Digestive Tract Disorders

Digestive Tract Disorders
Chapter 38 Digestive Tract Disorders 1

Learning Objectives Identify the nursing responsibilities in the care of patients undergoing diagnostic tests and procedures for disorders of the digestive tract. List the data to be included in the nursing assessment of the patient with a digestive disorder. Describe the nursing care of patients with gastrointestinal intubation and decompression, tube feedings, total parenteral nutrition, digestive tract surgery, and drug therapy for digestive disorders. Describe the pathophysiology, signs and symptoms, complications, and medical treatment of selected digestive disorders. Assist in developing nursing care plans for patients receiving treatment for digestive disorders.

Anatomy and Physiology of the Digestive Tract
Mouth Where teeth, tongue, and salivary glands begin food digestion Pharynx Muscular structure shared by the digestive and respiratory tracts It joins the mouth and nasal passages to the esophagus Esophagus Long muscular tube that passes through the diaphragm into the stomach Stomach Churns and mixes food with gastric secretions until a semiliquid mass called chyme The digestive tract is also called the gastrointestinal tract (or GI tract) and the alimentary tract. How long is the digestive tract? As the teeth cut and grind the food, the salivary glands secrete saliva, a watery solution that contains amylase (ptyalin). Gravity helps but is not essential for the movement of food through the esophagus. The stomach is not very large when empty, but it expands considerably when food is present. 3

Small intestine Chemical digestion and absorption of nutrients take place Approximately 20 feet long and consists of three sections: the duodenum, the jejunum, and the ileum Liver and pancreatic secretions enter the digestive tract in the duodenum What are the three layers of the walls of the small intestine? Digested food molecules are absorbed through the villi into the bloodstream. Muscle layers contract to continue mixing the chyme, moving it toward the large intestine. 4

Large intestine and anus The first section of the large intestine is the cecum Ascending colon goes up right side of the abdomen Transverse colon crosses abdomen just below waist Descending colon goes down left side of abdomen The last 6 to 8 inches of the large intestine is the rectum, which ends at the anus, where wastes leave the body What is the purpose of the sphincters in the anus? Unlike the small intestine, the large intestine has no villi and secretes no digestive enzymes. Its function is to absorb water from the chyme and eliminate the remaining solid wastes in the form of feces. 5

Figure 38-1 6

Age-Related Changes Teeth are mechanically worn down with age
The jaw may be affected by osteoarthritis A significant loss of taste buds with age Xerostomia (dry mouth) is common Walls of esophagus and stomach thin with aging, and secretions lessen Production of hydrochloric acid and digestive enzymes decreases Gastric motor activity slows Movement of contents through the colon is slower Anal sphincter tone and strength decrease 7

Health History Chief complaint and history of present illness
A detailed description of the present illness Complaints include weight changes, problems with food ingestion, symptoms of digestive disturbances, or changes in bowel elimination 8

Health History Past medical history
Recent surgery, trauma, burns, or infections Serious illnesses, such as diabetes, hepatitis, anemia, peptic ulcers, gallbladder disease, and cancer Alternative methods of feeding or fecal diversion Prescription and over-the-counter medications Food allergy or intolerance 9

Health History Review of systems
Description of the patient’s general health state Changes in skin: dryness, bruising, and pruritus Whether the patient has any mouth problems Document if the patient has dentures, partial plates, or natural teeth, and record the last dental examination Problems with chewing or swallowing Changes in appetite, food intake, and weight Nausea, vomiting, dyspepsia, heartburn, flatus, abdominal distention, or pain Assessment of elimination 10

Health History Functional assessment
Information about general dietary habits should include the daily pattern of food intake Attitudes and beliefs about food, and changes in dietary habits related to health problems Effects of chief complaint on usual functioning Note whether the patient is able to obtain and prepare food, and eat independently 11

Physical Examination Head and neck Abdomen Rectum and anus
Inspect the mouth Abdomen Inspection Auscultation Percussion Palpation Rectum and anus Palpate for lumps and tenderness in the rectum Describe caries, moisture, color, and lesions. Note any unpleasant or unusual odors of the mouth. What are the four quadrants of the abdomen? 12

Figure 38-2 13

Diagnostic Tests and Procedures
Radiographic studies Upper gastrointestinal (UGI or GI) series Small bowel series Barium enema examination 14

Endoscopic examinations Upper GI Esophagoscopy, gastroscopy, gastroduodenoscopy, esophagogastroduodenoscopy, endoscopic retrograde cholangiography Lower GI Colonoscopy, proctoscopy, and sigmoidoscopy 15

Laboratory studies Gastric analysis Occult blood test Stool examination 16

Figure 38-3 17

Figure 38-4 18

Therapeutic Measures 19

Gastrointestinal Intubation
Tube feedings Delivered by gravity flow or by infusion pump Gastrointestinal decompression For the relief or prevention of distention Levin and gastric sump tubes Tubes that are passed through the nose are called nasogastric, nasoduodenal, or nasoenteric tubes, depending on whether the end is located in the stomach or the small intestine. What is a levin and a gastric sump tube used for? Gastrostomy tube? Dobbhoff tube? Nasoenteric tubes used for decompression of the small intestine include the Miller-Abbott, Cantor, and Harris tubes. 20

Total Parenteral Nutrition
Bypasses digestive tract by delivering nutrients directly to the bloodstream Patients who are unable to eat or swallow normally may have feeding tubes inserted. Feedings may be delivered by gravity flow or by infusion pump. How often should a the tubing and bag be changed when using a feeding pump? 21

Figure 38-5 22

Figure 38-6 23

Figure 38-7 24

Figure 38-9 25

Gastrointestinal Surgery
Preoperative nursing care The digestive tract is usually cleansed Magnesium citrate or large-volume cathartic (laxative) solutions; enemas Diet limited to liquids 24 hours before surgery Intravenous fluids Oral antibiotics Nasogastric tube inserted and attached to suction Changes in vital signs (abnormal heart rate or rhythm, hypotension) or mental state during the bowel cleansing process should be reported to the physician. Why are oral antibiotics give before surgery? 26

Gastrointestinal Surgery
Postoperative nursing care Be sure gastrointestinal suction is draining Inspect, describe, and measure the drainage Abdomen for distention and bowel sounds Administer intravenous fluids Keep strict intake and output records Drug therapy Emetics, antiemetics, laxatives, cathartics, antidiarrheals, antacids, anticholinergics, mucosal barriers, histamine-2 (H2)-receptor blockers, prostaglandins, and antibiotics 27

Disorders of the Digestive Tract
28

Anorexia Causes Nausea, decreased sense of taste or smell, mouth disorders, and medications Emotional problems such as anxiety, depression, or disturbing thoughts Unpleasant odors or sights can quickly dampen a patient’s enthusiasm for a meal. What factors may cause a decreased appetite in the older adult? 29

Anorexia Medical diagnosis Physician assesses for malnutrition
Weight may be monitored over several weeks Complete history and physical examination Serum hemoglobin, iron, total iron-binding capacity, transferrin, calcium, folate, B12, zinc Thyroid function tests 30

Anorexia Medical treatment
Correctable causes of anorexia are treated, but sometimes no physical cause is found Nutritional supplements 31

Anorexia Assessment Record chronic and recent illnesses, hospitalizations, medications, and allergies Female patient’s obstetric history Symptoms: pain, nausea, dyspnea, extreme fatigue The functional assessment reveals patterns of activity and rest, usual dietary patterns, current stressors, and coping strategies—all can affect appetite What signs of malnutrition should be noted during the physical assessment? It is very important to have the patient remove the dentures before the gums are assessed. 32

Anorexia Interventions Assist with oral hygiene before and after meals
Teach proper oral hygiene; refer for dental care Relieve nausea before presenting a meal tray Before serving meal tray, remove bedpans/emesis basins from sight, conceal drains and drainage collection devices, deodorize room if necessary Socialization during mealtime Respect food likes and dislikes Position patient comfortably with easy access to food Poorly fitting dentures need to be relined for a tighter fit or to be replaced. 33

Feeding Problems Patients with paralysis, arthritis, neuromuscular disorders, confusion, weakness, or visual impairment are likely to need assistance Medical diagnosis and treatment Identifying problems, prescribing treatment Patients often referred to physical therapy and occupational therapy 34

Feeding Problems Assessment Assess each patient’s ability to feed self
Determine nature of patient’s difficulty and identify remaining abilities Assess visual acuity, range of motion and muscle strength in both arms, and range of motion and grip strength in both hands; ability to follow instructions 35

Feeding Problems Interventions
Proper positioning and arrangement of the meal tray Provide assistive devices Open milk cartons, cut meat, butter bread, and season food What points should be remembered when feeding a patient? 36

Stomatitis A general term for inflammation of the oral mucosa
Medical treatment is directed toward determining the cause and eliminating it; a soft, bland diet may be ordered What factors may cause stomatitis? If specific pathogenic organisms are identified, appropriate antibiotics (usually topical) or antiviral agents may be prescribed. A soft, bland diet may be ordered. 37

Vincent’s Infection Bacterial infection that causes a metallic taste and bleeding ulcers in the mouth, foul breath, and increased salivation Topical antibiotics and mouthwashes to treat infection; rest, a nutritious diet, and good oral hygiene Why has Vincent’s infection been called trench mouth? The patient also may have signs of a general infection, such as fever, enlarged lymph nodes, and anorexia. 38

Herpes Simplex Caused by the herpes simplex virus, type 1
Ulcers and vesicles in mouth and on lips Occur with upper respiratory tract infections, excessive sun exposure, or stress Spirits of camphor, topical steroids, and antiviral agents as treatment 39

Aphthous Stomatitis (“Canker Sore”)
May be caused by a virus Characterized by ulcers of the lips and mouth that recur at intervals Topical or systemic steroids may be used 40

Candida albicans Yeastlike fungus causes the oral condition known as thrush or candidiasis Bluish white lesions on the mucous membranes Patients at high risk include those on steroid or long-term antibiotic therapy Treated with oral or topical antifungal agents; vaginal nystatin tablets can be used like lozenges and allowed to dissolve in the mouth 41

Nursing Care Assessment
Pain location, onset, and precipitating factors Record any known illnesses and treatments, including drugs and radiation therapy Describe habits, including diet, oral care practices, alcohol intake, and use of tobacco Assess patient’s stress level Inspect lips and oral cavity for redness, swelling, and lesions 42

Nursing Care Interventions Gentle oral hygiene, prescribed mouthwashes
The teeth and tongue can be cleansed with a soft-bristle toothbrush, sponge, or cotton-tipped applicator Medications must be given as ordered Instead of just swallowing the medication, the patient may need to swish liquid medication in the mouth or to permit tablets to dissolve in the mouth. What important teaching should the patient receive regarding oral care? 43

Dental Caries A destructive process of tooth decay
The only treatment for dental caries is removal of the decayed part of the tooth, followed by filling the cavity with a restorative material Dental decay starts with the presence of plaque on the teeth. Plaque is a substance made up of bacteria, saliva, and cells that sticks to the surface of the teeth. How can tooth decay be prevented? 44

Periodontal Disease Begins with gingivitis; progresses to involve the other structures that support the teeth Gums red, swollen, painful, and bleed easily Primarily from inadequate oral hygiene Treatment in early stage: dental care for teeth cleaning and correction of contributing problems Untreated, abscesses develop around the roots, the teeth loosen, and extraction is necessary 45

Figure 38-10 46

Nursing Care Assessment Observe condition of teeth and gums
Document missing or broken teeth, caries, redness or lesions of the gums, and gum recession 47

Nursing Care Interventions
Most patients are treated for dental and gum conditions in dentists’ offices Interventions directed at minimizing pain until the problem can be corrected by a dentist Provide oral care for patients who cannot do it themselves 48

Oral Cancer Squamous cell carcinoma and basal cell carcinoma
Risk factors Cancer of the lip related to prolonged exposure to irritants, including sun, wind, and pipe smoking Factors that increase the risk of cancers inside the mouth include tobacco and alcohol use, poor nutritional status, and chronic irritation Squamous cell carcinomas occur on the lips, buccal mucosa, gums, floor of the mouth, tonsils, and tongue. What is the most common site for basal cell carcinoma? 49

Oral Cancer Signs and symptoms
Tongue irritation, loose teeth, and pain in the tongue or ear Malignant lesions may appear as ulcerations, thickened or rough areas, or sore spots Leukoplakia: hard, white patches in the mouth; premalignant 50

Oral Cancer Medical diagnosis and treatment
A biopsy of suspicious lesions Treatment includes surgery, radiation, or chemotherapy, or a combination of these Grafts are sometimes needed to close large defects caused by the surgical procedures. What donor site may be used for a graft? 51

Oral Cancer Assessment
History of prolonged sun exposure, tobacco use, or alcohol consumption Assess for difficulty swallowing or chewing, decreased appetite, weight loss, change in ﬁt of dentures, and hemoptysis The physical examination should focus on examination of the mouth for lesions Assess the neck for limitation of movement and enlarged lymph nodes 52

Figure 38-11 53

Oral Cancer Interventions Impaired Oral Mucous Membrane
Ineffective Breathing Pattern Pain Imbalanced Nutrition: Less Than Body Requirements Impaired Verbal Communication Disturbed Body Image Risk for Infection Ineffective Tissue Perfusion 54

Parotitis Inflammation of the parotid glands
Causes painful swelling of the salivary glands below the ear next to the lower jaw; pain increases during eating Treated with antibiotics, mouthwashes, and warm compresses; surgical drainage or removal may be necessary Parotitis may develop in patients who are unable to take oral liquids for a long time, especially if their oral hygiene is poor. How can parotitis be prevented in susceptible patients? 55

Achalasia Progressively worsening dysphagia
Failure of the lower esophageal muscles and sphincter to relax during swallowing Thought to be a neuromuscular defect affecting the esophageal muscles Treatment includes drug therapy, dilation, and surgical measures What is the main complication with esophageal dilation? The patient can eliminate foods that seem to cause problems, find the eating position that works best, and avoid restrictive clothing. Elevating the head of the bed at night helps control esophageal reflux. 56

Esophageal Cancer Pathophysiology Signs and symptoms
No known cause, but predisposing factors are cigarette smoking, excessive alcohol intake, chronic trauma, poor oral hygiene, and eating spicy foods Signs and symptoms Progressive dysphagia What is the prognosis for esophageal cancer? Most esophageal cancers are located in the middle or lower portion of the esophagus. 57

Esophageal Cancer Medical diagnosis Medical and surgical treatment
Barium swallow, computed tomography, esophagoscopy, and endoscopic ultrasonography Medical and surgical treatment Surgery, radiation, chemotherapy, or various combinations General physical appearance and height and weight are important aspects of the physical examination. What information about dysphagia is important to assess? 58

Figure 38-12 59

Esophageal Cancer Assessment Dysphagia, pain, and choking
Hoarseness, cough, anorexia, weight loss, and regurgitation The functional assessment documents the use of alcohol and tobacco and dietary practices 60

Esophageal Cancer Interventions Pain
Imbalanced Nutrition: Less Than Body Requirements Anxiety Risk for Injury Impaired Gas Exchange Deficient Knowledge 61

Nausea and Vomiting Nausea: sometimes referred to as queasiness
Vomiting: forceful expulsion of stomach contents through the mouth Complications Significant losses of fluids and electrolytes Aspiration Medical treatment Antiemetics Intravenous fluids Oral fluids may be limited to clear liquids or withheld Nasogastric tube What factors may cause nausea and vomiting? Very forceful ejection of stomach contents is called projectile vomiting. Regurgitation is the gentle ejection of food or fluid without nausea or retching. 62

Nausea and Vomiting Assessment
Onset, frequency, and duration of present illness Conditions under which nausea and vomiting occur Amount, color, odor, and contents of the vomitus Surgeries, chronic illnesses, allergies, and medications General appearance; record vital signs, height/weight Assess pulse and blood pressure, tissue turgor, mental status, and muscle tone Inspect, auscultate, and palpate the abdomen for distention, bowel sounds, and tenderness 63

Nausea and Vomiting Interventions
Imbalanced Nutrition and Deficient Fluid Volume Risk for Aspiration 64

Hiatal Hernia Pathophysiology Causes
Protrusion of lower esophagus and stomach up through the diaphragm and into the chest Causes Weakness of diaphragm muscles where esophagus and stomach join, but exact cause is not known Factors are excessive intra-abdominal pressure, trauma, and long-term bed rest in a reclining position What are possible complications of a hiatal hernia? Hiatal hernia develops in about half of all people older than 60 years of age. 65

Hiatal Hernia Signs and symptoms
Many people have no symptoms at all; others report feelings of fullness, dysphagia, eructation, regurgitation, and heartburn Heartburn is a feeling of burning and tightness rising from the lower sternum to the throat. What may trigger the symptoms of heartburn? 66

Figure 38-13 67

Hiatal Hernia Medical diagnosis Medical treatment
Barium swallow examination with fluoroscopy Esophagoscopy Esophageal manometry Medical treatment Drug therapy, diet, and measures to avoid increased intra-abdominal pressure Surgery: fundoplication and placement of the synthetic Angelchik prosthesis Drug therapy includes antacids and, sometimes, drugs such as H2-receptor blockers (e.g., ranitidine [Zantac]) or proton pump inhibitors (e.g., omeprazole [Prilosec]) to reduce gastric acid secretion. When would surgery be necessary for a hiatal hernia? 68

Figure 38-14 69

Figure 38-15 70

Hiatal Hernia Assessment Interventions Document symptoms
Record factors that trigger symptoms as well as measures that aggravate or relieve them Patient’s dietary habits, use of alcohol and tobacco, and medication history Interventions Chronic Pain Risk for Aspiration Imbalanced Nutrition: Less Than Body Requirements 71

Hiatal Hernia Postoperative care Turning, coughing, and deep breathing
Patient might have nasogastric tube in place and connected to suction for a day or two Until bowel function returns, the patient is given only intravenous fluids Tell the patient to expect mild dysphagia for several weeks 72

GERD Backward flow of gastric contents from the stomach into the esophagus Pathophysiology Abnormalities around the LES, gastric or duodenal ulcer, gastric or esophageal surgery, prolonged vomiting, and prolonged gastric intubation Eventually causes esophagitis Signs and symptoms Painful burning sensation that moves up and down, commonly occurs after meals, and is relieved by antacids Acid regurgitation, intermittent dysphagia, and belching are common. When are symptoms likely to occur? 73

GERD Medical diagnosis Medical treatment and nursing care
Suggested by the signs and symptoms Endoscopy, biopsy, gastric analysis, esophageal manometry, 24-hour monitoring of esophageal pH, and acid perfusion tests Medical treatment and nursing care Like those described earlier for hiatal hernia Drug therapy may include H2-receptor blockers, prokinetic agents, and proton pump inhibitors If medical care unsuccessful, surgical fundoplication 74

Gastritis Pathophysiology Signs and symptoms
Inflammation of the lining of the stomach Mucosal barrier that normally protects the stomach from autodigestion breaks down Hydrochloric acid, histamine, and pepsin cause tissue edema, increased capillary permeability, possible hemorrhage Helicobacter pylori thought to be prime culprit Signs and symptoms Nausea, vomiting, anorexia, a feeling of fullness, and pain in the stomach area Gastritis is commonly classified as acute, chronic type A, and chronic type B. What may occur with a lack of intrinsic factor? 75

Gastritis Medical diagnosis Gastroscopy
Laboratory studies to detect occult blood in the feces, low blood hemoglobin and hematocrit, and low serum gastrin levels; H. pylori can be confirmed by breath, urine, stool, or serum tests, or by gastric tissue biopsy 76

Gastritis Medical treatment
Oral fluids and foods withheld until the acute symptoms subside; IV fluids administered Medications to reduce gastric acidity and relieve nausea Analgesics for pain relief and antibiotics for H. pylori Surgical intervention may be needed 77

Gastritis Assessment Patient’s present illness
Pain, indigestion, nausea, and vomiting Determine the onset, duration, and location of pain Note factors that trigger or relieve the symptoms Diet, use of alcohol and tobacco, activity/rest patterns Patient’s general appearance for signs of distress Compare vital signs, height, weight to previous readings Note the skin color and check turgor Inspect abdomen for distention; palpate for tenderness Auscultate abdomen for increased bowel sounds 78

Gastritis Interventions Pain
Imbalanced Nutrition: Less Than Body Requirements Deficient Fluid Volume Ineffective Coping 79

Peptic Ulcer Pathophysiology Causes
Loss of tissue from lining of the digestive tract Classified as gastric or duodenal Causes Contributing factors: drugs, infection, stress Most ulcers are caused by the microorganism H. pylori What substances in the stomach cause injury when there is no mucous barrier? Peptic ulcers are classified as gastric or duodenal, depending on their location. Gastric ulcers occur most often in men and in older adults. 80

Peptic Ulcer Signs and symptoms Complications Burning pain
Nausea, anorexia, weight loss Complications Hemorrhage, perforation, or pyloric obstruction When does the pain of a peptic ulcer usually occur? Intractability is the term used to describe symptomatic peptic ulcer disease that does not respond to treatment. 81

Peptic Ulcer Medical diagnosis Medical treatment
Barium swallow examination, gastroscopy, and esophagogastroduodenoscopy H. pylori can be detected by antibodies in the blood or stool, and by a breath test Medical treatment Drug therapy Diet therapy Managing complications Drug therapy is intended to relieve symptoms, heal the ulcer, cure H. pylori infections, and/or prevent recurrence. The current approach is to permit the patient almost any foods that do not produce discomfort. What foods commonly stimulate gastric acid secretion? Complications may be treated medically or surgically. If hemorrhage is suspected, a nasogastric tube is inserted and attached to suction to remove and measure blood in the stomach. 82

Peptic Ulcer Care of the patient managed medically Assessment
Pain, including location, aggravating factors, and measures that bring relief; relationship between pain and food intake Recent serious illnesses, previous peptic ulcer disease, and a medication history Functional assessment: patient’s usual diet, use of alcohol and tobacco, activities, sleep patterns, and stressors Vital signs; height and weight; skin and mucous membranes for turgor and moisture Inspect abdomen for distention and palpate for tenderness Auscultate for bowel sounds 83

Peptic Ulcer Care of the patient managed medically Interventions Pain
Imbalanced Nutrition: Less Than Body Requirements Risk for Injury Ineffective Coping 84

Peptic Ulcer Care of the patient managed surgically Assessment
Pain, nausea, and vomiting Measure vital signs at frequent intervals Note the amount and type of IV fluids, and check the infusion site for swelling or redness Document patency of the nasogastric tube as well as the color and amount of drainage Breath sounds; inspect the wound dressing for bleeding Inspect abdomen for distention and auscultate for bowel sounds Monitor urine output and palpate for bladder distention 85

Peptic Ulcer Care of the patient managed surgically Interventions
Risk for Injury Imbalanced Nutrition: Less Than Body Requirements Decreased Cardiac Output 86

Stomach Cancer Pathophysiology
Begins in the mucous membranes, invades the gastric wall, and spreads to the regional lymphatics, liver, pancreas, and colon No specific signs or symptoms in the early stages Late signs and symptoms are vomiting, ascites, liver enlargement, and an abdominal mass Cancer of the stomach is diagnosed in more than 22,000 people in the United States each year. In what population is the incidence the highest? Distant metastases are found in the lungs and bones. 87

Stomach Cancer Risk factors
H. pylori infection, pernicious anemia, chronic atrophic gastritis, and achlorhydria, type A blood, and a family history Cigarette smoking, alcohol abuse, and a diet high in starch, salt, pickled foods, salted meats, and nitrates 88

Stomach Cancer Medical diagnosis Medical treatment
Gastroscopy, endoscopic ultrasound, upper GI series, CT, PET scan, MRI, laparoscopy Laboratory studies include hemoglobin and hematocrit, serum albumin, liver function tests, and carcinoembryonic antigen Medical treatment Surgery, chemotherapy, and radiation therapy If the cancer is detected early, surgical options include subtotal gastrectomy with lymph node dissection and total gastrectomy. What are gene and immune-based therapies? 89

Figure 38-16 90

Stomach Cancer Preoperative care of the patient with stomach cancer
Inform about the nasogastric tube and IV fluids; teach coughing, deep breathing, and leg exercises Identify/support patient’s coping methods Include sources of support, such as family members or a spiritual counselor, in the preoperative care 91

Stomach Cancer Postoperative care of the patient with stomach cancer
Assessment Comfort, appetite, and nausea and vomiting Monitor weight changes and determine dietary preferences Identify the patient’s support system and coping strategies Interventions Pain Imbalanced Nutrition: Less Than Body Requirements Ineffective Coping 92

Obesity Increased weight caused by excessive body fat Causes
Heredity, body build/metabolism, psychosocial factors Basic problem: caloric intake exceeds metabolic demands Complications Cardiovascular and respiratory problems, polycythemia, diabetes mellitus, cholelithiasis (gallstones), infertility, endometrial cancer, and fatty liver infiltration When fat cells reach a certain size, they divide to form new fat cells. Fat cells decrease in size, but not in number, when a person loses weight. How may the hypothalamus be involved in the cause of obesity? 93

Obesity Medical diagnosis Medical and surgical treatment
Standard weight tables Measuring skinfold thickness Endocrine function tests Medical and surgical treatment Weight reduction diet accompanied by a planned exercise program Drug therapy Bariatric surgery What drug therapy may be used to treat obesity? 94

Obesity Assessment Identify factors that contribute to obesity
Ask about usual dietary practices Identify factors that trigger overeating and reactions to overeating Collect data about previous efforts to lose weight and current interest in losing weight Inquire about interpersonal relationships, stresses, and coping strategies. What procedure may make auscultating heart, lung, and bowel sounds for the obese patient easier? 95

Obesity Interventions for the obese patient managed nonsurgically
Imbalanced Nutrition: More Than Body Requirements Ineffective Tissue Perfusion Ineffective Breathing Pattern Disturbed Body Image 96

Obesity Interventions after bariatric surgery Impaired Gas Exchange
Impaired Tissue Perfusion Impaired Skin Integrity Imbalanced Nutrition: Less Than Body Requirements 97

Malabsorption One or more nutrients are not digested or absorbed
Many causes: bacteria, deficiencies of bile salts or digestive enzymes, alterations in the intestinal mucosa, and absence of all or part of the stomach or intestines What are the two types of malabsorption? 98

Malabsorption Signs and symptoms Steatorrhea
Weight loss, fatigue, decreased libido, easy bruising, edema, anemia, and bone pain Bloating, cramping, abdominal cramps, and diarrhea are symptoms of lactase deficiency 99

Malabsorption Medical diagnosis
Sprue: based on laboratory studies, endoscopy with biopsy, and radiologic imaging studies Lactase deficiency: based on the health history, the lactose tolerance test, a breath test for abnormal hydrogen levels, and if necessary, biopsy of the intestinal 100

Malabsorption Medical treatment
Sprue: diet and drug therapy; foods that aggravate symptoms eliminated from the diet Celiac disease: avoid products that contain gluten Tropical sprue: antibiotics, oral folate, and vitamin B12 injections Lactase deficiency: eliminate milk and milk products What may help to avoid symptoms of lactase intolerance? 101

Malabsorption Nursing care Document the patient’s symptoms
Note stool characteristics In the case of celiac sprue, teach the patient how to eliminate gluten from the diet Give antibiotics as ordered for tropical sprue If folic acid therapy continued, instruct patient in self-medication The effect of therapy is evaluated by the return of normal stool consistency Advise the patient with lactase deficiency of dietary restrictions and alternative products 102

Diarrhea The passage of loose, liquid stools with increased frequency
May have cramps, abdominal pain, and a feeling of urgency before bowel movements 103

Diarrhea Causes Complications
Spoiled foods, allergies, infections, diverticulosis, malabsorption, cancer, stress, fecal impactions, and tube feedings Adverse effect of some medications Complications Dehydration, electrolyte imbalances, and metabolic acidosis Malnutrition and anemia 104

Diarrhea Medical treatment
Acute diarrhea usually treated by resting the digestive tract and giving antidiarrheal drugs Severe, persistent diarrhea may require TPN 105

Diarrhea Assessment Diarrhea and onset, severity, precipitating factors, and measures that bring relief Ask about stool characteristics, including amount, color, odor, and unusual contents, such as blood, mucus, or undigested food Functional assessment focuses on usual diet, dietary changes, recent and current medications, recent travel to a foreign country Important aspects of the physical examination include vital signs, weight, and tissue turgor. How is tissue turgor assessed? 106

Diarrhea Interventions
Deficient Fluid Volume and Imbalanced Nutrition: Less Than Body Requirements Impaired Skin Integrity Pain Self-Care Deficit 107

Constipation Hard, dry, infrequent stools that are passed with difficulty 108

Constipation Causes Frequently ignoring the urge to defecate
Frequent use of laxatives or enemas Inactivity Inadequate water intake Diet low in fiber and high in cheese, lean meat, pasta Drugs that slow intestinal motility/increase urine output Diseases of the colon or rectum, as well as brain or spinal cord injury; abdominal surgery 109

Constipation Complications Medical treatment Valsalva maneuver
The rapid changes in blood flow can be fatal to a patient with heart disease Hemorrhoids Fecal impaction Medical treatment Laxatives, suppositories, enemas, or combination for prompt results Stool softeners Stool softeners, as the name suggests, promote normal elimination by allowing more water to be held in the stool so that it is softer and more easily passed. What are examples of stool softeners? 110

Constipation Assessment
Usual pattern of bowel elimination, including frequency, amount, color, unusual contents, and pain associated with defecation Information about diet, exercise, and drug therapy Any aids to elimination; type and frequency of use Examine abdomen for distention or visible peristalsis Auscultate for bowel sounds in all four quadrants of the abdomen 111

Constipation Interventions
Maintained with diet, fluids, exercise, and regular toilet habits Megacolon Regular enemas for bowel cleansing Fecal impaction Assess for impaction by inserting a gloved, lubricated finger into the rectum Remove impaction following agency protocol or specific physician’s orders If detected early, constipation may be treated easily with a mild laxative or suppository. Severe constipation may require repeated enemas and laxatives for relief. Megacolon is a condition in which the large intestine loses the ability to contract effectively enough to propel the fecal mass toward the rectum. What patients have special problems with constipation? 112

Intestinal Obstruction
Causes Strangulated hernia, tumor, paralytic ileus, stricture, volvulus (twisting of the bowel), intussusception (telescoping of the bowel into itself), and postoperative adhesions Signs and symptoms Vomiting (possibly projectile), abdominal pain, and constipation Blood or purulent drainage passed rectally Abdominal distention, especially with colon obstruction 113

Complications Fluid and electrolyte imbalances and metabolic alkalosis Gangrene and perforation of the bowel 114

Figure 38-17 115

Medical diagnosis History, physical examination, and laboratory studies; confirmed by radiologic studies Medical treatment Gastrointestinal decompression; intravenous fluids; and surgical intervention 116

Assessment Symptoms, including pain and nausea Onset and progression of symptoms Hernia, cancer of the digestive tract, and abdominal surgeries Ask when the patient’s last bowel movement was and if the characteristics were normal Take vital signs to detect signs of infection (fever, tachycardia) and impending shock (tachycardia, hypotension). Assess skin moisture and tissue turgor, along with moisture of the mucous membranes. What assessment of the abdomen should be made? 117

Interventions Acute Pain Deficient Fluid Volume Risk for Infection Ineffective Breathing Pattern Anxiety 118

Appendicitis Pathophysiology Inflammation of the appendix
A ruptured appendix allows digestive contents to enter the abdominal cavity, causing peritonitis What causes the appendix to become inflamed? Early detection of appendicitis may permit treatment before the appendix ruptures. 119

Appendicitis Signs and symptoms
Pain at McBurney’s point, midway between the umbilicus and the iliac crest Temperature elevation, nausea, and vomiting Elevated WBC count (10,000-15,000/mm3 ) Peritonitis: absence of bowel sounds, severe abdominal distention, increased pulse and temperature, nausea/vomiting; rigid abdomen 120

Figure 38-18 121

Appendicitis Medical treatment Nothing by mouth
A cold pack to the abdomen may be ordered Laxatives and heat applications should never be used for undiagnosed abdominal pain Immediate surgical treatment indicated Ruptured appendix: surgery may be delayed 6-8 hours while antibiotics and IV fluids given 122

Appendicitis Assessment
Location, severity, onset, duration, precipitating factors, and alleviating measures in relation to the pain Previous abdominal distress, chronic illnesses, surgeries; record allergies and medications Temperature; abdominal pain, distention, and tenderness; presence and characteristics of bowel sounds 123

Appendicitis Preoperative interventions
Semi-Fowler or side-lying position with the hips flexed Until physician determines the diagnosis, analgesics may be withheld If rupture suspected, elevate patient’s head to localize the infection 124

Appendicitis Postoperative interventions
Administer antibiotics, intravenous fluids, and possibly gastrointestinal decompression Assist the patient in turning, coughing, and deep breathing; incentive spirometry Splint the incision during deep breathing Early ambulation Assess abdominal wound for redness, swelling, and foul drainage Wound care as ordered or according to agency policy 125

Peritonitis Pathophysiology Signs and symptoms
Inflammation of peritoneum caused by chemical or bacterial contamination of the peritoneal cavity Signs and symptoms Pain over affected area, rebound tenderness, abdominal rigidity and distention, fever, tachycardia, tachypnea, nausea, and vomiting Chemical contamination may follow rupture of a digestive tract structure, including the appendix. Bacterial contamination may be caused by rupture of a digestive tract structure or fallopian tube or from nonsterile, traumatic wounds. What are possible complications of peritonitis? The older patient may have more subtle symptoms with less pain and the absence of abdominal rigidity. 126

Peritonitis Medical diagnosis History and physical
Complete blood cell count, serum electrolyte measurements, abdominal radiography, computed tomography, and ultrasound Paracentesis 127

Peritonitis Medical treatment
Gastrointestinal decompression, intravenous fluids, antibiotics, and analgesics Surgery to close a ruptured structure and remove foreign material and fluid from the peritoneal cavity 128

Peritonitis Assessment
Onset, location, and severity of the pain and any related symptoms Record a history of abdominal trauma, including surgery Take and record vital signs Inspect abdomen for distention and auscultate for the presence of bowel sounds 129

Peritonitis Interventions Acute Pain Decreased Cardiac Output
Imbalanced Nutrition: Less Than Body Requirements Anxiety

Abdominal Hernia Pathophysiology
Weakness in the abdominal wall that allows a portion of the large intestine to push through Weak locations include the umbilicus and the lower inguinal areas of the abdomen; may also develop at the site of a surgical incision Classified as reducible or irreducible A reducible hernia slips back into the abdominal cavity with gentle pressure or when the patient lies on his or her back. When the hernia cannot be manipulated back into place, it is said to be irreducible, or incarcerated. What complications may occur with an incarcerated hernia?

Abdominal Hernia Signs and symptoms A smooth lump on the abdomen
With incarceration, the patient has severe abdominal pain and distention, vomiting, and cramps

Figure 38-19

Abdominal Hernia Medical diagnosis Medical treatment
Health history and physical examination Medical treatment Surgical repair Herniorrhaphy Hernioplasty

Abdominal Hernia Assessment Chief complaint
Ask about pain and vomiting Inspect for abnormalities, and listen for bowel sounds in all four abdominal quadrants

Abdominal Hernia Preoperative interventions
Risk for Injury Impaired Skin Integrity Postoperative interventions Impaired Urinary Elimination Constipation Acute Pain

Inflammatory Bowel Disease
Pathophysiology Ulcerative colitis and Crohn’s disease Inflammation and ulceration of intestinal tract lining Exact cause is unknown Possible causes: infectious agents, autoimmune reactions, allergies, heredity, and foreign substances With ulcerative colitis, the inflammation typically begins in the rectum and gradually extends up the bowel toward the cecum. The progression of Crohn’s disease is different in that it can affect any area of the gastrointestinal tract.

Signs and symptoms Ulcerative colitis Diarrhea with frequent bloody stools, abdominal cramping Crohn’s disease If the stomach and duodenum are involved, symptoms include nausea, vomiting, and epigastric pain Involvement of the small intestine produces pain and abdominal tenderness and cramping An inflamed colon typically causes abdominal pain, cramping, rectal bleeding, and diarrhea Systemic signs and symptoms include fever, night sweats, malaise, and joint pain

Complications Hemorrhage, obstruction, perforation (rupture), abscesses in the anus or rectum, fistulas, and megacolon What systemic complications may occur?

Medical diagnosis History and physical examination Abdominal radiography Barium enema examination with air contrast; colonoscopy with biopsy, ultrasonography, CT, and cell studies Video capsule Medical treatment Drug therapy, diet, and rest What drugs may be used to treat IBD? A low-roughage diet without milk products is prescribed for mild to moderate IBD. Intravenous fluids or TPN may be needed to provide fluid, electrolytes, and nutrients when symptoms are severe.

Assessment Onset, location, severity, and duration of pain Note factors that contribute to the onset of pain Onset and duration of diarrhea; presence of blood Vital signs, height and weight, measures of hydration Inspect perianal area for irritation or ulceration Maintain accurate intake and output records Measure diarrhea stools if possible and count as output

Interventions Acute Pain Diarrhea Deficient Fluid Volume Imbalanced Nutrition: Less Than Body Requirements Ineffective Coping Risk for Injury

Diverticulosis Pathophysiology Risk factors
Small saclike pouches in intestinal wall: diverticula Weak areas of the intestinal wall allow segments of the mucous membrane to herniate outward Risk factors Lack of dietary residue Age, constipation, obesity, emotional tension Where are most diverticula found?

Diverticulosis Signs and symptoms
Often asymptomatic, but many people report constipation, diarrhea, or periodic bouts of each Rectal bleeding, pain in left lower abdomen, nausea and vomiting, and urinary problems

Figure 38-20

Diverticulosis Complications Medical diagnosis Diverticulitis Symptoms
Bleeding, obstruction, perforation (rupture), peritonitis, and fistula formation Medical diagnosis Symptoms Abdominal CT and barium enema examination

Diverticulosis Medical treatment High-residue diet without spicy foods
Stool softeners or bulk-forming laxatives; antidiarrheals; broad-spectrum antibiotics; anticholinergics Surgical intervention may be necessary During periods of acute inflammation, the patient is placed on bed rest and given nothing by mouth. Intravenous fluids are ordered. Gastrointestinal decompression also may be instituted. Why is a temporary colostomy created?

Diverticulosis Assessment
Assess patient’s comfort and stool characteristics; note nausea and vomiting Monitor patient’s temperature Assess abdomen for distention and tenderness

Diverticulosis Interventions
Fluids as permitted; monitor intake and output Antiemetics, analgesics, anticholinergics as ordered Be alert for signs of perforation Teach patient about diverticulosis, including the pathophysiology, treatment, and symptoms of inflammation

Colorectal Cancer Pathophysiology Cancer of the large intestine
People at greater risk for colorectal cancer are those with histories of inflammatory bowel disease, or family histories of colorectal cancer or multiple intestinal polyps High-fat, low-fiber diet and inadequate intake of fruits and vegetables also contribute to development Can develop anywhere in the large intestine Three fourths of all colorectal cancers are located in the rectum or lower sigmoid colon Where does colorectal cancer develop?

Figure 38-21

Colorectal Cancer Signs and symptoms Right side of the abdomen
Vague cramping until the disease is advanced Unexplained anemia, weakness, and fatigue related to blood loss may be the only early symptoms Left side or in the rectum Diarrhea or constipation and may notice blood in the stool Stools may become very narrow, causing them to be described as pencil-like Feeling of fullness or pressure in the abdomen or rectum

Colorectal Cancer Medical and surgical treatment
Usually treated surgically Combination chemotherapy postoperatively if tumor extends through the bowel wall or if lymph nodes involved Early stage rectal cancer sometimes treated with radiation and surgery

Colorectal Cancer Assessment
Vital signs, intake and output, breath sounds, bowel sounds, and pain Appearance of wounds and wound drainage If there is a colostomy, measure and describe the fecal drainage

Colorectal Cancer Interventions Risk for Injury
Ineffective Tissue Perfusion Acute Pain Sexual Dysfunction Ineffective Coping

Polyps Small growths in the intestine
Most benign but can become malignant Inherited syndromes: familial polyposis and Gardner’s syndrome Usually asymptomatic; found on routine testing Complications are bleeding and obstruction Diagnosed by barium enema or endoscopic exam Colectomy for familial polyposis or Gardner’s syndrome because of the high risk of malignancy

Hemorrhoids Internal or external dilated veins in the rectum
Thrombosed Blood clots form in external hemorrhoids; become inflamed and very painful Risk factors Constipation, pregnancy, prolonged sitting or standing Signs and symptoms Rectal pain and itching Bleeding with defecation External hemorrhoids easy to see; appear red/bluish They may be above the sphincter muscles of the anus (internal hemorrhoids) or below these muscles (external hemorrhoids). What is a key factor in the development of hemorrhoids?

Figure 38-22

Hemorrhoids Medical diagnosis and treatment
Diagnosed by visual inspection Nonsurgical treatment Topical creams, lotions, or suppositories soothe and shrink inflamed tissue Sitz baths often comforting The physician may order heat or cold applications Outpatient procedures: ligation, sclerotherapy. Thermocoagulation/electrocoagulation, laser surgery Hemorrhoidectomy The surgical excision (removal) of hemorrhoids

Hemorrhoids Assessment Interventions
After hemorrhoidectomy, monitor vital signs, intake and output, and breath sounds. Assess the perianal area for bleeding and drainage Interventions Acute Pain Impaired Skin Integrity Constipation

Anorectal Abscess An infection in the tissue around the rectum
Signs and symptoms are rectal pain, swelling, redness, and tenderness Treated with antibiotics followed by incision and drainage Preoperatively, pain is treated with ice packs, sitz baths, and topical agents as ordered The patient often reports a history of diarrhea. What symptoms may appear if the abscess becomes chronic?

Anorectal Abscess Postoperatively, pain treated with opioid analgesics
Patient teaching emphasizes importance of thorough cleansing after each bowel movement Advise patient to consume adequate fluids and a high-fiber diet to promote soft stools

Anal Fissure Laceration between the anal canal and the perianal skin
May be related to constipation, diarrhea, Crohn’s disease, tuberculosis, leukemia, trauma, or childbirth Signs and symptoms include pain before and after defecation and bleeding on the stool or tissue If fissure chronic, the patient may experience pruritus, urinary frequency or retention, and dysuria Usually heal spontaneously, but can become chronic Conservative treatment: sitz baths, stool softeners, and analgesics Surgical excision may be necessary

Anal Fistula Abnormal opening between anal canal and perianal skin
Develops from anorectal abscesses or related to inflammatory bowel disease or tuberculosis Patient typically complains of pruritus and discharge Sitz baths provide some comfort Surgical treatment is excision of fistula and surrounding tissue Sometimes a temporary colostomy to allow the surgical site to heal Postoperative care: analgesics and sitz baths for pain

Pilonidal Cyst Located in the sacrococcygeal area
Results from an infolding of skin, causing a sinus that is easily infected because of its closeness to the anus Once infected, it is painful and swollen and may form an abscess Surgical excision usually recommended Care is similar to that for the patient having a hemorrhoidectomy

Patient Education to Promote Normal Bowel Function
Good hand washing and proper food handling People who recognize that stress affects their gastrointestinal function may benefit from relaxation techniques and stress management training Signs and symptoms of digestive problems should be reported for prompt diagnosis and treatment if indicated Teaching patients what is normal, how to promote normal function, and how to detect problems can help to avoid serious gastrointestinal dysfunction Why is food poisoning often a problem for older adults?

Digestive Tract Disorders

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