guarding behavior.
stomach acid.
The acid can create a painful
open sore that may bleed.
2. Assess the patient's
Your digestive tract is coated
vital
signs
and
with a mucous layer that
characteristics of pain
normally protects against acid.
at least 30 minutes
after administration of
Reference:
(2020).
Mayo
Peptic
Clinic
Ulcer.
medication.
Rationale:
To
monitor
of
medical
Retrieved on February 13,
effectiveness
2022
treatment for the relief of
from
https://www.mayoclinic.org/di
heartburn and stomach pain.
seases-
The time of monitoring of vital
conditions/peptic-
ulcer/symptoms- causes/syc-
signs may depend on the peak
time of the drug administered.
3. Teach the patient on
35
how to perform nonpharmacological pain
relief methods such as
deep
breathing,
massage,
acupressure,
biofeedback,
distraction,
music
therapy. and guided
imagery.
Rationale: To reduce stress
levels, thereby relieving the
symptoms
of
peptic
ulcer
disease, especially stomach
pain and heartburn.
4. Encourage the patient
to assume a position of
comfort
Rationale:
Reduces
abdominal
tension
and
promotes a sense of control
5. Encourage the patient
to follow appropriate
mealtimes and meal
portions.
Rationale: To ensure that the
patient does not eat a huge
meal, or that he/she does not
eat
late
at
night/
before
bedtime as both of these may
trigger nausea/vomiting.
36
6. Instruct the patient to
avoid
aspirin,
ibuprofen, naproxen or
any
NSAIDS
medication.
Rationale:
These
medications
irritation
of
may
cause
the
gastric
mucosa.
7. Encourage the patient
to Increase oral fluid
Intake
unless
contraindicated.
Rationale: Fluid intake helps
dilute the acid in the stomach
which may aggravate the pain.
8. Inform the patient to
avold
spicy,
fried,
caffeinated, or acidic
foods.
Rationale:
Gastric
acid
secretion may be stimulated
by these types of food and
may worsen the ulcerations in
the stomach lining
9. Advice the patient to
include
probiotic
in
regular diet like yogurt,
banana,
watermelon,beans
37
carrots,
cucumber,
and green
Rationale: to help restore the
natural bacteria in the GI tract.
10. Inform the patient to
limit
or
avoid
the
aggravating factors of
the
pain
such
stress,
as
alcohol,
smoking, etc.
Rationale:
increase
The
the
factors
risk
for
complications and may hinder
the effectiveness of the drug
therapy.
Imbalanced
than
Nutrition:
Body
Less Within 8 hours of nursing
1. Create a daily weight
Requirements intervention the patient will
chart and a food and
related to insufficient dietary demonstrate maintenance of
fluid
intake
by nutritional requirements, and
with the patient the
pain, absence of complications as
short term and long-
burning
as
evidenced
stomach
chart.
Discuss
bloating, weight loss of 10 evidenced by:
term
pounds, nausea and vomiting,
weight goals related to
loss of appetite, heartburn.
a. verbalization
of
nutrition
and
peptic ulcer disease.
selection of foods or Rationale:
To
effectively
Rationale: Many people with
meals that will achieve monitor the patient's daily
peptic
a cessation of weight nutritional intake and progress
ulcers
particularly
complain of pain on an empty
loss.
in weight goals.
stomach. You may experience
relief immediately after eating
b. demonstrating healthy
only to have pain return or
eating
worsen within an hour. This
choices.
patterns
and
2. Help the patient to
select
dietary
appropriate
choices
to
38
brief reprieve does not cause
avoid spicy foods and
people with ulcers to overeat,
limit alcohol and coffee
however, as frequent nausea
intake.
and discomfort can quash
Rationale: To promote ulcer
appetite or the desire to eat.
healing
Some people feel that certain
habits. Caffeine is a stimulant
foods (like high-fat choices)
of gastric acid production.
make peptic ulcer symptoms
Decaffeinated coffee or tea
worse,
can still stimulate gastric acid
while
other
foods
soothe an ulcer. You can
and
healthy
food
secretion.
become deficient in vitamins
and minerals due to low food
intake. Immune deficiencies,
3. Refer the patient to the
dietitian.
bone weakness, and skin
Rationale: To provide a more
fragility can all result from
specialized care for the patient
malnutrition, but may not be
in terms of nutrition and diet in
noticeable at first.
relation to newly diagnosed
peptic ulcer disease.
Reference: Gillson, S. (2022,
June 7). Stomach (Peptic)
Ulcers:
Symptoms
Complications.
and
Verywell
Health.
4. Administer
the
prescribed
medications for peptic
ulcer disease.
https://www.verywellhealth.co
Rationale:
To
reduce
m/symptoms-of-peptic-ulcers-
stomach acid production or
1741794
neutralize the stomach acid,
relieving the burning stomach
pain and helping the patient to
have a better appetite.
5. Monitor
values
laboratory
for
serum
albumin.
39
Rationale: This test indicates
the degree of protein depletion
(2.5 g/dL indicates severe
depletion; 3.8 to 4.5 g/dL is
normal).
6. Instruct
in
the
importance
of
abstaining
from
excessive alcohol.
Rationale:
Alcohol
causes
gastric irritation and increases
gastric pain
7. Encourage the client to
limit
the
intake
of
caffeinated beverages
such
as
tea
and
coffee.
Rationale:
Caffeine
stimulates the secretion of
gastric acid. Coffee, even if
decaffeinated,
contains
a
peptide that stimulates the
release
of
gastrin
and
increases acid production.
8. Provide
good
oral
hygiene and dentition.
Rationale: Oral hygiene has a
positive effect on appetite and
on the taste of food. Dentures
need to be clean, fit
40
comfortably, and be in the
patient's mouth to encourage
eating.
9. Provide
a
pleasant
environment.
Rationale:
A
atmosphere
pleasing
helps
in
decreasing stress and is more
favorable to eating.
10. Teach
about
the
importance of eating a
balanced
meals
diet
at
with
regular
intervals.
Rationale: Specific dietary
restrictions are no longer part
of the treatment for PUD.
During the symptomatic phase
of an ulcer the client may find
benefit
from
meals
at
eating
more
small
frequent
intervals.
Anxiety related to the nature of Within 8 hours of nursing
the
disease secondary
peptic
ulcer
disease
1. Evaluate the client's
to intervention the patient will will
psychological
and
as demonstrate ways of reducing
physiological
status
evidenced by verbal reports of anxiety level as evidenced by:
fear and worry.
and level of anxiety.
Rationale: People suffering
a. verbalize
which from Peptic ulcer disease
Rationale: Clients with peptic
stressors most likely experience
ulcers are anxious, but their
affect
them,
anxiousness,
and though the level
of
their
41
anxiety level is not visible.
explore
Mental health problems such
habits can help them manifested. Encourage the
as stress, depression, and
to
suicidal ideation were closely
stressors.
correlated with PUD. These
what
overcome
daily anxiety
is
those client
to
not
open
usually
up
their
thoughts and ensure to them
b. exhibit coping patterns that we welcome them if they
psychological problems were
effectively
with
the do have any questions. Be
found to be associated with
modality of available patient in explaining to them
PUD. Individuals under severe
treatment,
stress or with a depressed
pharmacologic
mood might be more likely to
non-pharmacologic
develop PUD.
methods
the important details because
and they tend to be sensitive
because of fear.
2. Recognize
the
Reference: Lee, Y. H., Yu, J.,
understanding of the
Moon, J. H., Jeon, B., Kim, H.,
client's anxiety.
Kim, S., Kim, S. W., Park, Y.
Rationale:
Recognize
B., & Chae, H. S. (2020). The
client's feelings, be attentive in
association between peptic
listening to what they share. It
ulcer diseases and mental
develops the feeling of trust
health problems. Medicine,
and acceptance between the
96(34),
e7828.
client and healthcare provider.
https://doi.org/10.1097/md.00
This may help the client to
00000000007828
acknowledge anxiety and fear.
3. Give
support
the
by
allowing the client to
verbalize their fears
and concerns freely.
Rationale: Sustain a trustful
relationship with the client as
they
express
themselves
gives assurance that they can
speak up openly It gives
comfort
and
relieves
42
uneasiness
that
helps
in
reducing anxiety and stress
levels.
4. Communicate
simple
using
language,
easily
understood
statements
when
giving direction to the
client.
Rationale:
experiencing
Clients
moderate
to
severe anxiety may not be
able to understand statements
that are complex, vague, and
even lengthy instructions. The
right choice of words is also
necessary so we can catch
their interest and also avoid
their thoughts being triggered.
5. Maintain a calm and
quiet environment to
minimize
stressors
and stimuli.
Rationale: External stimuli
may escalate anxiety to panic
attacks
such
as
a noisy
environment. Avoid noise, too
loud
conversation,
and
equipment around the client.
In
dealing
with
clients,
establishing a non-threatening
43
environment
develops
security and peace for them. It
will help to put the client at
ease.
6. Ensure
emotional
support to the client.
Rationale:
Extending
emotional support to the client
will
provide
relaxing
a
calm
and
feeling
that
may
brighten up their mood and
ease their stress and anxiety.
Strong
emotional
support
offers unconditional comfort
measures. Promote wellness,
keep them: reminded with the
positive coping strategies, and
refrain from triggers.
7. Help the patient in
developing techniques
that
reduce
anxiety
and
stress
levels
management
strategies.
These
measures
include
biofeedback, positive
imagery, and behavior
modification.
Rationale:
Aside
pharmacological
from
treatments,
there are also nonchemical
44
ways that are effective in
dealing with anxiety. Learning
and with a regular habit of
practicing these techniques
provide confidence to the
client in overcoming anxiety.
8. Explain
reasons
for
planned
treatment
schedule,
such
as
Pharmacotherapy,
dietary
restrictions,
modification of activity
levels, reduce or stop
smoking.
Rationale:
Knowledge
reduces anxiety appears to be
a
sense of
ignorance.
fear
due
Knowledge
to
can
have a positive effect on
behavior change.
9. Assess
for
the
Influence of cultural
beliefs, and the norms,
values on a patient's
perspective
of
a
stressful situation.
Rationale: What the patient
considers stressful may be
based on cultural perceptions.
45
IX.
LITERATURE
Medicinal Plants with Prospective Benefits in the Management of Peptic Ulcer Diseases
in Ghana (Boakye-Yiadom et al., 2021)
Boakye-Yiadom, M., Kumadoh, D., Adase, E., & Woode, E. (2021). Medicinal Plants with
Prospective Benefits in the Management of Peptic Ulcer Diseases in Ghana. BioMed Research
International, 2021, 1–14. https://doi.org/10.1155/2021/5574041
The growth or multiplication of harmful microorganisms in addition to harmful human
activities has led to many disorders in humans. Consequently, there is a search for medications
to treat these disorders. Interestingly, medicines of plant origin are known to be among the most
attractive sources of new drugs and have shown promising results in the treatment of various
diseases including peptic ulcers. This review, therefore, is aimed at obtaining knowledge on some
Ghanaian ethnomedicinal plants used to treat peptic ulcers, their folkloric uses, their
phytochemicals, and their antiulcer and related pharmacological activities as well as finding areas
for prospective studies.Methods. Published peer-reviewed articles on ethnomedicinal plants used
for the management of peptic ulcers in Ghana from 1967 to 2020 were sourced and used for the
study. Results. In this review, 13 plants were identified which belong to 10 different families
including Sapindaceae, Apocynaceae, and Bignoniaceae. The parts most often used for most
preparations were the leaves (53%), followed by stem bark and roots (both having the same
percentage of use of 17.6%), the whole plant (5.9%), and the rhizomes (5.9%). Azadirachta indica
was the only plant that had undergone some patient studies in addition to animal studies.
Conclusion. A discussion of various antiulcer activity studies using ulcer models carried out on
selected medicinal plants used for the management of peptic ulcer disease in addition to brief
information on their folkloric uses and their phytochemical and other pharmacological properties
is presented. These medicinal plants may be used in developing herbal products for the
management of peptic ulcer disease.
Evidence-based clinical practice guidelines for peptic ulcer disease 2020 (Kamada et al.,
2021)
Kamada, T., Satoh, K., Itoh, T., Ito, M., Iwamoto, J., Okimoto, T., Kanno, T., Sugimoto,
M., Chiba, T., Nomura, S., Mieda, M., Hiraishi, H., Yoshino, J., Takagi, A., Watanabe, S.,
& Koike, K. (2021). Evidence-based clinical practice guidelines for peptic ulcer disease
2020. Journal of Gastroenterology, 56(4), 303–322. https://doi.org/10.1007/s00535-02101769-0
46
The Japanese Society of Gastroenterology (JSGE) revised the third edition of evidencebased clinical practice guidelines for peptic ulcer disease in 2020 and created an English version.
The revised guidelines consist of nine items: epidemiology, hemorrhagic gastric and duodenal
ulcers, Helicobacter pylori (H. pylori) eradication therapy, non-eradication therapy, drug-induced
ulcers, non-H. pylori, and nonsteroidal anti-inflammatory drug (NSAID) ulcers, remnant gastric
ulcers, surgical treatment, and conservative therapy for perforation and stenosis. Therapeutic
algorithms for the treatment of peptic ulcers differ based on ulcer complications. In patients with
NSAID-induced ulcers, NSAIDs are discontinued and anti-ulcer therapy is administered. If
NSAIDs cannot be discontinued, the ulcer is treated with proton pump inhibitors (PPIs).
Vonoprazan (VPZ) with antibiotics is recommended as the first-line treatment for H. pylori
eradication, and PPIs or VPZ with antibiotics is recommended as a second-line therapy. Patients
who do not use NSAIDs and are H. pylori negative are considered to have idiopathic peptic ulcers.
Algorithms for the prevention of NSAID- and low-dose aspirin (LDA)-related ulcers are presented
in this guideline. These algorithms differ based on the concomitant use of LDA or NSAIDs and
ulcer history or hemorrhagic ulcer history. In patients with a history of ulcers receiving NSAID
therapy, PPIs with or without celecoxib are recommended and the administration of VPZ is
suggested for the prevention of ulcer recurrence. In patients with a history of ulcers receiving LDA
therapy, PPIs or VPZ are recommended and the administration of a histamine 2-receptor
antagonist is suggested for the prevention of ulcer recurrence.
Current Status and Future Perspective of Artificial Intelligence in the Management of
Peptic Ulcer Bleeding: A Review of Recent Literature (Yen et al., 2021)
Yen, H., Wu, P. Y., Chen, M., Lin, W., Tsai, C., & Lin, K. (2021). Current Status and
Future Perspective of Artificial Intelligence in the Management of Peptic Ulcer Bleeding:
A Review of Recent Literature. Journal of Clinical Medicine, 10(16), 3527.
https://doi.org/10.3390/jcm10163527 [Original source:
https://studycrumb.com/alphabetizer]
With the decreasing incidence of peptic ulcer bleeding (PUB) over the past two decades,
the clinician experience of managing patients with PUB has also declined, especially for young
endoscopists. A patient with PUB management requires collaborative care involving the
emergency department, gastroenterologist, radiologist, and surgeon, from initial assessment to
hospital discharge. The application of artificial intelligence (AI) methods has remarkably improved
47
people’s lives. In particular, AI systems have shown great potential in many areas of
gastroenterology to increase human performance. Colonoscopy polyp detection or diagnosis by
an AI system was recently introduced for commercial use to improve endoscopist performance.
Although PUB is a longstanding health problem, these newly introduced AI technologies may soon
impact endoscopists’ clinical practice by improving the quality of care for these patients. To update
the current status of AI application in PUB, we reviewed recent relevant literature and provided
future perspectives that are required to integrate such AI tools into real-world practice. Patients
with PUB, which is a longstanding health problem, may achieve improved care management
through a new approach using AI techniques. However, with the declining PUB incidence and
clinician experience, further research is needed to apply these techniques in daily treatment
practice.
48
GASTROESOPHAGEAL REFLUX DISEASE
I.
DEFINITION
The term “gastroesophageal” refers to stomach and esophagus. Reflux means to flow
back or return. Gastroesophageal reflux is when what’s in your stomach flows back into your
esophagus. In normal digestion, your lower esophageal sphincter (LES) opens to allow food into
your stomach. Then it will close to stop food and acidic stomach juices from flowing back into your
esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes when it shouldn’t.
This lets the stomach's contents flow up into the esophagus (WebMD, 2022). It’s important to note
that there’s a very real distinction between occasional heartburn (which may not need medical
intervention), and GERD. Most people experience heartburn from time to time, and in general,
occasional heartburn isn’t a cause for concern. But if you’ve been experiencing heartburn more
than twice a week, and especially if you’ve also been experiencing a chronic cough and chest
pain, you might be dealing with GERD (DiGiacinto, 2021).
II.
ANATOMY/ PHYSIOLOGY
49
The organs that take in food and liquids and break them down into substances that the
body uses for energy, growth, and tissue repair. Waste products the body can’t use leaves the
body through bowel movements. The digestive system consists of the mouth, pharynx (throat),
esophagus, stomach, small intestine, large intestine, rectum, and anus. It also includes the
salivary glands, liver, gallbladder, and pancreas, which create digestive juices and enzymes that
help the body digest food and liquids. Also called gastrointestinal system.
Mouth
Mouth, also called buccal cavity or oral cavity, in human anatomy, orifice through which
the food and air enter the body. The mouth opens to the outside at the lips and empties into the
throat at the back; its borders are defined by the lips, cheeks, hard and soft palates, and glottis. It
is divided into two sections: the vestibule, the part between the cheeks and the teeth, and the oral
cavity proper. The latter section is mostly occupied by the tongue, a large muscle firmly anchored
to the floor of the mouth by the frenulum linguae. In addition to its primary role in the intake and
initial digestion of food, the mouth and its structures are important in humans to the formation of
speech. If stomach acid goes into your esophagus, you may experience heartburn and belching.
If it goes higher into your throat, you may experience hoarseness and sore throat. And if it gets
into your mouth, you’ll notice a bitter taste in your mouth, and you may have a cough. If it happens
a lot, it may wear down your tooth enamel or deteriorate the symptoms of asthma.
50
Esophagus
The core functions of the esophagus are to transport food and fluids from the pharynx to
the stomach, prevent the passive diffusion of substances from the food into the blood and to
prevent the reflux of gastric contents into the esophagus. Food is transported starting from the
pharynx to the stomach by a coordinated peristaltic contraction initiated in the upper esophagus,
which temporally trails a descending wave of inhibition. The control of the LES is critical to
esophageal function. Maintenance of sphincter tone is necessary to prevent the reflux of gastric
contents, which are under positive pressure relative to the esophagus due to their position in the
peritoneal cavity. Acid reflux happens because a valve at the end of your esophagus, the lower
esophageal sphincter, doesn’t close properly when food arrives at your stomach. Acid backwash
then flows back up through your esophagus into your throat and mouth, giving you a sour taste.
Stomach
The stomach is one of the important organs and the most dilated portion of the digestive
system. The esophagus comes first, and the small intestine follows. It is a large, muscular, and
hollow organ permitting for a capacity to hold food. It comprises 4 main regions, the cardia, fundus,
body, and pylorus. The primary functions of the stomach include the temporary storing of food
51
and the partial chemical and mechanical digestion of food. The upper portions of the stomach
(cardia, body, and fundus) relax as food enters to permit the stomach to hold increasing quantities
of food. The lower portion of the stomach contracts in a rhythmic fashion (mechanical digestion)
to aid with the breaking down of food and it mixes with stomach juices (chemical digestion) which
also serve to break down food and prepare the mixture, termed chyme at this point of digestion,
for further digestion. GERD happens when the digestive acids and enzymes in your stomach don’t
want to stay in your stomach. Instead, they flow back up into your esophagus toward your mouth.
This is due to a band of muscle around the base of your esophagus called the lower esophageal
sphincter weakens and doesn’t seal properly.
Large Intestine
Your large intestine is around five feet or 1.5 meters long. The large intestine is much
bigger than the small intestine and takes a much straighter path through your belly, or abdomen.
The function of the large intestine is to absorb water and salts from the material that has not been
digested as food, and get rid of any waste products left over. By the time the food mixed with
digestive juices reaches your large intestine, most digestion and absorption has already taken
place.
Small Intestine
The small intestine is made up of three parts, which form a passage from your stomach
(the opening between your stomach and small intestine is called the pylorus) to your large
intestine. It is the duodenum, jejunum, and ileum. By the time the food reaches your small
intestine, it has already been broken up and mashed into a liquid form by your stomach. Each
day, your small intestine obtains between one and three gallons or six to twelve liters of this liquid.
The small intestine carries out most of the digestive process, absorbing almost all of the nutrients
you get from the foods you’ve eaten into your bloodstream. The walls of the small intestine make
digestive juices, or enzymes, that work together with enzymes from the liver and pancreas to do
this.
Rectum
The rectum is a straight, 8-inch chamber that connects the colon to your anus. The
rectum's job is to receive stool from the colon, let you know that there is stool to be evacuated
(pooped out) and to hold the stool until evacuation happens. When anything such as gas or stool
52
comes into the rectum, sensors send a message to the brain. The brain then chooses and decides
if the rectal contents can be released or not.
III.
SIGNS AND SYMPTOMS
Signs and Symptoms
Rationale
Heartburn
The feeling of acid reflux is heartburn: it is a mild
burning sensation in the mid-chest, often happens
after meals or when lying down. Gastroesophageal
reflux disease (GERD) is a graver form of acid reflux.
In GERD, the backflow of stomach acid happens
chronically and causes damage to the body over time
(Pfizer, 2023).
Regurgitation
Regurgitation is when food, liquid, or stomach acid
comes up from the stomach into your mouth. This
symptom is usually described as a sour taste in the
mouth or a sense of fluid moving up and down in the
chest. It occurs in 80% of people with GERD, which
can be treated with over-the-counter and prescription
medications (Buoy health, 2018).
Coughing
Many are surprised to know that the issue behind their
chronic cough is not a cold, but rather due to
gastroesophageal reflux or GERD. The U.S. Library of
Medicine found that GERD was linked in 25% or more
cases of chronic coughing. The GERD cough is a dry
cough that gets worse at night and lasts longer than 8
weeks (Warf, 2021).
Chest pain
GERD causes chest pain that mimics a heart attack.
Described as a squeezing pressure behind the breast
bone, GERD-related chest pain lasts for hours. And
like a heart attack, it can also radiate down from your
53
arm to your back (Larson, 2022).
Swallowing problem
Difficulty swallowing, also known as dysphagia, is the
feeling of food “sticking” in your throat or chest and is
one of the complications of acid reflux/GERD. When
acid reflux occurs, acid flows back into your
esophagus causing irritation and discomfort. With
chronic acid reflux/GERD, this is happening frequently
causing irritation to the esophagus, which can lead to
other complications such as dysphagia (Endoscopy
Center of Red Bank, 2023).
Vomiting
People who have acid reflux frequently experience a
sour taste in their mouth from stomach acids. The
taste, along with the frequent burping and coughing
linked with reflux and GERD, can create nausea and
even vomiting in some cases (Roth, 2019).
Sore throat and hoarseness
Gastroesophageal reflux is a condition in which some
of the acid in the stomach travels backward out of the
stomach and into the esophagus and throat. Reflux is
usually worse when we are sleeping, but it can occur
at any time. When we sleep the valve between the
stomach and esophagus relaxes and opens. This lets
acid in the stomach move backward into the
esophagus and throat. This acid is irritating to the
throat and can result in laryngitis, a condition of
inflamed and irritated vocal cords or larynx (UMMC
Health Care, 2020).
IV.
ETIOLOGY
Predisposing factors
Rationale
54
Age
GERD can affect people of all ages, statistics show
that the risk increases as the age Increases and tends
to rise in the age after 40. (Scherer, 2022)
Gender
GERD tends to occur in both men and women.
However, The prevalence of having a GERD is higher
amongst men. (Sang, 2019)
Race
Studies show that older Caucasians and Europeans in
particular are more likely to have serious GERD than
other ethnicities and countries. African Americans and
Asians appear to be at lower risk for the development
of complicated GERD (Scherer, 2022)
Genetics
A pattern has been observed of GERD amongst
Multigenerational members of a family. However, the
gene responsible cannot be determined yet. (Scherer,
2022)
Precipitating factors
Rationale
Diet
Caffeinated food and drinks such as coffee, tea, and
colas aggravated GERD. Caffeine can trigger GERD
symptoms as it can relax the lower esophageal
sphincter (LES) which is the ring of muscle between
the esophagus and stomach. (Healthline, 2018)
Sedentary Lifestyle
Inactivity such as seating for a longer period of time
aggravates GERD. In fact, the American College of
Sports Medicine notes that regular light to moderate
exercise can reduce the occurrence of GERD.
Exercise may work by strengthening the sphincter that
55
keeps the lower end of the esophagus closed. (Miller,
2021)
Alcohol
Alcohol is a known trigger of GERD. Also, alcohol is a
diuretic, which means it Causes to urinate more
often.This can lead to dehydration, which makes acid
reflux symptoms worse. In addition, alcohol can also
cause the LES to malfunction, which leads to
increased symptoms of acid reflux. (Healthline, 2018)
Smoking
Relaxing the lower esophageal sphincter. Nicotine
tends to relax smooth muscle inside the body. One of
the body's main defenses against GERD is the lower
esophageal sphincter. (Healthline, 2018)
Stress
A person's emotions can increase the acid production
in the stomach, aggravating GERD. In people with
GERD, the lower esophageal sphincter muscle
doesn’t work properly thus allowing the acid to rise up
from the stomach then to the esophagus. (Golen,
2022)
Existing GI abnormalities
Medical problems such as hiatal hernia, peptic ulcer,
and connective tissue diseases if left untreated for so
long may lead to another condition called GERD.
(Hollman, 2022)
Medication
Medications such as anticholinergics, barbiturates,
antacids, and H2 antagonists if taken too much can
cause GERD. In specific, the H2 antagonist reduces
the amount of acid that the stomach produces and
helps treat GERD and has been a go to treatment of
choice for many acid-related stomach conditions.
(Carter, 2020)
Pregnancy
Gastroesophageal reflux disease (GERD) is reported
56
in up to 80% of pregnancies. It is likely caused by a
reduction in lower esophageal sphincter pressure due
to an increase in maternal estrogen and progesterone
during pregnancy. (Todd, 2022)
Obesity
The notion that obesity may be causal in GERD
makes biologic sense. Obesity may increase intraabdominal
pressure,
impair
gastric
emptying,
decrease lower esophageal sphincter (LES) pressure
and possibly increase transient LES relaxation, all of
which could lead to increased esophageal acid
exposure. (Todd, 2022)
V.
PATHOPHYSIOLOGY
57
Narrative:
58
Gastroesophageal reflux disease (GERD) or chronic acid reflux is a condition in which the
acids produced in the stomach passes to the lower esophageal sphincter and back flows to the
esophagus. This back flow of acids irritates the esophageal linings that could cause. since a
person is exposed to a multifactorial factor namely predisposing and precipitating, disease such
as GERD happens. The etiology of the disease is still idiopathic but multifactorial factors are being
taken into consider. First, are the factors that predisposes the person like gender, age, race and
genetics. A person that is prone to having this disease are those men and a person aging 40 years
old and above mainly living in the northern part of the world but to be more specific is a caucasian
and having a family history of this problem. Then we have what we called precipitating factors
which are those caused by the bad choices and habits by the patient. Having poor diet, sedentary
lifestyle, alcoholism, smoking, existing GI abnormalities such as hiatal hernia, medication use,
obesity and stress; as well as pregnancy, patients are at high risk of getting this disease.
When a person has been constantly affected by the factors mentioned above, it will result
in the following. First, there will be delayed gastric emptying. Signs and symptoms of it include
constipation. Second, there is an accumulation of gastric contents in the herniated part of the
stomach and for obese and pregnant women the stomach becomes distended. These three
factors increase pressure in the intra abdominal causing a pressure lower esophageal sphincter.
In pregnancy, relaxin is produced, which is a hormone secreted by the placenta that causes the
cervix to dilate in preparation for labor. This activates the collagenase where it will be broken
down, reducing muscle strength of the stomach leading to relaxation of the lower esophageal
sphincter. If there is a pressure to the LES and decreased muscle strength the LES weakens and
impairs LES motility allowing the gastric acids to flow back into the esophagus. The esophageal
lining cannot withstand the acidic nature of the acid reflux causing the lining to be irritated resulting
in signs and symptoms of heartburn, regurgitation and epigastric pain. If this backflow continues
it further reaches the larynx and irritates the laryngopharyngeal tissue resulting in hoarseness of
voice and belching. When there is a further irritation the laryngopharyngeal tissue becomes
inflamed and causes signs and symptoms lymphadenopathy, tonsil irritation, sore throat, difficulty
in swallowing, coughing and dysphagia. On the other hand the vagus nerve is stimulated resulting
in constriction of the airway and shortness of breath occurs. Furthermore, the gastric acids travel
to the pharynx and to the mouth the salivary glands are stimulated this will increase the production
of saliva. When the gastric acid mixes with saliva in the mouth this results in dysgeusia and
increases acidity in the mouth and causes the enamel to erode tooth decay. If persistent reflux
continues the esophagus will have an erosion and causes. First, the mucosal defenses will be
unable to counteract the damage leading to local inflammation such as ulcer formation and
59
esophagitis. Second, there will be a development of scar tissue and narrowing of esophagus then
blockages that prevent smooth flow of food in the stomach. Lastly, the squamous cells are
replaced with intestinal cells which complicates Barrett's esophagus and will result in bleeding.
These three problems mentioned above lead to permanent damage of esophagus if not
treated that could further lead to cancer then death which results in poor prognosis. The diagnostic
procedures are done such as CBC, urinalysis, Serum Electrolytes, CBG, FBS, ultrasound in the
abdomen, pylori determination and upper gastrointestinal determination. Medical management
given such as antiemetic medication, antiulcer, calcium channel blocker, h2 receptor antagonist,
antibiotic and antibacterial medications are given to a person with GERD. Fundoplication and linx
device implantation are surgical managements. All management mentioned will result in a good
prognosis.
VI.
MEDICAL MANAGEMENT
A. DIAGNOSTIC EXAMS
TEST
Upper Endoscopy
RATIONALE
NURSING RESPONSIBILITIES
An endoscopy can also be Before:
used to collect a sample of
●
Answer patient questions
tissue (biopsy) to be tested for
and
complications such as Barrett
concerns
esophagus. In some instances,
procedure.
if a narrowing is seen in the
●
address
their
regarding
the
Keep the patient informed
esophagus, it can be stretched
throughout the duration of
or dilated during this procedure.
the procedure.
This is done to improve trouble
●
Secure informed consent.
swallowing (dysphagia).
●
Change
the
patient's
gown.
●
Preparing the instruments,
equipment, and supplies
for the procedure.
●
Sedating patient before the
procedure.
During:
60
●
Observe
patients
vital
signs.
●
Assist
the
surgeon
throughout the procedure.
After:
●
Complete
documentation
of the procedure.
●
Reassess vital signs.
●
Check
for
complications
bloating,
any
such
cramping,
as
and
sore throat.
●
Make
the
patient
comfortable.
Ambulatory acid (pH)
probe test
This is generally considered the Before:
diagnostic gold standard for
●
Instruct patient not to eat
use in patients with GERD. pH
and/or drink before the
test help determine the causes
procedure is done.
and
severity
of
●
Instruct patient not to take
gastroesophageal reflux with
antacids 24 hours before
higher degrees of accuracy and
catheter placement.
comfort.In this study, a pH
monitor
is
placed
in
●
the During:
esophagus above the lower
●
esophageal sphincter, and the
pH
is
recorded
at
Do medical handwashing.
Assist
the
doctor
in
inserting the tube.
given After:
●
moments in time.
Complete
documentation
of the procedure.
●
Make
the
patient
comfortable.
X-Ray Of The Upper
Digestive System
An
upper
doctors
GI
X-ray
helps Before:
find the cause
of
●
Provide
relevant
61
swallowing
problems,
information to the client to
unexplained vomiting, nausea,
abdominal
discomfort,
and
ease anxiety.
●
severe indigestion. It can detect
signs of problems such as
Secure consent for the
procedure.
●
Look for allergies. Assess
ulcers, gastric reflux, hiatal
for any history of allergies
hernia,
to
or
blockages
or
narrowing of the upper GI tract.
iodinated
dye
or
shellfish, if contrast media
is to be used.
●
Get health history Ask the
patient about any recent
illnesses or other medical
conditions
and
current
medications being taken.
The
specific type of CT
scan determines the need
for an oral or
contrast
recent
I.V. in
medium, some
illnesses
may
contraindicate
the
procedure.
●
Check for NPO
status-
Instruct the patient to not
to eat or drink for a period
of time
especially if a
contrast material will
be
used.
●
Encourage the patient to
increase fluid intake (if a
contrast is given). This is
to promote excretion of the
dye.
●
Instruct
the
patient
to
62
remove
all
metallic
objects, including jewelry,
hairpins, or watches.
After:
●
Encourage the patient to
take plenty of water to
excrete contrast medium in
the urine.
●
Make
the
patient
comfortable.
Esophageal Manometry
This
test
measures
the Before:
rhythmic muscle contractions in
●
your esophagus when you
swallow.
Esophageal
Explain
the
procedure
process to the patient.
●
Make sure the patient has
manometry also measures the
been NPO for 8 hours and
coordination and force exerted
aware no sedation will be
by
given.
the
muscles
of
your
esophagus. This is typically
●
done in people who have
trouble swallowing.
Secure consent for the
procedure.
●
Assure
no
clothing
is
restricting the abdomen.
During:
●
While the patient is in the
sitting position gently insert
the probe into the patient's
nares, down the back of
the
throat
into
the
esophagus until the probe
tip reaches the stomach.
●
A topical anesthetic may
be instilled into the nose to
make
passage
of
the
63
probe more comfortable.
●
The patient may take sips
of water to assist with
probe placement.
After:
●
Document all the relevant
data from the procedure.
●
Make
the
patient
comfortable.
Transnasal
Esophagoscopy
Transnasal
esophagoscopy Before:
(TNE) is a minimally invasive
outpatient
procedure
●
that
Answer patient questions
and
address
utilizes an ultra thin endoscope
concerns
inserted
procedure.
through
passages
esophagus
patients
to
the
nasal
examine
and
the
●
evaluate
experiencing
their
regarding
the
Keep the patient informed
throughout the duration of
acid
the procedure.
chronic
●
Secure informed consent.
cough and globus sensation
●
Change
reflux,
dysphagia,
(the feeling of a lump in the
throat).
the
patient's
gown.
●
Preparing the instruments,
equipment, and supplies
for the procedure.
●
Sedating patient before the
procedure.
During:
●
Observe
patients
vital
signs.
●
Assist
the
surgeon
throughout the procedure.
After:
●
Complete
documentation
64
of the procedure.
●
Reassess vital signs.
●
Check
for
complications
bloating,
any
such
cramping,
as
and
sore throat.
●
Make
the
patient
comfortable.
B. MEDS
1. Antacids
-
When the stomach contents back up into the esophagus, it causes heartburn
because your esophagus is not built to withstand acidity, especially over a
prolonged period of time. Antacids help neutralize these acids, so the esophageal
lining is less exposed to gastric acids.
GENERIC NAME
Calcium Carbonate, Aluminum Hydroxide, Magnesium
hydroxide, Simeticone
BRAND NAME
Kremil-S
DRUG CLASSIFICATION
Antacids with antiflatulents
SUGGESTED DOSE
To relieve heartburn in adults and children 12 years and older:
1 tablet as needed. Or, as directed by a doctor.
Chew the tablet completely before swallowing.
Do not use more than 2 chewable tablets in 24 hours.
ROUTE
OF ORAL, IV
ADMINISTRATION
MODE OF ACTION
This product contains a combination of antacids, Aluminum
Hydroxide and Magnesium Hydroxide, which effectively
increase gastric pH by neutralizing the acid produced in the
stomach.
65
INDICATION
This medicine is used for the relief of heartburn associated with
acid indigestion and hyperacidity.
CONTRAINDICATION
Contraindicated in patients with advanced kidney disease are
at risk of Aluminum and Magnesium accumulation and toxicity.
Do not use these products in such patients.
SIDE EFFECTS
●
CNS: Headache, dizziness, paresthesia, depression,
anxiety, somnolence, insomnia, fever, seizures in renal
disease CV: Dysrhythmias, QT prolongation (impaired
renal functioning)
●
EENT: Taste change, tinnitus, orbital edema GI:
Constipation, nausea, vomiting, anorexia, cramps,
abnormal hepatic enzymes, diarrhea INTEG: Rash,
toxic epidermal necrolysis, Stevens-Johnson syndrome
●
ADVERSE EFFECTS
MS: Myalgia, arthralgia RESP: Pneumonia
Famotidine: Famotidine is generally well tolerated.
●
Undesirable effects involving stomach and intestines
include:
constipation,
diarrhea,
nausea,
vomiting,
abdominal and gas-related discomfort, decreased
appetite, dry mouth, heartburn, and loss of taste.
●
Famotidine may also cause the following skin reactions:
acne, itching, red, itchy patches on the skin (hives), rash
and dry skin. Headache, dizziness, weakness, fatigue,
muscle weakness, seizures, insomnia, drowsiness,
depression,
confusion,
disorientation,
anxiety,
decreased sexual desire, and hallucinations have been
reported.
●
Famotidine may also cause kidney problems (e.g.,
increased serum creatinine concentration and abnormal
amounts of protein in the urine) and liver disease such
as yellowing of the skin (jaundice).
●
Other undesirable effects include: fever, hypertension,
66
flushing, muscle cramps, pain in the joints, ringing in the
ears (tinnitus), and community-acquired pneumonia.
Antacids: Flatulence from increased carbon dioxide may occur
in some patients.
●
Calcium carbonate can stimulate acid rebound in some
people. Acid rebound causes the stomach to produce
even more acid, making heartburn worse. This,
however, is very rare.
●
Excessive doses of calcium carbonate and magnesium
hydroxide may result in high calcium and magnesium
levels in the blood in patients with kidney impairment.
●
Alkalosis (excess base in body fluids) may also occur
with excessive doses of antacid.
DRUG INTERACTIONS
●
Food appears to slightly increase and antacids appear
to slightly decrease the absorption of famotidine, but
these effects do not appear to be clinically important.
●
Unlike cimetidine, famotidine is considered to have little
effect on the actions of other drugs such as warfarin,
theophylline, phenytoin, diazepam, or procainamide.
●
Antacids may interact with other drugs such as
propranolol, isoniazid, prednisolone, diflunisal, and
naproxen which may cause formation of complexes that
are not absorbed.
●
Antacids decrease the absorption of tetracycline and
iron. Take tetracycline 1 hour before or 2 hours after
antacids and 2 hours before or 3 hours after iron
preparations and vitamin products that contain iron.
NURSING
RESPONSIBILITIES
1. Assess the patient for history of allergies,
R: The antacids are contraindicated in the presence of
any known allergy to antacid products or any component
of the drug to prevent hypersensitivity reactions.
2. Instruct patient to take drug with food.
67
R: It's best to take antacids with food or soon after eating
because this is when you're most likely to get indigestion
or heartburn. The effect of the medicine may also last
longer if taken with food.
3. Monitor the compliance with the regimen.
R: To achieve maximum desired effect.
4. Teach patient to avoid taking other medications within 2
hours of taking the antacid.
R: certain drugs may interact with the antacid and
effectiveness may diminish.
5. Encourage the client to lie on the left side with the head
of the bed elevated when complaints of chest discomfort
arise after administering antacid.
R: to relieve and make the client comfortable.
6. Assess for renal function.
R: patients with decreased renal function are at risk for
prolonged QT.
7. Instruct patient to avoid taking alcoholic beverages.
R: May increase or worsen the condition.
8. Instruct patient to avoid smoking.
R: It diminishes the effectiveness of the drug.
9. Instruct
patient/watcher
to
avoid
tasks
requiring
alertness.
R: Dizziness and drowsiness may occur.
10. Teach the patient/ family that the product must be
continued for prescribed time in the prescribed method.
R: To achieve maximum effect.
2. Antiulcer
-
Both classes of antiulcer medications block the pathways of acid production or secretion,
decreasing gastric acidity, improving symptoms and aiding in healing of acid-peptic
diseases.
68
GENERIC NAME
Famotidine (Pepcid)
BRAND NAME
Pepcid
DRUG CLASSIFICATION
Antiulcer agent (H2 antagonist)
SUGGESTED DOSE
Adult Dose:
●
Duodenal ulcer:
○
40 mg orally every night at bedtime for 4-8
weeks, then 20mg thereafter if needed for
maintenance.
○
IV; 20mg every 12 hours if unable to tolerate
PO
●
Gastric Ulcer:
○
●
40 mg orally every night at bedtime
GERD:
○
PO 20 mg twice daily for up to 6 weeks; for
esophagitis due to GERD, 20-40 mg twice daily
for up to 12 weeks
●
Hypersecretory conditions:
○
PO 20 mg every 6 hours; may give 160 mg
every 6 hours if needed.
○
IV 20 mg every 12 hours if unable to tolerate
PO
●
Heartburn or acid indigestion:
○
PO 10mg twice daily; to prevent heartburn,
69
10mg 1 hour before meals
●
Renal failure:
○
PO 20 mg at bedtime or increase dosing
interval to 36-48 hours
ROUTE
OF ORAL, IV
ADMINISTRATION
MODE OF ACTION
inhibit acid secretion by blocking H2 receptors on the parietal
cell (figure 1). H2RAs are well absorbed after oral dosing; peak
serum concentrations occur within one to three hours.
INDICATION
●
Short term and maintenance duodenal ulcer therapy
●
Short term benign gastric ulcer therapy
●
Pathological hypersecretory conditions (ZollingerEllison syndrome)
●
Gastroesophageal disease (GERD) and esophagitis
due to GERD
CONTRAINDICATION
Famotidine is contraindicated for use by patients with serious
hypersensitivity to famotidine itself or any component of the
formulation. Cross-sensitivity of H2RAs has been observed;
therefore, famotidine should not be administered to patients
with a history of hypersensitivity to cimetidine.
SIDE EFFECTS
ADVERSE EFFECTS
headache, dizziness, constipation, and diarrhea.
●
CNS: anxiety, depression, dizziness, fever, headache,
insomnia, paresthesia, seizures, somnolence
●
EENT: Orbital edema, taste change, tinnitus
●
HEME: Thrombocytopenia
●
RESP: Bronchospasm
●
Arthralgia, myalgia, rash
70
DRUG INTERACTIONS
●
Reduction of gastric acidity reduces absorption and
introduces potential for therapeutic failure:
ketoconazole, enoxacin, cefpodoxime, cefuroxime
●
Increased absorption, potential for hypoglycemia:
glipizide, glyburide
●
NURSING
RESPONSIBILITIES
Increased concentrations: nifedipine, nisoldipine
1. Monitor renal function.
R: Famotidine is substantially excreted by the kidneys.
2. Monitor patient's complete blood count (CBC), gastric
pH and occult blood in patients with gastrointestinal
(GI) bleeding.
R: may cause serious adverse effects.
3. Monitor patient for any allergic reactions such as rash,
itching/swelling (especially of the face/tongue/throat),
severe dizziness, trouble breathing.
R: This product may contain inactive ingredients, which
can cause allergic reactions or other problems and
provide immediate intervention.
4. Advise patient to administer drug at bedtime.
R: Gastrointestinal reflux is most likely to occur during
evening or nighttime hours. Because of this, famotidine
may be most effective in controlling reflux when it is
taken around the time of an evening meal.
5. Instruct patient to take drug one hour before eating.
R: to prevent indigestion.
6. If headache occurs, adjust lights, temperature, and
noise levels.
R: to aid the side effect.
7. Instruct
patient/watcher
to
avoid
tasks
requiring
alertness.
R: Dizziness and drowsiness may occur.
8. Instruct older adult patients to report any unusualities.
71
R: mental/ mood changes, seizure, and unusual
tiredness may occur during treatment regimen.
9. Instruct patient to notify the health care provider if
pregnancy is planned or suspected or if breastfeeding.
R: drug is under pregnancy category B.
10. Instruct patient not to take more or less of it or take it
more often or for a longer time than prescribed by the
doctor.
R: minimize adverse effects from happening.
3. Antiemetic
-
Prokinetic agents are used to induce gastric motility, whereas antiemetic agents are
used to relieve symptoms of nausea and vomiting.
GENERIC NAME
Metoclopramide
BRAND NAME
Reglan
DRUG CLASSIFICATION
GI stimulant, Antiemetic, Dopaminergic blocker
SUGGESTED DOSE
Nausea/vomiting (chemotherapy)
●
Adult: IV 1-2 mg/kg 30 min before administration of
chemotherapy, then q2hr × 2 doses, then q3hr × 3 doses
●
Child (unlabeled): IV 1-2 mg/kg/dose
Facilitate small-bowel intubation for radiologic exams
●
Adult and child >14 yr: IV 10 mg over 1-2 min
●
Child <6 yr: IV 0.1 mg/kg
●
Child 6-14 yr: IV 2.5-5 mg
Diabetic gastroparesis
●
Adult: PO 10 mg 30 min before meals, at bedtime × 2-8
wk
●
Geriatric: PO 5 mg 30 min before meals, at bedtime,
increase to 10 mg if needed
Gastroesophageal reflux
72
●
Adult: PO 10-15 mg qid 30 min before meals and at
bedtime
●
Child: PO 0.4-0.8 mg/kg/day in 4 divided doses
Renal dose
●
Adult: PO CCr <60 mL/min, 5 mg qid, max 20 mg/day,
or CCr 10-15 mL/min give 75% of normal dose; CCr <10
mL/min give 50% of normal dose.
ROUTE
OF PO, IM, IV
ADMINISTRATION
MODE OF ACTION
Metoclopramide enhances the motility of the upper GI tract and
increases gastric emptying without affecting gastric, biliary or
pancreatic secretions. It increases duodenal peristalsis which
decreases
intestinal
transit
time,
and
increases
lower
esophageal sphincter tone. It is also a potent central dopaminereceptor antagonist and may also have serotonin-receptor (5HT3) antagonist properties.
INDICATION
Metoclopramide is used to treat the symptoms of slow stomach
emptying (gastroparesis) in patients with diabetes. It works by
increasing the movements or contractions of the stomach and
intestines. It relieves symptoms such as nausea, vomiting,
heartburn, a feeling of fullness after meals, and loss of appetite.
Metoclopramide is also used to treat heartburn for patients with
gastroesophageal reflux disease (GERD). GERD is esophageal
irritation from the backward flow of gastric acid into the
esophagus.
CONTRAINDICATION
H sensitivity to this product, procaine, or procainamide; seizure
disorder, pheochromocytoma, GI obstruction Precautions:
Pregnancy,
disease,
breastfeeding,
breast
cancer
GI
hemorrhage,
(prolactin
Parkinson’s
dependent),
abrupt
discontinuation, cardiac disease, children, depression, diabetes
73
mellitus,
G6PD
hypertension,
deficiency,
infertility,
geriatrics,
malignant
heart
failure,
hyperthermia,
methemoglobinemia, procainamide/paraben hypersensitivity,
renal impairment.
SIDE EFFECTS
●
CNS:
Sedation,
fatigue,
restlessness,
headache,
sleeplessness, dystonia, dizziness, drowsiness
●
CV: Hypotension, supraventricular tachycardia
●
GI: Dry mouth, constipation, nausea, anorexia, vomiting,
diarrhea
●
GU: Decreased libido, prolactin secretion, amenorrhea,
galactorrhea
ADVERSE EFFECTS
●
INTEG: Urticaria, rash
●
CNS: suicidal ideation, seizures, EPS, neuroleptic
malignant syndrome; tardive dyskinesia (>3 mo, high
doses)
DRUG INTERACTIONS
●
HEMA: Neutropenia, agranulocytosis
●
Avoid use with MAOIs; may increase hypertension in
those patients Increase: sedation—alcohol, other CNS
depressants; avoid concurrent use
●
Increase: risk for EPS—haloperidol, phenothiazines;
assess for EPS
●
Decrease: action—anticholinergics, opiates; avoid using
together or assess carefully
Drug/Lab Test
●
NURSING
RESPONSIBILITIES
Increase: prolactin, aldosterone, thyrotropin
1. Assess history to metoclopramide.
R: to allow safe prescription and avoidance of the
specific drug or drug class.
2. Monitor vital signs, especially BP.
R: ECG may result in QT Prolongation.
3. Assess for mental status.
74
R: Drug effects may lead to depression, anxiety, and
irritability.
4. Assess for involuntary movements often.
R: Treatment with metoclopramide can cause tardive
dyskinesia, a serious movement disorder that is often
irreversible. The risk of developing tardive dyskinesia
increases with duration of treatment and total cumulative
dose.
5. Monitor the compliance with the regimen.
R: To achieve maximum desired effect.
6. Instruct patient to intake the drug with food.
R: GI irritation may occur.
7. Instruct
patient/watcher
to
avoid
tasks
requiring
alertness.
R: Dizziness and drowsiness may occur.
8. Instruct patient to avoid alcohol intake.
R: can cause extrapyramidal effects.
9. Instruct patient to take this drug exactly as prescribed.
R: to achieve maximal effect and avoid unwanted side
effects.
10. Teach the patient/ family that the product must be
continued for prescribed time in the prescribed method.
R: To achieve maximum effect.
4. Proton Pump Inhibitor
-
Many people take PPIs for gastroesophageal reflux disease (GERD). By lowering stomach
acid levels, they reduce acid reflux into the esophagus and the resulting heartburn
symptoms.
GENERIC NAME
BRAND NAME
Esomeprazole
Nexium
75
DRUG CLASSIFICATION
Proton Pump Inhibitor
SUGGESTED DOSE
Gastro-oesophageal reflux disease
●
ORAL
○
Adult: Erosive reflux oesophagitis: 20 mg or 40
mg once daily for 4-8 weeks, may extend for an
additional 4-8 weeks if necessary. Maintenance
(to prevent relapse of erosive oesophagitis): 20
mg once daily for up to 6 months. Symptomatic
treatment of GERD (without oesophagitis): 20
mg once daily for 4 weeks, may extend for an
additional 4 weeks if necessary.
○
Child: As granules for oral susp: 1 month to <1
year Erosive reflux oesophagitis: 3-5 kg: 2.5 mg
once daily for up to 6 weeks; >5-7.5 kg: 5 mg
once daily for up to 6 weeks; >7.5-12 kg: 10 mg
once daily for up to 6 weeks. 1-11 years Erosive
reflux oesophagitis: <20 kg: 10 mg once daily for
8 weeks; ≥20 kg: 10 mg or 20 mg once daily for
8 weeks. Symptomatic treatment of GERD: 10
mg once daily for up to 8 weeks. As tab, cap, or
granules for oral susp: 12-17 years Erosive reflux
oesophagitis: 20 mg or 40 mg once daily for 4-8
weeks.
Symptomatic
treatment
of
GERD
(without oesophagitis): 20 mg once daily for 4
weeks.
●
IV
○
Adult: Erosive reflux oesophagitis: 40 mg once
daily. Symptomatic treatment: 20 mg once daily.
Doses are given via slow inj over at least 3
minutes
or
infusion
over
10-30
minutes.
Treatment duration: Up to 10 days. Switch to oral
therapy as soon as possible.
76
○
Child: 1-11 years Erosive reflux oesophagitis:
<20 kg: 10 mg once daily; ≥20 kg: 10 mg or 20
mg once daily. Symptomatic treatment of GERD:
10 mg once daily. 12-18 years Same as adult
dose. Doses are given via slow inj over at least 3
minutes or infusion over 10-30 minutes. Switch
to oral therapy as soon as possible. Dosage
recommendations may vary among countries
and individual products (refer to specific product
guidelines).
ROUTE
OF PO, IV, PARENTERAL
ADMINISTRATION
MODE OF ACTION
Suppress gastric actions by inhibiting hydrogen/potassium
ATPase enzyme system in gastric parietal cell; characterized as
gastric acid pump inhibitor because it blocks the final step of
acid production.
INDICATION
●
Relieve symptoms of acid reflux, or gastroesophageal
reflux disease (GERD). This is a condition in which
food or liquid moves up from the stomach to the
esophagus (the tube from the mouth to the stomach).
●
Treat a duodenal or stomach (gastric) ulcer.
●
Treat damage to the lower esophagus caused by acid
reflux.
CONTRAINDICATION
Hypersensitivity to proton pump inhibitors (PPIs) Precautions:
Pregnancy,
breastfeeding,
children,
geriatric
patients,
hypomagnesemia, osteoporosis.
SIDE EFFECTS
●
headache
●
nausea
●
diarrhea
77
ADVERSE EFFECTS
●
gas
●
constipation
●
dry mouth
●
drowsiness
●
blisters, peeling, or bleeding skin; sores on the lips,
nose, mouth, or genitals; swollen glands; shortness
of breath; fever; or flu-like symptoms
●
rash; hives; itching; swelling of the eyes, face, lips,
mouth, throat, or tongue; difficulty breathing or
swallowing; or hoarseness
●
irregular, fast, or pounding heartbeat; muscle
spasms; uncontrollable shaking of a part of the
body; excessive tiredness; lightheadedness;
dizziness; or seizures
●
severe diarrhea with watery stools, stomach pain, or
fever that does not go away
●
new or worsening joint pain; rash on cheeks or arms
that is sensitive to sunlight
●
increased or decreased urination, blood in urine,
fatigue, nausea, loss of appetite, fever, rash, or joint
pain.
DRUG INTERACTIONS
●
Increase:
effect,
toxicity
of
diazePAM,
digoxin,
penicillins, saquinavir, cilostazol, cloZAPine, those
drugs metabolized by CYP2C19
●
Increase: effect of methotrexate, tacrolimus, warfarin
●
Decrease: effect—atazanavir, nelfinavir, dapsone, iron,
itraconazole,
carbonate,
ketoconazole,
vit
B12
,
indinavir,
clopidogrel,
iron
calcium
salts,
mycophenolate
Drug/Lab Test
●
Interference: sodium, Hgb, WBC, platelets, magnesium
False-positive CgA
78
NURSING
RESPONSIBILITIES
1. Monitor improvements in GI symptoms (gastritis,
heartburn, and so forth).
R: to help determine if drug therapy is successful.
2. Monitor the compliance with the regimen.
R: To achieve maximum desired effect.
3. Instruct patient/ watcher to avoid hazardous activities.
R: dizziness may occur.
4. Instruct patient to report any severe GI symptoms.
R: to immediately provide immediate intervention or
have the drug discontinued.
5. Instruct patient to take drug one hour before meal.
R: Esomeprazole should be taken in the morning on an
empty
stomach
to
optimize
benefits/
maximum
absorption.
6. Instruct patient not to crush and chew drug.
R: to get the maximum absorption of the drug.
7. Instruct patient to take drug as soon as remembered if
missed. Do not double dose.
R: To avoid double dosing and getting your disease
worse.
8. Instruct patient/ watcher to notify health care provider if
pregnancy is planned or suspected or if breastfeeding.
R: drug is under pregnancy category C.
9. Advise patient to discontinue/ avoid St. John’s wort herb
while taking esomeprazole.
R: It may stop esomeprazole working as well as it
should.
10. Advise patient to avoid alcohol and foods that may
cause an increase in GI irritation.
C. TREATMENT
79
TREATMENT
RATIONALE
NURSING RESPONSIBILITIES
Lifestyle and dietary
Dietary and lifestyle changes
changes
are the first step in treating
low residue diet to relieve
GERD. Certain foods make
abdominal
the reflux worse.
diarrhea.
●
●
Instruct patient to follow a
pain
and
If the patient experiences
strictures, instruct them to
avoid eating nuts, seeds,
beans and kernels.
●
Instruct to avoid foods that
may increase stool output
such as fresh fruits and
vegetables,
prunes
and
caffeinated beverages.
Medication
If lifestyle and dietary changes
●
Instruct
patient
to
take
do not work, the doctor may
medication
on
the
prescribe certain medications.
prescribed
time
and
There are two categories of
amount.
medicines
for
reflux.
One
●
decreases the level of acid in
your
stomach,
and
one
Instruct patient not to double
dose.
●
Encourage patient to report
increases the level of motility
any adverse effects of the
(movement)
drug administered.
in
the
gastrointestinal tract.
upper
●
Instruct patient to take full
course of the drug.
VII.
SURGICAL MANAGEMENT
Surgery for GERD is known as antireflux surgery and involves a procedure called a
fundoplication. The goal of a fundoplication is to reinforce the LES to recreate the barrier that
stops reflux from occurring.
80
PROCEDURE
Nissen fundoplication
RATIONALE
NURSING RESPONSIBILITIES
The Nissen fundoplication is Preoperative:
almost always chosen to control
GERD.
This
wrapping
a
is
done
portion
of
by
regarding the procedure.
●
Instruct
patient
not
to
the esophagus in an effort to
smoke or take any NSAIDS
strengthen,
or
or Aspirin products up to 1
recreate the LES valve. The
week prior to surgery date.
most
augment,
common
type
fundoplication
is
a
fundoplication
in
which
stomach
wrapped
degrees
is
around
of
Transoral
●
Nissen
the
2-3 miles a day prior to
surgery to get in the best
360
shape possible for surgery.
lower
●
Obtain informed consent.
●
Change the patient's gown.
●
Preparing the instruments,
incisionless
equipment, and supplies
fundoplication is a minimally
invasive procedure for GERD.
Unlike
the
fundoplication
incisions
in
the
transoral
fundoplication
for the procedure.
●
laparoscopic
that
requires
abdomen,
Intraoperative:
●
Instruct patient not to eat or
drink
performed
anything
after
midnight the night prior to
through the mouth, without
incisions.
Sedating patient before the
procedure.
incisionless
is
Encourage patient to walk
the
esophagus.
fundoplication
Answer patient questions
and address their concerns
the
stomach around the bottom of
Transoral incisionless
●
surgery.
●
Observe
patients
vital
signs.
●
Assist
the
surgeon
throughout the procedure.
Postoperative:
●
Complete
documentation
of the procedure.
81
●
Reassess vital signs.
●
Check
for
complications
bloating,
any
such
cramping,
as
and
sore throat.
●
Make
the
patient
comfortable.
VIII.
NURSING MANAGEMENT
NURSING DIAGNOSIS
GOAL
INTERVENTION
Imbalanced Nutrition: Less
After 8 hours of nursing
1. Accurately measure the
Than Body Requirements
care, the patient will be able
patient’s
related to inability to intake
to:
height.
enough food because of
reflux as evidenced by
a. ingest
daily
nutritional
weight loss.
requirements
2. Obtain a nutritional history.
accordance
activity
common cause is food that's
and
Rationale: For baseline data.
inadequate food intake and
Rationale: The most
weight
in Rationale:
to
level
Determining
the
his feeding habits of the client can
and provide a basis for establishing a
metabolic needs.
nutritional plan.
b. demonstrating
acidic or high in fat—like
healthy
eating
3. Encourage small frequent
citrus fruits, tomatoes,
patterns and choices.
meals of high calories and
onions, chocolate, coffee,
c. verbalization
of
high-protein foods.
cheese, and peppermint.
selection of foods or Rationale: Small and frequent
Spicy foods or large meals
meals
can also be the root of
achieve a cessation
distress. Other sources of
of weight loss.
heartburn include aspirin or
that
will meals are easier to digest.
4. Provide
a
pleasant
environment.
ibuprofen, as well as some
Rationale:
sedatives and blood
atmosphere helps in decreasing
A
pleasing
82
pressure medications.They
stress and is more favorable to
may experience nausea and
eating.
difficulty or pain when they
swallow. Over time, the
5. Instruct to remain in an
condition may lead to a loss
upright position at least 2
of appetite and persistent
hours after meals; avoid
vomiting, indicating
eating
complications of GERD.
bedtime.
3
hours
before
Rationale: Helps control reflux
and causes less irritation from
Reference: MediLexicon
reflux action in the esophagus.
International. (n.d.). Acid
reflux and weight loss:
6. Instruct the patient to eat
Causes, dangers,
slowly and masticate foods
management. Medical News
well.
Today. Retrieved from
Rationale: Helps prevent reflux.
https://www.medicalnewstod
ay.com/articles/acid-refluxweight-loss
7. Provide oral hygiene.
Rationale: A clean mouth can
enhance the taste of food.
8. Instruct in the importance
of
abstaining
from
excessive alcohol.
Rationale: Alcohol causes gastric
irritation and increases gastric
pain
9. Encourage the client to
limit
the
caffeinated
intake
of
beverages
such as tea and coffee.
Rationale: Caffeine stimulates the
83
secretion
of
gastric
acid.
It
contains a peptide that stimulates
the
release
of
gastrin
and
increases acid production.
10. Prepare the patient for
CBC procedure.
Rationale:
To
identify
the
presence of anemia that must be
ruled out.
Acute
Pain
related
to After 1 hour of nursing care,
1. Perform a comprehensive
aspiration as evidenced by the patient will be able to:
assessment
pain scale of 7 out of 10.
Determine
a. report pain is relieved
Rationale:
to 0 out of 10
Aspiration of large amounts
b. demonstrate the use
the
pain.
location,
characteristics,
duration,
onset,
frequency,
quality, and severity of
of gastric acid will result in
of
the induction of a chemical
diversional activities Rationale: It helps the nurse in
injury to the airways and lung
and relaxation skills.
parenchyma.
The
initial
insult triggers a cascade of
inflammatory responses with
the
recruitment
of
appropriate
of
c. Display improvement
pain via assessment.
planning
optimal
pain
management strategies.
in mood, coping.
2. Determine
the
client’s
perception of pain.
inflammatory cells and the
Rationale: Provide an opportunity
release
for the client to express in their
of
various
inflammatory mediators
own words how they view the pain
Stomach acid can break
and the situation to gain an
down
understanding of what the pain
tissue
esophagus,
in
the
causing
means to the client.
inflammation, bleeding, and
sometimes an open sore.
3. Pain assessments must be
initiated by the nurse.
84
Reference:
Sullivan,
Hunt, E. B.,
J.,
unique for each person, and some
MacSharry, J., & Murphy, D.
clients may be reluctant to report
M. (n.d.). Gastric aspiration
or voice out their pain unless
and
asked about it.
its
A.,
role
inflammation.
Galvin,
Rationale: Pain responses are
in
The
airway
open
respiratory medicine journal.
Retrieved
from
4. Determine
the
patient’s
anticipation for pain relief.
https://www.ncbi.nlm.nih.gov
Rationale: This influences the
/pmc/articles/PMC5806178/
perceptions of the effectiveness of
the treatment modality and their
eagerness to engage in further
treatments.
5. Assess
the
patient’s
willingness or ability to
explore
a
range
of
techniques to control pain.
Rationale: A combination of both
therapies may be more effective,
and the nurse has the duty to
inform the patient of the different
methods to manage pain.
6. Determine
factors
that
alleviate pain.
Rationale: Ask clients to describe
anything
they
have
done
to
alleviate the pain.
7. Evaluate
response
the
to
patient’s
pain
and
management strategies.
85
Rationale: It is essential to assist
patients to express as factually as
possible the effect of pain relief
measures.
8. Provide ample time and
effort
regarding
the
patient’s report of their
pain experience.
Rationale:
Patients
may
be
reluctant to report their pain as
they may perceive staff to be very
busy
and
have
competing
demands on their time from other
nurses.
9. Provide
measures
to
relieve pain such as deep
breathing exercises before
it becomes severe.
Rationale: It is preferable to
provide an analgesic before the
onset of pain or before it becomes
severe when a larger dose may be
required.
10. Acknowledge and accept
the client’s pain.
Rationale: Nurses have the duty
to ask their clients about their pain
and believe their reports of pain.
Deficient Knowledge related
After 8 hours of nursing
1. Identify the learner: the
86
to lack of information
care, the patient will be able
patient,
regarding the condition as
to:
significant
evidenced by verbalization
of problems and questions.
family,
other,
or
caregiver.
a. express comprehension
R: Some patients, especially older
regarding the signs and
adults or the terminally ill view
symptoms of GERD.
themselves as dependent on the
Rationale: Identifying a lack
caregiver, therefore will not allow
of cognitive information or b. recognize factors that
themselves to be part of the
psychomotor ability required may worsen GERD and
educational process.
for restoring, maintaining, or cause its symptoms to
promoting health is referred intensify.
2. Assess ability to learn or
to as a knowledge deficit.
Knowledge is a crucial factor
in a patient's recovery and
daily life. I The nurse has the
responsibility to work with
perform desired healthc. demonstrate
understanding of the
therapeutic regimen for
treating GERD.
related care.
R: Cognitive impairments must be
recognized so an appropriate
teaching plan can be outlined.
the patient to determine what
to teach, when to teach, and
3. Assess the motivation and
how to teach matters related
willingness of the patient
to
to learn.
health.
The
teaching-
learning process is guided by
R:
principles of adult learning.
Patients must see a need or
Learning requires energy.
purpose for learning. They also
have
Reference: Wagner, M.
the
right
to
refuse
educational services.
(2023, January 9).
Knowledge deficit nursing
4. Determine
priority
of
diagnosis & care plan.
learning needs within the
NurseTogether. Retrieved
overall care plan.
from
R: This is to know what needs to
https://www.nursetogether.c
be discussed especially if the
om/knowledge-deficit-
patient already has a background
about the situation. Knowing what
87
nursing-diagnosis-care-plan/
to prioritize will help prevent
wasting valuable time.
5. Allow the patient to open
up
about
experience
previous
and
health
teaching.
R: Older patients often share life
experiences at each learning
session. They learn best when
teaching
builds
on
previous
knowledge and experience.
6. Observe and note existing
misconceptions regarding
material to be taught.
R:
Assessment
important
provides
starting
point
an
in
education. Knowledge serves to
correct faulty ideas.
7. Acknowledge racial/ethnic
differences at the onset of
care.
R:
Acknowledgement
racial/ethnicity
enhance
issues
of
will
communication,
establish rapport, and promote
treatment outcomes.
8. Identify cultural influences
on health teaching.
R: Interventions need to be
88
specific
to
considering
each
their
patient
individual
differences and backgrounds.
9. Consider
the
patient’s
learning style, especially if
the patient has learned
and
retained
new
information in the past.
R: Every individual has his or her
learning style, which must be a
factor in planning an educational
program. Matching the learner’s
preferred
style
with
the
educational method will facilitate
success in mastery of knowledge.
10. Assess
barriers
to
learning (e.g., perceived
change
in
lifestyle,
financial
concerns,
cultural patterns, lack of
acceptance by peers or
coworkers).
R: The patient brings to the
learning
situation
a
unique
personality, established social
interaction patterns.
IX.
LITERATURE
New Research could change How Clinicians diagnose, Treat Unmanaged Heartburn
(Robinson, 2019)
89
Robinson, E. (2019. New research could change how clinicians diagnose, treat
Unmanaged Heartburn. OHSU News. Retrieved from
https://news.ohsu.edu/2019/10/23/new-research-could-change-how-clinicians-diagnosetreat-unmanaged-heartburn
Gastroesophageal reflux disease (GERD) is a prevalent digestive disorder that affects a
significant percentage of the US adult population, with a higher prevalence in individuals aged 40
years or older. However, GERD is not limited to adults, as babies and children may also
experience chronic acid reflux, with about a quarter of children displaying GERD symptoms. The
underlying issue causing heartburn and reflux is a weakened muscle at the top of the stomach
that is meant to remain closed between swallowing to keep stomach acid in check, which does
not function optimally in patients with GERD, leading to acid reflux. Recent research has
demonstrated that a substantial number of individuals who continue to experience heartburn
symptoms despite taking proton pump inhibitors (PPIs) may not actually have GERD as the root
cause of their discomfort. Instead, they may be suffering from a range of other conditions that
cause a similar burning sensation in the chest, which can be difficult to differentiate from heartburn
caused by GERD. To ascertain the underlying cause of persistent heartburn, the study utilized a
comprehensive battery of tests that were specifically designed to identify conditions other than
GERD that could be contributing to heartburn symptoms. This allowed the researchers to
determine whether the heartburn was linked to reflux of stomach contents into the esophagus
prior to considering surgical intervention as a treatment option.
A New Device is Helping Treat Acid Reflux and Heartburn (Dickson, 2022)
Dickson, D. (2022). A new device is helping treat acid reflux and Heartburn ahead of the
holidays. 25 News KXXV and KRHD. Retrieved from www.kxxv.com/brazos/a-newdevice-is-helping-treat-acid-reflux-and-heartburn-ahead-of-the-holidays
A novel medical device has been developed in 2022 to address acid reflux and heartburn. The
LINX Reflux Management System utilizes metal beads and is employed in a minimally invasive
surgical procedure where a flexible ring of small magnets is positioned around the esophagus,
just above the stomach. This procedure is designed to assist in the prevention of reflux. The LINX
system is suitable for individuals who have been diagnosed with GERD through pH testing and
desire an alternative to continuous acid suppression therapy. Testimonies have conveyed
90
immediate results and have expressed their satisfaction and relief with the said new device as
medication to GERD. However, prospective LINX recipients should be healthy enough for surgery,
at least 21 years of age, and have successfully managed their weight. Before undergoing antireflux surgery, a gastroenterologist will conduct pre-operative esophageal testing to determine its
efficacy.
Two surgeries for Chronic GERD yield Similar Long-term Outcomes (Hamza, 2022)
Hamza, Z. (2022). Two surgeries for chronic GERD yield similar long-term outcomes.
Medical
News.
Retrieved
from
https://www.medpagetoday.com/gastroenterology/gerd/98325
GERD has been a persistent condition affecting a significant portion of the global population for
many years. Its prevalence ranged from 18.1% to 27.8% in North America, 8.8% to 25.9% in
Europe, 2.5% to 7.8% in East Asia, 8.7% to 33.1% in the Middle East, 11.6% in Australia, and
23.0% in South America. Moreover, there are various surgical and non-surgical methods for
treating GERD. A recent randomized trial conducted in Sweden found that laparoscopic partial or
total fundoplication was similarly effective in improving the ability to swallow solid and liquid foods,
controlling reflux, and enhancing the quality of life in patients with chronic GERD. The trial
recruited 456 patients with GERD from 2001 to 2006, and the present analysis included 301 of
the 407 patients who completed follow-up questionnaires after 16 years. The study found no
significant differences in daily proton pump inhibitor use or additional surgery for recurrent GERD
between the two groups. This suggests that laparoscopic partial or total fundoplication could be a
valuable surgical option for patients with chronic GERD who seek long-term symptom relief.
GASTROENTERITIS
I.
DEFINITION
The term "gastroenteritis" also refers to the stomach or intestinal flu that is brought on by
a virus, chemical, medication, bacteria, or parasite. It comes in four different forms: bacterial
gastroenteritis, bacillary dysentery, amebic gastroenteritis, and viral gastroenteritis. The most
typical form of gastroenteritis is viral, and the rotavirus is the virus that mostly causes it. It affects
and irritates the digestive system, especially the stomach and intestines, or both, which frequently
causes diarrhea, abdominal cramps, nausea, and vomiting. Gastroenteritis can be transmitted
91
from person to person by viruses, bacteria, and parasites. When contacting an object with the
germs on it and then touching their eyes, mouth, or nose, they could become infected.
II.
ANATOMY/ PHYSIOLOGY
The alimentary canal, commonly known as the gastrointestinal tract, and the accessory
organs are the two main parts of the digestive system. Essentially, it serves two purposes. Two
things happen during digestion: first, food and liquids are converted into simple chemicals that
may be taken into the bloodstream and carried throughout the body; and second, wastes are
expelled through the stools. The person's general health will be significantly impacted if this
system fails, making it crucial.
A muscular hollow tube called the alimentary canal extends from the mouth to the anus.
The pharynx, esophagus, stomach, small intestine, and large intestine are also included. The liver,
biliary duct system, and pancreas are examples of auxiliary organs in contrast.
Mouth
It focuses mostly on swallowing, salivating, and chewing food. The sensation of taste is
provided by the tongue, and saliva moistens the food as it is being chewed. The parotid,
submandibular, and sublingual salivary glands generate saliva.
Pharynx or Throat
It is a cavity that connects the esophagus to the mouth cavity. In addition to accelerating
the meal toward the esophagus, it aids in swallowing.
Esophagus
92
It is a muscular tube that connects the throat to the stomach by passing through the
mediastinum. The cricopharyngeal sphincter relaxes as food is swallowed, allowing it to pass into
the esophagus. After that, peristalsis forces food and water into the stomach from the esophagus.
Stomach
It is a collapsible, pouch-like structure in the left upper region of the belly, right below the
diaphragm, and it serves as the body's food storage. Its top border is joined to the esophagus'
lower end. The cardiac and pyloric sphincters are located in the stomach. The stomach converts
food into chime, a semifluid material, creates the intrinsic factor required for vitamin B12
absorption, and transports the contents of the stomach to the small intestine.
Small Intestine
It is roughly 6 meters long, and it is where the majority of digestion and nutritional
absorption happens. It also has to do with the hormones' production, which regulates the release
of bile, pancreatic juice, and intestinal juice. There are three sections: the duodenum, jejunum,
and ileum. The villi, which are finger-like projections on the mucosa, the microvilli, which are tiny
projections on the surface of epithelial cells, and the plicae circulars, which are circular folds on
the mucosa, are some of the structures in the small intestine that aid in absorption.
Large Intestine or Colon
It retains food scraps, absorbs extra water and electrolytes, and excretes waste in the form
of feces. Cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum
are the six segments that make up this organ.
Liver
It has four lobes: the left, right, caudate, and quadrate. It is situated in the right upper
quadrant of the abdomen beneath the diaphragm. It is made up of hepatic cells that extend
outward from a central vein. Bile is secreted by the hepatic cells, which also perform numerous
metabolic, endocrine, and secretory tasks. The liver detoxifies numerous pollutants in the plasma
in addition to metabolizing proteins, lipids, and carbs. In addition, it produces plasma proteins,
vital amino acids, and vitamin A, controls blood glucose levels, and secretes bile. It also converts
ammonia to urea.
Gallbladder
93
It is a little, pear-shaped structure that lies midway beneath the right liver lobe. The liver
produces bile, which it stores and concentrates before releasing it into the common bile duct for
transportation to the duodenum. Bile, a greenish liquid, emulsifies fat and aids in the absorption
of fatty acids, cholesterol, and lipids through the intestinal wall.
Pancreas
It is visible in the horizontal abdomen, behind the stomach. Its tail rests on the spleen,
while its head and neck touch the duodenal curvature. Exocrine and endocrine functions are under
its control. Its exocrine function is carried out by dispersed cells, which daily produce a large
number of digesting enzymes. The pancreatic duct receives secretions from clustered lobules and
lobes before running through the pancreas and joining the bile duct from the gallbladder to enter
the duodenum. Blood glucose levels trigger the release of the islets of Langerhans, which have
an endocrine function and are made up of beta cells that secrete insulin and alpha cells that emit
glucagon.
III.
SIGNS AND SYMPTOMS
Signs and Symptoms
Rationale
Abnormal flatulence
Flatulence occurs in gastroenteritis due to bacterial or
viral overgrowth and infection which causes buildup of
gas.
Nausea and vomiting
It is unknown why some people with gastroenteritis vomit
and get nauseous, however it is hypothesized that this is
because of peripheral sensations coming from the
gastrointestinal system, primarily through the vagus
nerve or by serotonin stimulation of the gut's 5hydroxytryptamine 3 (5HT3 receptors).
94
Diarrhea
Several viral activities cause diarrhea when the GI tract
becomes infected during gastroenteritis. Enterocytes, a
type of gut cell, are destroyed as a result of
malabsorption. The virus can also cause secretory
diarrhea, which causes the loose, watery stools, and
interfere with the body's ability to absorb water.
Abdominal pain and cramps
Inflammation and irritation of intestines occurs as well as
malabsorption which causes pain. Gastroenteritis is
caused by viruses and bacteria which could result in
bacterial or viral tummy bugs and inflicts pain and
cramps to patients.
Low grade fever
Inflammation and infection in the GI tract are present
thus fever is an indicative sign that the body is fighting
and infection.
Dehydration
Due to diarrhea and vomiting dehydration occurs and the
body excretes a lot of water into the system out because
of malabsorption and dysfunction of the GI tract.
Weight loss
Diarrhea and vomiting lessen the body fluid in a short
time.
Having
gastroenteritis
also
leads
to
poor
absorption of nutrients and leads to weight loss.
IV.
ETIOLOGY
Predisposing factors
Rationale
Age (Young children and older
Due to their underdeveloped immune systems, infants
adults)
and young children are more vulnerable than adults,
who are vulnerable due to compromised immune
95
systems. As for older adults, their immune systems.
Environment
Viral, bacterial, or parasitic infections can result in
infectious gastroenteritis. In each instance, the infection
starts when the agent is swallowed typically through
food and drink. Moreover, it can spread through tainted
food, drinks and environmental factors like things we
touch.
Precipitating factors
Rationale
Rotavirus
The most typical cause of viral gastroenteritis. Rotavirus
is most often spread through a fecal-oral route. This is
often because a child does not wash their hands
properly or often enough. It can also be caused by
eating or drinking contaminated food or water. The virus
may live on surfaces such as doorknobs, toys, and other
hard objects for a long time.
Norovirus
The majority of norovirus outbreaks occur when infected
individuals directly contact uninfected individuals, such
as by caring for them, sharing food, or using the same
eating utensils. Norovirus outbreaks can also be
sparked by contaminated food, water, and surfaces.
Poor personal hygiene
The Gastroenteritis virus can spread when people dont
thoroughly wash their hands after coming into contact
with feces and vomit. Moreover, it is possible to contract
it by breathing vomit droplets hanging in the air. (Mayo
Clinic 2023)
Poor food preparation
Foodborne acute gastroenteritis is linked to poor food
handling practices in the home. The two most important
risk factors for foodborne acute gastroenteritis are
96
inappropriate food storage and infrequent thorough
heating (Mayo Clinic,2023)
I.
PATHOPHYSIOLOGY
97
Narrative:
“Gastro” refers to the stomach, “Enter” refers to the small intestine, and “itis” refers to
inflammation. So there are really two different types of gastroenteritis. There's acute
gastroenteritis, and there's chronic gastroenteritis. acute gastroenteritis doesn't last very long. It's
usually about a few days to a week. Chronic gastroenteritis, on the other hand, is persistent and
lasts for a pretty long period of time. We're gonna mostly be talking about acute gastroenteritis.
So people have acute gastroenteritis, they don't usually say you know, like, I have acute
gastroenteritis, they usually say something like, you know, I have the stomach flu, or the stomach
bug, or a stomach virus. So anyone who said they've had this is kind of familiar with some of the
symptoms associated with it. So to look at those symptoms, why don't we actually look at the
gastrointestinal tract over here? So here's the stomach, and here's the small intestine in green.
So after you consume a meal, you know, you'll have some stuff in your stomach that your digestive
system is really trying to digest and then absorb. But when you have gastroenteritis, your digestive
tract can't do that. So now you have all this stuff that your body is going to want to expel. So how's
it going to do that? Well, it can either come out this way right through your esophagus, and that's
really why you experienced some vomiting and nausea. It can also come out from the other end
as well, right? And that's why a lot of people may experience diarrhea. So there's a lot of nutrients
and a lot of water that you've consumed, but your body isn't taking it because you're vomiting and
excreting a lot of water out. You're not getting that water into your system, so you'll be pretty badly
dehydrated as well. Some other symptoms could include things like abdominal pain, and a fever.
And usually an acute gastroenteritis. These symptoms last for about a few days to a week.
So what's causing all these symptoms? to occur? What causes gastroenteritis? We know
sometimes people call it the stomach flu and I think that can be a bit misleading. The ordinary flu
is caused by the influenza virus, but this virus has absolutely nothing to do with gastroenteritis.
There are a number of different infectious pathogens that can cause this instead. So you may
have some different viruses or some different bacteria. So a few examples, right. Some really
common examples of the many different pathogens would be you know, like the rotavirus, the
norovirus. So these are examples of viruses that could cause the disease. An example of a
bacteria would be something called intero toxigenic E. Coli. So this is just a really fancy name for
some bacteria that can cause a disease but all in all, there are a lot of other types of pathogens
98
that could cause it as well. So how do these pathogens get into your system to begin with? It's
usually through fecal to oral transmission. So your feces is the stuff that gets undigested and
doesn't get absorbed into your system and gets excreted as waste. That feces can contain the
pathogen. So it's contaminated and oral just refers to someone's mouth. So maybe someone with
gastroenteritis uses the bathroom and they wash their hands but not well enough. So their hands
might actually be contaminated with some of the pathogen and they may go on to touch other
objects, right surfaces and foods and water that you may touch. And then if you touch those with
your hands or if you eat the contaminated food or water then you can give the pathogen very easy
access to your own gastrointestinal system. So once it's in your system, what is it going to do?
So going back to our diagram over here, you have this wall that really kind of extends over
the entire gastrointestinal tract, you know, your stomach and your small intestine and so on and
so forth. So we call this wall or this lining the gastrointestinal wall. And this is where we're going
to be focusing on. So let's actually zoom in on that a bit. So here I kind of have a zoomed in picture
of that. And I want to mostly focus on this green structure over here. This green structure is just
the epithelium. It contains all of the cells that will be specialized for digestion and absorption. So
maybe you eat some food over here, right? That's been partially digested, but in the food that you
ate, maybe there was some of the pathogen. The pathogen is then going to invade the epithelium.
So it's going to invade those cells and those cells are going to die off. These epithelial cells are
going to kind of slough off of the lining over here. So maybe you'll have some dead epithelial cells
and partially digested food that you're trying to eat. So now you don't have those epithelial cells
to digest and absorb food and water. So you're going to actually have a lot of water here. And
instead of going into your system, it's just going to stay here, right so now you can't digest some
of the foods that may lead to some vomit
II.
MEDICAL MANAGEMENT
A. DIAGNOSTIC EXAMS
TEST
RATIONALE
NURSING
RESPONSIBILITIES
The physical examination can help
Physical Examination
●
Prepare the
identify the cause of gastroenteritis
examination room and
and evaluate whether or not there is
equipment.
any dehydration present. Body
●
Assist the patient
99
weight, blood pressure, pulse, and
ready for specific
temperature
physical examination
can
all
show
a
problem's seriousness. There can
●
Provide gown, drape,
be a slight temperature increase
and assist in
(Lin, 2019).
positioning the patient
as needed.
●
Assist the doctor
during the
examination/assessm
ent.
There is no other
Rapid stool test
other
quick test for
gastroenteritis
●
-causing
the procedure to the
viruses, but a rapid stool test can
immediately detect rotavirus and
Discuss the test and
patient.
●
norovirus (Mayo Clinic 2022).
Provide appropriate
specimen containers
and instruct on how to
The
Stool culture &
sensitivity
underlying
cause
of
properly obtain the
gastroenteritis can be determined
using a stool culture & sensitivity.
specimen.
●
The test aims to check the stool for
diaper in a leak proof
bacteria, viruses, or parasites. It is
an indication that the culture is
bag.
●
positive if infection-causing bacteria
develop.
Chemical
microscope
may
tests
be
or
used
discover the best medication for
treating the infection (Nall, 2022).
containers with
to
test is occasionally performed to
Use gloves in
collecting the
a
determine the type of germ. This
For infants, place the
specimens.
●
Make sure to label the
container
appropriately (e.g
Patient’s name,
Date/time, and name
procedure).
100
A sigmoidoscopy is a diagnostic
Sigmoidoscopy
●
procedure used to examine the
lower portion of the colon or large
Explain the procedure
to the client.
●
Provide privacy with
intestine. To check for symptoms of
curtains and adequate
inflammatory bowel disease, the
draping.
doctor will insert a thin, flexible tube
●
Observe the client for
with a tiny camera from the anus
signs of perforation,
into the lower large intestine.The
such as bleeding,
sigmoidoscopy takes 15 minutes
liver, etc.
and is typically performed without
●
sedation (Cleveland Clinic 2023).
Make sure to label the
container correctly
and send the
specimen to the
laboratory.
B. MEDS
1. Antibiotics (Bacterial Gastroenteritis)
-
Bacterial gastroenteritis is sometimes treated with antibiotics. Antibiotics work to cure
some forms of bacterial gastroenteritis within a few days. Generally, the modes of action
of antibiotics for interference with cell walls.
GENERIC NAME
AMPICILLIN
BRAND NAME
Ampicin
DRUG CLASSIFICATION
PHARMACOTHERAPEUTIC: aminopenicillin
THERAPEUTIC: antibiotic
101
SUGGESTED DOSE
For Gastrointestinal Tract Infections:
PO
Adult dosage
— Typical dosage is 500 mg
— Four times per day.
Child dosage
(children who weigh more than 20 kg)
— Typical dosage is 500 mg
— Four times per day.
(children who weigh 20 kg or less)
— Typical dosage is 100 mg/kg per day
— Four equally divided and spaced doses
IV/IM
Adult dosage
<40 kg: 50 mg/kg/day — divided q6-8hr
≥40 kg: 500 mg; larger doses may be necessary in severe or
chronic infection — q6hr
Child dosage
<40 kg: 50-100 mg/kg/day — divided q6hr
≥40 kg: 500 mg — q6hr
ROUTE
OF PO, IV/IM
ADMINISTRATION
MODE OF ACTION
Exerts bactericidal activity via inhibition of bacterial cell wall
synthesis by binding one or more of the penicillin binding
proteins (PBPs). Exerts bacterial autolytic effect by inhibition of
certain PBPs related to the activation of a bacterial autolytic
process.
INDICATION
Infections of the Genitourinary Tract: including Gonorrhea, E.
coli, P. mirabilis, enterococci, Shigella, S. typhosa and other
102
Salmonella, and non penicillinase-producing N. gonorrhoeae.
Infections of the Respiratory Tract: Nonpenicillinase-producing
H. influenzae and staphylococci, and streptococci including
streptococcus pneumoniae.
Infections of the Gastrointestinal Tract: Shigella, S. typhosa and
other Salmonella, E. coli, P. mirabilis, and enterococci.
Meningitis: O. Meningitidis.
CONTRAINDICATION
●
Hypersensitivity reaction to any of the penicillins
●
Diarrhea from an infection with Clostridium difficile
bacteria
●
SIDE EFFECTS
Infectious mononucleosis.
FREQUENT
●
Nausea
●
Vomiting
●
Diarrhea
●
Rash
RARE
●
Hairy Tongue
●
Serum Sickness Reaction
●
Skin Disorder
●
Allergic Reaction Causing Inflammation of Blood
Vessels
ADVERSE EFFECTS
●
Damage To The Liver And Inflammation
●
Decreased Blood Platelets
●
Seizures
●
The Appearance Of Crystals In The Urine
●
Vocal Cord Swelling
●
Cardiovascular: Lethargy & hallucinations
103
●
Digestive: Glossitis, stomatitis, enterocolitis, &
pseudomembranous colitis
●
Liver: Moderate elevation in serum glutamic oxaloacetic
transaminase (SGOT)
●
Hematologic: Bone marrow depression, hemolytic
anemia; positive tests for antinuclear antibody, and
positive Coombs test.
●
DRUG INTERACTIONS
Others: Laryngeal stride and high fever
DRUG:
●
Probenecid with ampicillin can cause more side effects.
These can include severe nausea, vomiting, and
diarrhea.
●
Allopurinol increases the risk of skin rash when you
take it with ampicillin.
●
Chloramphenicol, macrolides, sulfonamides, and
tetracyclines can make penicillin less effective because
these antibiotics stop the growth of bacteria, and
ampicillin needs bacteria to grow in order to kill them.
LAB:
●
Elevate AST, ALT
FOOD:
●
NURSING
RESPONSIBILITIES
Decreased effect with acidic or juice
Baseline Assessment
●
Obtain patient’s health and allergic history.
●
Monitor vitals signs.
Intervention/Evaluation
104
●
Requests for laboratory tests such as rapid stool tests
as ordered by the physician.
●
Check IV site carefully for signs of thrombosis or drug
reaction.
●
Do not give IM injections in the same site; atrophy can
occur. Monitor injection sites.
●
Administer oral drug on an empty stomach should be 1
hr before or 2 hr after meals with a full glass of water; do
not give with fruit juice or soft drinks.
Patient/Family Teaching
●
The patient must take the drug at the appropriate time.
●
The patient should also take the full course of therapy;
do not stop taking the drug if you feel better.
●
Explain to patient/s that they might experience these
side effects: Nausea, vomiting, GI upset (eat frequent
small meals), diarrhea.
●
Discuss to the patient to immediately report pain or
discomfort at sites, unusual bleeding or bruising, mouth
sores, rash, hives, fever, itching, severe diarrhea,
difficulty breathing.
2. Antidiarrheal agents (Viral Gastroenteritis)
-
Antidiarrheals work by reducing the flow of fluids and electrolytes into the bowel and
slowing down the movement of the bowel to decrease the number of bowel movements.
This allows more fluid to be absorbed into your body, which helps with less diarrhea and
more formed and bulky stools.
GENERIC NAME
LOPERAMIDE
105
BRAND NAME
Imodium
DRUG CLASSIFICATION
PHARMACOTHERAPEUTIC: Adsorbents
CLINICAL: Antidiarrheal agents
SUGGESTED DOSE
For the treatment of Acute Diarrhea:
Oral administration (Capsule)
●
Adults and children 13 years of age and older
-
At first, 4 milligrams (mg) (2 capsules) after the first
loose bowel movement, then 2 mg (1 capsule) after
each loose bowel movement after the first dose has
been taken. However, dose is usually not more than 16
mg (8 capsules).
●
Children 8 to 12 years of age weighing more than 30
kilograms (kg)
-
2 mg (1 capsule) 3 times a day.
●
Children 6 to 8 years of age weighing 20 to 30 kg
-
2 mg (1 capsule) 2 times a day.
Oral administration (Oral solution)
●
Children 8 to 12 years of age weighing more than 30
kilograms (kg)
-
2 teaspoonfuls (2 mg) 3 times a day
●
Children 6 to 8 years of age weighing 20 to 30 kg
-
2 teaspoonfuls (2 mg) 3 times a day.
●
Children 2 to 5 years of age weighing 13 to 20 kg
-
1 teaspoonful (1 mg) 3 times a day.
106
For the treatment Chronic Diarrhea:
Oral administration
●
Adults
-
At first, 4 milligrams (mg) (2 capsules) after the first
loose bowel movement, then 2 mg (1 capsule) after
each loose bowel movement after the first dose has
been taken. Doctor may adjust your dose as needed.
ROUTE
●
Children 2 years of age and older
-
Use and dose must be determined by the doctor.
OF PO
ADMINISTRATION
MODE OF ACTION
It acts by slowing intestinal motility and by affecting water and
electrolyte movement through the bowel. Loperamide binds to
the opiate receptor in the gut wall.
INDICATION
CONTRAINDICATION
People with:
●
Chronic diarrhea in Adults
●
Infectious diarrhea in Adults
●
Bacterial Gastroenteritis
●
Irritable Bowel Syndrome
●
known hypersensitivity to loperamide hydrochloride or to
any of the excipients
●
torsades de pointes, a type of abnormal heart rhythm.
●
prolonged QT interval on EKG.
●
abnormal EKG with QT changes from birth.
●
paralysis of the intestines.
●
liver problems.
●
bloody diarrhea.
107
SIDE EFFECTS
ADVERSE EFFECTS
DRUG INTERACTIONS
●
Dizziness
●
Drowsiness
●
Tiredness
●
Constipation
●
stomach pain
●
skin rash
●
itching
●
severe constipation
●
severe nausea
●
severe vomiting
●
stomach or abdominal pain
●
uncomfortable fullness of the stomach or abdomen
●
Pramlintide
●
recent/current antibiotic use
●
drugs that can cause constipation
○
Anticholinergics
■
○
Antispasmodics
■
○
RESPONSIBILITIES
Diphenhydramine
tricyclic antidepressants
■
NURSING
Morphine
certain antihistamines
■
○
glycopyrrolate/oxybutynin
potent opioid pain medicines
■
○
belladonna/scopolamine
Amitriptyline
Baseline assessment
●
Assess the type and severity of the Diarrhea
●
Assess for presence of pain in the abdomen area
●
Assess patient allergies
108
●
Review past medical history
Intervention/evaluation
●
Monitor pulse, B/P, VS
●
Assist patient in a comfortable position
●
Administer oxygen if prescribed by physician
●
Assess for clinical improvement
Patient/family teaching
●
Inform patient about the likelihood of side effects like
dizziness, drowsiness, tiredness, constipation, stomach
pain, skin rash, or skin itching
●
Acquire adequate rest
●
Acquire adequate nutrition
●
Avoid tasks requiring exertion.
●
Report any presence of severe constipation, severe
nausea, severe vomiting, stomach or abdominal pain, or
uncomfortable fullness of the stomach or abdomen.
3. Antiemetics
-
Antiemetics are medications aimed at preventing or treating nausea and vomiting, which
are common symptoms that may be linked to numerous causes.
GENERIC NAME
BRAND NAME
ONDANSETRON
Zofran
109
DRUG CLASSIFICATION
SUGGESTED DOSE
Selective 5-HT3 Antagonist
●
Injectable Solution
○
●
●
Tablet
○
4mg
○
8mg
○
24mg
Oral Solution
○
●
●
ROUTE
2mg/mL
4mg/5mL
Oral Soluble Film
○
4mg
○
8mg
Orally Disintegrating Tablets
○
4mg
○
8mg
OF PO, IV
ADMINISTRATION
MODE OF ACTION
It works by blocking the action of serotonin, a natural
substance that may cause nausea and vomiting.
INDICATION
Used to prevent nausea and vomiting caused by cancer
chemotherapy, radiation therapy, and surgery. Recently,
ondansetron has been used to control vomiting related to
acute gastroenteritis.
CONTRAINDICATION
●
Contraindicated to those known to have hypersensitivity
(e.g., anaphylaxis) to ondansetron or any of the
components of the formulation
SIDE EFFECTS
More common
● Confusion
110
● dizziness/drowsiness
● fast heartbeat
● fever
● headache
● trouble breathing
ADVERSE EFFECTS
●
General: rare cases of hypersensitivity reactions,
sometimes severe (acute allergic reactions, rapid
swelling, difficulty breathing, cardiopulmonary arrest,
low blood pressure, laryngeal edema)
●
Local reactions: pain, redness, and burning at the
injection site
●
Lower respiratory: hiccups
●
Neurological: involuntary intermittent or sustained
deviation of the eyes
●
Cardiac: heart rate irregularities, palpitations, fainting
●
Skin and subcutaneous tissue: hives, Stevens-Johnson
syndrome, toxic epidermal necrolysis
DRUG INTERACTIONS
DRUG:
●
Selective serotonin reuptake inhibitors (SSRIs): causes
a possible interaction with SSRIs. Taking it with an SSRI
can raise the risk of a condition called serotonin
syndrome.
●
Certain
antibiotics
(Fluoroquinolones,
Macrolides):
Taking them with ondansetron can cause a higher
chance of an irregular heartbeat.
●
Heart rhythm medications (Quinidine, Amiodarone,
Sotalol): Combining these medications with ondansetron
raises chances of having heart rhythm problems.
NURSING
RESPONSIBILITIES
Baseline Assessment
●
Obtain patient’s health and allergic history.
111
●
Monitor vitals signs.
Intervention/Evaluation
●
Monitor improvements in GI symptoms (decreased
nausea and vomiting, increased appetite) to help
document whether drug therapy is successful.
●
Assess dizziness and drowsiness that might affect gait,
balance, and other functional activities
Patient/Family Teaching
●
Instruct patient to report bothersome side effects such
as severe or prolonged headache, weakness, fatigue, or
GI problems.
●
Explain to patient that the drug can be taken with or
without food.
●
Emphasize the importance of following the doctor's
dosing instructions very carefully.
C. TREATMENT
THERAPY
RATIONALE
NURSING
RESPONSIBILITIES
A type of fluid replacement
Oral rehydration therapy
●
Assess the severity of
utilized to prevent and treat
the dehydration of the
dehydration, primarily due to
patient.
diarrhea. It involves consuming
●
Explain
to
the
water with small salts, mainly
patient/family the steps
sodium, potassium, and sugar.
in preparing ORS.
A nasogastric tube can also be
used
to
rehydration
●
Monitor
the
patient
administer
oral
regularly to check if
treatment.
Oral
treatment is effective.
rehydration therapy is equally
effective as intravenous therapy
112
(Rehydreate.org 2019).
IV therapy
IV fluids are specially prepared
●
Assess the IV site every
liquids that are injected into a
1 to 2 hours or more
vein
frequently if required.
to
prevent
or
treat
dehydration. They are used in
●
people of all ages who are
unwell, injured, or dehydrated.
Calculate and ensure
designated flow rate.
●
Monitor for any signs of
Intravenous rehydration is a
unusualities
simple,
phlebitis or infiltration.
safe
and
standard
procedure with a low risk of
●
complications (Cleveland Clinic
as
Document actions and
observations.
●
2021).
such
Immediately report any
significant unusualities.
Maintain good personal
hygiene
One of the best defenses Health Teachings
against
gastrointestinal
or
●
infectious diseases is good
personal hygiene since it ward
Establish rapport to the
patient and family.
●
Explain the importance
off bacteria to prevent infections
of
(HealthDirect 2021).
personal hygiene.
●
Maintain clean & safe
Keeping the environment clean
environment
is crucial to being healthy. Many
through
good
personal hygiene and keeping
the environment clean (Taylor
the
to
safe environment. Such
as; disinfecting & proper
ones that cause diarrhea and
prevented
Instruct
maintain a clean and
dirty environments, such as the
that many diseases can be
good
patient/family
disease-causing germs live in
other infections. This implies
maintaining
waste management.
●
Encourage
patient/family
the
to
only
consume foods that do
not worsen symptoms.
Such as bland, easy-to-
2020).
113
Avoid specific foods or
Avoid foods that can trigger and
digest foods; crackers,
substances
worsen symptoms such as full-
toast, gelatin, bananas,
fat dairy products, such as
and applesauce.
whole milk and ice cream, and
sugary foods, such as sodas
and candy. Instead, consume
foods or drinks with potassium,
such as fruit juice and bananas
(Mayo Clinic 2021).
III.
SURGICAL MANAGEMENT
No surgical management is available for gastroenteritis.
IV.
NURSING MANAGEMENT
NURSING DIAGNOSIS
Acute
Pain
related
GOAL
to After
1
hour
INTERVENTION
of
nursing
1. Perform
a
Inflammation of the lining in intervention, the patient will be
comprehensive
the stomach and intestines as able
assessment
to
report
decreased
evidenced by cramps and abdominal pain of 1/10 and R: Identifying the location,
abdominal discomfort
improve comfort.
intensity,
frequency,
characteristics
pain
is
Rationale:
critical
Inflammation of the stomach,
underlying
small, and large intestines is
abdominal
referred to as gastroenteritis.
effectiveness of the current
Viral
treatment regimen.
gastroenteritis
infection
that
can
is
an
in
of
and
determining
the
cause
of
pain
and
the
induce
vomiting or diarrhea and is
2. Review and assess
brought on by a number of
diagnostic studies.
different viruses. Abdominal
R: Ultrasounds, abdominal x-
cramps,
rays, and CT scans may be
diarrhea,
and
114
vomiting
are
symptoms.
just
The
immune system
inflammation
by
a
few
body's
reacts
performed to help diagnose
the underlying condition.
to
releasing
3. Provide
cytokines and prostaglandins,
which
increase
vascular
medications
as ordered.
R: Analgesics and sedatives
permeability and create pain
are
provided
in the patient's abdomen.
management
for
pain
and
relief.
Medications to relieve gas,
nausea,
constipation,
and
diarrhea may also relieve
pain.
4. Assist to a position of
comfort.
R: Abdominal pain may be
relieved
with
position
a
that
specific
promotes
comfort. A knee-to-chest or
side-lying position tends to
decrease
the
intensity
of
abdominal pain. Raising the
head of the bed may also
relieve symptoms.
5. Provide
nonpharmacologic
pain management.
R:
Nonpharmacologic
methods in pain management
may
include
physical,
cognitive-behavioral
strategies.
115
6. Insert
nasogastric
(NG) tube.
R: With specific diagnoses
such as bowel obstruction,
bowel rest, and the insertion of
an NG tube is required to
decompress the stomach.
7. Assist
in
surgical
intervention.
R:
Depending
underlying
on
cause,
the
surgery
may be indicated in patients
with abdominal pain. Assist
and prepare the patient for
surgery as ordered.
Imbalanced
Than
Nutrition:
Body
Less After
2
days
of
nursing
1. Establish rapport
Requirements intervention, the patient will be R: To gain cooperation and
related to inadequate food able to consume adequate create
intake
as
evidenced
by nutrition,
nausea and vomiting
and
a
harmonious
identify relationship with the patient.
appropriate nutritional needs.
2. Measure client weight.
Rationale:
Vomiting
symptoms
disease
R: This will accurately monitor
is
one
of
a
of
the response to therapy.
common
known
gastroenteritis.
the
Usually,
as
3. Monitor and record the
a
number of vomiting,
bacterial or viral stomach virus
amount,
is the cause. Although it
frequency.
and
affects people of all ages,
116
young
children
susceptible.
Cumpian,
most
R: These data will help in
According
to
initiating nursing actions and
(2021),
a
subsequent treatment.
T.
are
balanced diet is essential for a
person's
health
and
well-
being. Imbalanced Nutrition
4. Monitor
the
client’s
food intake.
refers to food that is either too
R: To determine the amount of
much or too little for the body's
food that is consumed.
needs which any person can
experience.
5. Encourage
small,
frequent feedings.
R: Consistently offering the
patient something to eat can
improve their
total
caloric
intake. This can also prevent
dehydration, weight loss, and
constipation.
6. Provide a diverse diet
according
to
his
needs.
R: This will stimulate the
appetite of the client.
7. Provide
parenteral
fluids, as ordered.
R: To ensure adequate fluid
and electrolyte levels.
8. Refer to a dietitian if
indicated.
117
R:
Collaboration
with
the
dietician in order to guide the
client about proper nutrition.
Diarrhea related to bacterial After
8
hours
of
nursing
1. Inquire
about
the
infection as evidenced by intervention, the patient will be
patient's
watery stool more than 3 times able to release soft, formed
history: If the patient
a day
consumes
stool not more than 3 times.
recent
untreated
water. If the patient
Rationale:
consumes
According to Cleveland Clinic
undercooked
(2020), diarrhea is the primary
The last time when the
sign of gastroenteritis. Multiple
patient consumed raw
viral activities cause diarrhea
dairy products.
food.
when the GI tract becomes
R:
Consumption
infected during gastroenteritis.
contaminated foods or water
Enterocytes, which are gut
may expose the patient to
cells, are destroyed when
intestinal
there is malabsorption. The
intervention
virus can also cause secretory
doctor
diarrhea, which causes loose,
cause of intestinal infection.
watery stools, and interfere
Thus, he will be able to treat
with the body's ability to
the
absorb water.
appropriately.
infection.
will
know
patient's
help
the
of
This
the
possible
condition
2. Examine the patient's
feces pattern.
R:
If
the
doctor
is
knowledgeable of the patient's
feces pattern, he will be able
to
prescribe
appropriate
treatment immediately.
118
3. Examine the patient
for
abdominal
discomfort,
cramps,
hyperactive
bowel
movements,
recurrence,
urgency,
and watery stool.
R: These assessment findings
are frequently associated with
diarrhea. When gastroenteritis
affects the large intestine, the
colon cannot absorb water,
resulting in excessively watery
feces.
4. Submit the patient's
stool of the patient for
culture.
R: A culture is a test that
determines
microorganisms
which
trigger
an
infection.
5. Teach the patient the
necessity of cleaning
their hands after every
bowel movement and
before cooking meals
for others
R: Contaminated hands can
rapidly
microorganisms to
spread
utensils
119
and surfaces used in food
preparation.
This
hand
washing after each bowel
movement
is
the
most
effective strategy to avoid
infection
transmission
to
others.
6. After
each
movement,
the
bowel
educate
patient
about
perianal hygiene.
R: The anal area should be
thoroughly cleaned to avoid
skin
irritation
and
microorganism dissemination
after a bowel movement.
7. Advise the patient to
drink 1.5 to 2.5 liters of
liquids per 24 hours,
adding
200
ml
every
watery
for
stool,
otherwise
contraindicated.
R: Fluid lost in liquid stools is
replaced by increasing fluid
intake.
8. Advise the patient to
limit
his
or
her
consumption of coffee,
120
milk,
and
dairy
products.
R: These foods can upset the
stomach
lining
and
so
aggravate diarrhea.
9. Encourage patients to
consume
potassium-
rich meals.
R:
When
a
experiences
patient
persistent
diarrhea, the potassium-rich
stomach contents are flushed
out of the gastrointestinal
system into the feces and out
of
the
body,
leading
to
hypokalemia.
10. Advise the patient to
take
antidiarrheal
drugs as directed by
the
health
care
provider.
R: Adsorbent antidiarrheals
are often used to manage
gastroenteritis diarrhea. This
class
of
antidiarrheal
medications coats the gut
membrane
and
absorbs
bacterial toxins.
V.
LITERATURE
Acute Infectious Gastroenteritis in Infancy and Childhood
121
Posovszky, C., Buderus, S., Claßen, M., Lawrenz, B., Keller, K. M., & Koletzko, S. (2020b).
Acute Infectious Gastroenteritis in Infancy and Childhood. Deutsches Ärzteblatt International.
https://doi.org/10.3238/arztebl.2020.0615
According to Posovszky et al. (2020), acute infectious gastroenteritis is the second most
common non-traumatic cause of emergency hospitalization in children aged 1 to 5 years,
accounting for about 9% of cases, despite the introduction of the rotavirus vaccine and the fact
that it is frequently treated on an outpatient basis (39,410 cases in 2017% of adenovirus).
Globally, acute infectious gastroenteritis causes the deaths of close to 500,000 children
under the age of five every year. Infants and toddlers are sick one to two times a year on average
in Europe. Five children died out of the over 40 000 children under five who were hospitalized in
Germany in 2017 for acute infectious gastroenteritis, which represented about 9% of all
hospitalizations for illnesses other than trauma in this age range. In hospitalized children under
the age of 5, viral infections accounted for 93% of cases, with rotavirus accounting for 47%,
norovirus for 29%, and adenovirus for 14%. Due to their high daily fluid requirements of 100 to
160 mL per kilogram of body weight, infants and toddlers are particularly vulnerable.
The result of the study shows that weight loss and other clinical observations can be used
to determine the degree of dehydration. Oral rehydration with oral rehydration solution was just
as effective as intravenous rehydration with regard to weight gain, the length of diarrhea, and fluid
administration, and was linked to shorter hospital stays in 17 randomized controlled trials on a
total of 1811 kids with mild or moderate dehydration. Continuous nasogastric administration is the
first line of treatment for children who are vomiting or who reject oral rehydration solutions given
that it is equally as effective as intravenous rehydration. To conclude, despite the fact that
ambulatory oral rehydration is strongly supported by the available research, children in Germany
who are mildly or moderately dehydrated are frequently hospitalized for intravenous rehydration
therapy. Reducing unnecessary hospitalizations and consequently lowering the risk of nosocomial
infection requires overcoming barriers to intersectoral care, a staffing shortage, and inadequate
access.
Antiemetics in Children with Acute Gastroenteritis
Niño-Serna, L. F., Acosta-Reyes, J., Veroniki, A. A., & Florez, I. D. (2020). Antiemetics in
Children With Acute Gastroenteritis: A Meta-analysis. Pediatrics, 145(4).
https://doi.org/10.1542/peds.2019-3260
122
Fedorowicz et al., who first compiled the data on antiemetics for acute DG. In this study,
ondansetron showed a significant impact on the requirement for intravenous rehydration and the
cessation of vomiting. Dimenhydrinate showed a favorable effect on the length of vomiting;
however, metoclopramide was found to be effective in reducing vomiting bouts and hospital
admissions. However, the authors only included seven trials and did not compare antiemetics
between them. In a later network meta-analysis (NMA), Carter et al. included all antiemetics for
which there was data at the time. The best strategy, according to the authors, was ondansetron,
which also decreased hospitalizations, the requirement for intravenous rehydration, and vomiting.
Ondansetron was linked to an increase in diarrhea; therefore, this prompted some questions.
Numerous RCTs comparing various antiemetics to a placebo or to one another have been
published in the past ten years but have not yet been synthesized. New data have been made
public specifically from trials looking at ondansetron, metoclopramide, domperidone, and
dexamethasone. There is presently no systematic review or NMA comparing all the antiemetics
currently on the market for children with ADG. In order to compare antiemetics, directly and
indirectly, using an NMA, we sought to evaluate their relative efficacy and safety in children with
ADG. The result of the study shows that, in comparison to the placebo, ondansetron showed the
most improvement in the prevention of vomiting. The only treatment that decreased the frequency
of vomiting episodes and the requirement for intravenous rehydration was ondansetron.
Dimenhydrinate was the only treatment worse than placebo in terms of side effects.
CROHN’S DISEASE
I.
DEFINITION
In 1932, Crohn, Ginzburg, and Oppenheimer presented a case series at the annual
meeting of the American Medical Association that was the first to identify Crohn's Disease (CD),
a chronic inflammatory bowel disease, as regional ileitis. (Petagna et al., 2020). It has a
progressive and destructive course, is characterized by chronic inflammation of any part of the
gastrointestinal tract, and is becoming more common worldwide. The deregulation of the immune
system, changed bacteria, genetic vulnerability, and environmental variables are some factors of
Crohn's disease. Still, the cause of the disease remains unknown. (Roda et al., 2020). Although
less invasive biomarkers are in development, diagnosis still relies on endoscopy and histological
assessment of biopsy specimens.
II.
ANATOMY/ PHYSIOLOGY
Mouth
123
This oval-shaped opening in your skull starts at your lips and ends at your throat. The two
main functions of the mouth are eating and speaking. Parts of the mouth include the lips, vestibule,
mouth cavity, gums, teeth, hard and soft palate, tongue and salivary glands.
Esophagus
The primary function of the esophagus is to transport food entering the mouth through the
throat and into the stomach. This function begins at the very beginning of the esophagus, following
some taste buds located on the organ, at the upper esophageal sphincter (UES). Once you begin
swallowing, the process becomes automatic. Your brain signals the muscles of the esophagus
and peristalsis begins.
Stomach
After food enters your stomach, the stomach muscles mix the food and liquid with digestive juices.
The stomach slowly empties its contents, called chyme, into your small intestine. The stomach
serves as a temporary receptacle for storage and mechanical distribution of food before it is
passed into the intestine.
Large Intestine
Any part of the digestive tract from the mouth to the anus can be involved in Crohn's
disease, although it most commonly affects the end of the small intestine called the terminal ileum
and the beginning of the large intestine called the cecum. The main function of cecum is to absorb
fluids and salts that remain after completion of intestinal digestion and absorption and to mix its
contents with a lubricating substance, mucus. The internal wall of the cecum is composed of a
thick mucous membrane, through which water and salts are absorbed. According to expanding
knowledge on the role of cecum, it is an essential organ for maintaining a diverse and
physiologically beneficial microbiota in the colon.
124
Any undigested material moves to the large intestine. The large intestine or colon has four
sections called the 1) cecum/ascending colon, 2) transverse colon, 3) descending colon/sigmoid,
and 4) rectum. The main job of the large intestine is to remove water and salts (electrolytes) from
the undigested material and to form solid waste (feces) that can be excreted. The remaining
contents of the large intestine move to the rectum, where feces are stored until they leave the
body through the anus as a bowel movement.
III.
SIGNS AND SYMPTOMS
SIGNS & SYMPTOMS
RATIONALE
Bloating
According to Chron's and Colitis Canada, 2019, As food is
absorbed poorly by small intestines, more undigested food
reaches the colon, in that the bacteria in the colon can digest
it but, in turn, produces more gas, thus causing bloating.
Constipation
Crohn's disease can cause a section of the intestines to
narrow due to severe inflammation. This section is called a
stricture, which can block or slow the passage of stool or
digested food through the bowels, leading to constipation.
(Stuart, 2019)
Fever
A fever sometimes develops when the intestine becomes
inflamed. There may also be an infection with Crohn's, or
medications can cause agitation to help treat the disease.
(Temple Health Org, 2023)
Weight Loss
The upset stomach and stress that come with an episode of
Crohn's can make it difficult, or even unappealing, to eat,
causing weight loss or loss of appetite. (Temple Health Org,
2023)
Pain or bleeding with a bowel
Crohn's can lead to tears (fissures) in the lining of the anus,
movement
which may cause pain and bleeding, especially during bowel
movements, as well as infection. (Creaky Joints Org, 2020)
125
Mouth Sores
The digestive system becomes damaged for people with
Crohn's and can't properly absorb vitamins and minerals.
Those deficiencies, paired with inflammation, can result in
canker sores in the mouth. (Creaky Joints Org, 2020)
IV.
ETIOLOGY
Predisposing factors
Rationale
Age
While Crohn's disease can affect people of all ages, it’s
primarily an illness of the young. Most people are diagnosed
before age 30, but the disease can happen in people in their
50s, 60s, 70s, or even later in life (WebMD, 2022).
Ethnicity
Although Crohn's disease can affect any ethnic group, whites
have the highest risk, especially people of Eastern European
(Ashkenazi) Jewish descent. However, the incidence of
Crohn's disease is increasing among Black people who live
in North America and the United Kingdom. Crohn's disease
is also being increasingly seen in the Middle Eastern
population and among migrants to the United States (Mayo
Clinic, 2020).
Family history
Although the condition is not hereditary, it appears to run in
some families, as it is present in more than one family in
roughly 15% of cases. You're at higher risk if you have a firstdegree relative, such as a parent, sibling or child, with the
disease. As many as 1 in 5 people with Crohn's disease has
a family member with the disease (Mayo Clinic, 2020).
126
Sex
Women are more likely than men to have Crohn's disease,
but men are more likely to develop ulcerative colitis. Crohn's
disease is 1.1-1.8 times more common in women than in men
(Ehrlich, 2021).
Precipitating factors
Rationale
Cigarette Smoking
Smoking can raise your risk of developing Crohn's disease and
make the condition worse and more difficult to cure. Smokers
experience more severe Crohn's symptoms as well as more
relapses. Individuals with Crohn's who smoke may experience
the following: Severer symptoms and consequences, such as
strictures, which are narrowings in the intestine that can result
in hazardous blockages (Watson, 2022).
Nonsteroidal Anti-
The American College of Gastroenterology recommends that
Inflammatory Drug
people with Crohn's avoid NSAIDs when possible because
they could cause symptom flare-ups as well as stomach or
intestinal ulcers. Using NSAIDs raises your risk of an
emergency hospital admission for your Crohn's (Winsborough,
2022).
High Fat Diet
A high fat diet may lead to specific changes in gut bacteria that
could fight harmful inflammation. Diets high in animal fats are
associated with increased risks of inflammatory bowel
disease, but the mechanism remains unclear (Li et al., 2019).
Use of Oral Contraceptives
Research has shown that combination birth control pills aren’t
kind to your gut. They could raise your risk of Crohn’s disease
by 24% to 50%, especially if you have certain genes. And
people with Crohn’s who use the pill are more likely to have
severe symptoms and need surgery for their disease (Rath,
2022).
127
V.
PATHOPHYSIOLOGY
128
129
130
Narrative:
Crohn’s disease is an inflammatory bowel disease that causes inflammation and ulcer
formation in the GI tract. Although the disease can be found anywhere in the GI tract, from the
mouth to the anus, it is most commonly found in the terminal ileum and the beginning of the colon
in a skip lesion pattern or scattered patches.
The mechanism behind the skipping pattern
of lesions is still unclear however, this is a distinguishing characteristic of Crohn’s disease to
Ulcerative colitis.
The etiology of the disease is still unknown and the mechanism of IBD is not fully
understood yet, all that is known is that it is caused by a faulty immune system. However, there
are several factors that contribute to the progression of the disease, including age, ethnicity, family
history and sex. On the other hand, there are also precipitating factors that affect the disease
including cigarette smoking, NSAIDs, high fat diet, and the use of oral contraceptives.
These factors have the potential to either impaired barrier function or activate m-cells,
which is the main pathway for starting the production of mucosal immunoglobulin A (IgA), the one
that protects mucosal tissues against microbial invasion and commensal enteric bacteria. As a
result of the m-cells' function, antigens from the lumen are delivered to the mucosal tissues, where
they trigger the activation of immune cells. Once activated, the creation of immunoglobulins by
activated B cells allows them to pass through the bloodstream, penetrate other body fluids, and
bind specifically to the foreign antigen that initially induced their formation. Once the antigen binds
131
to the receptor, it causes the release of inflammatory mediators. The antigen-presenting cell,
which is the macrophage, will process these antigens and present them to the CD4 T cells. After
that, the CD4 T-cell is activated, which may result in one of two outcomes. First, the adjacent
macrophages are stimulated and further activated by the CD4 T cell, and second, both the CD4
and the macrophages start releasing a lot of cytokines, such as TNF alpha and interleukin 1 & 6.
The ongoing release of these cytokines may result in chronic inflammation. It is the production of
cytokines and chronic inflammation that produces the local and systemic problems associated
with inflammatory bowel disease. After the chronic inflammation, the GI tract lining will experience
transmural systemic inflammation, which means that the entire intestinal layer—from the mucosa
to the serosa—has already suffered damage. This could occur across the entire GI tract from the
mouth to the anus in random patches, but it only occurs frequently in the terminal region of the
ileum up to the cecum, and that is what we now refer to as Crohn's disease.
Furthermore, a person with Crohn's disease may experience periods of remission and
flare-ups, which may also be brought on by certain food, lifestyle, and environmental variables.
When the GI tract's blood vessels become more permeable throughout this time of remissions
and flare-ups, more fluid may seep into the GI tract and result in severe intestinal damage. On the
other hand, persistent inflammation prevents healing, which led to the deposition of an
extracellular matrix to support preserving the body's equilibrium. However, an excessive
extracellular matrix along with the fluids that had leaked within the GI tract can cause tissue
scarring which will lead to a stricture – a narrowing of GI lumen that can cause bowel obstruction.
Crohn’s disease damages mucosal epithelial cells thus leading to apoptosis and ulceration
within the affected area. This event could cause prolonged bleeding which can lead to
complications like anemia, disappearing transport proteins because of the programmed cell death
and can lead to inability of the lumen to absorb sodium and water causing diarrheal problems,
and microperforations through the intestinal wall because of the ulcerations. The initial problem
that had occurred because of the stricture and these microperforations could predispose abscess
formation – a swollen area containing pus that might actually leak. When abscesses are drained,
a passage may remain between the anal gland and the skin, resulting in a fistula. Since Crohn’s
disease affects the entirety of the GI tract, it can also cause damage within the small intestine and
could lead to the scarring of the intestinal villi within the area which could actually lead to bloating
or worse, weight loss.
When left untreated, all of these conditions could result in organ sepsis, colon cancer,
severe joint, skin, eye, mouth, and liver problems, as well as subsequent complications that could
result in death and a poor prognosis. Crohn's disease doesn't have a cure however, when
132
managed with specific medications and surgical care, combined with some adjustments in lifestyle
and diet it could lead to a good prognosis.
VI.
MEDICAL MANAGEMENT
A. DIAGNOSTIC EXAMS
TEST
Blood Tests
RATIONALE
NURSING RESPONSIBILITIES
The main characteristic of Crohn's Before the procedure:
disease and ulcerative colitis is
●
Explain the test procedure.
inflammation in the gastrointestinal
About what type of sample
tract. White blood cells are attracted
is needed, how it will be
to sites of inflammation. These tests
collected,
check
equipment to use.
for
signs
of
infection,
inflammation, internal bleeding, and
●
and
what
Explain
that
low levels of substances such as
discomfort
may
iron, protein, or minerals.
when the skin is punctured.
●
slight
be
felt
Apply manual pressure and
dressings
puncture
over
site
the
after
the
blood is drawn.
After the procedure:
●
Monitor the puncture site
for oozing or hematoma
formation.
●
Instruct to resume normal
activities and diet.
Stool Culture
Blood in your stool is a sign of Before the procedure:
digestive
problems,
such
as
●
Assess the patient’s level of
Crohn's disease. They may also
comfort.
Collecting stool
order stool tests to check for
specimens may produce a
disease-causing organisms in your
feeling of embarrassment
digestive tract. This can help them
and
rule out other possible causes of
patient.
discomfort
to
133
the
your symptoms.
●
Encourage the patient to
urinate. Allow the patient to
urinate before collecting to
avoid
contaminating
the
stool with urine.
●
Avoid laxatives. Advise the
patient
that
laxatives,
enemas, or suppositories
are avoided three days
prior to collection.
●
Inform the client how many
stool
specimens
required
and
are
a
supply
specimen container.
After the procedure:
●
Label the container
●
Promptly
send
the
specimen to the laboratory
for analysis.
●
Instruct the patient to do
handwashing.
Allow
the
patient to thoroughly clean
his
or
her
hands
and
perianal area.
●
Resume
activities.
The
patient may resume his or
her
normal
diet
and
medication therapy unless
otherwise specified.
Magnetic resonance
imaging (MRI)
An MRI scanner uses a magnetic Before the procedure:
field and radio waves to create
● Explain to the patient the
134
detailed images of organs and
purpose of the test. Tell him
tissues. MRI is particularly useful for
who will perform the test
evaluating a fistula around the anal
and where it will take place.
area (pelvic MRI) or the small
● Inform the patient that he’ll
intestine (MR enterography).
Sometimes an MR enterography
can be performed to check for
disease status or progression. This
need to lie flat on a narrow
bed, which slides into a
large cylinder that houses
the MRI magnets.
test may be used instead of CT
● Advise the patient to avoid
enterography to reduce the risk of
alcohol, caffeine-containing
radiation, especially in younger
beverages, and smoking
people.
for at least 2 hours and food
for at least 1 hour before
the test. Explain to the
patient that he can continue
taking medications, except
for iron, which interferes
with the imaging.
● Advise the patient that he’ll
have to remain still for the
entire procedure.
● Instruct
the
patient
to
remove all metallic objects,
including jewelry, hairpins,
and watches.
● Make sure that the patient
or a responsible family
member has signed an
informed consent form.
● Administer the prescribed
sedative if ordered.
After the procedure:
135
●
Tell the patient that he may
resume his usual activities
as ordered.
●
Provide comfort measures
and pain medication as
needed
and
because
of
ordered
prolonged
positioning the scanner.
●
Monitor the patient for the
adverse reaction to the
contrast medium (flushing,
nausea,
urticaria,
and
sneezing)
CT Scan
A special X-ray technique that Before the procedure:
provides
more
detail
than
a
●
Take off some or all of the
standard X-ray does. This test looks
clothing
at the entire bowel as well as at
hospital gown.
●
tissues outside the bowel.
and
getting
intravenous contrast images of the
a
Remove any metal objects,
which might interfere with
scan that involves drinking an oral
material
wear
such as a belt or jewelry,
CT enterography is a special CT
contrast
and
image results.
●
Stop eating for a few hours
before the scan. If a patient
intestines. This test provides better
is going to have a contrast
images of the small bowel and has
injection, he or she should
replaced barium X-rays in many
not have anything to eat or
medical centers.
drink for a
few hours
before
CT
the
scan
because the injection may
cause stomach upset.
●
To receive the contrast
injection, an IV is inserted
136
into the arm just prior to the
scan. The contrast then
enters the body through the
IV.
●
Prior to most CT scans of
the abdomen and pelvis, it
is important to drink an oral
contrast
agent
that
contains dilute barium. This
contrast agent helps the
radiologist
identify
gastrointestinal
the
tract
(stomach, small and large
bowel),
detect
abnormalities
of
these
organs, and to separate
these structures from other
structures
within
the
abdomen.
●
If the patient has a history
of
allergy
to
contrast
material (such as iodine),
the requesting physician
and radiology staff should
be notified.
●
The patient will be asked to
drink slightly less than a
quart spread out over 1.5 to
2 hours.
After the procedure:
●
After the exam, patients
can return to their normal
routine.
137
●
If a patient were given a
contrast
material,
the
patient may receive special
instructions.
In
some
cases, patients may be
asked to wait for a short
time
before
leaving
to
ensure that they feel well
after the exam. After the
scan, patients are likely to
be told to drink lots of fluids
to
help
remove
their
kidneys
the
contrast
material from the body.
Capsule Endoscopy
For this test, you swallow a capsule Before the procedure:
that has a camera in it. The camera
takes
pictures
of
your
●
small
the prescribed liquid diet at
intestine and sends them to a
recorder you wear on your belt. The
Instruct the patient to start
12:00 Noon.
●
images are then downloaded to a
Administer the two packets
of Klean-Prep starting at
computer, displayed on a monitor
6:00 PM the evening prior
and checked for signs of Crohn's
to
disease. The camera exits your
the
scheduled
procedure. Dissolve each
body painlessly in your stool.
packet in one liter of water.
●
Do not take any medication
two hours before having the
exam.
●
Do not apply body lotion or
powder to your abdomen.
●
Wear
loose-fitting,
two-
piece clothing. Your upper
138
clothing should be opaque.
After the procedure:
●
You may drink colorless
liquids starting two hours
after
swallowing
the
capsule.
●
You may have a light snack
four hours after ingestion.
After the examination is
completed, you may return
to your normal diet.
●
Use the provided Capsule
Endoscopy Event Form, to
note the time of any event
such as eating, drinking or
a change in your activity.
Return
the
Event
Form
completed
to
your
physician at the time you
return the equipment.
●
Avoid
strong
electromagnetic fields such
as MRI devices or ham
radios after swallowing the
capsule and until you pass
it in a bowel movement.
●
Do
not
disconnect
the
equipment or completely
remove the recorder at any
time during the procedure.
●
Avoid sudden movements
and
banging
of
139
the
recorder.
●
Avoid direct exposure to
bright sunlight.
Balloon-assisted
For this test, a scope is used along
enteroscopy
with a device called an overtube.
Before the procedure:
This enables the doctor to look
●
Secure the consent form
further into the small bowel where
●
Provide information about
the procedure.
standard endoscopes don't reach.
This technique is useful when
capsule
endoscopy
●
Instruct patient to wear
loose comfortable clothing
shows
abnormalities but the diagnosis is
and
leave
valuables
still in question.
including jewelry at home.
Avoid using nail polish.
●
Check the vital signs and
review the medical history
and medication list. An IV
line will be started in a vein
in the patient’s arm for IV
fluids
and
sedation
medication.
After the procedure:
●
Call for a family member to
converse with the Doctor to
discuss the procedure.
●
Do not drive, operate heavy
machinery, or drink alcohol
for 24 hours after the
procedure. Patient should
go home and rest after the
procedure.
●
Instruct to eat something
light since they have not
140
eaten for over 8 hours.
Avoid
fried
foods,
fatty
foods and large quantities
of food. Things such as:
scrambled eggs, toast, and
a
sandwich
are
good
choices.
Colonoscopy
This test allows your doctor to view Before the procedure:
your entire colon and the very end
●
Secure informed consent.
of your ileum (terminal ileum) using
●
Obtain a medical history of
a thin, flexible, lighted tube with a
the
camera at the end. During the
allergies,
procedure, your doctor can also
histories, medications, and
take
information relevant to the
small
samples
of
tissue
(biopsy) for laboratory analysis,
which
may
help
to
make
a
such
as
bleeding,
current complaint.
●
diagnosis. Clusters of inflammatory
cells called granulomas may help
patient
Provide information about
the procedure.
●
suggest a diagnosis of Crohn's.
Ensure that the patient has
complied with the bowel
preparation. He/she must
have maintained a clear
liquid diet for 24-48 hours
before the test, NPO after
midnight,
and
taken
a
laxative, as ordered.
●
Inform the patient that an IV
line will be started and a
sedative
will
be
administered
before
the
procedure. Also, advise the
patient to have someone
drive him/her home after
141
the
procedure
since
sedatives will be given.
●
Instruct the patient to empty
the bladder prior to the
procedure.
●
Instruct
the
patient
to
remove all metallic objects
from
the
area
to
be
patient
to
examined.
After the procedure:
●
Instruct
the
resume
a
normal
diet,
unless otherwise directed
by the doctor.
●
Inform the patient to refrain
from driving or operating
heavy machinery.
●
Instruct patient to take any
pain medications or stool
softeners that have been
prescribed by the doctor.
●
Encourage the patient to
drink plenty of liquids.
●
Inform the patient to avoid
consuming alcohol.
●
Provide privacy while the
patient
rest
after
the
procedure.
●
Monitor unusualities such
as rectal bleeding.
B. MEDS
142
1. Aminosalicylates - These medicines contain 5-aminosalicylic acid (5-ASA), which helps
control inflammation. Doctors use aminosalicylates to treat people newly diagnosed with
Crohn’s disease who have mild symptoms. Aminosalicylates include
GENERIC NAME
Sulfasalazine
BRAND NAME
Azulfidine, , Azulfidine EN-tabs, Salazopyrin
DRUG CLASSIFICATION
PHARMACOTHERAPEUTIC:5-Ami-nosalicylic acid derivative.
CLINICAL: Anti-inflammatory.
SUGGESTED DOSE
ROUTE
3-6 g/day PO in divided doses for up to 16 wks
OF PO
ADMINISTRATION
MODE OF ACTION
It is metabolized by intestinal bacteria, resulting in the release
of sulfapyridine and 5-aminosalicylate. The drug is useful in the
treatment of active ulcerative colitis as well as in preventing
relapses of the disease in remission.
INDICATION
It's thought to stop your body producing chemicals that cause
redness and swelling in the gut and in the joints. It has a similar
effect to immunosuppressants.
CONTRAINDICATION
●
Hypersensitivity to sulfasalazine, sulfa, salicylates;
porphyria; GI or GU obstruction.
●
Urinary tract or intestinal obstruction; Porphyria
Cautions: Severe allergies, bronchial asthma, impaired
hepatic/renal function, G6PD deficiency, blood
dyscrasias, history of recurring or chronic infections.
SIDE EFFECTS
Anorexia, nausea, vomiting, headache, rash, urticaria, pruritus,
fever, anemia, hypoglycemia, diuresis, photosensitivity.
143
ADVERSE EFFECTS
Anaphylaxis,
Stevens-Johnson syndrome,
hematologic
toxicity, hepatotoxicity, nephrotoxicity occur rarely.
DRUG INTERACTIONS
●
May
increase
hypoglycemic
action/risk
agents,
of
toxicity
phenytoin,
from
oral
methotrexate,
zidovudine, or warfarin.
●
Increase the risk of drug-induced hepatitis with other
hepatotoxic agents.
●
Increase the risk of crystalluria with methenamine. May
decrease metabolism and increase effects/toxicity of
mercaptopurine or thioguanine.
NURSING
1. Assess the patient for allergy to sulfonamides and
RESPONSIBILITIES
salicylates.
R: Therapy should be discontinued if rash, difficulty breathing,
swelling of face or lips, or fever occur.
2. Monitor CBC with differential and liver function tests
before and every second week during the first 3 months
of therapy, monthly during the second 3 months, and
every 3 months thereafter as clinically indicated.
Discontinue sulfasalazine if blood dyscrasias occur.
R: Sulfasalazine may cause blood problems and induce liver
injury that can result in minor ALT and alkaline phosphatase
elevations, acute self-limited hepatitis, and even acute liver
failure.
3. Assess for rash periodically during therapy. Discontinue
therapy if severe or if accompanied by fever, general
malaise, fatigue, muscle or joint aches, blisters, oral
lesions, conjunctivitis, hepatitis, and/or eosinophilia.
R: May cause Stevens-Johnson syndrome.
4. Assess abdominal pain and frequency, quantity, and
consistency of stools at the beginning of and during
therapy.
R: A dosage increase may be needed if diarrhea continues or
144
recurs.
5. Administer after meals or with food; and with a full glass
of water. Drink several glasses of water between meals.
Do not crush or chew enteric-coated tablets.
R: To minimize GI irritation and drink plenty of water to prevent
possible kidney problems.
6. Varying dosing regimens of sulfasalazine may be used.
R: To minimize GI side effects.
7. Instruct
the
patient
on
the
correct
method
of
administration. Advise patient to take medication as
directed, even if feeling better. Take missed doses as
soon as remembered unless almost time for the next
dose.
R: Taking medicine on time, as prescribed, is essential to
making sure your body has an effective amount of the drug at
all times. If not, this can cause the disease to develop a
resistance to the medicine or simply prolong the amount of time
it takes to feel better.
8. Advise patient to notify health care professional if skin
rash, sore throat, fever, mouth sores, unusual bleeding
or bruising, wheezing, fever, or hives occur.
R: To facilitate prompt management .
9. Caution patient to use sunscreen and protective
clothing.
R: To prevent photosensitivity reactions.
10. Inform the patient that this medication may cause
orange-yellow discoloration of urine and skin, which is
not significant. May permanently stain contact lenses
yellow.
R: To avoid the patient from worrying since this is a normal side
effect of the drug.
145
2. Corticosteroids - This lowers the activity of your immune system and limits the
inflammation in the digestive tract. They are used as short-term treatments for Crohn's
disease and ulcerative colitis flares because they reduce inflammation quickly, sometimes
within a few days to a few months.
Generic Name
HYDROCORTISONE
Brand Name
Hydrocort, Alphosyl, Aquacort, Cortef, Cortenema, and SoluCortef.
Classification
Mode of Action
Corticosteroids
Decreases inflammation
polymorphonuclear
by
suppressing migration
of
leukocytes and lysosomal stabilization
(systemic); antipruritic, anti-inflammatory (topical)
Suggested Dose
Inflammation:
●
Adult: 15-240 mg (PO/IM/IV) every 12 hours
●
Children under 12 years: 2.5-10 mg/kg/day orally divided
every 6-8 hours; if 12 years and older: 15-240 mg
(PO/IM/IV/SC) every 12 hours
Route of Administration
PO/IM/IV
Indications
It works by calming down your body's immune response to
reduce pain, itching and swelling. It can also be used as
hormone replacement for people who do not have enough of
the natural stress hormone, cortisol.
146
Contraindications
Hypersensitivity, fungal infections
Precautions: Pregnancy C, breastfeeding, diabetes mellitus,
glaucoma, osteoporosis, seizure disorders, ulcerative colitis,
myasthenia gravis, renal disease, esophagitis, peptic ulcer,
metastatic carcinoma, septic shock, Cushing syndrome, hepatic
disease,
hypothyroidism,
coagulopathy,
acute
glomerulonephritis, amebiasis, AIDS, TB
Side Effects
Aggression, anxiety, blurred vision, itching eyes, decrease in the
amount of urine, dizziness, dry mouth, ear congestion, fever,
headache, irregular heartbeats, irritability, numbness or tingling
in the arms or legs, swelling of eye, eyelid, or inner lining of the
eyelid, stuffy nose, sneezing, sore throat, unusual tiredness or
weakness and weight gain.
Adverse Effects
CNS:
Depression, flushing,
sweating, headache,
mood
changes, pseudotumor cerebri, euphoria, insomnia, seizures
CV:
Hypertension,
circulatory
collapse,
thrombophlebitis,
embolism, tachycardia, edema, heart failure
EENT:
Fungal infections, increased
intraocular
pressure, blurred vision, cataracts, glaucoma
GI:
Diarrhea,
nausea,
abdominal distention,
increased
appetite, pancreatitis, vomiting
HEMA: Thrombocytopenia
INTEG:
Acne, poor
wound healing, ecchymosis,
petechiae
MISC: Adrenal insufficiency (after stress/ withdrawal)
MS: Fractures,
Drug Interaction
osteoporosis,
weakness
Amphotericin B, cyclosporine, digoxin: increased side effects
Bosentan,
carbamazepine,
cholestyramine,
colestipol,
ephedrine, phenytoin, rifampin, theophylline: decreased action
of hydrocortisone
Classifications:
Acetaminophen,
NSAIDs,
salicylates:
increased risk of GI bleeding
147
Anticoagulants,
calcium
supplements,
toxoids,
vaccines:
decreased action of each specific drug
Anticonvulsants: decreased effects of anticonvulsant
Antidiabetics: decreased effects of antidiabetics
Barbiturates: decreased action of hydrocortisone
Diuretics: increased side effects
Herb: Ephedra: decreased hydrocortisone levels
Nursing Responsibilities
1. Make sure the medicine is appropriate for the patient's
condition before administering it.
R: To ensure the patient is receiving the correct medication, for
the correct reason, and at the correct time.
2. Monitor potassium, blood glucose, urine glucose while
the patient is on long-term therapy; hypokalemia and
hyperglycemia may occur.
R: Corticosteroids are shown to cause a decrease in serum
potassium levels in patients known to administer them. Regular
monitoring of serum potassium levels can prevent hypokalemia
symptoms and complications
3. Monitor I&O ratio; be alert for decreasing urinary output
and increasing edema.
R: Cortisol urine tests can help with the diagnosis of various
medical conditions.
4. Assess for infection.
R: Hydrocortisone can weaken your body's response to
infection because the drug weakens your immune system.
5. Assess mental status: affect, mood, behavioral changes,
aggression.
R: Chronic stress and elevated cortisol levels also increase
one's risk for depression, mental illness, and lower life
expectancy.
148
6. Assess GI effects such as gastritis and pancreatitis.
R: It is assumed to occur when ulcers erode into underlying
vessels. The mechanism by which corticosteroids might induce
GI bleeding or perforation has not been fully established,
but corticosteroids may impair tissue repair, thus leading to
delayed wound healing.
7. Check
for
potassium
depletion:
fatigue, nausea,
vomiting, depression, polyuria, dysrhythmias, weakness.
R: A low potassium level can make muscles feel weak, cramp,
twitch, or even become paralyzed, and abnormal heart rhythms
may develop.
8. Avoid alcohol and caffeine.
R: It can cause damage to the liver and kidneys and may
contribute to steroid-ulcer development in long-term therapy.
9. Teach patient to avoid live-virus vaccines if using
steroids long term.
R: Corticosteroids used in greater than physiologic doses also
may reduce the immune response to vaccines. Physicians
should wait at least 3 months after discontinuation of
therapy before administering a live-virus vaccine to patients who
have received high-dose, systemic steroids for greater than or
equal to 2 weeks.
10. Teach patient to immediately report abdominal pain,
black tarry stools, as GI bleeding/perforation can occur.
R: Black stools are a worrisome symptom because it may be due
to a large amount of bleeding into the digestive system.
3. Immunomodulators - These medicines reduce immune system activity, resulting in less
inflammation in your digestive tract. It works by reducing IBD inflammation. They impact the
149
number or function of immune cells (cells of the immune system) and by doing so, they suppress
the immune system in order to reduce inflammation caused by these type of cells in your body.
GENERIC NAME
Methotrexate
BRAND NAME
Otrexup, Rasuvo, Rheumatrex, Trexall
DRUG CLASSIFICATION
Pharmacologic: Folic acid antagonist
Therapeutic: Antineoplastics, Antimetabolite
MODE OF ACTION
Inhibit several enzymes in the metabolic pathway of folic acid.
While the cytotoxic and antiproliferative effects of high dose
methotrexate are ascribed to inhibition of dihydrofolate reductase,
with consequent inhibition of DNA, RNA, and protein synthesis,
the anti-inflammatory and immunomodulatory actions of low
doses are probably due to inhibition of other folate dependent
enzymes.
SUGGESTED DOSE
Adult: Start with 25mg IM once a week up to 16 weeks then
reduced to 15mg IM once a week or consider changing to oral
therapy at this point (15mg once per week)
ROUTE
ADMINISTRATION
INDICATION
OF
IM
It works by interrupting the activity of the immune system to
reduce inflammation in the bowel. reduces the chance of
complications caused by uncontrolled inflammation.
150
CONTRAINDICATION
Hypersensitivity,
leukopenia,
thrombocytopenia,
anemia,
psoriatic patients with severe renal disease, alcoholism, HIV
infection
SIDE EFFECTS
Nausea, vomiting, stomatitis, burning/erythema at psoriatic site,
Diarrhea, rash, dermatitis, pruritus, alopecia, dizziness, anorexia,
malaise, headache, drowsiness, blurred vision.
ADVERSE EFFECT
CNS:
Dizziness,
seizures,
headache,
confusion,
encephalopathy, hemiparesis, malaise, fatigue, chills, fever,
leukoencephalopathy; arachnoiditis (intrathecal)
EENT: Blurred vision, optic
neuropathy
GI: Nausea, vomiting, anorexia, diarrhea, ulcerative stomatitis,
hepatotoxicity,
cramps,
ulcer,
gastritis,
GI
hemorrhage,
abdominal pain, hematemesis, hepatic fibrosis, acute toxicity
GU: Urinary
retention, renal failure, menstrual irregularities,
defective spermatogenesis, hematuria, azotemia, uric acid
nephropathy
HEMA:
Leukopenia,
thrombocytopenia,
myelosuppression,
anemia
INTEG: Rash, alopecia, dry skin, urticaria, photosensitivity,
folliculitis, vasculitis, petechiae, ecchymosis, acne, alopecia,
severe fatal skin reactions
RESP: Methotrexate-induced lung disease
SYST: Sudden death, Pneumocystis jiroveci pneumonia, tumor
lysis syndrome
151
DRUG INTERACTION
Drug:
●
Acitretin: increased hepatitis; avoid concurrent use
●
Alcohol,
phenylbutazone,
probenecid,
radiation,
theophylline: increased toxicity
●
Digoxin (PO), fosphenytoin, phenytoin: decreased effect
of each specific product
●
Folic acid: decreased effect of methotrexate
●
Radiation: increased bone marrow suppression
Drug classifications:
●
Anticoagulants (oral): increased hypoprothrombinemia
●
Antineoplastics, NSAIDs, penicillins, salicylates, sulfa
products: increased toxicity
●
NURSING
RESPONSIBILITIES
Live virus vaccines: decreased antibodies
1. Assess symptoms indicating severe allergic reaction:
rash, pruritus, urticaria, purpuric skin lesions, itching,
flushing
R: Information from allergy tests may help your doctor develop an
allergy treatment plan that includes allergen avoidance,
medications or allergy shots.
2. Assess tachypnea, ECG changes, dyspnea, edema,
fatigue; identify dyspnea, crackles, unproductive cough,
chest pain.
R: It helps to determine the adequacy of respiration and enables
the identification of changes to respiratory function.
3. Assess for bleeding: hematuria, stool guaiac, bruising or
petechiae, mucosa or orifices; check for inflammation of
mucosa, breaks in skin
R: A person who is bleeding can die from blood loss within five
minutes; therefore it is important to quickly stop the blood loss.
152
4. Teach patient that hair may be lost during treatment; a wig
or hairpiece may make patient feel better; new hair may
be different in color, texture.
R: It is important to inform the patient ahead of time so she can
already anticipate what to do.
5. Identify edema in feet, joint and stomach pain, shaking;
prescriber should be notified.
R: It's very important to see your healthcare provider if you
experience edema or swelling in your body. Edema can stretch
your skin and if not treated, swelling could increase and cause
serious health problems.
6. Monitor methotrexate levels, adjust leucovorin dose
based on the level.
R: Methotrexate may increase the risk of problems with your liver
or lungs, especially if you take a high dose.
7. Advise patient to report stomatitis: any bleeding, white
spots, ulcerations in mouth to prescriber.
R: Stomatitis is a complex oral complication of cancer treatment
resulting from toxicities, tissue damage, and inflammation
8. Caution patient not to have any vaccinations without the
advice of the prescriber
R: Serious reactions can occur.
9. Advise patient to use sunblock or protective clothing to
prevent burns
R: A sunscreen protects from sunburn and minimizes suntan by
absorbing or reflecting UV rays. Selecting a good sunscreen is
important in protecting the skin.
153
10. Teach the patient to use good dental care.
R: To prevent overgrowth of infection in the mouth.
4. Biologic therapies - It can help achieve remission by reducing symptoms, as well as provide
healing for damage to intestines caused by inflammation. Biologic therapies are usually prescribed
in people with more severe Crohn's symptoms who haven't found relief with other methods.
GENERIC NAME
Adalimumab
BRAND NAME
Humira, Amgevita, Hyrimoz, Idacio, Imraldi, Yuflyma, Cyltezo
DRUG CLASSIFICATION
PHARMACOTHERAPEUTIC: Monoclonal antibody.
CLINICAL: Antirheumatic, disease modifying; GI agent; TNF
blocking agent.
154
SUGGESTED DOSE
Crohn’s Disease
Induction: 160 mg SC either as 4 injections of 40 mg on day 1
or as 2 injections of 40 mg daily on 2 consecutive days, then 80
mg SC 2 weeks later (day 15)
Maintenance (beginning Week 4 [Day 29]): 40 mg SC q2wk
ROUTE
OF SQ Injection
ADMINISTRATION
MODE OF ACTION
Binds specifically to tumor necrosis factor (TNF) alpha cell,
blocking its interac-tion with cell surface TNF receptors and
cytokine-driven inflammatory processes.
Therapeutic Effect: Decreases signs/symptoms of RA,
psoriatic arthritis, ankylos-ing spondylitis, Crohn’s disease,
ulcerative colitis. Inhibits progression of rheumatoid and
psoriatic arthritis. Reduces epidermal thickness, inflammation
of plaque psoriasis.
INDICATION
It is used to treat inflammation of the: joints (rheumatoid arthritis,
polyarticular juvenile idiopathic arthritis and active enthesitisrelated arthritis) skin (plaque psoriasis and hidradenitis
suppurativa) joints and skin (psoriatic arthritis)
CONTRAINDICATION
Contraindications: Hypersensitivity to adalimumab. Severe
infections (e.g., sep-sis, TB).
SIDE EFFECTS
Injection site erythema, pruritus, pain, swelling, Headache,
rash, sinusitis, nausea, Abdominal or back pain, hypertension.
ADVERSE EFFECTS
●
Hypersensitivity reactions (rash, urticaria, hypotension,
dyspnea), infections (pri-marily upper respiratory tract,
bronchitis, urinary tract) occur rarely.
●
May increase risk of serious infections (pneumonia, tu-
155
berculosis, cellulitis, pyelonephritis, septic arthritis).
●
May increase risk of reactivation of hepatitis B virus in
pts who are chronic carriers.
●
May cause new-onset or exacer-bation
of
central
nervous demyelinating disease; worsening and newonset HF.
●
May increase risk of malignancies. Immunoge-nicity
(anti-adalimumab autoantibodies) occured in 12% of
pts.
DRUG INTERACTIONS
●
May increase the adverse effects of abatacept,
anakinra,
belimumab,
canakinumab,
natalizumab,
tofaci-tinib, vaccines (live), vedolizumab.
●
May
decrease
the
therapeutic
effect
of
BCG
(intravesical), vaccines (live).
●
May increase the immunosuppressive effects of
certolizumab, infliximab.
●
Tocilizumab may increase the immunosuppressive
effect.
NURSING
RESPONSIBILITIES
1. Ask if the patient have or have ever had HIV, hepatitis B
or C (a viral liver infection)
R: You will usually have a blood test to check for these diseases
before starting adalimumab.If you have hepatitis B or have had
it in the past, using Humira may cause reactivation of the virus.
2. Review immunization status/screening for TB. If pt is to
self-administer, instruct on SQ injection
technique,
including areas of the body acceptable for injection
sites.
R: If you have any history of tuberculosis (TB) or any recent
exposure to people with TB. You should not be given
adalimumab if you have active TB, and if you have underlying
inactive TB, this will need to be treated before starting
156
adalimumab.
3. Monitor lab values, particularly CBC.
R: You will need regular checks and may need additional blood
tests. Monitoring your treatment in this way helps your doctors
fit your treatment to your needs. It can also make sure that any
complications or problems with your treatment are avoided or
caught at an early stage.
4. Assess history of
infections, cancer, liver and heart
problems.
R: If you have a history of infections, currently have an infection
or have symptoms such as feeling feverish or generally unwell
your adalimumab treatment may need to be postponed.
5. Monitor neurological status closely. Report any change
in status such as blurred vision or paresthesia.
R: Humira can cause nervous system problems. Symptoms of
some nervous system problems may include changes in your
vision.
6. Try to avoid close contact with people who have
infections. Do
not
receive
live
vaccines
during
treatment.
R: Adalimumab affects the way your immune system works, so
you may be more prone to infections. Also, even a mild infection
such as a cold or sore throat could develop into a more serious
illness if you are taking adalimumab.
7. Take care with food hygiene and avoid eating raw eggs
or undercooked pate, meat and poultry, as well as
unpasteurised dairy products and soft or blue cheeses.
R: You may be more open to the type of infections caused by
157
bacteria such as listeria when being treated with adalimumab.
8. Report swelling, redness, bruising and itching on the
injection site.
R: Others may experience reactions to the injection such as
pain or swelling, redness, bruising and itching. This can be very
common, affecting at least one in 10 people.
9. Take extra precautions when in the sunlight, for example
wearing a hat and high factor sun cream.
R: Adalimumab can increase the risk of skin reactions, and in
rare cases skin cancer.
10. Do not breastfeed when taking this medication, consult
your doctor first.
R: Breastfeeding during treatment with Humira may not be safe.
This is because Humira passes into breast milk.
C. TREATMENT
THERAPY
Medications
RATIONALE
NURSING RESPONSIBILITIES
Treating Crohn’s disease is Before the procedure:
designed to suppress your
●
Instruct patient to take the
immune system’s abnormal
proper dosage, and process
inflammatory response that is
of
causing
prescribed by their doctor or
your
symptoms.
Suppressing inflammation not
only offers relief from common
the
medications
physician.
●
Educate to not take drugs all
symptoms like fever, diarrhea,
at once or together with
and pain, it also allows your
other drugs as this may
intestinal tissues to heal.
lessen the effect of the
prescribed drug or it may
158
In addition to controlling and
cause
suppressing
effects
symptoms
(inducing
severe
adverse
remission),
medication can also be used to After the procedure:
decrease the frequency of
symptom
flare
ups.
●
With
Advice on proper bed rest
after
intake
of
proper treatment over time,
medications
periods of remission can be
proper absorption of the
extended
drug.
and
periods
of
to
the
facilitate
symptom flare ups can be
reduced. Several types of
medication are being used to
treat Crohn's disease today.
Surgery
This
becomes
necessary Before the procedure:
when
medications can
no
●
Secure an informed consent
longer control symptoms, or if
●
Obtain a medical history of
you develop a fistula, fissure,
or
intestinal
Surgery
removal
obstruction.
often
of
the
the patient.
●
involves
diseased
Provide information about
the procedure.
●
Ensure that the patient has
segment of bowel (resection),
complied with the bowel
the two ends of healthy bowel
preparation.
together
●
Establish an IV line.
(anastomosis). While these
●
Instruct the patient to empty
are
then
joined
procedures may cause your
the bladder prior to the
symptoms to disappear for
procedure.
many
years,
Crohn’s
frequently recurs later in life.
●
Instruct
the
patient
to
remove all metallic objects
from the area.
After the procedure:
● Obtain and record the
patient’s vital signs. Monitor
159
vital signs and neurological
status every 15 minutes for
1 hour, then every 2 hours
for 4 hours, or as ordered.
Assess temperature every 4
hours for 24 hours.
● Instruct patient to resume a
normal
diet,
fluids,
and
activity as advised by the
health care provider.
● Provide privacy while the
patient
rest
after
the
procedure.
● Monitor patient for any
unusualities.
● Encourage
patient
to
increase oral fluid intake.
Diet and Nutrition
It is essential to maintain good
nutrition
because
●
Crohn’s
Inform the client as well as
family members regarding
often reduces your appetite
the
while increasing your body’s
healthy and nutritious diet.
energy
needs.
Additionally,
●
importance
of
the
Educate patient about best
common Crohn’s symptoms
and easy ways to achieve a
like diarrhea can reduce your
good nutritious diet.
body’s
ability
to
absorb
●
protein, fat, carbohydrates, as
well as water, vitamins, and
Maintenance of adequate
hydration.
●
minerals.
Maintaining
parental
nutrition for the client.
●
Helps in monitoring the
Many people who experience
conditions of the client like
Crohn's disease flare ups find
vomiting,
that soft, bland foods cause
electrolyte
input-output,
monitoring,
in
160
less discomfort than spicy or
order
to
add
different
high-fiber foods. While your
components in the diet.
diet can remain flexible and
should include a variety of
foods from all food groups,
your
doctor
will
likely
recommend restricting your
intake of dairy if you are found
to be lactose-intolerant.
VII.
SURGICAL MANAGEMENT
PROCEDURE
Strictureplasty
RATIONALE
NURSING RESPONSIBILITIES
It is repairing a stricture by Before the procedure:
widening the narrowed area
● Provide answers to patient
without removing any portion
queries and address their
of your intestine. It is important
concerns
to repair structures because
process.
regarding
the
the narrowing of your intestine
● Secure the consent
could lead to a blockage that
● Remove all jewelry and nail
prevents stool from passing
polish before the surgery.
through
strictures
the
are
body.
When
caused
by
disease inflammation, initial
treatment may typically include
medication to help improve the
narrowing of the intestines.
Small and Large Bowel
It is a surgical procedure to
Resection
remove a portion of your small
● Inspect the patient's mouth
and remove dentures or
plates.
● Change the gown of the
patient
● Prepare
the
equipment,
instruments, and supplies
needed for the procedure.
or large intestine that has been
damaged by Crohn’s disease.
161
● Take the vital signs, start an
During
diseased
the
surgery,
section
of
the
your
IV, and give the patient any
medication required
intestine is removed and the
two healthy ends are joined
together.
162
● Transfer
Proctocolectomy and
Ileostomy
It is to remove your entire
colon
and
ileostomy
is
rectum.
a
Operating
An
stoma,
patient
to
Room
the
and
Administer Sedative.
or
opening in your abdomen, that
a surgeon creates from a part
of your ileum. The surgeon
After the Procedure:
●
the procedure thoroughly.
brings the end of your ileum
through an opening in your
●
●
●
●
Advise patients that they are
allowed to drink water 6
located in the lower part of
hours after surgery.
your abdomen, just below the
●
beltline.
Ensure that the patient is
comfortable.
inch to a little less than 2
inches wide and is most often
Check for any unusualities
such as rectal bleeding
outside your body. The stoma
is about three-quarters of an
Re-evaluate the patient's
vital signs.
abdomen and attaches it to
your skin, creating an opening
After the surgery, document
Provide
a
relaxing
and
noise-free environment to
A
removable
external
aid in uninterrupted rest.
collection pouch, called an
ostomy
pouch
or
ostomy
appliance, connects to the
stoma
outside
and
your
collects
stool
body.
Stool
passes through the stoma
instead of passing through
your anus. The stoma has no
muscle, so it cannot control the
flow of stool, and the flow
occurs whenever it occurs.
VIII.
NURSING MANAGEMENT
163
NURSING DIAGNOSIS
Imbalanced
than
nutrition:
body
related
to
GOAL
less After 8 hours of nursing
INTERVENTION
Independent
requirements intervention, the patient will
increased be able to:
metabolism as evidenced by
weight loss.
R: Provides information about
a. maintain weight within
the normal BMI range,
Rationale:
1. Weigh daily.
dietary
needs
and
effectiveness of therapy.
b. recognize factors that
If your metabolism is "high" (or
are contributing to
fast), you will burn more
being underweight,
and
calories at rest and during
and
during the acute phase
activity. A high metabolism
means you'll need to take in
2. Encourage
c. consume adequate
nutrition.
bedrest
limited
activity
of illness.
R:
Decreasing
aids
metabolic
more calories to maintain your
needs
in
preventing
weight. That's one reason why
caloric
some people can eat more
conserves energy.
depletion
and
than others without gaining
weight.
3. Recommend
rest
before meals.
Reference:
R:
Quiets
peristalsis
and
Harvard Health. (2021,
increases available energy for
October 6). Does metabolism
eating.
matter in weight loss?
Retrieved February 25, 2023,
4. Provide oral hygiene.
from
R:
A
clean
mouth
https://www.health.harvard.ed
enhance the taste of food.
can
u/diet-and-weight-loss/doesmetabolism-matter-in-weightloss
5. Serve foods in wellventilated,
pleasant
surroundings, with an
unhurried atmosphere,
164
congenial company.
R: Pleasant environment aids
in reducing stress and is more
conducive to eating.
6. Promote
patient
participation in dietary
planning as possible.
R: Provides a sense of control
for patients and opportunity to
select foods desired, which
may increase intake.
7.
Assess the patient's
overall safety.
R: Imbalanced nutrition can
decrease
the
patient’s
strength and overall safety.
8. Remind foods to avoid
during flares.
R:
When
the
patient
experiences a flare-up, highfiber fruits and vegetables,
whole grains, nuts and seeds,
fatty and spicy foods, caffeine,
and
alcohol
can
worsen
symptoms.
Dependent
9. Administer
supplements
as
165
prescribed.
R: Supplements can help
replenish the body’s essential
vitamins and nutrients since
the patient is at risk for
malnutrition
and
malabsorption.
Collaborative
10. Consult
with
a
nutritionist or dietitian.
R: A dietician can assist the
patient
in
creating
a
customized diet by providing
information on the foods that
are recommended or should
be avoided.
Knowledge deficit related to After 2 hours of nursing
unfamiliarity of the treatment intervention, the patient will
plan
as
evidenced
by be able to:
nonadherence with prevention
and
1. Assess the patient’s
knowledge of Crohn’s
disease.
management a. Verbalize knowledge about
recommendations.
Independent
R: This will help the nurse to
Crohn's disease and its signs
determine what should be
and symptoms,
focused on during teaching.
Rationale:
Patients may not heed the b. Identify trigger factors that
2. Stress importance of
guidance provided by their can exacerbate Crohn's
good skin care (proper
physicians for many reasons. disease, and
handwashing
Changes may be difficult for
techniques
the patient, either because of c. Verbalize understanding of
perineal skin care).
other
obligations,
lack
of therapeutic regimen.
and
R: Reduces spread of bacteria
166
commitment,
interest,
understanding.
economic
mean
or
Socio-
conditions
or
breakdown, infection.
may
treatments
unaffordable
and risk of skin irritation or
are
3. Involve the patient in
living
the development of the
conditions are difficult. Issues
of
language,
culture,
or
care plan.
R: Patient engagement in the
literacy may also come into
care
play.
independence,
Non-adherence
plan
will
promote
commitment,
generally may be as high as
and
40%.
prevention of exacerbations
and
Reference:
adherence
to
management
the
of
symptoms of Crohn’s disease.
What to do when patients do
4. Welcome clarifications
not follow the doctor’s advice:
and questions.
Dealing with non-adherence.
R:
Patients
with
Crohn’s
(2021, November). CMPA.
disease experience anxiety,
Retrieved from
embarrassment,
https://www.cmpa-
powerlessness.
acpm.ca/en/advice-
and questions from patients
publications/browse-
should be encouraged and
articles/2013/what-to-do-
welcomed. An approachable
when-patients-do-not-follow-
manner will create a trusting
the-doctor-s-advice-dealing-
environment
with-non-adherence
nurse and patients.
fear,
and
Clarification
between
5. Appreciate
the
the
patient’s efforts.
R: Express appreciation for
the
patient’s
efforts
and
commitment to their care plan.
Adhering to the management
167
of Crohn’s disease requires a
lifetime commitment.
6. Ask the patient to list
the
preventive
measures for Crohn’s
disease.
R: Avoiding triggering factors
is the best way to manage
symptoms and prevent flareups. Evaluate the patient’s
understanding by having them
list factors that trigger their
symptoms.
7. Assess the motivation
and willingness of the
patient to learn.
R: Learning requires energy.
Patients must see a need or
purpose for learning.
8. Observe
and
note
existing
misconceptions
regarding material to
be taught.
R: Assessment provides an
important starting point in
education. Knowledge serves
to correct faulty ideas.
9. Assess
barriers
to
168
learning
(e.g.,
perceived change in
lifestyle,
financial
concerns,
cultural
patterns,
lack
of
acceptance by peers
or coworkers).
R: The patient brings to the
learning situation a unique
personality, established social
interaction patterns, cultural
norms
and
values,
and
environmental influences.
Collaborative
10. Refer
to
an
IBD
specialist.
R:
Inflammatory
disease
deliver
and
(IBD)
bowel
specialists
professional
expertise.
advice
They
can
answer inquiries and guide the
patient about Crohn’s disease
care.
Risk for fluid volume deficit as After 4 hours of nursing
evidenced by vomiting and intervention, the patient will
Independent
1. Monitor
I&O.
Note
diarrhea due to narrowing in be able to maintain adequate
number,
the small intestine.
and amount of stools;
fluid volume as evidenced by:
estimate
Rationale:
character,
insensible
a. Good skin turgor (<2
fluid
seconds),
(diaphoresis).
losses
169
Crohn’s disease can lead to
Measure urine specific
long-term inflammation that b. Capillary refill (<3
gravity;
can cause a stricture, which is seconds), and
oliguria.
observe
for
a narrowing in the small
R: Provides information about
intestine that can lead to a c. Balanced intake and
overall fluid balance, renal
blockage over time. A stricture output.
function, and bowel disease
can
control, as well as guidelines
prevent
food
from
traveling normally through the
digestive
tract,
for fluid replacement.
causing
nausea and vomiting.
2. Observe
excessively
dry skin and mucous
Reference:
membranes,
Holmer, A. (2022, October 7).
decreased skin turgor,
Five inflammatory bowel
slowed capillary refill.
disease symptoms you
R: Indicates excessive fluid
should never ignore. NYU
loss or resultant dehydration.
Langone Health. Retrieved
February 25, 2023, from
3. Assess vital signs (BP,
https://nyulangone.org/news/fi
pulse, temperature).
ve-inflammatory-bowel-
R:
Hypotension
(including
disease-symptoms-you-
postural), tachycardia, fever
should-never-ignore
can indicate response to fluid
loss.
4. Weigh daily.
R: Indicator of overall fluid and
nutritional status.
5. Maintain
oral
restrictions,
bedrest;
avoid exertion.
R: Colon is placed at rest for
healing
and
to
decrease
170
intestinal fluid losses.
6. Note
generalized
muscle weakness or
cardiac dysrhythmias.
R: Excessive intestinal loss
may
lead
to
electrolyte
imbalance, e.g., potassium,
which is necessary for proper
skeletal and cardiac muscle
function. Minor alterations in
serum levels can result in
profound or life-threatening
symptoms.
Dependent
7. Administer parenteral
fluids,
blood
transfusions
as
indicated.
R: Maintenance of bowel rest
requires
alternative
fluid
replacement to correct losses
and anemia.
8. Monitor
studies
laboratory
such
as
electrolytes (especially
potassium,
magnesium)
ABGs
and
(acid-base
balance).
R: Determines replacement
171
needs and effectiveness of
therapy.
9. Observe
for
overt
bleeding and test stool
daily for occult blood.
R:
Inadequate
decreased
diet
and
absorption
may
lead to vitamin K deficiency
and defects in coagulation,
potentiating
risk
of
hemorrhage.
Collaborative
10. Collaborate
with
dietician as indicated.
R:
Nutritional
may
be
consultation
beneficial
determining
in
individual
needs/dietary plans.
IX.
LITERATURE
Prevention and Treatment of Stricturing Crohn’s Disease – Perspectives and Challenges
(Seliman et al., 2020)
Sleiman, J., El Ouali, S., Qazi, T., Cohen, B., Steele, S. R., Baker, M. E., & Rieder, F. (2020).
Prevention and Treatment of Stricturing Crohn’s Disease – Perspectives and Challenges. Expert
Review of Gastroenterology &Amp; Hepatology, 15(4), 401–411.
https://doi.org/10.1080/17474124.2021.1854732
Although the pathophysiology of stricturing CD is still not fully known, it involves a complex
interplay of inflammatory and non-inflammatory processes in the growth of fibrostenosis. The
172
amount of stricture reversibility and the existence of fibrotic pathways distinct from inflammatory
pathways have undergone paradigm shifts over the past 15 years.
Although obstruction
symptoms such nausea, vomiting, postprandial abdominal pain, distention, and food limitations
may point to the presence of a stricture, they are not closely associated with strictures on imaging
or endoscopy. Moreover, there is no connection between the severity of small bowel strictures
and the occurrence of obstructive symptoms. This indicates that additional testing is necessary to
diagnose strictures as symptoms alone are insufficient. Patient risk stratification close to diagnosis
in naïve, non-complicated CD would be ideal to determine which patients may or may not progress
to stricturing CD. This would direct clinical judgment (e.g. combination therapy, how often to
monitor, and additionally the design of future clinical trials). Reversing fibrosis in already-existing
strictures would therefore be a key objective in CD care given the current incapability to identify
strictures. In fact, reversibility of fibrosis has been demonstrated in various organs, including the
lung, heart, skin, and kidney. Complications involving restriction are prominent in CD patients.
Despite advances in medical and endoscopic therapies, most CD patients eventually undergo
surgery for complicated CD. Postoperative recurrence is, unfortunately, frequent. So, the ultimate
objective would be to stop intestinal fibrosis, which results from abnormal tissue repair, from
developing. Although there are more biologic medicines available now than ever before, the path
to stricturing problems has, for the most part, stayed constant. Hence, trying to reverse alreadypresent fibrosis would be a crucial current goal.
Nutritional Treatment in Crohn’s Disease (Caio et al., 2021)
Caio, G., Lungaro, L., Caputo, F., Zoli, E., Giancola, F., Chiarioni, G., De Giorgio, R., & Zoli, G.
(2021). Nutritional Treatment in Crohn’s Disease. Nutrients, 13(5), 1628.
https://doi.org/10.3390/nu13051628
Skip lesions and transmural inflammation from the mouth to the anus are symptoms of the
chronic inflammatory bowel disease Crohn's Disease. In both adults and children, CD prevalence
is rising globally, and its commencement is frequently marked by typical presenting symptoms
such diarrhea, abdominal pain, rectal bleeding, fever, weight loss, and exhaustion. The best
methods for determining a diagnosis and the degree of CD are endoscopy and cross-sectional
imaging. Moreover, laboratory results including thrombocytosis, C-reactive protein (CRP), and
some stool markers like fecal calprotectin are helpful screening tests to evaluate the disease. In
approximately 65-75% of people with CD and 18-62% of patients with ulcerative colitis,
malnutrition is a common, natural result of IBD (UC). Around 70% of CD patients experience
173
stricturing or penetrating problems, which frequently necessitate elective surgery within the first
20 years of diagnosis, despite major advancements in medical therapy. The worst post-operative
results were typically linked to poor nutritional status and a loss of more than 10% of body weight
in the six months before surgery. Nutritional supplementation may lessen the gut's inflammatory
process, promoting intestinal relaxation, and improving the prognosis for recovery after surgery.
The European Crohn's and Colitis Organization (ECCO) and the European Society of Clinical
Nutrition and Metabolism (ESPEN) guidelines for malnourished patients undergoing major
gastrointestinal surgery and/or as a minor supportive therapy in addition to an oral diet are both
in favor of enteral nutrition (EN) and parenteral nutrition (PN) in CD patients. Enteral nutrition (EN)
is a liquid diet plan that provides all the required calories while excluding solid meals. This kind of
diet is especially advised during a disease relapse, when it should be followed for 6–8 weeks to
bring about remission. A central venous catheter is used to administer nutrients (macronutrients,
micronutrients, and electrolytes) through parenteral nutrition (PN) and its unique version, total
parenteral nutrition (TPN). Consistent findings suggest that CD is a disorder resulting from the
intricate interplay of various causes, such as gene abnormalities, altered immune response,
environmental alterations, and gut microbiota changes. In this case, nutrition, including dietary
modification and EN/PN, is crucial to the management of IBD, and in particular CD. Food
ingredients can affect gene expression, activate metabolic pathways, and change the makeup of
the microbiota, as is becoming increasingly obvious. Since they lessen inflammation, encourage
mucosal healing, and lessen post-operative problems, liquid diets serve as the main therapy for
CD treatment.
Surgical management of Crohn’s disease: a state of the art review (Meima - Van Praag et
al., 2021)
Meima - Van Praag, E. M., Buskens, C. J., Hompes, R., & Bemelman, W. A. (2021). Surgical
management of Crohn’s disease: a state of the art review. International Journal of Colorectal
Disease, 36(6), 1133–1145. https://doi.org/10.1007/s00384-021-03857-2
An inflammatory bowel illness with granulomatous symptoms that can affect both
extraintestinal organs and the entire gastrointestinal tract is called Crohn's disease. Patients often
have terminal ileal or colonic penetrating illness when they first present. With a peak occurrence
in adolescence and early adulthood, Crohn's disease has the highest incidence and prevalence
rates in western nations. Many medicines have been investigated due to the fact that Crohn's
disease is well known for its intermittent and relapsing course and the significant impact it has on
174
a patient's quality of life. Surgery was traditionally used as a last resort after medical treatments
failed and is typically started as the first line of treatment. With surgical treatments becoming less
invasive, it has become clear over the past few decades that earlier surgery can be used for some
disease variations and in individuals with severe disease. Because it has been found to be
associated with quicker recovery, less problems, fewer adhesions and incisional hernias, and
preserved body image and fertility, the surgical approach in IBD must generally be minimally
invasive. The function of surgery in Crohn's disease is growing in significance. For example, it is
still unclear how to treat the mesentery after ileocolonic resection and proctectomy, though current
research appears to support mesenterectomy in the latter. According to the study, laparoscopic
ileocaecal resection is a more cost-effective treatment option for Crohn's terminal ileitis and can
provide the gastroenterologist a new lease on life. The waiting period for surgery becomes an
issue once it has been determined that surgery is the best course of action. There is currently a
longer waiting period for both active and inactive Crohn's disease surgeries (such as pouch
surgery following subtotal colectomy), as oncological surgery is prioritized above benign surgery.
According to a recent cohort research, 15% of patients with inactive illness and 19% of patients
with active disease experienced difficulties while waiting for surgery, and 13% of inflammatory
bowel disease patients had to undergo acute- or semi-acute surgery while waiting. Consequently,
cutting the waiting time to a tolerable amount could not only aid patients during the waiting period
but also help prevent more complicated diseases. Eventually, surgery has been shown to be a
good alternative in terms of effectiveness, quality of life, and cost as a first-line therapy or as part
of combination therapy with biologicals for some conditions, and should no longer be viewed as a
last resort therapy for medically refractory or complex Crohn's disease.
ULCERATIVE COLITIS
I.
DEFINITION
Ulcerative colitis is an Idiopathic inflammatory bowel disease that causes chronic
inflammation and ulceration in the innermost linings of the large colon and rectum. It is an
autoimmune disease when the T-cells Lymphocytes mistakenly attack the gut bacteria in the colon
resulting in symptoms like abdominal pain, diarrhea, fever, fatigue, weight loss, and presence of
blood in the stool. Nonetheless, This condition is one of the most common inflammatory bowel
diseases along with Crohn’s disease with an estimated 156 to 291 cases per 100,000 persons
per year. (Lynch, 2022)
There are five types of ulcerative colitis which are ulcerative proctitis, Proctosigmoiditis,
Left-sided colitis, Pancolitis, and acute severe ulcerative colitis. Ulcerative proctitis is the mildest
175
form of UC which only affects the rectum. Proctosigmoiditis affects the rectum to the lower end of
the colon called sigmoid. Left-sided colitis includes the left side of the colon called descending
colon down to rectum. Pancolitis and acute severe ulcerative colitis both include the entire colon.
However, acute severe ulcerative colitis causes severe abdominal pain. People with UC will
experience flare-ups, where the symptoms of the condition become worse, and periods of
remission, which are times when the symptoms go away. (Smith, 2021)
II.
ANATOMY/ PHYSIOLOGY
The digestive system performs mechanical processing, digestion, absorption of food,
secretion of water, acids, enzymes, buffer, and salt, as well as excretion of waste materials. The
digestive tract and accessory organs comprise the digestive system. The oral cavity, pharynx,
esophagus, stomach, small intestine, and large intestine make up the gastrointestinal system. The
teeth, tongue, and glandular organs such the pancreas, liver, gallbladder, and salivary glands are
examples of accessory organs. These organs work together to provide mechanical processing,
the production of bile and enzymes to aid in compound breakdown, and the excretion of waste.
Mouth
Even before food reaches the mouth, the digestion starts. The salivary glands start
secreting saliva when a person smells or thinks about food or eating. When food enters the mouth,
saliva moistens it, the teeth and tongue mechanically break it down, and salivary amylase, an
enzyme, turns the food into starch. A tiny, round blob, or bolus, is formed from the food after
chewing and amylase digestion. This makes it simple for an individual to swallow.
Esophagus
After being ingested, the bolus travels through the esophagus, where it is helped descend
to the stomach by peristalsis, a process involving muscular contractions and gravity. Smooth
muscles slowly contracting in and around the digestive system is known as peristalsis.These
contractions push the bolus towards the direction of the stomach as it travels through the
esophagus.
176
Stomach
A muscle known as the lower esophageal sphincter, which resembles a ring, allows the
bolus to enter the stomach. The bolus can enter the stomach when this sphincter relaxes.
Temporary food storage occurs in the stomach. Gastric fluids are produced by cells in the
stomach. Hydrochloric acid is one of them, and it keeps the stomach's pH between 1.5 and
2.0.Three muscular layers in the stomach mix and churn the contents. Through these procedures,
the food is transformed into chyme, a thick paste. Pepsin, a protein-digesting enzyme, is activated
by the breakdown of proteins and plant fibers. However, because the stomach lining is vulnerable
to injury from the acid, some cells create mucus to shield it. The chyme reaches the small intestine
through the pyloric sphincter because the stomach does not absorb many nutrients from the
chyme into the bloodstream.
Small Intestine
90% of the nutrients from food are absorbed into the bloodstream through the small
intestine, which is around 20 feet (6 meters) long. First is the duodenum, which takes chyme from
the stomach and digestive enzymes from the liver and pancreas. The majority of chemical
digestion and absorption takes place in the jejunum, which comes in second. Third is the ileum,
which houses the ileocecal valve, a sphincter via which food enters the large intestine. The villi
absorb the nutrients after the meal has been completely digested, allowing them to reach the
bloodstream. The small intestine is lined with vili, which resemble tiny fingerlike projections.
Lacteals, which are very small capillaries, are found inside villi. The villi maximize their absorption
of nutrients by expanding their surface area.
Large intestine
The large intestine is about five feet (or 1.5 meters) long. The large intestine is much
broader than the small intestine and takes a much straighter path through the abdomen. The
purpose of the large intestine is to absorb water and nutrients from the material that has not been
digested as food, and get rid of any waste products left over.
177
Appendix
The safe house theory of appendix states that the appendix contains a particular type of
tissue associated with the lymphatic system, which carries the white blood cells needed to fight
infections. In recent years, scientists have found that lymphatic tissue encourages the growth of
some beneficial gut bacteria, which play an important role in human digestion and immunity.
Cecum
This first section of the large intestine looks like a pouch, about two inches long. It takes
in digested liquid from the ileum and passes it on to the colon.
Colon
This is the major section of the large intestine. The colon is also the principal place for
water reabsorption, and absorbs salts when needed. The colon consists of four parts:
●
Ascending colon: Using muscle contractions, this part of the colon pushes any undigested
debris up from the cecum to a location just under the right lower end of the liver.
●
Transverse colon: Food moves through this second portion of the colon, across the front
(or anterior) abdominal wall, traveling from left to right just under the stomach.
●
Descending colon: The third portion of colon pushes its contents from just near the spleen,
down to the lower left side of the abdomen.
●
Sigmoid colon: The final S-shaped length of the colon, curves inward among the coils of
the small intestine, then empties into the rectum.
Rectum: The final section of digestive tract measures from 1 to 1.6 inches (or 2.5 to 4 cm). Leftover
waste collects there, expanding the rectum, until defection occurs. At that time, it is ready to be
emptied through the anus.
Anus: The anus is the last part of the digestive tract. It's at the end of the rectum. It's where stool
comes out of the body. It consists of a muscular ring (called a sphincter), that opens during a
bowel movement to allow stool (feces) to pass through, as well as flat cells that line the inside of
the anus.
III.
SIGNS AND SYMPTOMS
Signs and Symptoms
Rationale
178
Bloody stool
Rectal bleeding is more common in ulcerative
colitis. It is a result of small ulcerations in the
lining of the large intestine, this leads to blood
in stools. (Smith, 2021)
Diarrhea
During an UC flare, the lining of the intestine
becomes inflamed and cannot absorb all fluid.
This results in stools being loose and watery,
or even entirely liquid. The looser stool can
also move more rapidly through the colon,
causing more frequent bowel movements.
Other causes of diarrhea can include side
effects of medications, changes in diet, and
infections. (Basson, 2021)
Abdominal pain
Abdominal pain is caused by inflammatory
process of the body that is further exacerbate
By eating gas forming foods and food high in
fiber that irritates the stomach. (Smith, 2021)
Tenesmus
Tenesmus is most often caused by the
inflammation in the colon (large intestine). It
may be a continuous or recurring sensation,
and it can occur just after finishing a bowel
movement. Ulceration, narrowing, blocking, or
scarring of the intestinal wall can also
contribute to tenesmus. (Wint, 2021)
Weight Loss
Symptoms
like
diarrhea,
nausea,
and
abdominal pain can make the person less
interested in eating. Also, inflammation can
increase energy expenditure making the
calorie burn quickly. (Watson, 2021)
179
Fatigue
Medication side effects, sleep difficulties,
associated illnesses such as anemia, and
flare-ups are all possible causes of fatigue in
patients with IBD. (Basson, 2022)
Fever
Fever
is
an
increase
in
your
body’s
temperature in response to disease or
infection.
It
can
be
developed
as
an
inflammatory process or side effects that treat
several medications of UC. (Basson, 2022)
Nausea
People may experience nausea during a flareup of ulcerative colitis. They may find that
certain
factors
trigger
nausea
or
other
symptoms of ulcerative colitis, such as
diarrhea or stomach pain. (Padua, 2022)
Anemia
People with ulcerative colitis may be anemic
either due to frank blood loss from the intestine
or to an iron deficiency. Malabsorption of
vitamins and minerals is common in patients
with IBD, and without enough iron, folic acid,
and vitamin B12, the body can't make more red
blood cells. (Tresca, 2020)
IV.
ETIOLOGY
Predisposing factors
Rationale
Age
Ulcerative colitis usually begins before the age of 30,
but it can occur at any age. Some people may not
develop the disease until after age 60. Since this is an
autoimmune disease, cells in our body tend to change
as we age thus can produce defective or bad cells.
180
(Martin, 2021)
Gender
Women are more likely to develop Crohn's disease
than men, but more men develop ulcerative colitis
than women. Even though the average age of
developing IBD is between 15 and 35, more men are
diagnosed with ulcerative colitis in their 50s and 60s
than women of the same age. (Ehrlich, 2021)
Race/Ethnicity
Ulcerative colitis is more common in white people
than in any other race. The incidence currently
appears to have stabilized in western countries but
continues to rise in Asia and South America.
Consequently, for ethnicity, a genetic variation may
predispose the Ashkenazi community to a greater risk
of Ulcerative colitis than non-Jewish persons.
(Wiginton, 2022)
Family history
People who have a relative who has ulcerative colitis
are at risk of acquiring the same disease. A firstdegree relative of a patient with ulcerative colitis has
a four times higher risk of developing the disease.
(Sethi, 2022)
Immune Reaction
In ulcerative colitis, a theory is that the immune
system mistakes "friendly bacteria" in the colon, which
aid digestion, as a harmful infection, leading to the
colon and rectum becoming inflamed.The imbalance
of the T helper cells can also be the primary precursor
of the disease process of ulcerative colitis, causing an
immune response in the body can be a factor in
acquiring ulcerative colitis in patients. (NHS, 2022)
Decreased Bacterial Diversity
Decreased diversity, considered an indicator of an
181
unhealthy microbiome, has been linked to different
chronic conditions such as obesity and type 2
diabetes. The intestinal microbial population and the
available variety and stability of intestinal bAnacteria
are compromised in ulcerative colitis patients, with
decreases in particular Firmicutes bacteria and
increases in Bacteroidetes bacteria and facultative
anaerobes. (NHS, 2020)
Precipitating factors
Rationale
Diet
There's no firm evidence that diet causes ulcerative
colitis but certain foods and beverages can aggravate
your signs and symptoms, especially during a flareup. It should also be pointed out that diet has the
potential to impact the mucous layer, which protects
the epithelium from the contents of the gut. (Mayo
Clinic, 2023)
Antibiotics
Using antibiotics can cause the bacterium Clostridium
difficile (C. diff) to grow and infect the lining of the
intestine,
which
produces
the
inflammation.
Particularly drugs with a larger microbiological scope,
may be linked to an increased risk of new-onset
ulcerative colitis. (Cleveland Clinic, 2023)
NSAIDs
Local and/or systemic effects of NSAIDs on mucosal
cells
might
lead
to
an
increased
intestinal
permeability, which is a prerequisite for colitis. The
use of non-steroidal anti-inflammatory drugs can harm
the colon by developing non-specific colitis or
aggravating an existing colonic condition. (Mayo
Clinic, 2023)
182
Stress
Your body goes into fight-or-flight mode when
stressed. That triggers the release of lots of
chemicals, including cytokines. Those are molecules
that turn on your immune system and lead to
inflammation. Chronic stress promotes colitis by
disturbing the gut microbiota and triggering immune
system response. (Pathak, 2021)
183
V.
PATHOPHYSIOLOGY
A. SCHEMATIC DIAGRAM
184
185
186
Narrative:
Ulcerative colitis is a long-term inflammatory condition that starts in your rectum and may
spread to your colon. The colon is the large intestine (bowel) and the rectum is the end of the
bowel where excrement is stored. Small ulcers can develop on the colon's lining, and can bleed
and produce pus. Ulcerative colitis is thought to be an autoimmune or idiopathic condition. This
means the immune system, the body's defense against infection, goes wrong and attacks healthy
tissue, but there are some factors that may aggravate the condition. The predisposing factors
include the age, gender specifically males are more prone, race/ethnicity, a family history of
inflammatory bowel conditions, Immune reactions wherein your own cells attack healthy ones,
and lastly Decreased Bacterial Diversity in the intestines. The precipitating factors then include,
Diet, Antibiotics with a larger microbiological scope, NSAIDs which are said to lead to an increased
intestinal permeability, and lastly, stress which triggers the release of cytokines.
The epithelial barrier, covered by a mucinous layer, is the first-line of defense of the
mucosal immune system, because it provides physical separation between host immune cells and
luminal microbes, and synthesized antimicrobial peptides. The mentioned predisposing and
precipitating factors of ulcerative colitis, associated with its uncertain cause, weaken the intestinal
mucin barrier's ability to function and thus increases the permeability of the intestinal epithelial
cells. As a result, a movement of microbial products into the intestinal wall takes place, activating
immune cells like the T-cells and antigen-presenting cells. Then, these T-cells, when accumulated
with the antigen presenting cells, stimulate the release of inflammatory cytokines. These
inflammatory cytokines include the IL - 4 which is known to increase the immune response of the
body, thus contributing to the development of chronic inflammation; and the IL - 12 which
increases the release of cytotoxic T-cells which contributes to the destruction of intestinal tissues.
Moreover, the other inflammatory cytokines such as the IL - 1, IL - 6, and TNF stimulate both the
plasma cells and the endothelial cells of the blood vessels.
To specify, the stimulation of the plasma cells by the three inflammatory cytokines, causes
the plasma cells to differentiate into a specific antibody called the P-ANCA (perinuclear
antineutrophil cytoplasmic antibody) that destroy neutrophils instead of pathogens, thus
aggravating the inflammation caused by other cytokines such as IL - 4 which then lead to chronic
inflammation. Furthermore, the three inflammatory cytokines also stimulate the endothelial cells
of the blood vessels which leads to an increased expression of the cell adhesion molecule that
interacts with WBCs; this makes the WBCs, specifically Neutrophils, travel into the intestinal wall,
thus increasing its number in the intestinal wall causing more tissue destruction. Then, this chronic
inflammation and tissue destruction lead to the manifestations of which include tenesmus,
187
abdominal pain, fever, fatigue, gastrointestinal bleeding, bloody diarrhea, weight loss and
dehydration. Along with chronic inflammation is tissue destruction which can lead to lesions hitting
the blood vessels, which causes gastrointestinal bleeding and bloody diarrhea. These symptoms
are assessed as blood in stool. Diagnostic tests that are relevant to the symptoms are stool
exams, blood tests and endoscopy. Simultaneously, chronic inflammation and tissue destruction
lead to the inflammation and ulceration of the colon resulting in Ulcerative Colitis.
Unfortunately, ulcerative colitis has no known cure, however, as mentioned, it can be
managed with proper medication and diet. The prognosis of this disease lies in whether or not the
patient gets treated. With proper interventions, the symptoms may be relieved. The longer periods
of remission, the better outlook for the patient which leads to a fair prognosis. However, as
ulcerative colitis is a chronic condition, the patient will experience periods of flare-ups and
remissions throughout their life. If ulcerative colitis is left untreated, the symptoms will escalate
and will further lead to complications and get worse over time. If the inflammation has reached
the deeper layers of the large intestine, it can spread throughout the colon and result in
complications like malnutrition, chronic fatigue, kidney failure, osteoporosis, and toxic megacolon,
which causes the gut to enlarge and stop functioning. The likelihood of the colon's lining suffering
extra harm rises with each flare-up. Also, people who have had ulcerative colitis for more than ten
years and those who have not gotten therapy have a higher risk of getting colorectal cancer
because uncontrolled inflammation can change the colon's cell structure and may result in a poor
prognosis resulting in death.
VI.
MEDICAL MANAGEMENT
A. DIAGNOSTIC EXAMS
TEST
RATIONALE
NURSING
RESPONSIBILITIES
Complete blood count
Blood tests can look for signs of Before the procedure:
infection as well as anemia, which
●
Explain
the
test
could indicate bleeding in your
procedure. About what
colon or rectum. CBC can also
type
detect thrombocytosis
needed, how it will be
that most
of
sample
patients with ulcerative colitis
collected,
have (Ulcerative Colitis Diagnosis
equipment to use.
is
and what
188
●
and Testing, n.d.-b).
Explain
that
slight
discomfort may be felt
when
the
skin
is
punctured.
●
Encourage patients to
avoid stress if possible
because
altered
physiologic
status
influences
and
changes
normal
hematologic values.
●
Explain that fasting is
not
necessary.
However, fatty meals
may alter some test
results
due
to
lipidemia.
●
Apply
manual
pressure
and
dressings
over
the
puncture site after the
blood is drawn.
After the procedure:
●
Monitor the puncture
site
for
oozing
or
hematoma formation.
●
Instruct
to
resume
normal activities and
diet.
Stool Culture
Your
stool
specimen
will
be Before the procedure:
analyzed to eliminate the possibility
●
Assess the patient’s
189
that your symptoms are caused by
level
of
comfort.
bacteria, a virus, or a parasite
Collecting
stool
(Ulcerative Colitis Diagnosis and
specimen
may
Testing, n.d.-b).
produce a feeling of
embarrassment
and
discomfort
the
to
patient.
●
Encourage the patient
to urinate. Allow the
patient
to
urinate
before
collecting
to
avoid
contaminating
the stool with urine.
●
Avoid
laxatives.
Advise the patient that
laxatives, enemas, or
suppositories
avoided
are
three
days
prior to collection.
●
If any special dietary
restrictions
are
applicable, instruct the
client as indicated
●
Inform the client how
many stool specimens
are required and a
supply
specimen
container.
After the procedure:
●
Label the container
●
Promptly
send
the
specimen
to
the
190
laboratory for analysis.
●
Instruct the patient to
do
handwashing.
Allow the patient to
thoroughly clean his or
her
hands
and
perianal area.
●
Resume activities. The
patient may resume
his or her normal diet
and
medication
therapy
unless
otherwise specified.
X-ray
In
ulcerative
colitis,
bowelwall Before the procedure:
inflammation extends proximally
●
Remove all metallic
from the rectum. Therefore, x-ray
objects. Items such as
suggests that inflammation affects
jewelry, pins, buttons
the whole colon. Radiological
etc can hinder the
features of UC may also include
visualization
rectal narrowing,
chest.
widening of
presacral space and stranding of
●
perirectal fat (Jones, 2019).
No
of
preparation
the
is
required. Fasting or
medication restriction
is not needed unless
directed by the health
care provider.
●
Ensure the patient is
not
pregnant
suspected
to
or
be
pregnant. X-rays are
usually
not
recommended
for
191
pregnant
unless
women
the
benefit
outweighs the risk of
damage to the mother
and fetus.
●
Provide
appropriate
clothing. Patients are
instructed to remove
clothing from the waist
up and put on an X-ray
gown to wear during
the procedure.
●
Instruct
patient
to
cooperate during the
procedure. The patient
is asked to remain still
because
any
movement will affect
the
clarity
of
the
image.
After the procedure:
●
No special care. Note
that no special care is
required following the
procedure
●
Provide comfort. If the
test is facilitated at the
bedside, reposition the
patient properly.
CT Scan
CT
scans
use
digital
X-ray Before the procedure:
detectors instead of traditional film
●
Take off some or all of
192
detectors to create a clearer image
the clothing and wear
of a person’s internal structure and
a hospital gown.
●
how much of a
person’s
colon
any
metal
inflamed
objects, such as a belt
(Osborne, 2022). It is performed if a
or jewelry, which might
complication from ulcerative colitis
interfere with image
is suspected. CT scan typically
results.
demonstrates
is
Remove
circumferential,
●
Stop eating for a few
symmetrical wall thickening with
hours before the scan.
fold enlargement (Frcr, n.d.).
If a patient is going to
have
a
contrast
injection, he or she
should
not
anything
to
have
eat
or
drink for a few hours
before the CT scan
because the injection
may cause stomach
upset.
●
To receive the contrast
injection,
an IV
is
inserted into the arm
just prior to the scan.
The
enters
contrast
the
then
body
through the IV.
●
Prior to most CT scans
of the abdomen and
pelvis, it is important to
drink an oral contrast
agent
dilute
that contains
barium.
This
contrast agent helps
193
the radiologist identify
the
gastrointestinal
tract (stomach, small
and
large
bowel),
detect abnormalities of
these organs, and to
separate
these
structures from other
structures within the
abdomen.
●
If the patient has a
history of allergy to
contrast
material
(such as iodine), the
requesting
and
physician
radiology
staff
should be notified.
●
The patient will be
asked to drink slightly
less
than
a
quart
spread out over 1.5 to
2 hours.
After the procedure:
●
After
the
exam,
patients can return to
their normal routine.
●
If a patient were given
a contrast material, the
patient may receive
special instructions. In
some cases, patients
may be asked to wait
194
for a short time before
leaving to ensure that
they feel well after the
exam. After the scan,
patients are likely to be
told to drink lots of
fluids to help their
kidneys remove the
contrast material from
the body.
Biopsy sample
During the biopsy, a small piece of Before the procedure:
tissue is removed from the inside of
●
the intestine for further testing and
analysis. Your biopsied tissue will
be
analyzed
in
a
laboratory
and
disease
(Ulcerative
sterile dressing.
●
pathology
screened
Cover the site with a
Help the patient to a
comfortable position.
for
Colitis After the procedure:
Diagnosis and Testing, n.d.-b).
●
Monitor his vital signs
and
assess
puncture
site
the
for
bleeding.
●
Properly
label
and
promptly transport all
specimens to the lab.
sigmoidoscopy
A sigmoidoscopy allows your doctor Pretest Nursing
to examine the extent of the Responsibilities:
inflammation in your lower colon
and
rectum
(Ulcerative
●
Colitis
Instruct the patient to
eat a low-residue diet
Diagnosis and Testing, n.d.-b).
for 3 days prior to the
procedure.
This procedure is the
"gold
standard" for diagnosing ulcerative
●
Instruct the patient to
only take clear liquids
195
colitis.
Sigmoidoscopy
allows
that
should
be
doctors to look at the inside of the
consumed the evening
patient’s colon as well as to take a
before.
biopsy that will examine via a
●
Inform the client to be
microscope to look for any changes
NPO 8 hours prior to
of UC, together with the signs of
the procedure.
other health conditions (Phillips,
●
2021).
Note the intake of oral
iron
preparations
within
one
week
before the procedure
because
cause
they
black,
may
sticky
stools that are hard to
remove
with
bowel
preparation.
Post-test Nursing
Responsibilities
●
Patient may have mild
abdominal discomfort
and may feel bloated
or pass gas for a few
hours as he/she clears
the air from his/her
colon. By this, walking
may help relieve any
discomfort.
●
Patient should be able
to return to their usual
diet and activities right
away. Patient
may
also notice a small
amount of blood with
196
their
first
bowel
movement after the
exam,
which usually
does not cause alarm.
Consult a doctor if a
patient continues to
pass blood or blood
clots or if he/she has
persistent
abdominal
pain or a fever of 100
F (37.8 C) or higher.
Colonoscopy
A total colonoscopy is similar to a Pretest Nursing
sigmoidoscopy, but this procedure Responsibility
allows your doctor to examine your
entire
colon
(Ulcerative
●
Colitis
Diagnosis and Testing, n.d.-b).
Secure
informed
consent.
●
Obtain
a
medical
history of the patient
It is also the "gold standard" for
such
diagnosing ulcerative colitis. This
bleeding,
procedure looks for UC damage
medications,
such as swelling, redness, and
information relevant to
sores in the intestine. This shows
the current complaint.
how severe the disease is and how
●
the colon is greatly affected.
as
allergies,
histories,
Provide
and
information
about the procedure.
●
Ensure that the patient
has complied with the
bowel
preparation.
He/she
must
maintained
a
have
clear
liquid diet for 24-48
hours before the test,
NPO after midnight,
197
and taken a laxative,
as ordered.
●
Inform the patient that
an IV line will be
started and a sedative
will be administered
before the procedure.
Also,
advise
patient
to
the
have
someone
drive
him/her home after the
procedure
since
sedatives
will
be
given.
●
Instruct the patient to
empty
the
bladder
prior to the procedure.
●
Instruct the patient to
remove
all
metallic
objects from the area
to be examined.
Posttest Nursing
Responsibilities:
●
Observe the patient
closely for signs of
bowel perforation.
●
Obtain and record the
patient’s vital signs.
Signs
of
bowel
perforations such as
severe
pain,
abdominal
nausea,
198
vomiting, fever, and
chills must be reported
immediately.
●
Instruct the patient to
resume a normal diet,
fluids,
and
activity
advised by the health
care provider.
●
Provide privacy while
the patient rest after
the procedure.
●
Monitor for any rectal
bleeding.
●
Encourage increased
fluid intake to replace
the fluid lost during the
procedure.
Chromoendoscopy
Chromoendoscopy
involves
the Before the procedure:
topical application of stains or
pigments
to
localization,
diagnosis
improve
tissue
characterization,
during
●
consent is signed prior
or
endoscopy.
Ensure the informed
to premedication.
●
Encourage questions,
During a chromoendoscopy, a blue
and provide answers
liquid dye is sprayed into the colon
and support.
to
highlight
and
detect
slight
●
Withhold
food
and
changes in the lining of your
fluids for 6 to 8 hours
intestine(Ulcerative
before the procedure.
Colitis
Diagnosis and Testing, n.d.-b).
●
Remove dentures and
eyewear.
Provide
mouth care.
After the procedure:
199
●
After the procedure,
you will be allowed to
eat and drink as soon
as your gag reflex
returns and you are
able to swallow.
●
You may experience
mild
bloating,
belching, or flatulence
following
the
procedure.
●
Contact your physician
immediately
if
you
develop any of the
following:
difficulty
swallowing;epigastric,
substernal or shoulder
pain; vomiting blood or
black tarry stools; or
fever.
B. MEDS
1. Aminosalicylates (5-ASA)
Aminosalicylates are medications that contain 5-aminosalicylic acid (5-ASA) and work in
the lining of the gastrointestinal tract to decrease inflammation. Aminosalicylates work best in the
colon and are often given orally in the form of delayed release tablets, or rectally as enemas or
suppositories. Aminosalicylates are thought to be effective in treating mild-to-moderate ulcerative
colitis flares and can be useful as a maintenance treatment in preventing relapses of the disease
(Medication Options for Ulcerative Colitis, 2022.).
Examples: Sulfasalazine, Mesalamine, Olsalazine, Balsalazide
GENERIC NAME
Sulfasalazine
200
BRAND NAME
Azulfidine, , Azulfidine EN-tabs, Salazopyrin
DRUG CLASSIFICATION
PHARMACOTHERAPEUTIC:5-Ami-nosalicylic acid derivative.
CLINICAL: Anti-inflammatory.
SUGGESTED DOSE
PO:
ADULTS, ELDERLY: Initially, 3-4 g/day in divided doses q8h.
May initiate at 1-2 g/day to reduce GI intolerance.
Maximum: 6 g/day.
Maintenance: 2 g/day in divided doses at intervals less than
or equal to q8h.
CHILDREN 6 YRS AND OLDER: Initially, 40–70 mg/kg/day in
3–6 divided doses.
Maximum initial dose: 4 g/day.
Maintenance: 30–70
mg/kg/day
in
3–6
divided
doses.
Maximum daily dose: 4 g/day
ROUTE
OF PO
ADMINISTRATION
MODE OF ACTION
Modulates
local
mediators
of
inflam-matory
response.
Inhibits tumor necrosis factor (TNF).
Therapeutic
Effect:
Decreases
inflammatory
response,
interferes with GI secretion. Effect appears topical rather
than sys-temic.
INDICATION
Treatment of mild to moderate ulcerative colitis, adjunctive
201
therapy in severe ulcerative colitis, rheumatoid arthritis (RA),
juvenile rheumatoid arthritis.
CONTRAINDICATION
-Hypersensitivity to sulfasalazine, sulfa, salicylates; porphyria;
GI or GU obstruction.
-Urinary tract or intestinal obstruction; Porphyria
Cautions: Severe allergies, bronchial asthma, impaired
hepatic/renal function, G6PD deficiency, blood
dyscrasias, history of recurring or chronic infections.
SIDE EFFECTS
Frequent (33%): Anorexia, nausea, vomiting,
headache,
oligospermia (generally reversed by withdrawal of drug).
Occasional (3%): Hypersensitivity reaction (rash, urticaria,
pruritus, fever, anemia).
Rare (less than 1%): Tinnitus, hypoglycemia, diuresis,
photosensitivity.
ADVERSE EFFECTS
Anaphylaxis, Stevens-Johnson syndrome, hematologic toxicity
(leukopenia, agranulocytosis), hepatotoxicity, nephrotoxicity
occur rarely.
DRUG INTERACTIONS
●
May
increase
hypoglycemic
action/risk
agents,
of
toxicity
phenytoin,
from
oral
methotrexate,
zidovudine, or warfarin.
●
Increase the risk of drug-induced hepatitis with other
hepatotoxic agents.
●
Increase the risk of crystalluria with methenamine. May
decrease metabolism and increase effects/toxicity of
mercaptopurine or thioguanine.
NURSING
RESPONSIBILITIES
1. Assess the patient for allergy to sulfonamides and
salicylates.
R: Therapy should be discontinued if rash, difficulty breathing,
swelling of face or lips, or fever occur.
202
2. Monitor CBC with differential and liver function tests
before and every second week during the first 3 months
of therapy, monthly during the second 3 months, and
every 3 months thereafter as clinically indicated.
Discontinue sulfasalazine if blood dyscrasias occur.
R: Sulfasalazine may cause blood problems and induce liver
injury that can result in minor ALT and alkaline phosphatase
elevations (sometimes with other signs of hypersensitivity and
with hepatic granulomas), acute self-limited hepatitis, and even
acute liver failure.
3. Assess for rash periodically during therapy. Discontinue
therapy if severe or if accompanied by fever, general
malaise, fatigue, muscle or joint aches, blisters, oral
lesions, conjunctivitis, hepatitis, and/or eosinophilia.
R: May cause Stevens-Johnson syndrome.
4. Assess abdominal pain and frequency, quantity, and
consistency of stools at the beginning of and during
therapy.
R: A dosage increase may be needed if diarrhea continues or
recurs.
5. Administer after meals or with food; and with a full glass
of water. Drink several glasses of water between meals.
Do not crush or chew enteric-coated tablets.
R: To minimize GI irritation and drink plenty of water to prevent
possible kidney problems.
6. Varying dosing regimens of sulfasalazine may be used.
R: To minimize GI side effects.
7. Instruct
the
patient
on
the
correct
method
of
203
administration. Advise patient to take medication as
directed, even if feeling better. Take missed doses as
soon as remembered unless almost time for the next
dose.
R: Taking medicine on time, as prescribed, is essential to
making sure your body has an effective amount of the drug at
all times. If not, this can cause the disease to develop a
resistance to the medicine or simply prolong the amount of time
it takes to feel better.
8. Advise patient to notify health care professional if skin
rash, sore throat, fever, mouth sores, unusual bleeding
or bruising, wheezing, fever, or hives occur.
R: To facilitate prompt management .
9.
Caution patient to use sunscreen and protective
clothing.
R: To prevent photosensitivity reactions.
10. Inform the patient that this medication may cause
orange-yellow discoloration of urine and skin, which is
not
significant. May permanently stain contact lenses yellow.
R: To avoid the patient from worrying since this is a normal
side effect of the drug.
11. Instruct the patient to notify the health care professional
if symptoms worsen or do not improve. If symptoms of
acute intolerance (cramping, acute abdominal pain,
bloody
diarrhea,
discontinue
fever,
therapy
and
headache,
notify
the
rash)
occur,
health
care
professional immediately.
R: Relapses occur in about 40% of patients after an initial
204
satisfactory response. Response to therapy and duration of
treatment are governed by endoscopic examinations.
2. CORTICOSTEROIDS
Corticosteroids suppress the immune system and are used to treat moderate to severely
active ulcerative colitis. These drugs work non-specifically, meaning that they suppress the entire
immune response, rather than targeting specific parts of the immune system that cause
inflammation. These medications are available orally and rectally. Corticosteroids have significant
short and long-term side effects and should not be used as a maintenance medication. Because
they cause the adrenal glands to slow or even stop producing the body’s natural cortisol, these
medications cannot be stopped abruptly.
If you cannot come off steroids without suffering a relapse of your symptoms, your doctor
may need to prescribe other medications to help manage your disease (Medication Options for
Ulcerative Colitis, n.d.). Examples: Prednisone, Prednisolone, Methylprednisolone, Budesonide
GENERIC NAME
Prednisone
BRAND NAME
Intensol, Rayos, Winpred
DRUG CLASSIFICATION
PHARMACOTHERAPEUTIC:
Adrenal
corticosteroid.
CLINICAL: Anti-inflammatory, immunosuppressant.
SUGGESTED DOSE
PO: ADULTS, ELDERLY: 10–60 mg/day in divided doses.
Range: 2.5–100 mg/day.
CHILDREN: 0.05–2 mg/kg/day in 1–4 divided doses
205
ROUTE
OF PO
ADMINISTRATION
MODE OF ACTION
Inhibits accumulation of inflammatory cells at inflammation
sites, phagocytosis, lysosomal enzyme release/synthesis,
release of mediators of inflammation.
Therapeutic
Effect:
Prevents/suppresses
cell
mediated
immune reactions. Decreases/prevents tissue response to
inflammatory process.
INDICATION
●
Replacement therapy in adrenal cortical insufficiency.
●
Hypercalcemia associated with cancer.
●
Short-term management of various inflammatory and
allergic disorders, such as rheumatoid arthritis, collagen
diseases
(eg,
SLE),
dermatologic
diseases
(eg,
pemphigus), status asthmaticus, and autoimmune
disorders.
●
Hematologic disorders: Thrombocytopenia purpura,
erythroblastopenia.
●
Ulcerative colitis, acute exacerbations of MS and
palliation in some leukemias and lymphomas.
●
CONTRAINDICATION
Trichinosis with neurologic or myocardial involvement.
Hypersensitivity to predniSONE. Acute superficial herpes
simplex
keratitis,
systemic
fungal
infec-tions,
varicella,
administration of live or attenuated virus vaccines.
SIDE EFFECTS
Frequent: Insomnia, heartburn, nervous-ness,
abdominal
distention,
increased
diaphoresis,
acne,
mood
swings,
appetite, facial flushing, delayed wound healing, increased
susceptibility to infection, di-arrhea, constipation.
Occasional: Head-ache, edema, change in skin color, frequent
urination.
Rare: Tachycardia, allergic reaction (rash, urticaria), psychological changes, hallucinations, de-pression.
206
ADVERSE EFFECTS
Long-term therapy: Muscle wasting (esp. in arms, legs),
osteoporosis, spon-taneous fractures, amenorrhea, cataracts,
glaucoma, peptic ulcer, HF.
Abrupt with-drawal following long-term therapy: Anorexia,
nausea, fever, headache, re-bound
weakness,
inflammation,
fatigue,
lethargy, dizziness, orthostatic hypoten-sion.
Sudden discontinuance may be fatal.
DRUG INTERACTIONS
●
CYP3A4 inducers (e.g., carBA-Mazepine, phenytoin,
rifAMPin) may decrease effects.
●
Live
virus
vaccines may
increase
vaccine
side
effects, po-tentiate virus replication, decrease pt’s
antibody response to vaccine.
●
May
in-crease effect of warfarin. May decrease
therapeutic
effect
of
aldesleukin.
May
increase
hyponatremic effect of des-mopressin.
NURSING
RESPONSIBILITIES
1. Obtain baselines for height, weight,
B/P,
serum
glucose, electrolytes.
R: Serves as a baseline in comparison with the effects of the
medication.
2. Check results of initial tests (tuberculosis [TB] skin test,
X-rays, ECG).
R: Prednisone may cause what is known as tachycardia, or a
rapid heart rate over 100 beats per minute. In clinical studies,
other possible adverse cardiovascular effects reported were:
Cardiac arrhythmias. Bradycardia (slowed heart rate). In
patients with latent tuberculosis or tuberculin reactivity, the use
of pharmacologic dosages of corticosteroids may cause a
reactivation of the disease. During prolonged corticosteroid
therapy, tuberculosis chemoprophylaxis may be considered.
207
3. Monitor B/P, serum electrolytes, glucose, results of bone
mineral density test, height, weight in children.
R: Corticosteroids can raise blood glucose level by antagonizing
the action and suppressing the secretion of insulin, which results
in inhibition of peripheral glucose uptake and increased
gluconeogenesis. Corticosteroids can cause hypernatremia,
hypokalemia, and fluid retention. All corticosteroids also
increase excretion of calcium and can cause hypocalcemia.
Prolonged steroid use is significantly associated with short
stature and heavier weight.
4. Be alert to infection (sore throat, fever, vague
symptoms); assess oral cavity daily for signs of
Candida infection.
R: Additional predisposing factors for Candida infection include
the use of antibiotics, oral contraceptives, or adrenal
corticosteroids (such as prednisone).
5. Monitor
for
symptoms
of
adrenal
insufficiency,immunosuppression.
R: Long-term steroid therapy can result in secondary adrenal
insufficiency due to suppression of the hypothalamic-pituitaryadrenal axis. Systemic intercurrent illness can often precipitate
adrenal crisis in such patients if steroid therapy is not increased
temporarily to tide over the period of metabolic stress.
6. Report fever, sore throat, muscle aches, sudden weight
gain, swelling, loss of appetite, or fatigue.
R: General aches and pains, headache, an increased appetite
that may result in weight gain, increased sweating, indigestion,
and insomnia are the most common side effects reported.
7. Avoid alcohol, minimize use of caffeine.
208
R: Limit or avoid alcohol use while taking prednisone to help
prevent stomach ulcers.
8. Report symptoms of elevated blood sugar levels (blurred
vision, headache, increased thirst, frequent urination).
R: All corticosteroids, including prednisolone, can cause salt
and fluid retention, which may lead to blood pressure elevation
and increased potassium excretion. Calcium excretion is also
increased. Cataracts, glaucoma, eye infections, an increase in
new episodes of optic neuritis, and corneal perforation
associated with herpes simplex of the eye, have all been
reported with prednisone use.
9. Do
not
abruptly
discontinue
without
physician’s
approval.
R: May cause withdrawal symptoms if stopped suddenly after
long-term or high-dose therapy. Symptoms include fever,
vomiting, loss of appetite, diarrhea, weight loss, general aches,
and pains.
10. Avoid exposure to chickenpox, measles.
R: Prednisone may decrease your ability to fight infection and
can prevent you from developing symptoms if you get an
infection. Stay away from people who are sick and wash your
hands often while you are taking this medication.
11. Gradually reduce dosage after long-term therapy.
R: Long-term use may significantly increase risk of serious
infections.
3. IMMUNOMODULATORS
This class of medication controls or suppresses the body’s immune system response so it
cannot cause ongoing inflammation. Immunomodulators, which may take several months to begin
209
working, are generally used when aminosalicylates and corticosteroids haven’t been effective, or
have been only partially effective. These medications may be useful in reducing or eliminating the
need for corticosteroids, and in maintaining remission in people who haven’t responded to other
medications given for this purpose. Some immunomodulators are used to make other
medications, such as biologics, work better (Medication Options for Ulcerative Colitis, 2022).
Examples: Azathioprine, 6-mercaptopurine, Cyclosporine, Tacrolimus
GENERIC NAME
Azathioprine
BRAND NAME
Azasan, Imuran
DRUG CLASSIFICATION
PHARMACOTHERAPEUTIC: Immunologic agent.
CLINICAL: Immunosuppressant.
SUGGESTED DOSE
Ulcerative Colitis (Off-label):
Maintenance, remission, or reduction of steroid
1.5-2.5 mg/kg PO once daily
ROUTE
OF PO/IV
ADMINISTRATION
MODE OF ACTION
Metabolites are incorporated into replicating DNA and halt
replication. Blocks purine synthesis pathway. Therapeutic
Effect: Suppresses cell-mediated hypersensitivities;
alters
antibody production, immune response in transplant recipients.
Reduces symptoms of arthritis severity.
210
INDICATION
●
Renal homotransplantation: Adjunct for prevention of
rejection
●
Rheumatoid arthritis: Use only with adults meeting
criteria
for
classic
rheumatoid
arthritis
and
not
responding to conventional management
●
Unlabeled use: Treatment of chronic ulcerative colitis,
myasthenia gravis, Behçet’s syndrome, Crohn’s disease
CONTRAINDICATION
Contraindications: Hypersensitivity to azaTHIOprine. Pregnant
women with RA, and pts previously treated for RA with alkylating
agents (cyclophosphamide, chloram-bucil, melphalan) may
have a prohibitive risk of malignancy with azathioprine.
Cautions: Immunosuppressed pts, pts with hepatic/renal
impairment, active infection. Testing for genetic deficiency of
thiopurine methyltransferase should be obtained. (Absence or
reduced levels increase risk of myelosuppression.)
SIDE EFFECTS
Frequent: Nausea, vomiting, anorexia (particularly during early
treatment and with large doses).
Occasional: Rash.
Rare: Severe nausea/vomiting with diarrhea, abdominal pain,
hypersensitivity reaction.
ADVERSE EFFECTS
Increases risk of neoplasia (new abnormal-growth tumors).
Significant leukopenia and thrombocytopenia may occur,
particularly in pts undergoing renal transplant rejection.
Hepatotoxicity occurs rarely.
DRUG INTERACTIONS
Allopurinol may increase activity and toxicity. May increase the
immunosuppressive effect of baricitinib,
fingolimod,
and
mercaptopurine. May decrease the therapeutic effect of BCG
(intra-vesical), and vaccines (live). May increase
adverse
effects of natalizumab, and vaccines (live).
NURSING
1. History: Allergy to azathioprine; rheumatoid arthritis
211
RESPONSIBILITIES
patients previously treated with alkylating agents;
pregnancy or male partners of women trying to become
pregnant; lactation
R:IMURAN should not be given to patients who have shown
hypersensitivity to the drug. Patients with rheumatoid arthritis
previously treated with alkylating agents (cyclophosphamide,
chlorambucil, melphalan, or others) may have a prohibitive risk
of malignancy if treated with IMURAN. IMURAN should not be
used
for
treating
rheumatoid
arthritis
in
pregnant
women.IMURAN can cause fetal harm when administered to a
pregnant woman. IMURAN should not be given during
pregnancy without careful weighing of risk versus benefit.
2. Physical: T; skin color, lesions; liver evaluation, bowel
sounds; LFTs, renal function tests, CBC
R: Taking azathioprine can sometimes affect your liver, kidneys
or bone marrow. You will have blood tests to check your liver
function, kidney function and blood count before you start taking
this medicine.
3. Give drug IV if oral administration is not possible; switch
to oral route as soon as possible.
R: Intravenous azathioprine should only be used when the oral
route is impractical.It should be switched to the oral route as
soon as possible as this is a very irritant solution due to alkaline
nature of injection. Use only if oral route not feasible, and avoid
extravasation
4. Administer in divided daily doses or with food if GI upset
occurs.
R: These should be taken with a meal to reduce upset stomach.
5. BLACK BOX WARNING: Monitor blood counts regularly;
212
severe
hematologic
effects
may
require
the
discontinuation of therapy; increases risk of neoplasia.
R: Azathioprine can cause a decrease in the number of blood
cells in your bone marrow, which may cause serious or lifethreatening infections. You will need to have regular blood tests
to monitor for side effects and to check whether the treatment is
effective.
6. Monitor I&O ratio; note color, character, and specific
gravity of urine. Report an abrupt decrease in urinary
output or any change in I&O ratio.
R: Decreased urine output may lead to toxicity with this
medication.
7. Avoid infections; avoid crowds or people who have
infections.
Instruct
patient
to
not
receive/take
vaccinations or other immunity-conferring agents during
therapy
R: Azathioprine may lower your body's resistance and the
vaccine may not work as well or you might get the infection the
vaccine is meant to prevent. In addition, you should not be
around other persons living in your household who receive live
virus vaccines because there is a chance they could pass the
virus on to you.
8. Avoid prolonged or unnecessary exposure to sunlight
and
wear
protective
clothing,
sunglasses,
and
sunscreen.
R: To decrease the risk that you will develop skin cancer,
Azathioprine may increase your risk of developing certain types
of cancer, especially skin cancer and lymphoma (cancer that
begins in the cells that fight infection).
213
9. Notify your health care provider if you think you are
pregnant or wish to become pregnant, or if you are a
man whose sexual partner wishes to become pregnant.
R: Using this medicine while you are pregnant can harm your
unborn baby. Use an effective form of birth control to keep from
getting pregnant. If you think you have become pregnant while
using this medicine, tell your doctor right away.
10. Report unusual bleeding or bruising, fever, sore throat,
mouth sores, signs of infection, abdominal pain, severe
diarrhea, darkened urine or pale stools, severe nausea
and vomiting.
R: These could be symptoms of a serious reaction to the
medicine in your bowel. Azathioprine can temporarily lower the
number of white blood cells in your blood, increasing the chance
of getting an infection. It can also lower the number of platelets,
which are necessary for proper blood clotting.
4. BIOLOGICS
Biologics are used to treat people with moderate-to-severe ulcerative colitis. Unlike other
medications, biologics are protein-based therapies that are created out of material naturally found
in life. These medications are antibodies that stop certain proteins in the body from causing
inflammation (Medication Options for Ulcerative Colitis, 2022).
Examples: Adalimumab, Golimumab, Infliximab, Ustekinumab, Vedolizumab
GENERIC NAME
Adalimumab
214
BRAND NAME
Humira, Amgevita, Hyrimoz, Idacio, Imraldi, Yuflyma, Cyltezo
DRUG CLASSIFICATION
PHARMACOTHERAPEUTIC: Monoclonal antibody.
CLINICAL: Antirheumatic, disease modifying; GI agent; TNF
blocking agent.
SUGGESTED DOSE
Ulcerative Colitis
SQ: ADULTS, ELDERLY: Initially, 160 mg (4 injections in 1
day or 2 injections over 2 consecutive days) then 80 mg 2
wks later (day 15), then 40 mg every other wk beginning
on day 29.
ROUTE
OF Subcutaneous Injection
ADMINISTRATION
MODE OF ACTION
Binds specifically to tumor necrosis fac-tor (TNF) alpha cell,
blocking its interac-tion with cell surface TNF receptors and
cytokine-driven inflammatory processes.
Therapeutic Effect: Decreases signs/symptoms of RA,
psoriatic arthritis, ankylos-ing spondylitis, Crohn’s disease,
ulcerative colitis. Inhibits progression of rheumatoid and
psoriatic arthritis. Reduces epidermal thickness, inflammation
of plaque psoriasis.
INDICATION
●
Reduces signs/symptoms, progression of structural
damage and improves physi-cal function in adults
215
with moderate to severe RA. May be used alone or in
com-bination
with
other
disease-modifying
antirheumatic drugs.
●
First-line treatment of
moderate
to
severe
RA,
treatment of psoriatic arthritis, treatment of anky-losing
spondylitis, to induce/maintain remission of moderate
to severe active Crohn’s disease, moderate to severe
plaque psoriasis in pts 6 yrs of age and older.
●
Reduces signs and symptoms of moderate to severe
active polyarticular juvenile rheumatoid arthritis in pts 2
yrs and older.
●
Treatment
of
active
ulcerative
colitis
in
pts
unresponsive to immunosuppressants.
●
Treatment
of
moderate
to
severe hidradenitis
suppurativa.
●
Treatment
of
uveitis
(noninfectious
intermediate,
posterior and panuveitis) in adults.
CONTRAINDICATION
Contraindications: Hypersensitivity to adalimumab. Severe
infections (e.g., sep-sis, TB).
SIDE EFFECTS
Frequent
(20%): Injection
site
erythema,
pruritus, pain,
swelling.
Occasional (12%–9%): Headache, rash, sinusitis, nausea.
Rare (7%–5%): Abdominal or back pain, hypertension.
ADVERSE EFFECTS
●
Hypersensitivity reactions (rash, urticaria, hypotension,
dyspnea), infections (pri-marily upper respiratory tract,
bronchitis, urinary tract) occur rarely.
●
May increase risk of serious infections (pneumonia, tuberculosis, cellulitis, pyelonephritis, septic arthritis).
●
May increase risk of reactivation of hepatitis B virus in
pts who are chronic carriers.
216
●
May cause new-onset or exacer-bation
of
central
nervous demyelinating disease; worsening and newonset HF.
●
May increase risk of malignancies. Immunoge-nicity
(anti-adalimumab autoantibodies) occured in 12% of
pts.
DRUG INTERACTIONS
●
May increase the adverse effects of abatacept,
anakinra,
belimumab,
canakinumab,
natalizumab,
tofaci-tinib, vaccines (live), vedolizumab.
●
May
decrease
the
therapeutic
effect
of
BCG
(intravesical), vaccines (live).
●
May increase the immunosuppressive effects of
certolizumab, infliximab.
●
Tocilizumab may increase the immunosuppressive
effect.
NURSING
RESPONSIBILITIES
1. Assess history of
infections, cancer, liver and heart
problems.
R: If you have a history of infections, currently have an infection
or have symptoms such as feeling feverish or generally unwell
your adalimumab treatment may need to be postponed. If you
have heart problems, as adalimumab may make your symptoms
worse, and your heart will need to be monitored closely before,
during, and after treatment. If you have a history of cancer.
Adalimumab affects the way in which your immune system
works and you may have an increased risk of developing some
types of cancer. Humira may cause you to develop liver
problems. If you have liver problems or have had them in the
past, tell your doctor before using Humira.
2. Ask if the patient have or have ever had HIV, hepatitis B
or C (a viral liver infection)
R: You will usually have a blood test to check for these diseases
217
before starting adalimumab.If you have hepatitis B or have had
it in the past, using Humira may cause reactivation of the virus.
They’ll likely monitor you more closely throughout your Humira
treatment to make sure your hepatitis B symptoms don’t return.
3. Review immunization status/screening for TB. If pt is to
self-administer, instruct on SQ injection
technique,
including areas of the body acceptable for injection
sites.
R: If you have any history of tuberculosis (TB) or any recent
exposure to people with TB. You should not be given
adalimumab if you have active TB, and if you have underlying
inactive TB, this will need to be treated before starting
adalimumab. Most doctors now use a blood test to check for
underlying or inactive TB, but you may be given a chest x-ray
as well.
4. Monitor lab values, particularly CBC.
R: you will need regular checks and may need additional blood
tests. Monitoring your treatment in this way helps your doctors
fit your treatment to your needs. It can also make sure that any
complications or problems with your treatment are avoided or
caught at an early stage. You may also be given a special blood
test to check the levels of adalimumab in your blood. This can
help your doctor see how well the adalimumab is working, and
whether you have developed antibodies to it.
5. Monitor neurological status closely. Report any change
in status such as blurred vision or paresthesia.
R: Humira can cause nervous system problems. Symptoms of
some nervous system problems may include changes in your
vision.
218
6. Try to avoid close contact with people who have
infections. Do
not
receive
live
vaccines
during
treatment.
R: Adalimumab affects the way your immune system works, so
you may be more prone to infections. Also, even a mild infection
such as a cold or sore throat could develop into a more serious
illness if you are taking adalimumab. You may also be at greater
risk of becoming more seriously ill from viruses and bacteria
such as those that cause chickenpox and shingles, measles,
and pneumococcal disease.
7. Take care with food hygiene and avoid eating raw eggs
or undercooked pate, meat and poultry, as well as
unpasteurised dairy products and soft or blue cheeses.
R: You may be more open to the type of infections caused by
bacteria such as listeria when being treated with adalimumab.
8. Report swelling, redness, bruising and itching on the
injection site.
R: Others may experience reactions to the injection such as
pain or swelling, redness, bruising and itching. This can be very
common, affecting at least one in 10 people.
9. Take extra precautions when in the sunlight, for example
wearing a hat and high factor suncream
R: Adalimumab can increase the risk of skin reactions, and in
rare cases skin cancer.
10. Tell your doctor immediately if you develop any of the
following symptoms: A severe rash, hives (swollen red
patches of skin) or other signs of allergic reaction
Swollen face, hands and feet Trouble breathing or
swallowing, Shortness of breath, Persistent fever,
219
bruising, bleeding or paleness, Fatigue, cough, or flu-like
symptoms.
R: Symptoms that mean you are having an allergic reaction to
adalimumab. For example, rashes, hives (a raised itchy rash
that appears on the skin), a swollen face, hands and feet, or
trouble breathing and shortness of breath. Some of the more
common side effects of adalimumab include abdominal pain,
nausea, headaches, fatigue and joint pain.
11. Do not breastfeed when taking this medication, consult
your doctor first.
R: Breastfeeding during treatment with Humira may not be safe.
This is because Humira passes into breast milk.
5. Janus kinase inhibitors (JAK inhibitors)
These are oral medicines that can work quickly to get and maintain a remission in
ulcerative colitis. Tofacitinib (Xeljanz) is the first JAK inhibitor that is FDA-approved for the
treatment of ulcerative colitis (Pathak, 2021).
GENERIC NAME
Tofacitinib
BRAND NAME
Xeljanz, Xeljanz XR
DRUG CLASSIFICATION
PHARMACOTHERAPEUTIC: Janus-associated kinase (JAK)
inhibitor.
CLINICAL: Antirheumatic, disease-modifying.
220
SUGGESTED DOSE
PO: ADULTS/ELDERLY: (Xeljanz): Induc-tion: 10 mg twice
daily for 8 wks. May transition to maintenance dose or
con-tinue 10 mg twice daily for additional 8 wks. Discontinue
if 10 mg twice daily is in-effective after 4 mos. Maintenance: 5
mg twice daily. May increase to 10 mg twice daily for
shortest duration. Use lowest ef-fective dose to maintain
response.
ROUTE
OF PO
ADMINISTRATION
MODE OF ACTION
Inhibits JAK enzymes, which are intracel-lular enzymes
involved in stimulating he-matopoiesis and immune cell
functioning through a signaling pathway. Therapeutic Effect:
Reduces inflammation, tenderness, swelling of joints; slows or
prevents progres-sive joint destruction in rheumatoid arthritis
(RA). Prevents cytokine or growth factor gene expression,
reducing circulating natu-ral killer cells and increasing B cells.
INDICATION
●
Treatment of adult pts with moderate to se-vere active
rheumatoid arthritis with previous inadequate response
or intolerance to meth-otrexate.
●
May be used as monotherapy or in combination with
methotrexate or other nonbiologic disease-modifying
antirheu-matic drugs (DMARDs).
●
Treatment of active psoriatic arthritis (PsA) in pts who
have had inadequate response to methotrexate, other
DMARDs.
●
Treatment of moderate to severe active ulcerative
colitis (UC) in adults. Do not use in combination
with
other
biologic DMARDs
immunosuppressants
(e.g.,
or
with
potent
azaTHIOprine,
cycloSPORINE).
CONTRAINDICATION
Contraindications: Hypersensitivity to to-facitinib.
221
Cautions: Pts exposed to TB, his-tory of serious opportunistic
infections, con-ditions that predispose to infections (e.g.,
diabetes), pts at risk for GI perforation (e.g., diverticulitis), pts
who resided or traveled in areas where TB is endemic,
moderate
to severe renal impairment, elderly pts, he-patic
impairment, history of anemia, hyper-lipidemia, hepatitis, Asian
ancestry, pts with history of interstitial lung disease, heart rate
less than 60 bpm, conduction abnormali-ties, ischemic heart
disease, HF.
SIDE EFFECTS
Rare (4%–2%): Upper respiratory tract infection, diarrhea,
nasopharyngitis, headache, hypertension.
ADVERSE EFFECTS
Neutropenia, lymphopenia may increase risk
Serious
infections
may
for
infection.
include aspergillosis, BK virus,
cellulitis, coccidioidomycosis, cryptococcus, cy-tomegalovirus,
esophageal candidiasis, histoplasmosis,
infections,
listeriosis,
tuberculosis,
UTI,
invasive
pneumocystosis,
sepsis.
Increased
risk
fungal
pneumonia,
for
various
malignancies. May induce viral re-activation of hepatitis B or
C virus infection, herpes zoster, HIV. Epstein-Barr virus–associated post-transplant lymphoproliferative disorder reported
in 2% of pts with renal transplant. Increased risk for GI
perforation.
DRUG INTERACTIONS
Immunosuppressants (e.g., azaTHIOprine, cycloSPORINE)
may increase risk for added immunosuppression, infection.
CYP3A4
inhibitors
concentration/effect.
(e.g.,
ketoconazole)
CYP3A4
inducers
may
(e.g.,
increase
phenytoin,
rifAMPin) may decrease concentration/effect. May increase
adverse effects; decrease therapeutic effect of vaccines
(live).
NURSING
RESPONSIBILITIES
1. Obtain vital signs, CBC, BMP, LFT, lipid panel, urine
pregnancy test results.
222
R: A baseline complete blood count (CBC) should be done
before starting tofacitinib and 1 to 2 months following initiation,
and every 12 weeks after that. Subjects with hemoglobin (Hb)
levels below 9 g/dL, absolute lymphocyte count below 500
cells/mm^3, and absolute neutrophil count below 1000
cells/mm^3 should not be started on therapy. Baseline lipid
levels should be obtained and monitored 4 to 8 weeks after
initiation of treatment. Dose-dependent increases in total
cholesterol, low-density lipoprotein (LDL) cholesterol, and highdensity lipoprotein (HDL) cholesterol may occur.
2. Evaluate for active tuberculosis (TB) and test for
latent
infection
prior
to
and
during
treatment.
Induration of 5 mm or greater with purified protein
derivative (PPD) is considered positive result when
assessing for latent TB.
R: Before initiating treatment with tofacitinib, the patient should
be tested for active or latent TB. In the case of a positive active
or latent TB test, patients should be treated accordingly prior to
receiving treatment with tofacitinib.
3. Question possibility of pregnancy or breastfeeding.
R: Using this medicine while you are pregnant can harm your
unborn baby. Use an effective form of birth control to keep from
getting pregnant.If you think you have become pregnant while
using this medicine, tell your doctor right away.
4. Obtain a full medication history including vitamins,
herbal products.
R: Do not take other medicines unless they have been
discussed with your doctor. This includes prescription or
nonprescription (over-the-counter [OTC]) medicines and herbal
or vitamin supplements.
223
5. Obtain CBC every 4–8 wks, then every 3 mos, lipid
panel 4–8 wks after initiation; hepatic function panel if
hepatic
impairment suspected.
R: May increase ALT, AST, bilirubin, lipids, creatinine. May
decrease Hgb, neutrophils, lymphocytes. Liver function tests
should also be monitored routinely as tofacitinib may cause
hepatotoxicity. If hepatic injury from tofacitinib is suspected,
treatment should be interrupted. Use in severe hepatic
impairment is not recommended.
6. Monitor for TB regardless of baseline PPD.
R: Studies have suggested that its administration leads to
increased TB reactivation. Thus, as with TNF inhibitor, LTBI
screening and treatment are recommended prior to starting
tofacitinib.
7. Routinely monitor blood levels.
R: You should not receive XELJANZ/XELJANZ XR if your
lymphocyte count, neutrophil count, or red blood cell count is
too low or your liver tests are too high.This will allow your doctor
to see if this medicine is working properly and to decide whether
you should continue to use it. Blood tests are needed to check
for unwanted effects.
8. Consider
infection,
discontinuation
opportunistic
if
pt
infection,
develops
acute
sepsis;
initiate
appropriate antimicrobial therapy.
R: Patients receiving treatment should be routinely monitored
for the development of any severe infections. If you have any
kind of infection. You may be at a higher risk of developing
shingles (herpes zoster).
224
9. Immediately
abdominal
report
pain,
any
hemorrhaging, melena,
hemoptysis
(may
indicate
GI
perforation).
R: People who take anti-inflammatory medications such as
NSAIDs or corticosteroids while they are also taking tofacitinib
may be more likely to experience a tear in the lining of the
stomach, which can cause serious bleeding.
10. Do not receive live virus vaccines.
R: While you are being treated with tofacitinib, and after you
stop treatment with it, do not have any immunizations (vaccines)
without your doctor's approval. Tofacitinib may lower your
body's resistance and there is a chance you might get the
infection the vaccine is meant to prevent. Some examples of live
vaccines include measles, mumps, influenza (nasal flu vaccine),
poliovirus (oral form), rotavirus, and rubella.
11. Educate patients about the risk of infection and tell them
to immediately report any signs and symptoms of
infection to their healthcare provider.
R: Your body's ability to fight infections may be reduced while
you are using tofacitinib. It is very important that you call your
doctor at the first sign of an infection. Check with your doctor
right away if you have a fever, chills, cough, flu-like symptoms,
or unusual tiredness or weakness.
12. Re-port history of HIV, recent infections, hepa-titis B or
C, TB or close relatives who have active TB.
R: XELJANZ/XELJANZ XR may cause serious side effects,
including Hepatitis B or C activation infection in people who
carry the virus in their blood. If you are a carrier of the Hepatitis
B or C virus (viruses that affect the liver), the virus may become
active while you use XELJANZ/XELJANZ XR.you should not be
225
around other persons living in your household who have active
TB because there is a chance they could pass the virus on to
you.
13. Report any travel plans to possible endemic areas.
R: Tofacitinib can temporarily lower the number of white blood
cells in your blood, increasing the chance of getting an infection.
If this occurs, there are certain precautions you can take,
especially when your blood count is low, to reduce the risk of
infection.
14. Notify physician if pregnant or planning pregnancy.
R: If you plan to have children, talk with your doctor before using
this medicine. Some women using this medicine have become
infertile (unable to have children).
15. Tell your doctor right away if you have black, tarry
stools, general feeling of illness, swollen glands, weight
loss, yellow skin and eyes, persistent non-healing sore,
reddish patch or irritated area, shiny bump, pink growth,
or white, yellow or waxy scar-like area on the skin.
R: This medicine may increase your risk of cancer (eg,
lymphoma, lung cancer, non-melanoma skin cancer).
16. Tell your doctor right away if you start to have swelling
of your face, lips, tongue, throat, arms, or legs, or if you
are having trouble swallowing or breathing.
R: This medicine can cause serious allergic reactions, including
angioedema or urticaria.
17. Check with your doctor right away if you have anxiety,
chest pain, cough, dizziness, lightheadedness, or
fainting, fast heartbeat, pain, redness, or swelling in the
226
arm or leg, pains in the chest, groin, or legs, especially
calves of the legs, severe headaches, sudden loss of
coordination, sudden onset of slurred speech, sudden
vision changes, or trouble breathing.
R: This medicine may increase your risk of developing blood
clots (eg, arterial thrombosis, deep vein thrombosis, pulmonary
embolism), especially in patients with rheumatoid arthritis who
are 50 years of age and older and with a heart or blood vessel
disease.
18. Avoid grapefruit products.
R: It is best to avoid taking Tofacitinib with grapefruit juice and
to avoid grapefruit juice completely during your Tofacitinib
treatment. Grapefruit juice may increase the levels of Tofacitinib
and the risk for side effects from your treatment.
C. TREATMENT
THERAPY
RATIONALE
Medications
Medication for ulcerative colitis
NURSING RESPONSIBILITIES
●
Educate
client
about
can suppress the inflammation
medications such as The
of the colon and allow for
purpose of the medication,
tissues to heal. Symptoms
the dosage, the side effects,
including diarrhea, bleeding,
and the possible adverse
and abdominal pain can also
effects of the medication
be reduced and controlled with
●
effective medication.
Educate
client
medication
on
self-
administration procedures
In addition to controlling and
suppressing
(inducing
symptoms
remission),
●
Prepare
and
administer
medications, using rights of
medication administration
227
medication can also be used to
●
Review pertinent data prior
decrease the frequency of
to medication administration
symptom
ups
(e.g., contraindications, lab
(maintaining remission). With
results, allergies, potential
proper treatment over time,
interactions)
flare
periods of remission can be
extended
and
periods
●
of
vials when necessary (e.g.,
symptom flare ups can be
reduced. Several types of
Mix medications from two
insulin)
●
Administer and document
medication are being used to
medications
treat ulcerative colitis today
common routes (e.g., oral,
(crohn’scolitisfoundation.org,
topical)
●
2022).
given
Administer and document
medications
Combination Therapy
In some circumstances, a
health
care
provider
may
adding
an
recommend
additional therapy that will
parenteral
effectiveness.
combination
●
the addition of
a
biologic
to
an
●
glucose
toxicity.
Your
healthcare
dosage
of
based
on
(e.g.,
giving
levels,
titrating
medication to maintain a
specific blood pressure)
●
Dispose
of
unused
medications according to
of IBD treatment, but there
of additional side effects and
medication
insulin according to blood
can increase the effectiveness
may also be an increased risk
Titrate
parameters
combination
therapy. Combining therapies
in
assessment and ordered
therapy, there are risks and
of
Participate
medication
immunomodulator. As with all
benefits
(e.g.,
reconciliation process
could
include
routes
by
subcutaneous)
For example,
therapy
given
intravenous, intramuscular,
work in combination with the
initial therapy to increase its
by
facility/agency policy
●
Evaluate
appropriateness
and accuracy of medication
order for client
228
provider
will
identify
the
●
treatment option that is most
effective for your individual
Educate the patient abouot
the following:
●
How
and
where
the
health care needs (crohn's
medication should be safely
colitis foundation.org, 2022).
stored,
such as in the
refrigerator or in a dark
place.
●
The importance of and the
method for checking the
medication's label for the
name, dose, and expiration
date.
●
Special instructions such as
shaking
the
medication,
taking the medication with
meals or between meals
and on an empty stomach.
●
When to call the doctor
about any side effects
●
The importance of taking
the medication as instructed
●
The need to continue the
medication
unless
the
doctor discontinues it
●
Information
supplements
about
foods,
and
other
medications, including over
the counter medications and
preparations,
that
can
interact with the ordered
medication
●
The safe disposal of unused
and expired medications
229
●
The importance of keeping
medications in a secure
place that would not place a
curious child or a cognitively
impaired adult at risk for
taking
medications
not
intended for them
●
The
proper
disposal
and
safe
of
biohazardous
any
equipment
such as used needles that
the client uses for insulin
and other medications.
Surgery
Surgery
is
an
option
if PREOPERATIVE
NURSING
medications aren’t working or CARE:
you have complications, such
as
bleeding
or
●
abnormal
lesions,
or
routine
preoperative care for the
growths. You might develop
precancerous
Provide
surgical client.
●
Arrange
for
consultation
growths that can turn into
with enterostomal therapy
colorectal
cancer.
A
(ET)
healthcare
provider
can
appropriate. The ET nurse
remove these lesions with
is trained to identify and
surgery
mark an appropriate stoma
(a
colectomy)
or
during a colonoscopy.
specialist
location,
taking
if
into
consideration the level of
There are two kinds of surgery
ostomy, skinfolds, and the
for ulcerative colitis:
client’s
1. Proctocolectomy
and
clothing
preferences. Initial ostomy
ileoanal pouch- The
care
teaching
also
is
proctocolectomy
and
provided by the ET nurse
ileoanal pouch (also
during the preoperative visit.
230
called
J-pouch
●
Insert a nasogastric tube if
surgery) is the most
ordered.Although it is often
common procedure for
inserted in the surgical suite
ulcerative colitis.
just prior to surgery, the
2. Proctocolectomy
ileostomy-
If
and
nasogastric tube may be
placed
preoperatively
ileoanal pouch won’t
remove
secretions
work
empty stomach contents.
for
you,
an
your
healthcare team might
recommend
permanent
(without
an
●
a
and
Perform bowel preparation
procedures as ordered. Oral
ileostomy
ileoanal
to
and
●
parenteral antibiotics as well
pouch)(Cleveland
as cathartics and enemas
Clinic, 2020).
may be
●
prescribed preoperatively to
clean the bowel and reduce
the
risk
of
contamination
peritoneal
by
bowel
contents during surgery.
POSTOPERATIVE
NURSING
CARE:
●
Provide routine care for the
surgical client.
●
Monitor bowel sounds and
degree
of
abdominal
distention.
Surgical
manipulation of the bowel
disrupts
peristalsis,
resulting in an initial ileus.
Bowel
sounds
and
the
passage of flatus indicate a
return of peristalsis.
●
Assess the position and
231
patency of the nasogastric
tube, connecting it to low
suction. If the tube becomes
clogged, gently irrigate with
sterile
normal
saline.
A
nasogastric or gastrostomy
tube is used postoperatively
to provide gastrointestinal
decompression
facilitate
and
healing
of
the
anastomosis. Ensuring its
patency is important for
comfort and healing.
●
Assess color, amount, and
odor
of
surgical
drainage
drains
colostomy
(if
from
and
the
present),
noting any changes or the
presence of clots or bright
bleeding. Initial, drainage
may be bright red and then
become dark and finally
clear or greenish yellow
over the first 2 to 3 days. A
change in the color, amount
or odor of the drainage may
indicate a complication such
as hemorrhage, intestinal
obstruction, or infection.
●
Alert all personnel caring for
the
client
with
an
abdominoperineal resection
to
avoid
rectal
232
temperatures,
suppositories, or
●
other
These
rectal
procedures.
procedures
could
disrupt the anal
●
suture
line,
bleeding,
causing
infection,
or
impaired healing.
●
Maintain intravenous fluids
while nasogastric suction is
in place. The client on
nasogastric
suction
is
unable to take oral food and
fluids and, moreover, is
losing electrolyte-rich fluid
through
the
nasogastric
tube. If replacement fluid
and electrolytes are not
maintained, the client is at
risk for dehydration; sodium,
potassium,
and
chloride
imbalance; and metabolic
alkalosis.
●
Provide
antacids,
histamine2-receptor
antagonists, and antibiotic
therapy as ordered. The
above medications may be
ordered
for
postoperative
the
client,
depending on the procedure
performed.
therapy
is
Antibiotic
a
common
233
measure
to
infection
prevent
resulting
contamination
abdominal
from
of
the
cavity
with
gastric contents.
●
Resume oral food and fluids
as ordered. Initial feedings
may
●
be clear liquids, progressing
to full liquids, and then
frequent small feedings of
regular
foods.
Monitor
bowel sounds and monitor
for
abdominal
frequently
distention
during
this
period. Oral feedings are
reintroduced
slowly
minimize
to
abdominal
distention and trauma to the
suture lines.
●
Begin discharge planning
and teaching. Consult with a
dietitian for instructions and
menu planning; reinforce
teaching.
Teach
potential
postoperative
complications,
abdominal
bowel
about
such
as
abscess,
or
obstruction,
their
signs and symptoms, and
preventive measures.
Diet and Nutrition
While ulcerative colitis is not
●
Educated about best and
234
caused by the foods you eat,
easy ways to achieve a
you may find that once you
good nutritious diet.
have the disease, particular
foods
can
aggravate
●
the
Educates the client as well
as
family
members
symptoms. It’s important to
regarding the importance of
maintain
the healthy and nutritious
a
healthy
and
soothing diet that helps reduce
your symptoms, replace lost
nutrients,
and
diet.
●
promote
Nurse
maintains
the
adequate diet plans for the
healing.
client.
●
Helps in monitoring the
For people diagnosed with
conditions of the client like
ulcerative colitis, it is essential
vomiting,
to
electrolyte
monitoring,
because the disease often
order
add
reduces your appetite while
components in the diet.
maintain
good
nutrition
increases your body’s energy
●
needs. Additionally, common
symptoms like diarrhea can
reduce your body’s ability to
absorb
protein,
carbohydrates,
as well
to
Maintaining
input-output,
in
different
parental
nutrition for the client.
●
Maintenance of adequate
hydration.
fat,
as
water, vitamins, and minerals.
Many people with ulcerative
colitis find that soft, bland
foods cause less discomfort
than spicy or high-fiber foods.
While your diet can remain
flexible and should include a
variety of foods from all food
groups, your doctor will likely
recommend restricting your
235
intake of dairy foods if you are
found to be lactose-intolerant
(crohn’scolitisfoundation.org,
2022).
VII.
SURGICAL MANAGEMENT
PROCEDURE
Proctocolectomy with
Ileal Pouch-Anal
Anastomosis (IPAA)
RATIONALE
NURSING RESPONSIBILITIES
This procedure doesn't require PREOPERATIVE CARE
a
permanent
surgery
is
stoma.
also
restorative
This
called
a
stool
routine
care
and
teaching
●
Refer to an enterostomal
the
therapist for marking and
anus. The colon and rectum are
teaching about the stoma
removed,
location, ostomy care, and
and
through
Provide
preoperative
proctocolectomy.
The patient is still able to
eliminate
●
the
small
intestine is used to form an
options
internal pouch or reservoir --
appliances. It is important
called a J-pouch -- that will
to begin teaching prior to
serve as a new rectum. This
surgery
pouch is connected to the anus.
learning and acceptance of
This procedure is frequently
the
done in two operations. In
postoperatively.
between the operations, you’d
●
for
to
bowel
(Khatri, 2022).
ordered.
facilitate
ostomy
Provide
need a temporary ileostomy
ostomy
preoperative
preparation
as
Cathartics,
enemas, and preoperative
Total Proctocolectomy
This proctocolectomy surgical
with End Ileostomy
procedure removes the colon,
rectum, and anus, and creates
antibiotics
are
often
ordered to reduce the risk
of
abdominal
an end ileostomy so that waste
can exit your body into an
236
ostomy bag. This procedure is
contamination
similar
infection after surgery.
to
the
temporary
and
ileostomy in the IPAA surgery,
except the ileostomy will be POSTOPERATIVE CARE
permanent
(Surgery
for
●
Ulcerative Colitis, n.d.).
Provide
routine
postoperative
care
and
teaching
continent ileostomy or
Kock pouch
is an option for people who
would
like
their
●
ileostomy
over the stoma. Stool from
converted to an internal pouch.
an ileostomy is expressed
It's also an option for people
continuously or irregularly,
who aren’t able to have IPAA. In
and it is liquid in nature:
this procedure, you’ll have a
continuous use of a pouch
stoma but no bag. The colon
to collect the drainage is
and rectum are removed, and
an internal reservoir is created
therefore necessary.
●
from the small intestine. An
opening
abdominal
is
made
wall,
in
the
and
the
amounts of blood in the
pouch are expected. A
healthy
inserts a catheter through the
It
preferred surgical treatment for
(Khatri, 2022).
appears
result of mucus production.
This procedure isn’t not the
should
protrude
approximately 2 cm from
has
in the need for more surgery
stoma
pink or red and moist as a
valve into the internal reservoir.
uncertain results and may result
for
postoperative period, small
drain the pouch, the patient
It
frequently
and function. In the early
skin with a nipple valve. To
patients.
Assess
bleeding, stoma viability,
reservoir is then joined to the
ulcerative
Apply an ostomy pouch
the abdominal wall.
●
Frequent assessment is
particularly important in the
initial postoperative period
to ensure stoma Health
and monitor for possible
complications.
A
dusky
237
brown,
black,
or
white
stoma indicates circulatory
compromise
Other
possible
stoma
complications
include
retraction (indentation or
loss of the external portion
of the stoma) or prolapse
(outward telescoping of the
stoma,
that
is,
an
abnormally long stoma).
●
As the stoma starts to
function, empty the pouch,
explaining the procedure to
the client. Initial drainage is
dark green, viscid, and
usually odorless. Drainage
gradually
thickens
and
becomes yellow brown.
●
Empty the pouch when it is
one-third full. Emptying the
pouch when it is no more
than one-third full helps
prevent the skin seal from
breaking as a result of the
weight of the pouch.
●
Measure
drainage,
and
Include it as output on
intake and output records.
Rinse
reapply
the
pouch
the
and
clamp.
Because of the potential for
excess fluid loss through
238
ileostomy drainage, it is
important to include it as
fluid output.
●
Assess the peristomal skin.
Skin around the stoma
should remain clean and
pink
and
free
of
irritation,rashes
inflammation,
or
excoriation.
Skin
complications may arise
from appliance irritation or
hypersensitivity,
excoriation from a leaking
appliance.or
Candida
albicans, a yeast infection.
●
Protect
peristomal
skin
from enzymes and bile
salts
in
effluent.
the
Using
ileostomy
a
skin
barrier on the pouch is
essential.
Change
the
pouch if leakage occurs or
if the client complains of
burning or itching skin.
Enzymes and bile salts
normally reabsorbed in the
large intestine are irritating
to the skin. Excoriation of
skin surrounding the stoma
impairs the first line of
defense
against
microorganisms and can
239
interfere with the ability to
achieve a tight skin seal
and
prevent
pouch
leakage.
●
Report
the
abnormal
following
assessment
findings to the physician:
a. Allergic
or
contact
dermatitis. A rash may
result from contact with
fecal drainage or sensitivity
to pouch, paste, tape, or
sealant.
b.
Indicate
Purulent
ulcerated
areas
surrounding
the
stoma
Disruption of the protective
barrier of the skin allows
bacterial entry.
c.
A red, bumpy, itchy rash or
white-coated area.This is a
manifestation of Candida
albicans, a yeast infection.
d. Buiging around the stoma.
This finding may indicate
herniation, caused by loops
of
intestine
through
the
protruding
abdominal
wall.
●
Apply protective ointments
to the perirectal area of
clients
functioning
with
newly
ileoanal
240
reservoirs
and
anastomoses. This helps
protect the skin from the
initial
stools.
As stools
thicken and become fewer
per
day,
the
client
experiences less perirectal
irritation.
VIII.
NURSING MANAGEMENT
Nursing Diagnosis
Diarrhea
related
Goal
Interventions
to Within the 24 hours of nursing Independent:
inflammation of the bowel as intervention, the patient will be
evidenced
urgency
by
to
increased able
defecate
abdominal cramping.
to
and urgency
exhibit
to
decreased
defecate
Rationale:
Report
decrease
the patient the reason
and
specifically will be able to:
a.
1. Explain thoroughly to
behind the diarrhea
Rationale:
Promotes
of cooperation from the client
cramping b. Exhibit improved and
understanding
of
the
Inflammation causes the colon stool consistency from type 7 current situation
to constrict and empty more to type 6 from bristol stool
regularly,
which
is
why scale
2. Provide
a
quiet
patients may have diarrhea c. Consumes 1500 ml to 2000
environment for the
and
patient
need
to
go
bathroom frequently.
to
the ml of water
d. Reports 2 ways on how to
Rationale: To promote the
lessen diarrhea
health
and
patients
well-being
of
improve
the
and
patient’s perception of the
healing environment
3. Examine for signs of
diarrhea,
such
as
241
stomach
cramps,
discomfort,
watery
stools, frequency and
urgency
of
stools
Rationale: To monitor
the bowel frequency
4. Encourage patients to
drink more water
Rationale:
To
avoid
dehydration
5. Inform the patient to
limit
milk
products,
caffeinated
beverages,
alcohol
and food heavy in fiber
and fat
Rationale: To ease intestinal
cramps,
diarrhea
and
encourage
healthy
eating
habits
6. Monitor
input
and
output of the patient
Rationale: To assess and
avoid dehydration
7. Monitor
patient’s
for
the
stool
and
characteristics
Rationale: To detect
for
changes
in
242
characteristic of the
stool of the patient
8. Educate the patient on
the
need
of
disinfecting
hands
after
bowel
each
movement Rationale:
To
decrease
the
spread of germs and
pathogen transmission
9. Encourage the patient
to enhance his or her
potassium intake by
eating more potassium
rich food
Rationale:
To
hypokalemia
due
potassium
avoid
to
deficiency
a
10.
Weigh the patient daily and
note for decreasing weight
Rationale: To note and avoid
severe water loss from the
body
Imbalanced
than
Body
Nutrition:
Less Within 3 days of nursing
Requirement intervention the patient will be
1. Establish rapport.
R: To easily gain cooperation
related to altered absorption of able to present normal BMI to client.
nutrients as evidenced by BMI and healthy physical status
2. Monitor
Rationale:
assess
Ulcerative colitis can impact
status
I&O
and
hydration
your body’s ability to properly
243
digest
food
and
absorb
R: to monitor the imbalances
nutrients, which may lead to
in
fluids
and
serious vitamin deficiencies
deficiencies based on the
and malnutrition
symptoms
the
identify
client
will
present.
Malnutrition and IBD. Crohn's
& Colitis Foundation. (n.d.).
3. Weigh the patient daily
Retrieved April 26, 2022, from
R:
serve
as
an
initial
https://www.cr o h n s c olitis
assessment particularly in the
fo u n d a tio n.o r g / di et-and-
nutrition status of the patient.
nutritio n/malnutrition -andibd#:~:txt=Crohn's%2
4. Administer IV therapy
0disease%20
and%20ulcer
ative%20coliti
s,serious%20
R: IV nutrition therapy is also
vitamin%20d
eficiencies%2
important if you have trouble
0and%20mal nutrition.
as ordered
with malabsorption
5. Increase OFI
R: replacing fluid losses and
correcting dehydration
6. Encourage ORS
R: can replenish lost fluid,
sugar and salt
7. Encourage
and
bedrest
limited
activity
during acute phase of
illness.
R:
Decreasing
needs
caloric
aids
in
metabolic
preventing
depletion
and
conserves energy.
244
8. Recommend
rest
before meals.
R:
Quiets
peristalsis
and
increases available energy for
eating.
9. Provide oral hygiene.
R: a clean mouth can enhance
the taste of food.
10. Serve foods in wellventilated,
pleasant
surroundings,
with
unhurried atmosphere,
congenial company.
R: Pleasant environment aids
in reducing stress and is more
conducive to eating.
11. Avoid foods such as
mil products, food high
in fiber or fat, alcohol,
caffeinated beverage
chocolate,
peppermint, tomatoes
and orange juice.
R:
It
abdominal
can
exacerbate
cramping
flatulence.
and
Individual
tolerance varies, depending
on stage of disease and area
of bowel affected.
245
12. Encourage
client
to
participate in dietary
planning
R: allows the patient to have a
sense of control to food intake.
13. Encourage to eat low
residue
with
high
protein
and
high
caloric diet. Food must
be
caffeine
free,
nonspicy and low fiber
as indicated
R: Protein is needed for
wound healing. The diet of the
patient is dependent on the
severity of the disease. In
most cases of mild Ulcerative
colitis, patient is suggested to
eat a low residue diet to
improve the symptoms such
as diarrhea.
Impaired
Skin
Integrity Within 24 hours of nursing
1. Instruct
in
and
(perianal) related to frequent interventions, the patient will
encourage
passage of loose stools as verbalize
relaxation techniques,
relief
from
evidenced by redness over discomfort and will have a
such
as
and burning sensation over healthy intact skin.
breathing,
perianal area.
CDs/tapes.
use
of
focused
imaging,
R: To distract attention and
Rationale:
reduce tension/pain.
One major manifestation of
Ulcerative
Colitis
is
the
frequent passage of loose
246
stools or diarrhea. Due to
2. Administer analgesics
diarrhea, the anal skin is
as prescribed if pain is
overhydrated making it more
not tolerable.
at risk for friction and shearing
R: To provide comfort and
forces.
relief from pain.
Moreover,
makes
the
it
skin
also
more
permeable to chemicals and
pathogens.
Furthermore,
diarrhea
also
can
cause
tenesmus which contributes to
3. Administer a warm sitz
bath as ordered.
R: To prevent excoriation and
provide comfort.
the tearing of the anal area.
With this, the skin may be
4. Provide perianal care
inflamed and thus causes a
every after each loose
burning sensation. With this,
stool motion, keeping it
the skin may be inflamed and
clean and dry.
thus
causes
a
burning
sensation.
R: To cleanse the skin and
protect it from injury.
5. Apply moisture barrier
Rudd, A. (2019). Can diarrhea
such as petroleum jelly
cause impaired skin integrity.
or medicated ointment
Retrieved April 25, 2022 from
as
https://www.nbcco
perianal
medyplayground.
diarrheakin-integ
com/can-
cause-impaired-s
ordered
to
area
the
after
cleaning
R: To protect perianal skin
from contact with liquid stools.
6. Adjust the temperature
of the room to avoid
humidity
R: To prevent further irritation
as humidity aggravates the
irritation.
247
7. Adjust
the
patient’s
position when sitting
within
2-3
hour
intervals.
R:
To
prevent
further
discomfort.
8. Encourage the patient
to increase oral fluid
intake of at least 1500
ml to 2000 ml of fluid.
R: To replenish fluid losses
from diarrhea and prevent
dehydration and further skin
breakdown.
9. Perform
regular
hydration rounds.
R: To monitor the hydration
status and look out for signs of
dehydration
which
may
contribute to the impairment of
skin integrity.
IX.
LITERATURE
Ulcerative Colitis Narrative Global Survey Findings: The Impact of Living With Ulcerative
Colitis—Patients’ and Physicians’ View
U.S. National Library of Medicine. (n.d.). Ulcerative colitis narrative global survey findings: The
impact of living with ulcerative colitis-patients' and physicians' view. Inflammatory bowel
diseases. Retrieved February 15, 2023, from https://pubmed.ncbi.nlm.nih.gov/33529314/
248
More than half of ulcerative colitis (UC) patients claim that it took longer than a year
between their initial symptoms and diagnosis. The patient may become frustrated and anxious if
the diagnosis of UC is delayed, which could also have a negative impact on the patient-physician
relationship. Delayed diagnosis can result in difficulties, such as an increased risk of intestinal
surgery due to UC, and delayed commencement of UC therapy.
Only 37% of people report that their overall health is excellent or good, which may indicate
that patients have low expectations for their condition's treatment. The findings imply that UC
management conversations require more time.
Many people with ulcerative colitis (UC) worry about infertility and are worried about
passing the condition on to their offspring. The impact of UC on patients' professional lives is
significant, and many report absenteeism from work as well as a decline in confidence at work as
a result. It is important to note that rather than experiencing actual UC symptoms, patients in
Europe and Japan reported missing work due to concern over the symptoms. The results of this
global survey show that people with UC have poor illness control, delayed diagnosis, and
unfavorable effects on their quality of life. Patients claim that having UC is mentally taxing,
although emotional and mental health problems are rarely discussed during periodic checkups.
Demographic profile and clinical presentation of IBD among inpatients: a UERMMMC
experience
Gomes TNF;de Azevedo FS;Argollo M;Miszputen SJ;Ambrogini O; (n.d.). Clinical and
demographic profile of inflammatory bowel disease patients in a reference center of São Paulo,
Brazil. Clinical and experimental gastroenterology. Retrieved February 15, 2023, from
https://pubmed.ncbi.nlm.nih.gov/33762838/
In the past, the Philippines had only a small amount of clinical and demographic data on
inflammatory bowel disease. At the University of the Eastern Ramon Magsaysay Memorial
Medical Center in the Philippines, IBD diagnoses have increased during the previous six years.
This article's goal is to present clinical and demographic information about IBD among patients
seen at our hospital.
There were 24 patients in total with an IBD diagnosis. 15 patients (62.5%) have Crohn's
disease, and 9 (37.5%) have ulcerative colitis. Over the past two years, 5–6 new cases have been
diagnosed, with an average of 2-3 people being diagnosed each year. Three new instances were
249
reported on average each year, with more men than girls (19 vs. 5). The age at presentation had
a bimodal peak between individuals between the ages of 21 and 40, with the mean age being 40.
Diarrhea (58.3%), abdominal pain (20.8%), lower GI hemorrhage (12.5%), and recurrent perianal
fistula (8.3%) were common symptoms. Two cases were initially negative. One instance had HIV
and MTB co-infections, while the other two just had a biopsy that suggested Crohn's disease.
Esophageal fistula was present in one patient. Ninety percent of UC cases had rectosigmoid
colitis, and ten percent had pancolitis. 60 percent of CD patients had pure colitis, 35 percent had
ileo-colitis, and 5 percent had terminal ileitis.
Inflammatory Bowel Disease: An emerging problem in the Philippines
Garcia, L., & Ypil, G. (2021, August 31). Inflammatory bowel disease: An emerging problem in
the Philippines. Philippine Journal of Internal Medicine. Retrieved February 15, 2023, from
https://www.herdin.ph/index.php?view=research&cid=18595
Filipinos from the Visayas and Mindanao regions were found to have six documented
cases of inflammatory bowel disease, including two cases of Crohn's disease and four cases of
ulcerative colitis. There were 5 women and 1 man, with a mean age of 42. The most common
clinical symptoms included abdominal discomfort, rectal bleeding, diarrhea, fever, and cramps.
One Crohn's disease patient experienced arthritis, a subcutaneous nodule, erythema nodosum,
and erythema multiforme, whereas three ulcerative colitis patients experienced arthralgia and
petechial skin abnormalities. In the course of the disease's active stage, the ESR of every patient
was high. All responded well to steroids, but only patients with ulcerative colitis responded well to
sulfasalazine. Repeated treatment with anti-amoebic drugs for the mistaken diagnosis of amoebic
colitis delayed the correct diagnosis in all four patients with ulcerative colitis. Both patients with
Crohn's disease received prolonged treatment for intestinal tuberculosis before the correct
diagnosis was made. Inflammatory bowel disease should now be included in the differential
diagnosis of Filipino patients with amoebic colitis and intestinal tuberculosis who do not respond
readily to conservative treatment.
HEMORRHOIDS
I.
DEFINITION
250
Hemorrhoids are swollen blood vessels in the lower rectum. They are among the most
common causes of anal pathology, and subsequently are blamed for virtually any anorectal
complaint by patients and medical professionals alike, Confusion often arises because the term
"hemorrhoid" has pathologic structures. the context of this article. "hemorrhoids" refers to
pathology. been presentation used to refer to hemorrhoidal both normal venous anatomic
cushions; structures and Hemorrhoidal venous cushions are normal structures of the anorectum
and are anatomically present unless a previous intervention has taken place Because of their rich
vascular supply., highly sensitive location, and tendency to engorge and prolapse, hemorrhoidal
venous cushions are common causes of anal pathology. Symptoms can range from mildly
bothersome, such as pruritus, to quite concerning. such as rectal bleeding. Although hemorrhoids
are a common condition diagnosed in clinical practice, many patients are too embarrassed to seek
treatment. Consequently, the true prevalence of pathologic hemorrhoids is not known. In addition,
although hemorrhoids are responsible for a large portion of anorectal complaints, it is important
to rule out more serious conditions, such as other causes of gastrointestinal (GI) bleeding, before
reflexively attributing symptoms to hemorrhoids.
II.
ANATOMY/ PHYSIOLOGY
Hemorrhoids are highly vascular submucosal cushions that typically occur in three
columns in the anal canal: left lateral, right anterior, and right posterior. These vascular cushions
are formed of elastic connective tissue and smooth muscle, but because some lack muscular
walls, they may be classified as sinusoids rather than arteries or veins. Clinically visible bleeding
is caused by perisinusoidal arterioles and is thus arterial in character. Hemorrhoids protect the
anal sphincter muscles and augment closure of the anal canal during moments of elevated
abdominal pressure (e.g., coughing, sneezing) to prevent incontinence, contributing 15 to 20% of
the resting anal canal pressure. Abdominal pressure increases the pressure in the inferior vena
251
cava, causing these vascular cushions to engorge and prevent leaking. This tissue is also
suggested to aid in the separation of stool, liquid, and gas in the anal canal.
The dentate line distinguishes between exterior and internal hemorrhoids. External
hemorrhoids are positioned below the dentate line and drain into the pudendal vessels, which
then drain into the internal iliac vein via the inferior rectal veins. These vessels are protected by
anoderm, which is made out of modified squamous epithelium. As a result, pain fibers are present
in various tissues, influencing how patients present and are treated. Internal hemorrhoids are
located above the dentate line and are surrounded by columnar cells with visceral innervation.
They drain into the internal iliac arteries via the middle rectal veins. Internal hemorrhoids are
further characterized based on the degree of prolapse. Hemorrhoids of the first degree extend
into the anal canal but do not prolapse out of it. Second-degree hemorrhoids prolapse outside of
the canal, but reduce spontaneously. Third-degree hemorrhoids prolapse out of the canal and
require manual reduction; fourth-degree hemorrhoids are irreducible.
III.
SIGNS AND SYMPTOMS
Signs and Symptoms
Rationale
Rectal Bleeding
Straining or passing a particularly hard stool can
damage the surface of a hemorrhoid, causing it to
bleed. Blood from a hemorrhoid will look bright red on
a piece of toilet paper. Internal, external, and
thrombosed hemorrhoids can all bleed.
Painful Swelling
The veins around your anus tend to stretch under
pressure and may bulge or swell. Hemorrhoids can
develop from increased pressure in the lower rectum
due to: Straining during bowel movements.
Pruritus
The most common cause of occasional anal itching
(pruritus ani) is a fungus/yeast infection. Enlarged
hemorrhoids cause the leakage of moisture, stool,
252
and fungus. Repeated wiping, cleaning, scratching,
and the use of harsh cleaners make the itching worse.
Painless rectal bleeding
Internal hemorrhoids lie inside the rectum. You
usually can't see or feel them, and they rarely cause
discomfort. But straining or irritation when passing
stool can cause: Painless bleeding during bowel
movements.
IV.
ETIOLOGY
Predisposing factors
Rationale
Family History
Genetics can influence the condition of the muscles
and cartilage. In some families, these structures have
a higher chance of weakening over time. The genes
for weakened colorectal muscles and connective
tissue may run in your family if you have a history of
hemorrhoids (Chandler, 2021).
Age
Hemorrhoids are most common between ages 45 and
65, however it’s not unusual to see them in younger
adults as well. According to the NIDDK, as people
age, the connective tissue between the anus and
rectum weakens, making them more susceptible to
hemorrhoids (Theobald, 2023).
Precipitating factors
Rationale
Constipation
Spending much time in the toilet puts extreme
pressure on your anus and rectum. While in the
washroom, your rectum gets lower than the rest of
your buttocks; hence gravity pulls down the blood
253
pools in the veins. If you are already suffering from
constipation, you increase this pressure further (Mayo
Clinic 2021).
Diarrhea
When someone has diarrhea, they are frequently
forced to sit on the toilet for a long time or they could
strain more than normal. Hemorrhoids may be
brought on by prolonged sitting down as well as the
strain from diarrhea (Saks, 2022).
Obesity
Hemorrhoids are more prevalent in the overweight
population for various reasons, including insufficient
fiber consumption, a decline in physical activity, and
prolonged sitting (Obesity Action Coalition 2023).
Pregnancy
Although hemorrhoids can arise anytime, most
pregnant women get them in the third trimester,
starting around week 28. The veins in the anus may
bulge due to increased blood supply to the pelvic
region, pressure from the expanding uterus, and the
growing fetus (HonorHealth 2023).
Sitting or Standing for a Prolonged
Hemorrhoids develop while sitting because the
Time
pressure causes the gluteal muscles to spread out.
The small rectum and anal veins stretch out and lose
flexibility. As the veins which have become brittle swell
up with blood, hemorrhoids occur (FLEXISPOT 2022).
Frequent Heavy Lifting
When lifting heavy weights, people commonly strain
and hold their breath. Thus, the internal organs will be
put under more pressure while holding breath and
grunting, which will cause the veins surrounding your
rectum to grow into hemorrhoids (Perryman, 2023).
V.
PATHOPHYSIOLOGY
254
Narrative:
255
Several factors may affect the formation of hemorrhoids. Hereditary bowel/rectal
problems, advanced age, and other factors may also cause the development of hemorrhoids,
such as increased intra-abdominal pressure (e.g., pregnancy, constipation, diarhhea, chronic
straining, lifting). This may cause the weakening of the anal cushion and the supporting tissue
and spasms of the internal sphincter. It might also prevent venous return, which would enlarge
the hemorrhoidal plexus and the arteriovenous anastomoses of the anorectal junction, resulting
in hemorrhoids (Kibret et al., 2021).
External hemorrhoids occur since hemorrhoidal venous cushions have a rich vascular
supply, highly sensitive location, and can engorge and prolapse along the anal canal. This leads
to inflammation of the vascular wall and connective tissues. Thrombosed hemorrhoids will then
develop since the inflammation will lead to a blood clot forming inside a hemorrhoidal vein,
obstructing blood flow and causing painful swelling of the perianal tissues. Thrombosed
hemorrhoids can also cause rectal bleeding if they become ulcerated (Castillo, 2022).
Moreover, enlarged internal hemorrhoids cause the majority of symptoms. Abnormal
swelling of the anal cushions provokes dilatation and engorgement of the arteriovenous plexuses.
This will then lead to stretching the suspensory muscles and eventual prolapse of rectal tissue
through the anal canal, and the engorged anal mucosa is easily traumatized, leading to rectal
bleeding that is typically bright red due to high blood oxygen content within the arteriovenous
anastomoses. Prolapse leads to soiling and mucus discharge (triggering pruritus) and
predisposes to incarceration and strangulation.
There are different degrees of internal hemorrhoids. First-degree internal hemorrhoids
bulge into the anal canal during bowel movements. A second-degree internal hemorrhoid bulges
from the anus during bowel movements before returning inside on its own. In comparison, a thirddegree hemorrhoid protrudes from the anus and needs to be pulled back with a finger during
bowel movements. A constant protrusion from the anus is a fourth-degree hemorrhoid.
Moreover, hemorrhoids can be treated depending on their type and severity. If provided
with appropriate treatments and there will be elimination or removal of hemorrhoids, it will result
in a good prognosis. But if left ignored and untreated long enough, the prolapsing will continue,
leading to blood loss, severe pain, & infection related to the disease resulting in poor prognosis
(Itriago, 2022).
VI.
MEDICAL MANAGEMENT
A. DIAGNOSTIC EXAMS
256
TEST
RATIONALE
NURSING
RESPONSIBILITIES
Digital Rectal Exam
A digital rectal exam, or DRE, is a
medical
test
that
checks
1. Explain the patient on
for
the procedure.
abnormalities in the rectum, anus R: to promote cooperation and
and prostate gland. a healthcare inform
the
procedure
for
provider will put on gloves and proper understanding.
apply lubricant before gently sliding
their index finger into the rectum.
(Cleveland Clinic, n.d)
2. Ask you to lie down on
your left side, with your
knees
Anoscopy
Anoscopy is an examination of the
anal canal and rectum with an
anoscope to help diagnose anal
lifted
up
towards your chest.
R: This is the easiest position
to examine your rectum.
and rectal conditions. An anoscope
is a small-diameter plastic or metal
hollow tube (slightly wider than a
finger) with an insert called an
obturator. The device is about 5
3. Wear gloves during
the procedure.
R: to avoid acquiring bacterias
from the rectum.
inches long. After inserting the
anoscope into the anal canal, the
doctor removes the obturator insert
and is able to see inside the rectum.
By shining a light through the tube,
the doctor can get a look at the
lining of the anal canal and lower
4. Put some lubricating
gel on 1 finger and
gently slide it into your
rectum.
R: this is to avoid irritating the
rectal tissue.
rectum. (John Hopkins Medicine,
2023)
Sigmoidoscopy
A flexible sigmoidoscopy
5. Inform the patient to
is an
the result of the test.
exam used to evaluate the lower
part of the large intestine (colon).
During a flexible sigmoidoscopy
257
exam,
a
thin,
flexible
tube
(sigmoidoscope) is inserted into the
rectum. (John Hopkins Medicine,
2023)
B. MEDS
1. Analgesic
-
Analgesics, commonly known as painkillers, are drugs that treat a variety of pain,
such as headaches, injuries, and arthritis. Both opioid analgesics and antiinflammatory analgesics alter how the brain interprets pain. While certain
analgesics can be purchased without a prescription, others need one.
2. Antipyretic
-
Antipyretics do not affect body temperature in the afebrile state, but they can
prevent or reverse the cytokine-mediated rise in core temperature that occurs with
fever. These should be separated from hypothermia agents, or cryogens, which
can lower core temperatures even when a person is not febrile.
GENERIC NAME
Acetaminophen
BRAND NAME
Tylenol
DRUG CLASSIFICATION
Pharmacotherapeutic: Central Analgesic
Clinical: Non Narcotic analgesic, Antipyretic
SUGGESTED DOSE
Dosage Considerations Analgesia and Fever
Maximum dose
●
Acetaminophen containing products: Not to exceed a
cumulative dose of 3.25 g/day of acetaminophen; under
258
supervision of healthcare professional, daily doses of up
to 4 g/day may be used
●
Tylenol Extra-Strength (i.e., 500 mg/tab or cap): Not to
exceed 3 g/day (6 tabs or caps); under supervision of a
healthcare professional, daily doses of up to 4 g/day may
be used
Renal Impairment
●
Longer dosing intervals and the reduced total dose may
be warranted in patients with severe renal impairment
(CrCl less than or equal to 30 mL/min)=
Hepatic Impairment
●
Use caution with any type of liver disease.
Pediatric Pain & Fever Relief
Weight-based dosing
●
Children under 12 years: 10-15 mg/kg/dose taken orally
once every 4-6 hours; not to exceed 5 doses in 24 hours
Fixed dosing
●
Children under 6 years: Ask a healthcare provider
●
Children 6-12 years: 325 mg orally once every 4-6 hours;
not to exceed 1.625 g/day for not more than 5 days
unless directed by a healthcare provider
●
Children under 12 years and older:
○
Regular strength: 650 mg once every 4-6 hours;
not to exceed 3.25 g in 24 hours; under
supervision of healthcare professional, doses of
up to 4 g/day may be used
○
Extra strength: 1000 mg once every 6 hours; not
to exceed 3 g in 24 hours; under supervision of
healthcare professional, doses of up to 4 g/day
may be used
○
Extended-release: 1.3 g once every 8 hours; not
to exceed 3.9 g in 24 hours
259
ROUTE
OF PO, IV, Rectal
ADMINISTRATION
MODE OF ACTION
Analgesic:
Activates
descending
serotonergic
inhibitory
pathways in CNS.
Antipyretic: Inhibits hypothalamic heat-regulating centre.
Therapeutic Effect: Results in antipyresis. Produces analgesic
effect.
INDICATION
Acetaminophen (APAP) is a non-opioid analgesic and
antipyretic agent used to treat pain and fever. Clinicians can use
it for their patients as a single agent for mild to moderate pain
and in combination with an opioid analgesic for severe pain.
CONTRAINDICATION
Contraindications
to
using
acetaminophen
include
hypersensitivity to acetaminophen, severe hepatic impairment,
or severe active hepatic disease. However, there is a general
debate among experts as to whether hepatic impairment is truly
a limiting factor, as it would likely be associated with decreased
production
of
the
toxic
metabolite,
N-acetyl-p-
benzoquinoneimine (NAPQI).
SIDE EFFECTS
Rare: Hypersensitivity reaction
ADVERSE EFFECTS
Early Signs of Acetaminophen Toxicity:
●
Anorexia, nausea, diaphoresis, fatigue within the first
12–24 hrs.
Later Signs of Toxicity:
●
Vomiting, right upper quadrant tenderness, elevated
LFTs within 48–72 hrs after ingestion. Antidote:
Acetylcysteine.
DRUG INTERACTIONS
DRUG: Alcohol (chronic use), hepatotoxic medications (e.g.,
phenytoin), hepatic enzyme inducers (e.g., phenytoin, rifAMPin)
may increase risk of hepatotoxicity with prolonged high dose or
single toxic dose. Dasatinib, probenecid may increase
260
concentration/effect.
HERBAL: None significant.
FOOD: Food may decrease the rate of absorption. LAB
VALUES:
May increase serum ALT, AST, bilirubin; prothrombin levels
(may indicate hepatotoxicity).
NURSING
RESPONSIBILITIES
1. Instruct patients to never take more than 4,000 mg of
acetaminophen per 24 hours. This includes all forms of
acetaminophen
and
acetaminophen-containing
products.
R: Taking too much acetaminophen can damage the liver,
sometimes leading to a liver transplant or death.
2. Do not take acetaminophen with alcohol due to the risk
of liver toxicity.
R: Mixing too much alcohol with any acetaminophen (or too
much acetaminophen with any alcohol) can make removal of
this substance even more difficult. The excess substance
attacks your liver. This can cause severe liver damage.
3. Educate that acetaminophen can increase anticoagulant
effects. Teach the patient to monitor for bruising and
signs of bleeding, and to prevent the risk of injury.
R: If the patient is taking warfarin, acetaminophen can increase
the risk of bleeding.
4. Acetaminophen may not be safe for children under the
age of 2. Always discuss with a healthcare provider first.
Acetaminophen comes in preparations and doses for
children such as Children’s Tylenol liquid. Always use
the appropriate dropper or measuring cup provided
when administering to children.
261
R: It may cause long-term neurodevelopmental problems.
5. Store at room temperature. Suppositories should be
stored in the refrigerator.
R: Some medications in suppository form need to be stored in
the refrigerator so that they do not melt before use.
6. Assess overall health status and alcohol usage before
administering acetaminophen.
R: Patients who are malnourished or chronically abuse alcohol
are at higher risk of developing hepatotoxicity with chronic use
of usual doses of this drug.
7. Monitor the patient’s response to the medication.
R: To ensure that the medication is effectively managing the
patient’s pain and to make any necessary adjustments to the
dosage or treatment plan.
8. Assess the patient’s allergies and previous reactions to
medications before administering acetaminophen.
R: The patient’s allergies and previous reactions to medications
are important things to consider to avoid potential allergic
reactions.
Acetaminophen
may
cause
Stevens-Johnson
syndrome.
9. Assess fever; note the presence of associated signs
(diaphoresis, tachycardia, and malaise).
R: Assessing a patient’s fever is an important nursing
consideration when administering acetaminophen. Fever is a
common symptom of many illnesses and can be an indicator of
an underlying infection or condition.
10. Monitor patients with liver or kidney dysfunction for
potential adverse effects and adjust the dosage
262
accordingly.
R: Individuals with liver or kidney disease should be extra
careful when taking acetaminophen, as it is metabolized by the
liver and excreted by the kidneys.
3. Non-steroidal anti-inflammatory drug
NSAIDs block the body from producing specific molecules that lead to inflammation.
NSAIDs are effective at treating pain brought on by gradual tissue deterioration, including arthritis
pain. NSAIDs are effective in treating headaches, menstrual cramps, and back discomfort.
GENERIC NAME
Acetylsalicylic acid
BRAND NAME
Aspirin
DRUG CLASSIFICATION
Pharmacotherapeutic: Non-steroidal anti-inflammatory drug
(NSAID)
Clinical: Anti-inflammatory, antipyretic, analgesic, anti-platelet
SUGGESTED DOSE
Analgesia, Fever
PO: ADULTS, ELDERLY, CHILDREN 12 YRS AND OLDER
AND WEIGHING 50 KG OR MORE: 325–650 mg q4–6h or 975
mg q6h prn or 500–1,000 mg q4–6h prn.
Maximum: 4 g/day. RECTAL: 300–
600 mg q4h prn.
INFANTS, CHILDREN WEIGHING LESS THAN 50 KG: 10–15
mg/kg/dose q4–6h. Maximum: 4 g/day or 90 mg/kg/day.
Revascularization
PO: ADULTS, ELDERLY: 80–325 mg/day.
Kawasaki’s Disease
PO: CHILDREN: 80–100 mg/kg/day in divided doses q6h up to
14 days (until fever resolves for at least 48 hrs). After fever
resolves, 1–5 mg/kg once daily for at least 6–8 wks.
263
MI, Stroke (Risk Reduction)
PO: ADULTS, ELDERLY:(Durlaza): 162.5 mg
once daily.
Dosage in Renal/Hepatic Impairment
Avoid use in severe impairment.
ROUTE
OF PO, Rectal
ADMINISTRATION
MODE OF ACTION
Irreversibly inhibits cyclo-oxygenase enzymes, resulting in a
decreased formation of prostaglandin precursors. Irreversibly
inhibits formation of thromboxane, resulting in inhibiting platelet
aggregation.
Therapeutic Effect: Reduces inflammatory response, intensity
of pain; decreases fever; inhibits platelet aggregation.
INDICATION
Aspirin is indicated for temporary relief of headache, pain and
fever of colds, minor pain of arthritis, muscle pain, menstrual
pain, and toothache.
CONTRAINDICATION
Aspirin is contraindicated in patients with known allergy to
NSAIDs and in patients with asthma, rhinitis, and nasal polyps.
It may cause anaphylaxis, laryngeal edema, severe urticaria,
angioedema, or bronchospasm (asthma).
SIDE EFFECTS
Occasional: GI distress (including abdominal distention,
cramping, heartburn, mild nausea); allergic reaction (including
bronchospasm, pruritus, urticaria).
ADVERSE EFFECTS
High doses of aspirin may produce GI bleeding and/or gastric
mucosal lesions. Dehydrated, febrile children may experience
aspirin toxicity quickly. Reye’s syndrome, characterized by
persistent vomiting, signs of brain dysfunction, may occur in
children taking aspirin with recent viral infection (chickenpox,
264
common cold, or flu). Low-grade aspirin toxicity characterized
by tinnitus, generalized pruritus (may be severe), headache,
dizziness, flushing, tachycardia, hyperventilation, diaphoresis,
thirst.
Marked
toxicity
characterized
by
hyperthermia,
restlessness, seizures, abnormal breathing patterns, respiratory
failure, coma.
DRUG INTERACTIONS
Aspirin may decrease the effect of angiotensin-converting
enzyme
(ACE)
inhibitors,
diuretics,
beta-blockers,
and
uricosurics (probenecid and sulfinpyrazone); increase the
toxicity
of
acetazolamide
and
methotrexate;
prolong
prothrombin time and bleeding time in patients taking warfarin;
increase the anticoagulant activity of heparin; lower phenytoin
blood levels; raise valproic acid serum levels; and increase the
efficacy of oral hypo-glycemics to the point that the patient may
experience hypoglycemia. If given concurrently with other
nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin can
increase bleeding or reduce renal function.
NURSING
RESPONSIBILITIES
1. Instruct patient to be aware that aspirin can prolong
bleeding time.
R: Note that aspirin prolongs the bleeding time for 4 – 7 days
and, in large doses, may cause prolonged prothrombin time. A
prolonged PT means that the blood is taking too long to form a
clot. Aspirin alters platelet function through interference with
prostaglandin biosynthesis.
2. Evaluate the patient's lifestyle.
R: Determine patient’s alcohol use, tobacco use, and diet, which
may impact the effectiveness and safety of aspirin therapy.
3. Review patient’s history for GI bleeding and ulceration.
R: Review the patient’s health history, including any previous
gastrointestinal bleeding or ulceration, liver or kidney disease,
265
or bleeding disorders.
4. Assess patient’s allergy to aspirin.
R: Ask about any allergies or intolerances the patient may have
to aspirin. Patients who have asthma, allergies, and nasal
polyps or who are allergic to tartrazine are at an increased risk
for developing hypersensitivity reactions.
5. Determine current aspirin regimen.
R: Assess the patient’s current aspirin regimen, including the
dose, frequency, and route of administration.
6. Assess pain and limitation of movement.
R: Determine type, location, and intensity before and at the peak
after administration.
7. Assess fever and note associated signs.
R: Manifestations such as diaphoresis, tachycardia, malaise,
and chills should be documented for baseline data and to
determine effectiveness of therapy.
8. Monitor hepatic function.
R: May cause increased serum AST, ALT, and alkaline
phosphatase, especially when plasma concentrations exceed
25 mg/100 mL. May return to normal despite continued use or
dose reduction. If severe abnormalities or active liver disease
occurs, discontinue and use with caution in the future.
9. Monitor serum salicylate levels periodically.
R: Especially with prolonged high-dose aspirin therapy to
determine dose, safety, and efficacy, especially in children with
Kawasaki disease.
10. Instruct patient to be aware that aspirin can alter results
266
of some lab tests.
R: Note that aspirin may alter the results of serum uric acid,
urine vanillylmandelic acid (VMA), protirelin-induced thyroidstimulating hormone (TSH), urine hydroxy indole acetic acid (5HIAA) determinations, and radionuclide thyroid imaging.
11. Monitor for signs of toxicity and overdose.
R: Monitor for the onset of fever, tinnitus, headache,
drowsiness, hyperventilation, agitation, mental confusion,
lethargy, diarrhea, and sweating. If these symptoms appear,
withhold medication and notify a healthcare professional
immediately.
4. Corticosteroid
Steroids function by suppressing immune system activity and reducing inflammation.
White blood cells and other molecules in the body can fight infection and foreign agents like
bacteria and viruses during the process of inflammation. The immune system, the body's defense
mechanism, however, malfunctions in several diseases. Inflammation could then start to damage
the body's tissues as a result.
GENERIC NAME
Hydrocortisone
BRAND NAME
Anusol HC
DRUG CLASSIFICATION
Pharmacotherapeutic: Corticosteroid
267
Clinical: Glucocorticoid
SUGGESTED DOSE
Acute Adrenal Insufficiency
IV: ADULTS, ELDERLY: 100 mg IV bolus, then 25–75 mg q6h
for 24 hrs (or 200 mg/24h as continuous infusion), then taper
slowly.
INFANTS, CHILDREN, ADOLESCENTS: 50–100 mg/m2 once,
then 50–100 mg/m2/day in 4 divided doses.
Anti-inflammation, Immunosuppression
IV, IM: ADULTS, ELDERLY: 100–500 mg/dose at intervals of 2
hrs, 4 hrs, or 6 hrs.
CHILDREN: 1–5 mg/kg/day in divided doses q12h.
PO: ADULTS, ELDERLY: 20–240 mg q12h.
CHILDREN: 2.5–10 mg/kg/day in divided doses q6–8h.
Adjunctive Treatment of Ulcerative Colitis
Rectal: (Enema): ADULTS, ELDERLY: 100mg at bedtime for 21
nights or until clinical and proctologic remission occurs (may
require 2–3 mos of therapy).
(Rectal Foam): ADULTS, ELDERLY: 1 applicator 1–2 times/day
for 2–3 wks, then every second day until therapy ends.
Usual Topical Dose
ADULTS, ELDERLY: Apply sparingly 2–4 times/day.
Dosage in Renal/Hepatic Impairment
No dose adjustment.
ROUTE
OF IV, IM, Rectal, PO
ADMINISTRATION
MODE OF ACTION
Inhibits accumulation of inflammatory cells at inflammation
268
sites, phagocytosis, lysosomal enzyme release, synthesis and/
or release of mediators of inflammation. Reverses increased
capillary permeability. Therapeutic Effect: Prevents/suppresses
cell-mediated immune reactions. Decreases/prevents tissue
response to inflammatory processes.
INDICATION
Topical corticosteroids are indicated for the relief of the
inflammatory and pruritic manifestations of corticosteroidresponsive dermatoses.
CONTRAINDICATION
Topical corticosteroids are contraindicated in those patients with
a history of hypersensitivity to any of the components of the
preparation.
SIDE EFFECTS
Frequent: Insomnia, heartburn, anxiety, abdominal distention,
diaphoresis, acne, mood swings, increased appetite, facial
flushing, delayed wound healing, increased susceptibility to
infection, diarrhea or constipation.
Occasional: Headache, edema, change in skin color, frequent
urination.
Topical: Pruritus, redness, irritation.
Rare: Tachycardia, allergic reaction (rash, hives), psychological
changes, hallucinations, depression.
Topical: Allergic contact
dermatitis, purpura.
Systemic: Absorption more likely with use of occlusive dressings
or extensive application in young children.
ADVERSE EFFECTS
Long-term
therapy:
Hypocalcemia,
hypokalemia,
muscle
wasting (esp. arms, legs), osteoporosis, spontaneous fractures,
amenorrhea, cataracts, glaucoma, peptic ulcer, HF.
Abrupt withdrawal after long-term therapy: Nausea, fever,
headache, sudden severe joint pain, rebound inflammation,
fatigue, weakness, lethargy, dizziness, orthostatic hypotension.
269
DRUG INTERACTIONS
DRUG: May increase hypokalemic effects of diuretics (e.g.,
furosemide).
CYP3A4 inducers (e.g., carBAMazepine, phenytoin, rifAMPin)
may decrease effects. Live virus vaccines may decrease pt’s
antibody response to vaccine, increase vaccine side effects,
potentiate virus replication. May decrease therapeutic effect of
aldesleukin, BCG (intravesical). May increase the hyponatremic
effect of desmopressin.
HERBAL: St. John’s wort may decrease concentration.
Echinacea may decrease therapeutic effect.
FOOD: None known.
LAB VALUES: May increase serum glucose, lipids, sodium. May
decrease serum calcium, potassium, thyroxine; WBC count.
NURSING
RESPONSIBILITIES
1. Instruct patient to avoid contact with people who have
infections that may spread to others (such as
chickenpox, measles, flu).
R: Rarely, this drug can make you more likely to get infections
or may worsen any current infections.
2. Do not abruptly discontinue taking the drug.
R: Doses are gradually reduced to prevent withdrawal
symptoms.
3. Do
not
give
IM
injections
if
the
patient
has
thrombocytopenic purpura.
R: Intramuscular injection is avoided due to the possibility of
causing bleeding into the skin.
4. Instruct to avoid alcohol and caffeine.
270
R: To decrease the risk of stomach/intestinal bleeding.
5. Before having surgery or emergency treatment, or the
patient gets injured, instruct the patient to tell the doctor
that they are using the medication.
R: Rarely, using corticosteroid medications for a long time can
make it more difficult for your body to respond to physical stress.
6. If the patient is still growing, advise the guardian to see
a doctor regularly to check the child's height.
R: Though it is unlikely, this medication may temporarily slow
down a child's growth if used for a long time.
7. During pregnancy, this medication should be used only
when clearly needed and not for prolonged periods.
R: Other forms of hydrocortisone (given by mouth or by
injection) may harm an unborn baby. Discuss the risks and
benefits with your doctor.
8. Use minimal doses for minimal duration.
R: To minimize adverse effects.
9. Instruct patient to get medical help right away if you
notice any symptoms of a serious allergic reaction,
including: rash, itching/swelling (especially of the
face/tongue/throat), severe dizziness, trouble breathing.
R: A very serious allergic reaction to this drug is rare.
10. Before using hydrocortisone, tell your doctor or
pharmacist if you are allergic to it; or to other
corticosteroids (such as prednisone); or if you have any
other allergies.
R: This product may contain inactive ingredients, which can
271
cause allergic reactions or other problems. Talk to your
pharmacist for more details.
C. TREATMENT
THERAPY
RATIONALE
NURSING RESPONSIBILITIES
Medications
Your doctor might advise over-
●
Administration
includes
the-counter creams, ointments,
ensuring
suppositories, or pads if your
medication
hemorrhoids only cause mild
drawn up in the correct
discomfort. These lotions have
dose, and administered at
chemicals including witch hazel,
the right time through the
hydrocortisone, and lidocaine that
right route to the right
help reduce itching and pain
patient.
momentarily. If not prescribed by
●
that
the
is
right
properly
To limit or reduce the risk
a doctor, avoid using an over-the-
of administration errors,
counter steroid cream for longer
many hospitals employ a
than a week because it can thin
single-dose system.
your
skin.
(Hemorrhoids
-
●
The
client
should
be
Diagnosis and Treatment - Mayo
educated about the safe
Clinic, 2021).
and correct method of self
administration
of
medications. In addition to
the education discussed
immediately above, some
clients may also have to be
instructed about special
procedures like the proper
use of an inhaler, taking
insulin,
giving
mixing
insulins,
oneself
an
intramuscular injection or
272
self-administering
tube
feedings.
●
Educate
client
about
medications
●
Dispose
of
unused
medications according to
facility/agency policy
Home Remedies
You can often relieve the mild
●
Advise patient that some
pain, swelling and inflammation of
home remedies may help
hemorrhoids
alleviate
with
home
treatments.
short-term
symptoms, but they won't
treat an underlying illness.
●
Consume fiber-rich meals.
It's
Consume
address your symptoms
more
whole
grains, fruits, and veggies.
By doing this, the stool will
important
that
you
and pain with your doctor.
●
Inform patient that there is
become softer and more
no guarantee of safety for
bulk, preventing you from
doing home remedies.
straining, which can make
the
symptoms
existing
of
pre-
hemorrhoids
worse. To avoid issues
with
gas,
progressively
incorporate more fiber into
your diet.
●
Apply topical remedies.
Use pads with witch hazel
or a numbing ingredient,
or
apply
an
over-the-
counter hemorrhoid cream
or
suppository
with
hydrocortisone.
273
●
Regularly take sitz baths
or warm baths. Take a 10to 15-minute bath in plain,
warm water twice or three
times daily to treat your
anal area. The toilet may
fit over a sitz bath.
●
Take oral pain relievers.
To temporarily ease your
discomfort, you can take
acetaminophen (Tylenol,
among others), aspirin, or
ibuprofen (Advil, Motrin IB,
among
others).
(Hemorrhoids - Diagnosis
and Treatment - Mayo
Clinic, 2021).
Surgical Therapy
Only a small percentage of people Before
the
with hemorrhoids require surgery. Procedure/Examination:
However, if other procedures
haven't been successful or you
●
Assess
patient
for
the
have large hemorrhoids, your
presence of hemorrhoids,
doctor might recommend one of
discomfort
the following:
associated
or
hemorrhoids,
●
Hemorrhoidectomy
-
thorough
and
with
diet,
fluid
intake, and presence of
Hemorrhoidectomy is the
most
pain
constipation.
●
Instruct
patient
and/or
effective
method
of
family regarding causes of
treating
severe
or
hemorrhoids, methods of
recurrent
hemorrhoids.
avoiding hemorrhoids, and
Urinary
tract
infections
274
can occur as a result of
treatments that can be
temporary
performed.
problems
emptying your
●
●
Instruct
patient
This side effect generally
family
regarding
follows spinal anesthesia.
procedures required.
Hemorrhoid
bladder.
stapling
-
●
Instruct
patient
and/or
all
and/or
Stapled hemorrhoidopexy,
family in comfort measures
also known as hemorrhoid
to use with the presence of
stapling, prevents blood
hemorrhoids.
from
reaching
hemorrhoidal
tissue. During
the
Usually, it is exclusively Procedure/Examination:
applied
to
internal
●
Note for the time the
hemorrhoids.
surgery and the general
Hemorrhoidectomy
anesthesia started.
typically
causes
more
●
discomfort than stapling,
Ensure the IV fluids given
to the patient.
which enables a sooner
return to normal activities. After
the
Nevertheless, stapling has Procedure/Examination:
been linked to a higher
incidence of recurrence
●
and rectal prolapse, in
which a portion of the
Monitor the patient closely
in the recovery room.
●
IV
fluid
should
be
rectum protrudes from the
monitored if working well
anus,
and enough fluids.
compared
to
hemorrhoidectomy.
●
(Hemorrhoids - Diagnosis
and Treatment - Mayo
Give
medications
as
indicated.
●
Clinic, 2021).
Provide a warm sitz bath
as appropriate.
●
Cleanse the rectal area
with mild soap and water or
275
wipes after each stool and
provide skin care.
●
Encourage patient to move
around
to
prevent
breathing and circulation
problems.
VII.
SURGICAL MANAGEMENT
PROCEDURE
Hemorrhoidectomy
RATIONALE
NURSING RESPONSIBILITIES
Surgery to remove hemorrhoids Before
is
called
the
hemorrhoidectomy. Procedure/Examination:
The doctor makes small cuts
around the anus to slice them
away.
You
may
anesthesia (the
get
●
local
Assess
patient
discomfort
operated on is numb, and you're
associated
awake
hemorrhoids,
relaxed)
the
presence of hemorrhoids,
area being
though
for
or
or
pain
with
diet,
fluid
general anesthesia (you're put
intake, and presence of
to sleep). Hemorrhoidectomy is
constipation.
often an outpatient procedure,
●
Instruct
patient
and/or
and you can usually go home
family regarding causes of
the same day (Khatri, 2022).
hemorrhoids, methods of
avoiding hemorrhoids, and
Procedure for Prolapse
PPH is also called a stapled
and Hemorrhoids
hemorrhoidectomy. The doctor
(PPH)/Hemorrhoid
will use a stapler-like device to
stapling
reposition the hemorrhoids and
cut
off
their
blood supply.
treatments that can be
performed.
●
Instruct
patient
family
regarding
and/or
all
procedures required.
Without blood, they'll eventually
shrivel and die. It can treat
276
hemorrhoids that have and
Instruct
patient
and/or
have not prolapsed, or slipped
family in comfort measures
down out of the anus (Khatri,
to use with the presence of
2022).
hemorrhoids.
Hemorrhoidal Artery
Hemorrhoidal Artery Ligation
Ligation and Recto
and Recto Anal Repair (HAL-
Anal Repair (HAL-
RAR) is a new procedure in
RAR)
●
which
a
miniature
Doppler
During
Procedure/Examination:
●
sensor is inserted in the anus to
to
surgeon
hemorrhoids.
can
arteries
The
pinpoint
supplying
●
are
no
reduced
After
longer
the
Procedure/Examination:
●
Monitor the patient closely
in the recovery room.
●
noticeable. The procedure is
IV
fluid
should
be
monitored if working well
effective and virtually painless
(Khatri, 2022).
Ensure the IV fluids given
to the patient.
almost immediately and within
weeks,
the time the
the
off to cut the blood supply. The
are
for
anesthesia started.
the
hemorrhoids and can tie them
hemorrhoids
Note
surgery and the general
detect the arteries supplying
blood
the
and enough fluids.
●
Give
medications
as
indicated.
●
Provide a warm sitz bath as
appropriate.
●
Cleanse the rectal area
with mild soap and water or
wipes after each stool and
provide skin care.
●
Encourage patient to move
around
to
prevent
breathing and circulation
problems.
277
VIII.
NURSING MANAGEMENT
NURSING DIAGNOSIS
GOAL
Acute Pain related to difficulty After
nursing
1. Examine the patient
in defecation as evidenced by intervention, the patient will be
for headaches, sore
a pain scale of 7/10 and able to report decreased rectal
throats,
swelling
pain as evidenced by a pain
malaise
scale of 1/10 and shows
weakness,
improvement in comfort.
spasms,
Rationale:
1
hour
of
INTERVENTION
If a hemorrhoid forms a clot,
overall
or
bodily
muscle
and
soreness.
the person may experience
R:
pain when they sit down,
elevated
defecate, urinate, or walk.
frequently the root cause of
According
headaches,
to
Caruso,
S.
Inflammation
or
an
temperature
is
sore
throat,
malaise,
muscle
(2021), acute pain can start
general
slowly or suddenly. A painful
pains,
sensory
symptoms may indicate acute
and
emotional
experience is what is referred
and
pain.
These
pain caused by hemorrhoids.
to as acute pain, where most
of the time, it is connected to
2. Examine the patient's
tissue damage in the body.
vital
signs
The muscles that open and
deviations
close the anus may stop
baselines.
for
from
hemorrhoids from receiving
R: The autonomic response to
blood
pain
(strangulated
hemorrhoid). The hemorrhoid
usually
causes
an
increase in vital signs.
tissues could die as a result. If
this occurs, they will have
3. Administer analgesics,
severe rectal pain and can
as ordered.
notice blood and pus at the
R:
Analgesics
are
a
anus.
pharmacologic treatment for
278
pain
and
discomfort
that
reduces brain prostaglandin
production. If the pain is
intolerable,
analgesics
are
beneficial.
4. Provide a relaxing and
peaceful environment
for the patient.
R: This method decreases
stimulation
that
may
aggravate discomfort.
5. Give
the patient
a
warm sitz bath.
R:
Warmth
induces
vasodilation, which relieves
hemorrhoids' discomfort.
6. For the treatment of
hemorrhoids,
apply
topical ointments or
use a suppository.
R:
Topical
ointments and
suppositories can help relieve
the pain and discomfort of
hemorrhoids.
7. Educate the patient or
significant other about
breathing, relaxation,
meditation, massage,
and
other
279
nonpharmacologic
interventions.
R: This strategy helps patients
focus less on pain. These
techniques will change the
patient's perception of pain
and
may
improve
discomfort
the
they
are
experiencing.
Impaired Skin Integrity
related
to
After
8 hours
of
nursing
1. Assess the patient for
hemorrhoidal intervention, the patient will be
the
presence
surgery and procedures as able to maintain intact skin
hemorrhoids,
evidenced by swelling and with no signs and symptoms
discomfort
disruption of skin layers from of
associated
the incision site
rectal
prolapse
and
bleeding
of
or
pain
with
hemorrhoids, diet, fluid
intake, and presence
Rationale:
The
of constipation.
skin
is
the
body's
R:
Provides
baseline
outermost line of protection,
information as to the type of
preventing
hemorrhoids
germs
penetrating
disease.
and
Cuts,
from
(external
or
spreading
internal), degree of venous
abrasions,
thrombosis, and presence of
ulcers, incisions, and wounds
complications,
damage the skin, allowing
bleeding, and risk factors that
germs to enter and cause
preclude
infections. Even after having
hemorrhoids
hemorrhoids
initiation
removed,
the
patient may still feel like they
including
the
of
patient
to
a
from
enable
care
plan
appropriate for the patient.
have hemorrhoids in the skin
tags that surround the anal
area.
This
includes some
2. Assess
impaired
the site
of
tissue
post-operative swelling, which
280
will go away over time. Some
integrity
may be brought on by tissue
condition.
that
was
removed
not
during
completely
surgery.
and
its
R: Redness, swelling, pain,
burning,
and
itching
are
Impairment of the skin can be
indications
of
due
surgical
and
body’s
on
the
system response to localized
patient. Although it has the
tissue trauma or impaired
highest
tissue integrity.
to
certain
procedures
done
likelihood
complications,
of
immune
surgical
hemorrhoidectomy is the most
successful
the
inflammation
treatment
3. Assess
for
the
characteristics of the
hemorrhoids.
wound, including color,
size
(length,
width,
depth), drainage, and
odor.
R: These findings will give
information on the extent of
the impaired tissue integrity or
injury. Pale tissue color is a
sign
of
decreased
oxygenation. An odor may
result from the presence of
infection on the site; it may
also be coming from necrotic
tissue. Serous exudate from a
wound is a normal part of
inflammation and must be
differentiated from
pus
or
purulent discharge present in
the infection.
281
4. Provide tissue care as
needed.
R: Each type of wound is best
treated based on its etiology.
Skin wounds may be covered
with wet or dry dressings,
topical creams or lubricants,
hydrocolloid dressings (e.g.,
DuoDerm),
or
permeable
vapormembrane
dressings such as Tegaderm.
5. Keep a sterile dressing
technique
during
wound care.
R: A sterile technique reduces
the risk of infection in impaired
tissue integrity. This involves
the use of a sterile procedure
field, sterile gloves, sterile
supplies and dressing, and
sterile instruments
6. Monitor
patient’s
continence status and
minimize exposure of
skin impairment site
and other areas to
moisture
from
incontinence,
perspiration, or wound
drainage.
282
R:
Prevents
exposure
to
chemicals in urine and stool
that can strip or erode the skin
causing
further
impaired
tissue integrity.
7. Administer antibiotics
as ordered.
R:
Although
intravenous
antibiotics may be indicated,
wound
infections
managed
well
may
and
be
more
efficiently with topical agents.
8. Tell
the
avoid
patient
rubbing
scratching.
to
and
Provide
gloves or clip the nails
if necessary.
R: Rubbing and scratching
can cause further injury and
delay healing.
9. Discuss
the
relationship
between
adequate
nutrition
consisting
of
fluids,
protein, vitamins B and
C, iron, and calories.
R: Nutrition plays a vital role in
maintaining intact skin and in
promoting wound healing.
283
10. Instruct
patient,
significant others, and
family in the proper
care of the wound,
including
handwashing, wound
cleansing,
dressing
changes,
and
application of topical
medications).
R:
Accurate
information
increases the patient’s ability
to
manage
therapy
independently and reduces
the risk of infection.
11. Educate the patient on
the need to notify the
physician or nurse.
R: This is to prevent further
impaired
tissue
integrity
complications.
Constipation related to low After
nursing
1. Assess the patient's
residue diet as evidenced by intervention, the patient will be
bowel habits, lifestyle,
the passage of hard-formed able to establish and maintain
capacity to detect a
stool
passage of soft, formed stool
defecation
at a frequency perceived as
severe
hemorrhoids,
normal by the patient.
and
history
Rationale:
Constipation
typically
8 hours
of
urge,
of
constipation.
happens when waste or stool
R: This intervention aids in
passes too slowly through the
determining an efficient bowel
digestive tract or cannot be
regimen, impairment, and the
284
efficiently evacuated from the
need for support. As a result of
rectum, which may result in
poor digestion, Gl function
the stool becoming hard and
may
dry.
is
impairment caused by muscle
constipated, patients are more
weakness and immobility may
prone to push forcefully when
result in reduced abdominal
defecating. As a result, the
peristalsis
rectum and anus veins could
identifying
get larger. These protruding
defecate.
When
a
person
suffer.
and
the
Functional
trouble
need
to
veins are called hemorrhoids.
Hemorrhoids and constipation
2. Examine the patient's
may get worse if the patient
stool
frequency,
will not consume enough fiber.
features,
flatulence,
stomach
pain
or
distension, and stool
straining.
R:
Constipation
can
be
caused by aging factors such
as
diminished
rectal
compliance, discomfort, and
impaired rectal sensation.
3. Thoroughly
observe
the patient's nutrition
and fluid intake.
R: Sufficient amounts of fiber
and roughage produce bulk,
and at least 2 L of liquids per
day is beneficial in preventing
hard stools.
285
4. Examine
the
bowel
sounds for presence
and quality.
R: Atypical sounds, including
high-pitched tinkles, indicate
difficulties such as ileus.
5. Assess the patient for
complaints
of
abdominal discomfort
and distention.
R: Gas, abdominal distention,
or ileus could all contribute to
constipation.
Impaired
digestion can cause intestinal
distention
and,
in
severe
cases, Can result in ileus due
to a lack of peristalsis.
6. Keep an eye on the
patient's mental state,
syncope,
heart
palpitations, and any
transient
attacks.
doctor
ischemic
Inform
if
the
these
symptoms develop.
R: Excessive straining may
severely
affect
arterial
circulation, resulting in heart,
cerebral,
or
peripheral
ischemia.
286
7. Examine the patient
for rectal bleeding.
R:
Extreme
straining
can
result in hemorrhoids, rectal
prolapse, or anal perforations,
all of which cause damage to
the tissue and bleeding
8. As needed, administer
bulk stool softeners,
laxatives,
suppositories,
or
enemas.
R: These medications help
stimulate stool evacuation.
9. Advise the patient to
consume
high-fiber
foods such as wholegrain cereals, bread,
and fresh fruits.
R: This intervention enhances
peristalsis
and
aids
in
elimination
10. Monitor the patient's
medication that may
predispose them to be
constipated.
R: Some medications are
known to cause constipation
include
analgesics,
287
anesthetics, anticholinergics,
and diuretics.
11. Educate the patient in
activity
or
routines
for
the
exercise
appropriate
disease
process.
R:
Activity
peristalsis
and
enhances
defecation
Exercises serve to strengthen
the stomach muscles, which
helps with bowel movement.
IX.
LITERATURE
Hemorrhoids: A range of treatments
Bora & Gorgun (2020) Hemorrhoids: A range of treatments. Retrieved on February 20,
2023, from: https://www.ccjm.org/content/86/9/612
Hemorrhoids accounted for more than 3.5 million US outpatient visits in 2010, and they
were the third leading cause of hospital admissions related to gastrointestinal disease. In choosing
the treatment for hemorrhoids, one should consider the disease grade and severity, its impact on
the quality of life, the degree of pain it causes, the patient’s likelihood of adhering to treatment,
and the patient’s personal preference. Treatments can be grouped in 3 categories: conservative,
office-based, and surgical. Conservative measures are aimed at softening the stool, relieving pain,
and correcting bad toileting habits. In most cases, the primary precipitating factor is lifestyle, and
unless patients change it, they are more likely to have recurrent symptoms in the long term. Officebased treatments rubber band ligation, infrared photocoagulation, and sclero-therapy are
commonly used for grade I, II, and III hemorrhoids that have not responded to conservative
management. The primary goal of these treatments is to decrease blood flow into the
hemorrhoidal sac. Although nonsurgical treatments have substantially improved, surgery is the
288
most effective and strongly recommended treatment for patients with high-grade internal
hemorrhoids (grades III and IV), external and mixed hemorrhoids, and recurrent hemorrhoids. The
most popular surgical options are open or closed hemorrhoidectomy, stapled hemorrhoidopexy,
and Doppler-guided hemorrhoidal artery ligation.
“PNR-Bleed” classification and Hemorrhoid Severity Score a novel attempt at
classifying the hemorrhoids
Kahn, Chowdri, et al. (2020) “PNR-Bleed” classification and Hemorrhoid Severity Score
a novel attempt at classifying the hemorrhoids Retrieved on February 20, 2023, from:
https://jcol.elsevier.es/en-pnr-bleed-classification-hemorrhoid-severity-scorea-articuloS2237936320300423
Hemorrhoids are generally classified on the basis of their location and degree of prolapse.
To describe the hemorrhoidal disease more vividly, they devised the “PNR-Bleed” (or PNRBooking) classification system. They classified hemorrhoids based on the four main
characteristics of the hemorrhoidal disease i.e. the degree of hemorrhoidal Prolapse (P), Number
(N) of the primary hemorrhoidal columns involved, Relation (R) of the hemorrhoidal tissue to
dentate line and the amount of Bleeding (B) from it. All the four components in this classification
system are graded into five grades ranging from 1 to 5. Based on this “PNR-Bleed” classification,
They introduced another concept of scoring the severity of hemorrhoids. In this article, they refer
to this scoring system for hemorrhoids as the Hemorrhoid Severity Score (HSS) which is the total
score obtained by the sum of the numerical grades of all four characteristics of hemorrhoids in
“PNR-Bleed” classification. This new “PNR-Bleed” system of classifying the hemorrhoids and
calculation of HSS seems to be more comprehensive, detailed, more objective and easily
reproducible. This new classification of hemorrhoids may provide a new dimension of research
for the management of hemorrhoidal disease.
Midwifery Care for Mothers with Hemorrhoids
Sujawaty, Tompunuh, et al, (2023) Midwifery Care for Mothers with Hemorrhoids.
Retrieved on February 20, 2023, from:
https://www.aisyah.journalpress.id/index.php/jika/article/view/812
Women die from complications during pregnancy, childbirth and the puerperium. It was
found that respondents suffered from grade IV hemorrhoids where in most cases pregnant women
with grade IV hemorrhoids would have section caesarea surgery to reduce pressure pain when
289
the mother pushes. In pregnancy, due to the influence of increased sex hormones and increased
blood volume, causing dilation of the veins in the rectal area. The increase in the hormone
progesterone in pregnant women will cause peristalsis of the digestive tract to slow down and the
muscles to relax, as well as relaxation of the anorectal venous valves, which will result in
constipation which will aggravate the venous system. Likewise, due to the suppression of the fetus
in the uterus on the veins in the pelvic area will result in damming. Coupled with straining to
defecate that often occurs in pregnant women because constipation will cause hemorrhoidal
prolapse. Hemorrhoids that do not because complaints do not require special treatment, except
for the preventive measures mentioned. After delivery, uncomplicated hemorrhoids will shrink on
their own. Hemorrhoids can be prevented by drinking enough water, eating lots of vegetables,
and lots of fruits, so that the stool does not harden. Hemorrhoids are not too dangerous, both for
the mother and the fetus, but when the doctor has entered the fourth degree, it is more advisable
to do a cesarean section to reduce pressure pain when the mother pushes.
290
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