Interventions for clients with stomack and intestinal disorders.

1. Interventions for clients with stomack and intestinal disorders.

2. Stomach Disturbances • Gastritis • Peptic Ulcer Disease • Gastric Surgery • Zollinger-Ellison Syndrome • Dumping Syndrome

3. Gastritis • Gastritis is defined as inflammation of the gastric mucosa; two types: • Acute gastritis • Chronic gastritis • Type A gastritis • Type B gastritis • Atrophic gastritis • Helicobacter pylori, Escherichia coli can cause gastritis.

4. Clinical Manifestations • Bloating • Hematemesis • Abdominal tenderness • Melena • Intravascular depletion and shock

5. Nonsurgical Management • Primary treatment: identification and elimination of causative factors • Drug therapy • H2-receptor antagonists • Antacids • Antisecretory agents • Vitamin B12 • Triple therapy for H. pylori infection

6. Other Therapies • Diet therapy • Limit intake of foods and spices that cause distress (tea, coffee, cola, chocolate, mustard, paprika, cloves, pepper, and hot spices), as well as tobacco and alcohol. • Stress reduction

7. Surgical Management • Partial gastrectomy • Pyloroplasty • Vagotomy • Total gastrectomy

8. Peptic Ulcer Disease • PUD is a mucosal lesion of the stomach or duodenum as a result of gastric mucosal defenses impaired and no longer able to protect the epithelium from the effects of acid and pepsin. • Acid, pepsin, and Helicobacter pylori infection play an important role in the development of gastric ulcers.

9. Duodenal Ulcers • Most duodenal ulcers occur in the first portion of the duodenum. • Duodenal ulcers present as deep, sharply demarcated lesions that penetrate through the mucosa and submucosa into the muscularis propria.

10. Gastric Ulcer Increase of pain with eating, antacids 30min Hematemesis Duodenal Ulcer Relief with food, antacids 90min-3hr Pain awakens at night Melena Differentiating Gastric and Duodenal Ulcers

11. Stress Ulcers • Acute gastric mucosa lesions occurring after an acute medical crisis or trauma • Associated with head injury, major surgery, burns, respiratory failure, shock, and sepsis. • Principal manifestation: bleeding caused by gastric erosion

12. Complications of Ulcers • Hemorrhage—hematemesis • Perforation—a surgical emergency • Pyloric obstruction—manifested by vomiting caused by stasis and gastric dilation • Intractable disease—the client no longer responds to conservative management, or recurrences of symptoms interfere with ADLs

13. Clinical Manifestations • Epigastric tenderness usually located at the midline between the umbilicus and the xiphoid process • Dyspepsia • Typically described as sharp, burning, or gnawing pain • Sensation of abdominal pressure or of fullness or hunger

14. Acute or Chronic Pain • One of the primary purposes for employing drug therapy is to eliminate or reduce pain. • Analgesics are not the mainstay of pain relief for PUD. • Ulcer drug regimen itself promotes relief of pain by eradicating H. pylori infection and promoting healing of the gastric mucosa.

15. Drug Therapy • Four primary goals for drug therapy: • Provide pain relief • Eradicate H. pylori infection • Heal ulcerations • Prevent recurrence

16. Hyposecretory Drugs • Hyposecretory drugs produce a reduction in gastric acid secretion. • Antisecretory agents • H2-receptor antagonists • Prostaglandin analogues

17. Antisecretory Agents • Antisecretory agents, also called proton pump inhibitors, include: • Prilosec • Prevacid • Aciphex • Protonix • Nexium H2-Receptor Antagonists • Drugs that block histamine-stimulated gastric secretion • May be used for indigestion and heartburn • Block the action of the H2-receptors of the parietal cells, thus inhibiting gastric acid secretion • The most common: Zantac, Pepcid, and Axid

18. Prostaglandin Analogues • These agents reduce gastric acid secretion and enhance gastric mucosal resistance to tissue injury. • Misoprostol (Cytotec) helps prevent NSAID-induced ulcers. • Uterine contraction is a significant adverse effect of misoprostol.

19. Antacids • Antacids buffer gastric acid and prevent the formation of pepsin; they are effective in accelerating the healing of duodenal ulcers. • The most widely used preparations are mixtures of aluminum hydroxide and magnesium hydroxide, such as Mylanta or Maalox. • For optimal effect, take about 2 hr after meals. • Antacids can interact with certain drugs and interfere with their effectiveness.

20. Mucosal Barrier Fortifiers • Sucralfate (Carafate) is a sulfonated disaccharide that forms complexes with proteins at the base of a peptic ulcer; this protective coat prevents further digestive action of both acid and pepsin. • Sucralfate binds bile acids and pepsins, reducing injury from these substances. • The main side effect of sucralfate is constipation.

21. Diet Therapy • Diet therapy may be directed toward neutralizing acid and reducing hypermotility. • A bland, nonirritating diet is recommended during the acute symptomatic phase. • Avoid bedtime snacks. • Avoid alcohol and tobacco.

22. Irritable Bowel Syndrome (IBS) • IBS is a chronic gastrointestinal disorder characterized by chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. • Manning criteria are present: • Abdominal pain relieved by defecation • Abdominal distention • The sense of incomplete evacuation of stool • The presence of mucus with stool passage • A flare-up of symptoms usually brings the client to the health care provider.

23. Treatment • Education—teaching the client to avoid problem stimulants • Diet therapy—elimination of offending or upsetting foods • Drug therapy—bulk-forming laxatives, antidiarrheal agents, anticholinergic agents, tricyclic antidepressants, and 5-HT4 agonists. • Stress management based on the client’s current and ongoing stressors • Complementary and alternative therapies used to reduce symptoms and discomfort

24. Herniation • Weakness in the abdominal muscle wall through which a segment of bowel or other abdominal structure protrudes • Types of hernia include: • Indirect inguinal • Direct inguinal • Femoral • Umbilical • Incisional or ventral

25. Surgical Management • Preoperative care—NPO day of surgery • Operative procedure • Minimally invasive inguinal hernia repair (MIIHR) • Conventional herniorrhaphy • Postoperative care in minimally invasive inguinal hernia repair includes: • Elevate scrotum to prevent and control swelling. • Address difficulties in voiding that may occur. • Observe for signs and symptoms of complications.

26. Colorectal Cancer • Colorectal refers to the colon and the rectum, which together make up the large intestine. • 95% of cancers of the colon or rectum are adenocarcinomas. • Etiology • Genetic considerations • Personal factors • Dietary factors • Inflammatory bowel disease

27. Clinical Manifestations • Rectal bleeding, hematochezia, passage of red blood via the rectum • Anemia • Change in stool texture • Mass in abdomen

28. Laboratory Assessment • Hemoglobin and hematocrit values usually decreased • Fecal occult blood test • Possible elevation of carcinoembryonic antigen • Radiographic assessment • Other diagnostic assessments

29. Surgical Management • Colon resection • Colectomy • Abdominoperineal resection • Colostomy • Transanal approach

30. Surgical Management • Preoperative care includes: • Consultation with enterostomal therapist • Discussions with surgeon of risk of sexual and urinary dysfunctions • Bowel prep • Nasogastric tube and IV line placed for use after surgery • Assignment of case manager for long-term consequences

31. Surgical Management • Postoperative care includes: • Colostomy and wound management • Nasogastric tube • Colostomy management • Wound management

32. Colostomy Care • Normal appearance of the stoma • Signs and symptoms of complications • Measurement of the stoma • Choice, use, care, and application of appropriate appliance to cover stoma • Measures to protect the skin • Dietary measures to control gas and odor • Resumption of normal activities

33. Intestinal Obstruction • Mechanical obstruction • Nonmechanical obstruction, known as paralytic ileus • Strangulated obstruction resulting from tumors, hernias, fecal impactions, strictures, intussusception, volvulus, fibrosis, vascular disorder, and adhesions

34. Clinical Manifestations of Mechanical Obstruction • Midabdominal pain or cramping • Vomiting • Obstipation • Diarrhea • Alteration in bowel pattern and stool • Abdominal distention • Borborygmi • Abdominal tenderness

35. Clinical Manifestations of Nonmechanical Obstruction • Constant diffuse discomfort • Abdominal distention • Decreased to absent bowel sounds • Vomiting • Obstipation

36. Assessment • Laboratory assessment • Radiographic assessment • Endoscopy • Barium enema • Computed tomography

37. Surgical Management • Preoperative care • Teaching • Nasogastric intubation and suction if time permits • Operative procedure: exploratory laparotomy to determine procedure • Postoperative care • Exploratory laparotomy • Nasogastric tube in place • Usual postoperative care

38. Abdominal Trauma • Injury to the structures located between the diaphragm and the pelvis, including the large or small bowel, liver, spleen, duodenum, pancreas, kidneys, and urinary bladder • Blunt abdominal trauma, which often occurs in motor vehicle accidents • Penetrating abdominal trauma caused by gunshot wounds, stabbing

39. Assessment • Assess airway, breathing, and circulation • Assess for the following: • Hypovolemic shock • Cullen’s sign • Turner’s sign • Ballance’s sign • Kehr’s sign

40. Emergency Care: Abdominal Trauma • Two large-bore intravenous lines are placed • Central venous catheter • Balanced saline solution, crystalloids, and possibly blood • Arterial blood gas assessment • Fluid and electrolyte management • Continuous hemodynamic monitoring • Surgical management

41. Polyps • Small growths in the intestinal tract that are covered with mucosa and are attached to the surface of the intestine • Various types • Usually asymptomatic, but can cause gross rectal bleeding, intestinal obstruction, and intussusception • Nursing care focused on teaching

42. Hemorrhoids • Unnaturally swollen or distended veins in the anorectal region • Internal hemorrhoids • External hemorrhoids • Nonsurgical management • Surgical management: hemorrhoidectomy

43. Malabsorption Syndrome • Syndrome associated with a variety of disorders and intestinal surgical procedures • Primary clinical manifestations: Diarrhea and steatorrhea • Interventions: • Dietary management • Surgical or nonsurgical management • Drug therapy