The Human Digestive System

 Gastrointestinal System

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NUR 194

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Source:http://www.labyrinth.net.au/~daviddic/dig

estion.jpg

Quick Review: A&P

•

GI tract – 25 ft pathway from mouth to anus

•

Function of GI tract:

•

Break down food particles into molecules for digestion

•

Absorb into the bloodstream the small molecules

produced by digestion

•

Eliminate undigested and unabsorbed foodstuffs and

other waste products from the body

Mouth

→

•

Food entry

•

Process of digestion begins with

chewing (mastication) to break down

foods into small particles that can be

swallowed and mixed with digestive

enzymes

•

Saliva:

•

First secretion that comes in contact with

food; contains water and mucus; lubricant

for swallowing

•

Contains salivary amylase (enzyme:

ptyalin) digests starches

•

Produced in 3 pairs of glands: parotid,

submaxillary, and sublingual.

•

Approx. 1L of saliva is produced daily

Pharynx

•

The pharynx or throat extends from the soft palate to the esophagus.

It is lined with mucous membrane and contains 3 pairs of organs: the

adenoids, the lingual tonsils, and the tonsils.

Esophagus →

Responsible for food passage from

mouth to stomach

•

Distends

•

Smooth muscle contracts in

rhythmic sequence (peristalsis)

from upper esophagus to stomach

to propel food along

•

Upper Esophageal Sphincter 

(UES)

(entry). Closed at rest to prevent

air entering the esophagus during

respiration.

•

passes through diaphragm at

opening called diaphragmatic

hiatus

•

Lower esophageal sphincter

(LES)

relaxes to allow food to enter

stomach then 

closes tightly to

prevent reflux of stomach

contents back into esophagus.

•

about 24cm or 10 inches long

Stomach→

•

Lined with smooth muscle that promotes gastric

motility.

•

Expandable pouch, stores and mixes food with

secretions; holds approx. 1500ml

•

Parietal cells line wall and secrete hydrochloric acid

(HCl)

•

Breaks down food

•

Kills most ingested bacteria

•

Gastric secretions contain pepsin for protein

digestion

•

Gastric mucosa secretes intrinsic factor to combine

with Vitamin B

12

 in food to be absorbed in ileum

•

Parietal cells also produce 

intrinsic factor, which

works to facilitate the absorption of Vit B12.

Absence of the intrinsic factor causes pernicious

anemia.

•

Chyme: food particles mixed with gastric secretions

Stomach

→

•

Inlet: esophagogastric junction

surrounded by smooth muscle

(lower esophageal sphincter or

cardiac sphincter) which

contracts and closes off

stomach from esophagus

•

4 anatomic regions:

•

Cardia (entrance)

•

Fundus

•

Body or corpus

•

Pylorus or antrum: outlet

Outlet: Pyloric sphincter – circular

smooth muscle that controls

the opening of the stomach to

the intestine

3 phases of gastric secretion

•

Cephalic- begins with sight, smell, and taste of food

and is regulated by the vagus nerve.

•

Gastric- begins with the presence of food in the

stomach.

•

Intestinal- begins as the chyme passes from the

stomach into the duodenum, causing distention.

Secretin :  a hormone that inhibits further acid

production and decreases gastric motility.

Pancreas

•

Gland that lies behind the stomach and extends to the spleen

•

2 cellular bodies within Pancreas:

•

Exocrine: 80% of the organ and cells secrete enzymes needed for digestion of

carbohydrates, fats, and proteins (trypsin, chymotrypsin, amylase and lipase

•

Endocrine- produces glucagon & insulin.

Liver

•

Largest organ of body –other than skin

•

Located in RUQ of abdomen.

•

Primary functions:

•

Forms & secretes bile which is necessary for fat breakdown.

•

Bile empties into the duodenum at sphincter of Oddi.  If sphincter is

closed, the bile is stored in the gallbladder.

Small Intestine→

•

Longest segment – about 2/3 the total

length of GI tract

•

Approx 7000 cm of surface area for

secretion and 

absorption

 (the process

by which nutrients enter bloodstream

through intestinal wall --primary fx of

small intestine).

•

3 anatomic parts:

•

Duodenum (upper)

•

Sphincter of Oddi

•

Jejunum (middle)

•

Ileum (lower)

•

Cecum: junction between small and

large intestine; ileocecal valve controls

passage of contents into large intestine

& prevents reflux of bacteria into small

intestine.

•

Appendix located at junction of small

and large intestine

Small intestine

•

The common bile duct and pancreatic duct join to form the ampulla

of Vater, emptying into the duodenum at the duodenal papilla. This

papillary opening is surrounded by muscle known as the sphincter of

Oddi.

•

Sphincter of Oddi leads to the jejunum.

Small Intestine 

→

•

Duodenum: contains intestinal glands & receives secretions from pancreas, liver, and

gallbladder that aid in digestion (contain enzymes and bile)

•

Intestinal glands

:

•

secrete mucus, electrolytes, and enzymes: Coat cells and protect mucosa from

HCl

•

Hormones, neuroregulators, and local regulators control rate of secretion

production; influence GI motility

•

Pancreas:

•

Secretions have alkaline pH due to high bicarbonate concentration; neutralizes

acid entering from stomach

•

Digestive enzymes: Trypsin (protein digestion); Amylase (starch); lipase (fats)

•

Liver:

•

secretes bile (emulsify fats making them easier to digest and absorb) know all

functions of the liver –Chapter 55

•

Gallbladder: Bile storage

•

Two types of contractions- stimulated by presence of chyme

•

Segmentation: mixing waves; churns

•

Intestinal peristalsis: propels contents of small intestine to colon

•

Vitamins and minerals: absorbed essentially unchanged

•

Absorption begins in jejunum 

– diffusion and active transport

Large Intestine

•

Functions: movement, continuation of absorption and

beginning of elimination

•

Ileocecal valve allows passage of residual waste material

from terminal ileum into proximal colon—restricts reflux

of contents back into ileum,

•

Bacteria is major component of large intestine

•

2 colonic secretions: an electrolyte solution (bicarb to

neutralize) and mucus (protects mucosa and provides

adherence of fecal mass)

Waste materials reach and distend rectum in about 12

hours

Large Intestine

→

•

Components

:

•

Begins at cecum.

•

Ascending segment (R-side of

abdomen)

•

Transverse

 (

right to left of

upper abdomen)

•

Descending segment (L side of

abdomen)

•

Terminal portion: sigmoid and

anus

•

Anus -- striated muscles form

internal and external anal

sphincters

Waste Products

•

Feces – 75% fluid, 25% solid materials: foodstuffs, inorganic

materials, water and bacteria

•

Brown color comes from breakdown of bile

•

Chemicals formed by bacteria are largely responsible for odor

•

Approx 150 ml of gases are contained in GI tract: methane; hydrogen

sulfide; and ammonia—either absorbed into portal circulation and

detoxified by liver, or expelled through rectum as flatus

•

Process of elimination: Stimulation of rectum causes rectal distention

which reflexively initiates contraction of rectal muscles causing the

internal anal sphincter to relax (autonomic nervous system). The

external anal sphincter is under conscious control of the cerebral

cortex—once allowed to relax will allow contents to be expelled.

Contraction of the abdominal muscles (bearing down or straining)

facilitates the emptying of the colon.

•

Average frequency of defecation: once a day, but varies among

individuals

GI Changes with Aging

•

Stomach: Decreased gastric HCL

-Atrophic gastritis due to bacterial overgrowth

Encourage bland foods high in vitamins & iron

Assess for epigastric pain

•

Large Intestine: Decreased peristalsis

•

Constipation & Impaction

•

High fiber diet

•

Increased fluid intake (1500ml) if not contraindicated

•

Encourage activity as tolerated

•

Pancreas: Pancreatic duct change

•

Steatorrhea: excess fat in stool.

•

Small frequent feedings

•

Assess for diarrhea

•

Liver: Decreased enzyme activity & cholesterol synthesis

•

Depresses drug metabolism leading to accumulation of drug and possible toxicity

•

Assess for adverse effects of drugs

•

Know Chart 55-1

Assessment

•

Take a complete history; focus on symptoms common to GI dysfunction Read Gordon’s functional health

patterns-Chart 55-2

•

Family & Genetic HX * Ex: Familial adenomatous Polyposos(FAP)-rpedisposition to colon cancer

•

Previous hx of GI disease

•

Past and current medication use. Including OTC & herbal products

•

Previous or current treatments

•

Previous surgeries

•

Nutritional/Dietary hx:

•

Food Allergies

•

Tobacco and alcohol use

•

Changes in appetite or eating patterns

•

Anorexia (loss of appetite for food); dysphagia (difficulty swallowing); N/V; dyspepsia

(indigestion/heartburn)

•

Unexplained weight gain or loss

•

Stool characteristics

•

Socioeconomic, psychosocial, spiritual, or cultural factors

•

Cultural: food restrictions, use of ingredients. Fasting

•

80-90% African Americans are lactose intolerant. Lack of enzyme lactase which converts dairy to

glucose and galactose. (s/s: bloating, cramping, diarrhea)

•

PE: Abdominal girth; tenderness/guarding; rectal exam; pelvic exam

•

Diagnostics: CBC, urinalysis, abdominal x-rays, EKG, pregnancy test for the female

PQRST

•

P: precipitating or palliative

•

Q: quality or quantity

•

R: region or radiation

•

S: severity scale

•

T: timing

Symptoms Common to GI

Dysfunction

•

Pain: can be major symptom; assess character,

frequency, location, pattern, time of pain—be

aware of common sites of referred pain

•

Indigestion: Upper abdominal discomfort or

distress; most common symptom; Peristaltic activity

may be contributing; BMs may or may not relieve

pain. Fatty  foods often perpetrator—remain in

stomach longer. Coarse vegetables and highly

seasoned foods may cause distress.

Symptoms

•

Intestinal Gas: Accumulation of gas may leading to belching

(expulsion from stomach thorough mouth) or flatus (from

rectum)

•

Complaint of bloating, distension, or “full of gas”

•

Excessive flatulence may be a symptom of gallbladder disease or food

intolerance.

•

Nausea and Vomiting:

•

Nausea : usually triggered by odors, activity, or food intake

•

Emesis may vary in color and content; may contain undigested food

particles or blood (hematemesis).

•

Blood: If bright red signal of hemorrhage; if dark or has coffee-ground

appearance it has been subjected to gastric enzymes

Symptoms

•

Change in Bowel Habits and Stool Characteristics

•

May signal colon disease

•

Diarrhea: abnormal increase in frequency or liquidity of stool

•

Constipation: decrease in frequency of stools; stools that are hard, dry, or of

smaller volume than normal

Symptoms

•

Stool Characteristics – color and appearance

•

Color: can be affected by foods or meds

•

Blood: can present in several ways

•

Tarry-black: blood shed in upper GI tract

•

Bright red: blood enters in lower portion of GI

•

Dark red: passing rapidly through GI tract

•

Streaking of blood on surface of stool/toilet tissue: may be lower

rectal or anal bleeding

•

Common abnormalities of stool:

•

Bulky, greasy, foamy; foul in odor; gray with silvery sheen

•

Light gray or clay-colored caused by absence of urobilin

•

Mucus threads or pus visible on gross inspection

•

Small, dry, rock-hard masses called scybala—may be streaked with

blood from rectal trauma during passage

•

Loose, watery stool that may or may not be streaked with blood

Physical Assessment

•

Examination includes:

•

Mouth: tongue, buccal mucosa, teeth, gums –note any

ulcerations, nodules, swelling, inflammation; color changes

•

Abdomen

•

Rectum - –anal and perineal areas: rash or excoriation;

fissures or fistulas; hemorrhoids. Digital exam: masses or

tender areas

•

Performance of the exam must be followed in this order so

intestinal activity & bowel sounds are not increased prior to

exam.

•

Inspection

•

Auscultation

•

Percussion

•

Palpation

Inspection

•

Skin changes

•

May result from GI Tract disorders such as liver and biliary obstructions

•

Scars – trauma, previous surgeries

•

Contour and symmetry

•

Bulging

•

Distension

•

Peristaltic waves

•

Cullen’s sign

Auscultation

•

Bowel Sounds – all 4 quads – using the diaphragm

of the stethoscope (best for high-pitch and

gurgling):

•

Increased bowel sounds-borborygmus

•

Character

•

Location

•

Frequency

•

Normal – sound is heard every 5 to 20 seconds

•

Hypoactive – one or two sounds heard in 2 minute period

•

Hyperactive: 5 to 6 sounds heard in less than 30 seconds

•

Absent: No sounds heard in 3 to 5 minutes

BRUITS

Percussion and Palpation

•

Percussion:

•

Tympany (high pitched) or dullness

•

Palpation: 2 types:

•

Light: detects large masses & areas of tenderness.

•

Rebound tenderness (Blumberg’s sign-used to further evaluate areas

of pain).

•

: exert pressure over an area and release quickly—is there pain on

withdrawal of pressure? If so, report to health care provider.

•

Note any areas of tenderness or guarding for further evaluation

during deep palpation. If rigidity noted, indicative of peritoneal

inflammation.

•

Deep: identify masses in 4 quads. Current practice is that only MD or

APN’s perform deep palpation. Used to determine size & shape of organs

& masses.

Diagnostics

•

Blood Tests: CBC, PT, Carcinoembryonic antigen (CEA and the CA19-9);

total calcium, Potassium, Albumin levels

•

AST, ALT, amylase and lipase bilirubin, ammonia.

•

 Serum Cholesterol and Triglycerides

•

Urine Tests: amylase; urobilinogon

•

Stool Tests ( FOBT)-Fecal Occult Blood Test , FIT, Stool samples for ova/

parasites; stool test for clostridium difficile

•

Know:  Labs: Chart 55-3 for normal ranges

Diagnostics cont’d

•

Abdominal Ultrasound

•

Plain films of the abdomen

•

Upper GI Study

•

Lower GI study

•

PTC

•

CT

Endoscopy

•

Endoscopy: direct visualization of GI tract with a flexible fiberoptic

endoscope.

•

Used to evaluate bleeding, ulceration, inflammation, tumors, and cancer

of esophagus, stomach, biliary system, or bowel. May obtain specimans

for biopsy or studies (H.pylori).

•

 Requires Informed consent by patient prior to procedure.

•

EGD- examines esophagus, stomach & duodenum. May be used to dilate an

esophageal stricture (during procedure)

•

ERCP- includes exam of liver, gallbladder, bile ducts, and pancreas to identify cause &

location of obstruction(s). Uses contrast so x-rays may be obtained. May obtain

biopsies, or remove gallstones.Lasts 30 minutes to 2 hours. Reqiures Iv access for

moderate sedation drugs and contrast.

 Colonoscopy

•

Colonoscopy: endoscopic exam of entire large bowel..  Recommended every 10 years for all persons age 50+.

More frequently if family hx of colon cancer. Evaluates for causes of chronic diarrhea, source of GI bleeding.

•

Prep:

•

Clear liquid diet 12-24 hours  prior  to procedure.

•

  NPO 6-8 hours prior—may have water.

•

Avoid aspirin, NSAIDS, and anticoagulants (with MD order) for several days

•

Diabetic patients should check With MD re: diabetic meds as pt is NPO

•

Night before procedure, Pt drinks Sodium Phosphate (Phospho-Soda) to clean bowel. May be repeated the

morning of procedure. May prescribe Go-Lytely as a bowel cleanser the day before as well. Chill drinks  to

improve taste. Have pt drink quickly to avoid N/V. Watery diarrhea begins in about 1 hour. Additional

laxatives or cleansing enemas may be required.

•

Procedure:

•

IV access for moderate sedation. Versed. Air is instilled to prmoote better viewing.

•

Endoscopy passed through rectum to cecum.

•

Atropine Sulfate : available in case of bradycardia from vasovagal response.

•

After-Care:

•

NPO until sedation wear off and pt is fully alert. VS every 15 minutes until pt is stable. Siderails up until Pt

fully alert. Monitor for rectal bleeding or pain. May expect abdominal cramping for several hours. Monitor

for bowel perforation, hypovolemic shock.

•

Chart 55-4.

Tests cont.

•

Gastric Analysis, Gastric Acid Stimulation Test(Histolog), pH

monitoring

•

Ultrasonography,

•

Endoscopic ultrasonography

•

Liver-spleen scan

The nurse’s role

•

Is to prepare the client, explain the procedure, and provide the

necessary post procedure care.

•

Read and know the procedures so you can explain them to the client.

Oral and Esophageal Disorders

Chapter 56

•

Examining the Lips, Mouth, and Gums:

•

Examples of Lip Conditions :

Cold Sore

Chancre

Contact 

Dermititis

Stomatitis/Candidiasis

•

Stomatitis is a painful ulceration of the oral mucosa

that appear as inflammation and denudation of the

oral mucosa, known as canker sores

•

Candidiasis is a fungal/yeast infection resulting from

an overgrowth of normal flora. Type of secondary

stomatitis. Overgrowth may be caused by long term

antibiotic use, chemotherapy, radiation, and HIV.

White plaque on tongue. Red and painful underneath.

Mouth

Hairy Leukoplakia

Candidiasis

Lichen planus

Mouth and Gums

Periodontitis

Aphthous

Stomatitis

(Canker Sore)

Salivary Glands

•

Acute Sialadenitis:

•

Inflammation of salivary glands

•

Causes: dehydration; radiation therapy, malnutrition,

improper oral hygiene. Invasion of 

staph a.

;

 streptococcus

viridans

;

or 

pneumococcus

•

S/Sx: Pain, swelling, purulent discharge

•

Tx: Antibiotics; massage, hydration, corticosteroids;

surgery to drain; analgesics, warm compresses, use of

lemon slices & fruit/citrus flavor candy to stimulate

    saliva

•

Best prevented by good routine oral hygiene.

•

Xerostomia-very dry mouth . Usually caused by

exposure of glands to radiation.

Esophagus

Chapter 57

•

Dysphagia: difficulty swallowing

•

Most common symptom of esophageal disease

•

Odynophagia: acute pain on swallowing

•

Motility disorders:

•

Achalasia: rare disorder. absent or ineffective peristalsis;

accompanied by the  esophageal sphincter  that fails to

relax during swallowing resulting in sensation of food

sticking in lower esophagus.

•

Diffuse spasm: Motor disorder with unknown cause;

stress produces contractions of the esophagus

Esophagus

 Gastroesophageal Reflux Disease (GERD)

Caused by an incompetent lower esophageal sphincter

,

pyloric stenosis, or a motility disorder  that allows

backflow of gastric or duodenal contents

•

S/Sx: Pyrosis (burning sensation in the esophagus); dyspepsia

(indigestion); regurgitation; dysphagia; odynophagia- Chart 57-1

& Table 57-1

•

Tx: Low-fat diet; avoid caffeine, tobacco, beer, milk;

peppermint/spearmint; carbonated beverages; avoid eating 3

hours before bedtime; maintain a healthy weight; avoid tight-

fitting clothes; 

elevated head and/or HOB

; surgical intervention

for severe cases not responding to medical intervention. Chart

57-2

GERD

•

Tx: Meds:

•

Antacids;

•

Histamine receptor blockers (prevent or block the production of

gastric acid): Cimetidine (Tagamet); Famotidine (Pepcid);

Nizatidine (Axid); Ranitidine (Zantac)

•

Proton Pump Inhibitors (decrease gastric acid production): Prevacid

(lansoprazole), Aciphex (rabeprazole); Prilosec (Omeprazole); Nexium

(esomeprazole magnesium)

•

Prokinetic Agents (accelerate gastric emptying): Urecholine

(bethanechol); Motililium (domperidone) and Reglan

(metroclopramide)

•

Untreated GERD can lead to Barrett’s Esophagus – a

precancerous condition

Esophagus

•

Hiatal Hernia: opening in the diaphragm (through which the

esophagus passes) becomes enlarged and the upper part of the

stomach moves up into the lower part of the thorax.

•

2 major types:

•

Sliding HiatalHernia

•

Heartburn, regugitation, chest pain, dyshapgia, belching

•

Paraesophageal Hernia

•

Feels full after eating, breathless after eating, feeling of suffocation, chest

pain mimics angina, s/s worse in recumbent position.

•

Diverticulum: (Of esophagus). Herniation of mucosa into surrounding tissue. S/S:

dysphagia, reflux, bad breath, nocturnal cough.DX by EGD. Small meals of

semisoft foods, elevate HOB. May require surgical removal:

Gastric Disorders-Chapter 58

•

Gastritis

: inflammation of the gastric (stomach) mucosa;

membranes become edematous and hyperemic

(congested with fluid and blood) and begin to erode.

Leads to ulceration and a potential for hemorrhage

•

Acute: lasts hours to a few days; 

infection with Helicobactor

pylori

. usually caused by eating contaminated foods; highly

seasoned foods; 

overuse of aspirin or NSAIDs

; excessive

alcohol intake; bile reflux; radiation therapy; or the ingestion

of a strong acid or alkali.

•

S/Sx: Acute: abdominal pain; headache; N&V; anorexia; hiccoughing

•

Tx: Usually self-limiting; mucosa able to repair itself; refrain from

food and alcohol until resolved; non-irritating diet during recovery; IV

fluids. Acids or alkalis: dilution and neutralization; acids (common

antacids), alkali (diluted vinegar or lemon juice)

Gastric Disorders

Gastritis:

•

Chronic: repeated exposure to irritating agents; recurring

episodes of acute gastritis

•

Causes: Prolonged inflammation-- benign or malignant ulcers;

bacteria 

Helicobacter pylori; 

autoimmune diseases (pernicious

anemia) B12 deficiency; caffeine; medications; alcohol; smoking;

reflux of intestinal contents.

•

S/Sx: anorexia; heartburn; belching; N&V; sour taste in the mouth

•

Tx: Modify diet; promote rest; reduce stress; pharmacotherapy—

antibiotics; proton pump inhibitors; bismuth salts (Pepto-Bismol).

Gastric and Duodenal Ulcers

•

Peptic Ulcer: musocsal lesion of the stomach or duodenum.

•

Peptic Ulcer Disease (PUD): occurs when mucosal defenses are

impaired and no longer protect the epithelium from the effects

of acid and pepsin.

•

Types of Peptic Ulcers:

•

Gastric: occurs when break in mucosal barrier and HCL acid

injuries lining. Delays gastric emptying resulting in regurgitation

of duodenal contents. Deep & penetrating ulcers.

•

Duodenal: chronic break in duodenal mucosa and leaves a scar

after healing. High gastric acid secretion.. Most common ulcer.

•

Stress Ulcers: acute lesions that occur after an acute medical

crisis or trauma. Gastritis may lead to stress ulcers.

•

Review Table 58-2

Gastric and Duodenal Ulcers

•

Stress and anxiety formerly thought to be the cause

•

Caused by infection with gram-negative bacteria

Helicobacter pylori

•

Familial tendency may predispose; Blood Type O at

greater risk; also associated with chronic pulmonary

disease or chronic renal disease

•

Associated with chronic use of NSAIDs, alcohol

ingestion, and excessive smoking

Gastric and Duodenal Ulcers

•

S/Sx:

•

May come and go; days to weeks to months and then

disappear then reappear often without identifiable cause

•

Dull, gnawing pain; usually relieved with eating

•

Burning sensation 

in midepigastrium or back

•

Pyrosis (heartburn); belching

•

N&V (vomiting usually is indicative of complication and

often follows a bout of pain and bloating; usually consists

of undigested food )

•

Constipation or diarrhea (usually as a result of medication

or diet regimen)

Gastric and Duodenal Ulcers

•

Assessment

: Pain and epigastric tenderness;

abdominal distention

•

Diagnostics

: Barium study of Upper GI; Endoscopy;

Stool testing for occult blood

; biopsy and histology

with culture, breath test, or serological testing for

H. pylori

•

Tx

:

Medications:

Antibiotics for 

h. pylori

; histamine

2 (H

2

) receptor antagonists; proton-pump inhibitors

for ulcers not associated with 

h. pylori

. Also,

lifestyle changes and surgical intervention

•

Surgical Intervention read p.1278

Nursing Considerations

•

Relieving pain: meds; avoid aspirin, caffeine; regular meals;

relaxation techniques to manage stress and pain; smoking

cessation

•

Reduce anxiety: Answer questions, explain diagnostic tests;

administer meds on schedule; encourage family support.

•

Maintain optimal nutrition: Assess for malnutrition and wt

loss; teach about importance of complying with med and

dietary regimen.

•

Promote self-care—teach clients to manage disease and

factors that help or aggravate; medication regimen; dietary

considerations; smoking cessation

Nursing Considerations

•

Monitor and manage potential complications:

•

Hemorrhage (goal: to avoid hemorrhagic shock)—

hematemesis (may include NG tube insertion and care);

correct blood loss; assess for faintness, dizziness, or nausea;

Frequent VS; assess for tachycardia, hypotension, tachypnea;

monitor Hgb and Hct; urinary output; monitor O

2

 sats and

administer O

2

•

Perforation (erosion of ulcer through gastric serosa into the

peritoneal cavity) and Penetration (erosion of ulcer through

gastric serosa into adjacent structures)– 

requires immediate

surgery as peritonitis sets in quickly; sudden severe upper

abdominal pain (may be referred), Vomiting and collapse;

extremely tender and rigid abdomen

; hypotension and

tachycardia; Tx: NG insertion and care; monitor fluid &

electrolyte balance.

Nursing Considerations

•

Pyloric Obstruction (gastric outlet obstruction) – area distal to pyloric

sphincter scarred and stenosed

•

S/Sx:

•

N &V

•

Constipation

•

Epigastric fullness

•

Anorexia

•

Weight loss (later)

Irritable Bowel Syndrome (IBS)

•

One of the most common GI problems

•

More common in women than men

•

No anatomic or biochemical abnormalities identified to explain

symptoms; no evidence of inflammation or tissue changes

•

Factors associated with IBS:

•

Heredity

•

Psychological stress

•

Depression and anxiety

•

High-fat diet

•

Stimulating or irritating foods

•

Alcohol consumption

•

Smoking

IBS

•

Results from functional disorder of intestinal motility

(peristaltic waves  affected at specific segments of the

intestines and in the intensity at which they propel) that may

be related to:

•

Neurologic regulatory system

•

Infection or irritation

•

Vascular or metabolic disturbance

•

S/Sx: Wide variability; Range in intensity and duration from

mild and infrequent to severe and continuous

•

Primary symptom: alteration in bowel patterns: constipation,

diarrhea or a combination of both

•

Pain – often precipitated by eating and relieved by defecation

•

Bloating

•

Abdominal distention

IBS: Assessment and Diagnostics

•

Definite Dx: Tests that prove the absence of structural or other

disorders

•

Stool studies, X-ray, proctoscopy: to r/o colon diseases

•

Barium enema and colonoscopy: reveal spasm, distention, mucus

acculmulation

•

Manometry; Electromyography—study intraluminal pressure changes

generated by spasm

Medical and Nursing Management

•

Medical:

•

Relieve abdominal pain

•

Control constipation or diarrhea

•

Elimination and gradual reintroduction of foods suspected of being irritants (e.g.

caffeine; beans; fried foods; spicy foods; alcohol)

•

High-fiber diet

•

Exercise -reduces anxiety and increases intestinal motility

•

Stress reduction or behavior-modification programs

•

Anti-diarrheals (loperamide – Imodium) and hydrophilic colloids (i.e., bulk) to

control diarrhea and fecal urgency

•

Antidepressants: anxiety and depression

•

Anticholinergics and calcium channel blockers to 

↓ smooth muscle spasm

(decrease cramping and constipation

•

Nursing:

•

Reinforce good dietary habits:

•

eat at regular times; chew thoroughly

•

Avoid fluids with meals (causes distention)

•

Discourage alcohol use and smoking

Intestinal Obstruction

•

Occurs when intestinal contents cannot pass through

the GI tract –partial or complete blockage of the lumen

•

Medical emergency; Requires prompt treatment

•

If untreated, complete obstruction can cause death

within hours from shock and vascular collapse

Pathophysiology

•

Mechanical or non-mechanical blockage of the lumen

•

Fluid, air, gas collects near site

•

Peristalsis increases temporarily to break through the

blockage

•

Intestinal mucosa is injured and distention at and above

obstruction site occurs

•

Venous blood flow is impaired and normal absorptive

processes cease

•

Water, sodium, potassium secreted by bowel into fluid

pooled in the lumen

Intestinal Obstruction

•

Causes: Mechanical and non-mechanical.

•

Mechanical-occlusion of lumen. Most common in the ileum.

•

E.g. adhesions, strangulated hernias; carcinomas, volvulus (twisting

of bowel itself); intussusception (portion of bowel telescopes or

invaginates into an adjacent bowel portion)

•

Non-mechanical caused from neurologic or vascular

disorder. E.g. Paralytic ileus; electrolyte imbalances

•

Pseudo-obstruction: Looks like an mechanical

obstruction but shows no obstruction on x-rays.

•

Vascular: very rare and caused by emboli.

Etiology and Pathophysiology

•

Review daily bowel activity:

•

When obstruction occurs in pylorus metabolic alkalosis will

occur from loss of HCl. Also from use of NG tube suction.

•

Small bowel obstruction will cause dehydration and

electrolyte imbalance (if occurs proximal colon - most of the

fluids have been absorbed).

•

Solid fecal material accumulates until discomfort occurs.

•

Adhesions, hernias can cause obstructions as well.

•

Strangulation and gangrene can occur after two different

spots are obstructed.

Intestinal Obstruction

•

Clinical Manifestations:

•

Vary depending on obstructed area.

•

N & V, abdominal pain, distention, inability to

pass flatus, and obstipation

•

Assessment and Diagnostics

•

H&P, Abdominal x-rays, Barium enemas,

Upper GI series, Colonscopy, CBC,

Electrolytes, amylase, BUN; Stool tests to

check for occult blood.

Treatment

•

Decompression of Intestines with removal of gas and

fluid.

•

Maintenance of fluid;  and correction of electrolyte

imbalance.

•

Removal of obstruction.

•

NG tubes inserted, colonscopy to reduce voluvulus. IVF

and/or TPN.

•

Most mechanical obstructions are corrected surgically.

•

Nonsurgical approach is to use colonscopy to remove

polyps, dilate strictures, remove tumors or destroy

tumors via laser.

Nursing Management

•

Nursing Care:

•

NPO

•

NG tube to low-pressure, intermittent suction

•

Semi-Fowler’s position

•

Mouth and nose care

•

IV and medication therapy

•

Monitor VS; electrolytes

•

Watch for s/sx of shock

•

Monitor BS and signs of returning peristalsis

•

Monitor wound site (post-op)

•

Patient Teaching: TC & DB; ostomy care

Hemorrhoids

•

Dilated portions of veins in the anal canal

•

Very common

•

By age 50, 50% of people have hemorrhoids to some extent

•

May be internal (occurring above the internal sphincter) or external

(occurring outside the external sphincter).

•

Symptoms: bleeding, pruritus, prolapse, and pain.

Etiology & Pathophysiology

•

Thought to develop as a result of shearing forces

during defecation.

•

When straining, supporting tissues in the anal canal

weaken and the venules become dilated & blood

flow is impaired.  If the blood clots, a thrombosed

external hemorrhoid results

•

Most common cause of bleeding with defecation

•

Precipitating factors: pregnancy, prolonged

constipation, straining when having a BM, heavy

lifting, prolonged standing & sitting, portal HTN (as

found in cirrhosis).

Clinical Manifestations

•

Internal

:

•

May be asymptomatic but will have pain if they become

constricted.

•

Pain usually described as a chronic, dull aching discomfort,

particularly when the hemorrhoids have prolapsed.

•

Blood on toilet tissue when wiping

•

External:

•

Reddish-blue & seldom bleed or cause pain unless a vein

ruptures.

•

If thrombosed: become inflamed & painful.

•

S/Sxs are intermittent pain, pain on palpation, itching,

burning, bleeding noted on toilet paper when wiping.

Assessment and Diagnostics

•

Internal

: digital exam, anoscopy, or sigmoidoscopy.

•

External

: diagnosed by visual inspection & digital exam.

•

Therapy should be directed toward the causes & the client’s

symptoms.

Treatment

•

High fiber diet

•

Increased fluid intake

•

Creams

•

Suppositories

•

Impregnated pads containing anti-inflammatory

agents, astringents & anesthetics (e.g. witch hazel) to

shrink the mucous membranes and provide comfort

•

Stool softeners

•

Sitz baths

•

Ice packs followed by warm packs may provide

comfort for thrombosed external hemorrhoids

Treatment

•

Topical: shrinking the tissues with 5% phenol in oil or a

combination of quinine & urea.

•

Internal hemorrhoids: band ligation: through an anoscope

the hemorrhoid is identified & then ligated with a rubber

band.

•

Infrared coagulation where infrared or electrical current

produces local inflammation.

•

Cryotherapy where the hemorrhoid is frozen

•

Laser treatment

•

Hemorrhoidectomy when there is prolapse, excessive pain

or bleeding or large hemorrhoids.  The surgeon cauterizes,

clamps, or excises the hemorrhoids.

Nursing Management

•

Patient Teaching:

•

Constipation prevention techniques

•

Avoid prolonged standing or sitting

•

Proper use of OTC drugs

•

Seek medical care if excessive pain & bleeding occurs

•

Sitz baths for 15-20 mins 2-3 x per day for 7-10 days is helpful;

started 1-2 days postop

•

Pain can be severe: narcotics can be given initially

•

Topical preparations

•

Packing in the rectum: usually removed the first or second day

post-op

•

Provide privacy

•

Stool softeners.

Malabsorption

(

•

Impaired absorption of fats, carbohydrates, proteins, minerals, and vitamins

(especially B

12

).

•

Diseases of the small intestine are the most common cause of

malabsorption

•

Pathophysiology:

•

Mucosal (transport) disorders: celiac sprue; reginal enteritis

•

Infectious Diseases: small bowel bacterial overgrowth; tropical sprue; Whipple’s

disease (bacterial invasion of intestinal mucosa)

•

Luminal problems: bile acid deficiency; Zollinger-Ellison syndrome

•

Post-operative: following gastric or intestinal resection

•

Disorders of specific nutrients: dissacharidase deficiency leading to lactose

intolerance

•

S/SX: Diarrhea of frequent, loose bulky, foul-smelling, grayish stools with

increased fat content (steatorrhea); weakness; abdominal pain; 

↑flatus;

weight loss; decreased sense of well-being; malnutrition with s/sx of vitamin

and mineral deficiency (e.g. easy bruising; anemia; osteoporosis)

Assessment and Diagnostics

•

Stool studies: fat content

•

Lactose tolerance tests

•

Schilling test

•

Bile acid breath test: assess absorption of bile salts

•

Hydrogen breath tests-evaluate carbohydrate absorption

•

Pancreatic secretion/fuction test to test for insufficiency

•

Endoscopy of small intestine to biopsy (enzyme activity;

infection; destruction of mucosa)

•

Barium enema

•

Labs: CBC (anemia)

Medical and Nursing Management

•

Medical:

•

Avoid dietary substances that aggravate malabsorption

•

Nutrient supplementation

•

Dietary therapy (e.g.celiac sprue: reducing gluten intake)

•

Antibiotics

•

Antidiarrheals

•

Parenteral fluids to treat dehydration

•

Nursing:

•

Patient and Family teaching: diet and use of nutrient supplements;

Nutrient deficiencies– osteoporosis (calcium)

•

Monitor for fluid and electrolyte imbalances

Malabsorption Syndrome: Sprue

•

Types-nontropical and tropical kinds. Also called celiac

sprue, celiac disease, gluten-induced enteropathy.

•

Atrophy and flattening of the villi which reduces absorption

in small intestines.

•

Cause is hypersensivity response from gluten which leads to

inflammation of the mucosa.

•

Usually peaks in childhood. But can occur at anytime.

•

Signs includes-steatorrhea, diarrhea, wt loss, abdominal

distention, excessive flatulence. You might see glossitis  in

multi-vitamin deficiency

Sprue: Diagnosis and Care

•

Stool analysis and biopsy. Barium enema.

•

Care-depends on cause:

•

Nontropical – Gluten-free diet. Corticosteriods may be given when diet does

not work.

•

Tropical sprue– broad spectrum antibiotic and folic acid therapy. On

remission will remain on folic acid.

Malabsorption Syndrome: Lactose

Deficiency

•

Lactase enzyme is deficient or absent from the body.

•

S/SX:

•

Lactose intolerance, bloating, flatulence, crampy abdominal

pain, and diarrhea.

•

Usually occurs 30 minutes to several hours after ingestion.

•

Care

•

Lactose tolerence test

•

Lactose free diet

•

Lactaid OTC prior to intake of lactose containing foods.

Malabsorption Syndrome: Short

Bowel Syndrome

•

Results from resection of small intestines.

•

Rapid intestinal transit

•

Impaired digestion and absorption

•

Fluid and electrolyte loss

•

Varying symptoms: depends on the amount of colon resected

Short Bowel Syndrome:

Clinical Manifestations

and Management (Care)

•

Diarrhea and steatorrhea

•

Malnutrition – weight loss

•

Multiple vitamin and mineral deficiencies:, cobalamin and zinc deficiency,

hypocalcemia.

•

May be lactose intolerant

•

May have oxalate kidney stones

•

Care:

•

Fluid and electrolyte balance

•

Nutrient Supplementation: calcium, zinc, multivitamins. 

•

Dietary considerations; high carb/low-fat diet with soluble fiber; pectin; amino acid

glutamine; Encourage six small meals

•

Control of diarrhea – antidiarrheal agents

•

Post-op pts:

•

TPN

•

Proton pump inhibitors to decrease secretion of gastric acid.

•

Parenteral growth hormone improves nutrient absorption and decreases stool output –

helps to wean pt off of TPN

Appendicitis

Chapter 60

•

Inflammation of the appendix: most common acute

abdominal disorder

•

Appendix:

•

Finger-like appendage; 10 cm in length (4 inches)

•

Attached to cecum just below ileocecal valve

•

Fills with food and empties into cecum

•

Inefficient emptying and small lumen makes it prone to obstruction

and infection

•

Pathophysiology:-Inflammation and edema from kinking;

obstruction of the of the lumen by feces, foreign bodies,

tumor of cecum or appendix; inflamed appendix will fill with

pus.

•

Fatal if left untreated; gangrene and perforation usually

develop within 36 hours

Appendicitis

S/Sx:

•

Severe generalized or upper abdominal pain that becomes localized in the

right lower quadrant of the abdomen within a few and localizing at

McBurney’s point.

•

Low-grade fever

•

Nausea and sometimes vomiting

•

Loss of appetite

•

Local tenderness; Rebound tenderness (production or intensification of pain

when pressure is released); guarding; Pt usually laying flat often with right

leg flexed. Rovsing’s sign may be elicited when left lower quadrant is

palpated (pain is felt in RLQ).

•

Muscle spasm

•

Constipation or diarrhea may or may not be present

•

Must be cautious: Laxatives may produce perforation---never give to a

person with abdominal pain, fever, and nausea

•

Complications: Perforation, peritonitis, and abscesses.

Appendicitis

•

Dx Studies and Care:

•

H&P, physical exam, CBC (

↑

WBC), Urinalysis; X-ray; ultrasound; CT (RLQ

density or distention of the bowel)

•

Care: Surgical removal of appendix (appendectomy) under general or

spinal anesthesia (Low abdominal incision or laparsocopy).

•

If the appendix ruptures – can cause peritonitis--- antibiotic therapy,

with fluid therapy,

•

Encourage pt to seek medical attention.

•

Avoid laxatives, enemas, or analgesics until diagnosis is confirmed; Ice

bag maybe applied to decrease circulation of the RLQ—heat is

contraindicated as it may cause rupture.

•

NPO until surgery is performed; IV fluids

•

Pt placed in Fowler’s position for comfort and to decrease pain.

•

Usually ambulate the same day of surgery and will be discharged in 1 or

2 days.

Peritonitis

•

Inflammation of the peritoneum.

•

Decreased intestinal motility and causes intestinal distention

with gas

•

Usually caused by bacterial infection—bacteria coming from

diseases of the GI tract.

•

Most common bacteria: 

Escherichia coli; Klebsiella; Proteus;

Pseudomonas

•

In women, can be caused by bacteria from internal

reproductive organs

•

Can result from external sources: injury or trauma (Gunshot

wound: GSW or stab wound)

•

Can result from inflammation that extends from an organ

outside the peritoneal area (e.g. Kidney)

Peritonitis

•

S/Sx: universal sign is tenderness over the involved area.

Rebound tenderness, muscular rigidity, and spasm are other

major signs of irritation. Abdominal distention or ascities,

fever, tachycardia, tachypnea, N&V, and altered bowel

habits.

•

Complications: hypovolemic shock, septicemia,

intrabdominal abscess formation, paralytic ileus, and organ

failure.

•

Diagnostic Studies and Care:

•

CBC; X-ray; paracentesis (examines exudate/bacterial

culture); IV fluids; NG tube; NPO until function returns;

bedrest; antibiotics; analgesics.

Gastroenteritis

•

Self-limiting inflammation of the mucosa of the stomach and

small intestine. Also known as: Intestinal flu; 

traveler's

diarrhea; 

viral enteritis; food poisoning

•

S/Sx: N&V, diarrhea, abdominal cramping, and distention.

Fever, increased WBC, and blood or mucus in the stool .

•

Treatment:

•

Treat the underlying cause

•

Provide fluids after vomiting has passed; initially clear liquids and

progress as tolerated

•

Dehydration may be a problem especially in the elderly; Fluids

containing glucose and electrolytes should be given to prevent

dehydration. IV fluids to replace fluids while in hospital.

•

Most of the time hospitalization is not needed.

•

Bedrest

•

Antidiarrheals; antibiotics; anti-emetics

•

Chart 60-2

Inflammatory Bowel Disease (IBD)

•

2 chronic inflammatory GI disorders:

•

Ulcerative Colitis: inflammation & ulceration of the colon & rectum.

•

Regional Enteritis (Crohn’s Disease): affects any part of the GI tract from the

mouth to the anus; most common sites are the distal ileum and colon.

•

Both are more common in Caucasians, specifically Jewish people.

•

Most common in adolescents or young adults, but can appear any time

Causes of IBD

•

Cause: Unknown; but possible triggers are:

•

Infectious agent

•

Autoimmune reaction

•

Food allergies

•

Heredity

•

Pesticides

•

Food additives

•

Tobacco

•

Radiation

•

NSAIDs exacerbate IBD.

IBD

•

Elderly Considerations:

•

Second peak for IBD is around 55-65 yo.

•

Less inflammation with the older client

•

Disease process seems to be in the lower areas of the

intestine

•

Easier to correct via surgical resection

•

Increased morbidity with the older client because of the

increased risk of cardiovascular & pulmonary complications

•

More prone to inflammation of the colon from various

medications treating systemic vascular disease

(atherosclerosis & CHF).

•

More vulnerable to volume depletion & dehydration; may

have diminished renal & CV function.

IBD

•

S/S: VS-normal, may have low-grade temp.

•

Labs: low HCT & HGB; increased WBC.

•

Diagnostic: Colonoscopy. Barium enema to id between UC and

Chron’s.

•

Management:

•

Diarrhea

•

Chronic Pain

Diverticular Disease

•

A 

diverticulum

: a saccular

dilation or outpouching of the

mucosa through the circular

smooth muscle of the intestinal

wall.

•

Diverticulosis: 

multiple non-

inflamed diverticula (present but

asymptomatic).

•

Diverticulitis:

 inflammation of

the diverticula that begins to

cause problems.

•

Diverticula can occur at any point

within the GI tract but are most

commonly found in the sigmoid

colon.

Etiology & Pathophysiology

•

Affects 5% of population by age of 40  and 50% of

population by the age of 80 years

•

Affects both men & women

•

Asymptomatic until inflammation occurs

•

No known cause but lack of dietary fiber is associated

with it.

•

Factors contributing to diverticula formation:

•

When diverticula form, the smooth muscle of the colon wall

becomes thickened.

•

Lack of dietary fiber slows transit time, and more water is

absorbed from the stool, making it more difficult to pass

through the lumen

Etiology & Pathophysiology

•

Factors contributing to diverticula formation:

•

Decreased bulk of the stool, combined with a more

narrowed lumen in the sigmoid colon, causes high

intraluminal pressures.

•

Diverticulitis occurs r/t to the retention of stool & bacteria

in the diverticulum, forming a hardened mass called a

fecalith:

•

causes inflammation and usually small perforations

•

Inflammation of the diverticulum spreads to the surrounding area

in the intestines, causing the tissue to become edematous.

•

Abscesses may form, or complete perforation with peritonitis may

occur.

Clinical Manifestations

•

S/Sx:

•

If present, usually crampy abdominal pain located in the left

lower quadrant that is usually relieved by passage of flatus or

bowel movement.

•

Alternating constipation & diarrhea may be present.

•

Approx 15% progress to acute diverticulitis:

•

Tenderness & pain: localized over the involved area of the colon (usu

lower left quadrant) & mass may be felt.

•

Other s/sxs: fever, chills, nausea, anorexia, & elevated WBC.

•

Elderly: may not be febrile, may have a normal WBC, and may not have

abdominal tenderness.

Diverticular Disease

•

Complications:

•

Perforation with peritonitis

•

Abscess & fistula formation

•

Bowel obstruction

•

Ureteral obstruction

•

Bleeding -  common complication of diverticulitis;

manifested by hematochezia (maroon stools).

•

Diagnostics:

•

CT scan with oral contrast; Colonoscopy; sigmoidoscopy

(not usually performed in the acute phase)

•

CBC, UA, & fecal occult blood test.

Medical &

Nursing Management

•

Medical and Nursing Management:

Uncomplicated diverticular disease

:

•

A high fiber diet

•

Bulk laxatives such as psyllium hydrophilic mucilloid

(Metamucil).

•

Anticholinergic drugs such as Bentyl and Donnatal: used

to relieve discomfort from spasm of the bowel.

•

Increase fluids

•

Weight reduction,

•

Avoid straining to pass stool

•

Avoid vomiting, bending, lifting, and tight, restrictive

clothing.

TX &

Nursing Management

•

Acute diverticulitis

•

Allow the colon to rest and the inflammation to subside.

•

NPO

•

Bed rest

•

IVF’s

•

NG tube for decompression

•

Antibiotics

•

Monitor VS, WBC and observe for peritonitis.

•

When acute inflammation subsides:

•

Begin oral liquids and advance diet as tolerated.

•

Encourage ambulation

•

Observe for recurrent attack.

•

Approx 30% of clients with acute diverticulitis require surgery:

•

Colon resection with temporary colostomy is the usual surgery.

Cirrhosis

•

Chronic, progressive liver disease.

•

Irreversible reaction to hepatic inflammation & necrosis

•

Primary Causes:

•

ETOH: causes liver inflammation (alcoholic hepatitis) & enlargement leading to scar tissue

as a result of cellular necrosis: Laennec’s or alcoholic cirrhosis

•

Viral Hepatitis

•

Drugs & Toxins

•

OTC, Illicit, prescriptive, herbal supplements, mushrooms, exposure to environmental

toxins

•

Cardiovascular Disease

•

R-sided CHF (leads to enlarged/congested liver)

•

Biliary Disease

•

Chronic biliary obstruction, bile stasis leading to severe obstructive jaundice.

•

Various Metabolic & genetic disorders

Cirrhosis

•

Complications of Cirrhosis:

•

Portal HPTN- increased pressure in portal vein leading to spenomegaly

•

Ascites: free fluid in the peritoneal cavity. Increased abdominal girth

•

Bleeding Esophageal Varices:: esophageal veins  rupture

•

Coagulation Defects: decreased bile fats prevent absorption of fat-soluable

vitamins. PT bruises and bleeds easily.

•

Jaundice: due to liver’s inability to excrete bilirubin.

•

Hepatic Encephalopathy & hepatic coma: End stage liver failure. Altered LOC

•

S/S:weakness, fatigue, wt loss or gain, GI symptoms, abd pain, jaundice of skin &

sclerae, dry skin, rashes, pruritus,  hepatomegaly. Protruding umbilicus, fruit-musty

breath odor, asterixiis (Liver flap rapid tremor  with extension and flexion of wrist

and fingers), decreased serum protein & albumin, increased PT, increased Ammonia

levels,  elevated AST/ALT, enlarged liver.

•

Fig. 61-1

Care Management : Cirrhosis:

•

Low Na diet, No salt

•

Restrict fluids to 1000-1500 Ml/day if serum Na falls

•

Supplement with thiamine and folate

•

Diuretics, I&), daily wts, abdominal girth daily, elevate HOB.

•

Interventions: Chart 61-2 & 61-3

•

Concept Map: Chapter 61 pg 1351

Renal/ Urinary System

•

Urine Tests:  Chart 68-4

•

Urine Specimen Collection

•

Know table 68-4

•

Collect in am at first voiding

•

Catheterized speciman (straight cath)

•

24 Hour Urine Collection

•

Clean Catch: pt self-cleans prior to voiding.

•

Pt voids, then stops, then voids into container (30 mL).  --this is a mid-stream collection

Key points to remember

•

Clients with urinary disorders commonly have fluid and

electrolyte imbalances and must be monitored for

potential problems.

•

The fluid intake and output record is a key tool to

document all fluid taken in orally and parenterally, as

well as, the amount of fluid excreted and lost via

diarrhea, vomiting, and diaphoresis.

•

This record and the daily weight are essential for

determining the signs of fluid deficit or overload.

•

Alert: A 1kg weight gain = 1000cc of retained fluid.

Dysfunctional voiding patterns

review

•

Urinary incontinence

•

Stress incontinence

•

Urge incontinence

•

Reflex incontinence-is the involuntary loss of urine due to

hyper-reflexia in the absence of normal sensations usually

associated with voiding.

•

Overflow incontinence/residual urine

•

Functional incontinence: ex Alzheimer

•

Permanent causes

•

risk factors

•

Table 69-3

Geriatric considerations

•

Older adults can experience episodes of incontinence abruptly. When

this occurs, the nurse should question the patient or family.

•

Reasons: acute urinary infections, infection elsewhere in the body,

constipation, decreased fluid intake, a change in a chronic disease

pattern such as inc in blood glucose levels in diabetics, or 

dec estrogen

levels

, however, age ALONE is not a risk factor for incontinence.

Adult voiding dysfunction

   Neurogenic and non neurogenic disorders can cause adult voiding

problems. If this condition goes undetected and untreated upper

urinary system may be compromised. Chronic incomplete bladder

emptying from poor detrusor pressure results in recurrent bladder

infection. Incomplete bladder emptying related to BPH results in

kidney problems.

Behavioral interventions for urinary

incontinence

•

Fluid management

•

Standardized voiding frequency

•

Pelvic muscle exercises

Urinary retention

•

The inability to empty the bladder completely during attempts to

void. In a healthy adult, complete bladder emptying should occur

with each voiding. In adults older than 60, 50-100cc of residual urine

may remain after each void because of decreased contractility of the

detrusor muscle. It can also occur post op due to anesthetics.

Etiology

•

Medical conditions- DM, prostate enlargement, urethral pathology,

infection, tumor, calculus, trauma, pregnancy, CVA, spinal cord

injuries, MS and Parkinson’s disease.

•

Medications- inhibit bladder contractility=atropine, Bentyl,

antispasmodics, opioids, tricyclic antidepressants.

Urinary retention cont’d

•

Medications that increase bladder outlet resistance include:

Sudafed, Inderal, and estrogens.

•

Assessment and diagnostic findings

this can be done by client keeping a diary, post void residual,

ultrasound over bladder, also can palpate for bladder distention.

Urinary retention cont’d

•

Complications can lead to chronic infections. These can lead to

calculi, pyleonephritis, and sepsis. In addition skin breakdown and

kidney deterioration may occur.

Nursing management

•

Promoting normal urinary elimination-nursing measures to

encourage urine elimination are:

provide privacy, ensuring an environment and a position conducive to

voiding and assisting the client. Additional measures are: to use

warm compresses to perineum, sitz baths, reassurance, turning on

the faucet or letting client put their hands under warm running

water.

Urinary elimination continued

•

In the case of prostatic obstruction,when a catheter cannot be

passed. A suprapubic catheter is inserted.

•

In the home environment- no throw rugs, or other barriers should be

removed. Support bars in the bathroom, as well as a light. Wearing

clothing that is easy to remove, or placing a bedpan or urinal within

easy reach. If all else fails a Texas or condom cath can be used.

Catheterizations

•

Purposes:

•

Relieve urinary tract obstruction

•

Assist with post op drainage in urologic/ other surgeries

•

Provide a means to monitor accurate urine output in critically

ill patients

•

Promote urinary drainage in patients with neurogenic or

retention bladder problems

•

Prevent urinary leakage in pts who have stage III or IV pressure

ulcers.

•

NOTE a pt should be cathed only if necessary due to UTIs and

other complications such as bladder spasms, urethral strictures

and pressure necrosis.

Urinary tract infections

•

UTIs are the most commonly occurring nosocomial infections

accounting for 40% of infections. In patient nosocomial account for

80% of infections in patients who have catheters.

•

Pathogens responsible are: E-coli, Klebsiella, Proteus, Pseudomonas,

Enterobacter, Serratia, and Candida species. Many of these organisms

are part of normal bowel flora.

Infections cont’d

•

Catheters impede natural defenses of the body. They obstruct the

periurethral ducts, irritate the bladder mucosa, and enable organisms

to migrate along the epithelial surface of the urethra or external

surface of the catheter. The spout can become contaminated and

bacteria multiply rapidly and migrate up the tube and into the

bladder. They also colonize the internal surfaces and drainage

systems.

Suprapubic catheters

•

This allows the bladder to drain by making an incision above the

pubis and inserting a catheter which extends out of the lower

abdomen.

•

Reasons: for temporary diversion, due to injuries, strictures, prostatic

obstruction, sometimes after pelvic fractures, and after a Marshall-

Marchetti procedure.

Suprapubic cont’d

•

This type of drainage can be continued for weeks. It is

advantageous when the patient’s ability to void is being

tested. It reduces the straight cath for residual. When it

remains in place indefinitely, it is changed q 6-12 weeks.

•

This type catheter also allows greater mobility and less

risk for bladder infections. The patient requires liberal

amounts of fluid to prevent encrustation around the

catheter. Also another problem is formation of

stones,as well as, acute and chronic infections.

High risk patients for UTI

•

The elderly, women, and patients who are debilitated, malnourished,

chronically ill, immunosuppressed, or diabetic.

•

S/S of infection with indwelling catheter are similar to UTI:

cloudy foul smelling urine, hematuria,  

fever, chills,

anorexia, and malaise.

Urine cultures provide the most accurate means of assessing a patient

for infection.

A note about elderly

•

They do not always  exhibit the routine S/S of infection. Any change in

their mentation,or physical condition, such as, sleeping more, not

eating well, urinary incontinence where there was none before, ANY

change should be checked out for UTI.

•

Preventing infection-anchor,gentle washing, liberal fluid intake, periodic

urine cultures. There is controversy about treating bacteriuria in pts with

indwelling catheters.

Routes of infection

•

There are 3 routes by which bacteria enter the urinary tract:

•

Ascend the urethra

•

Through the bloodstream

•

By means of a fistula from the intestine

Clinical manifestations

•

About ½ of clients have no symptoms.

•

S/S uncomplicated cystitis(bladder inflammation) include frequent

pain and burning on urination, frequency, urgency, nocturia,

incontinence, suprapubic or pelvic pain, bladder spasms, and

perineal aching or fullness.  Hematuria and back pain may also be

present. In the elderly these symptoms are seldom noted. They may

complain of severe tiredness or no appetite.

Assessment

•

Cultures, colony counts, cellular studies, multi-strip dipstick methods

are all used to discover UTIs.

•

The dipstick tests for WBC known as the leukocyte esterase test, and

nitrite testing are common and quick and less expensive. If the

leukocyte esterase test is positive it is assumed the pt has pyuria and

should be treated. The Griess nitrate reduction test is positive if

bacteria reduce the normal urinary nitrates to nitrites. Also tests for

STDs can be done since some of the symptoms of vaginal infections

are similar to UTIs.

•

Other tests are IVP, CT scan, or ultrasonography, or transrectal

ultrasonography to assess prostate/ bladder problems.

Medical management

•

Involves meds and patient teaching. The nurse is usually responsible

for the teaching.

•

There is controversy about treating asymptomatic bacteriuria in the

institutionalized elderly b/c of antibiotic resistant organisms and

sepsis. Most experts now recommend withholding antibiotics until

symptoms develop. However this is the problem that the elderly do

not always have any symptoms until they become really ill.

Acute pharm therapy

•

The ideal treatment of UTI is an antibacterial agent that eradicates

bacteria from the urinary tract with minimal effects on fecal and

vaginal flora, thereby cutting down on yeast infections. The med

should be affordable, and produce few adverse effects. In

uncomplicated UTIs there is single dose administration, short course

or 7-10 days courses. 80% are cured after 3 days of treatment.

Pharmacology continued

•

Patients in institutional settings usually require 7-10

days of therapy.

•

Commonly used meds are: Ampicillin, Cephalosporin,

Bactrim, Septra, and Macrodantin. 

The E-coli organism

has become resistant to Ampicillin and Amoxicillin, so

Cipro has been found to be more effective in

community based patients.

•

Levaquin is another good choice for short term therapy

of uncomplicated mild to moderate UTI. Clinical trials

show high adherence rates and 96.4% eradication rate

when using Levaquin.

Pharmacology cont’d

•

The Furadantoins should not be used in patients with renal

insufficiency b/c it may cause peripheral neuropathy.

•

Pyridium is a urinary analgesic to relieve discomfort.

•

In pregnant women Ampicillin and Amoxicillin or Cephalosporin is

used for 7-10 days.

•

Usually after the antibiotic is finished, a week later the patient needs

to have another urine done to check, even though the symptoms

may have disappeared.

•

NOTE: a patient on a sulfa drug needs to drink fluids so the sulfa

crystals do not accumulate in the kidney.

Normal dosages

•

Ampicillin 250-500mg q6 hr

•

Amoxicillin 250-500mg q8 hr.or 875mg bid

•

Cephalosporin- Ancef 250-500mg IM or IV q6-12h.

•

Bactrim, Septra 80 mg TMP(trimethoprim and

400mg sulfamethoxazole q12h.

Ciprofloxacin-100-250 q12 hr for 3 days or 500mg x3

days.

Macrodantin-50-100mg qid for 10-14 days.

Levaquin 500mg daily

Long term

•

Although 3 day treatment is adequate in most of female

population about 20% have recurring infection.

Infections which occur within 2 weeks of therapy are

caused by bacteria which remained in the vagina. Some

re-infection is related to new bacteria. Some patients

have standing orders to begin therapy at the first signs

of UTI. Usually with these patients low dose

antimicrobial agents are indicated for a maintenance

dose at night.

•

The effectiveness of cranberry juice is controversial.

Gerontologic considerations

•

Bacteriuria increases with age and disability.

•

Women more than men

•

Gram neg sepsis carries a mortality of over 50% in patients over 65.

•

Structural abnormalities and neurogenic bladder secondary to CVAs

or autonomic neuropathy of diabetes may prevent complete

emptying of bladder.

Gerontologic cont’d

•

Post menopausal women lacking estrogen, they are at increase risk

to colonization and increased adherence of bacteria to vagina and

urethra. Tx: oral or topical estrogen has been used to restore the

glycogen content of vaginal epithelial cells and an acidic pH for some

postmenopausal women with recurrent cystitis.

Gerontologic cont’d

•

In men the antibacterial activity of prostatic secretions

that protects men from bacterial colonization of the

urethra and bladder decreases with age. Over 50 in men

approaches that of women of the same age.

•

In men UTI is due largely to prostatic hyperplasia, or

carcinoma, strictures of the urethra, and neuropathic

bladder. The incidence of UTIs also rises in men with

confusion, dementia, or bowel or bladder incontinence.

The MOST common cause of bacterial UTI in the elderly

male is chronic bacterial prostatitis.

Factors in nursing homes

•

High incidence of chronic illness

•

Frequent use of antimicrobial agents

•

Presence of infected pressure ulcers

•

Immobility and incomplete emptying of bladder

•

Use of bedpan rather than a commode of toilet.

Symptoms

in elderly

•

Generalized fatigue, a change in cognitive functioning, especially in

those with dementia, because these patients exhibit even more

profound cognitive changes with the onset of a UTI.

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