1. Problem of the Lower GI Tract Diverticulosis & Diverticulitis Diverticulum-is the outpouching of the intestinal mucosa, which may occur at any point in the GI Tract but more commonly in the sigmoid colon. Diverticulosis-is the presence of multiple diverticula. Diverticulitis-inflammation of diverticula.

2. Problem of the Lower GI Tract Characteristic No symptoms unless complications develop Large bowel diverticula are more apt to develop complications Complications are perforation, hemorrhage, inflammation, fistulas, and abscess

3. Assessment Problem of the Lower GI Tract Assessment Assess for cramp like pain Check for flatulence Assess for nausea Evaluate patterns of irregularity, irritability any spasticity of the intestine Assess for fever Examine dysuria associated with bladder involvement

4. Problem of the Lower GI Tract Implementation Provide care during acute phase Bedrest, IV fluids,NPO, NG decompression, Drugs:Abx, analgesic, antispasmodic. Monitor appropriate diet. High-residue diet-for diverticulosis Low residue- for severe diverticulitis Provide vitamin & iron supplements. Administer anticholinergics: Donnatal Provide sedatives and tranquilizers for anxiety Monitor stool normalization

5. Problem of the Lower GI Tract Ulcerative Colitis A chronic ulcerative and inflammatory disease of the colon and rectum, which commonly begins in the rectum and sigmoid colon and spread upward. The disease is characterized by periods of exacerbation and remissions.

6. Problem of the Lower GI Tract Assessment Asses for gradual onset Malaise Early-vague abdominal discomfort Later- cramp like abdominal pain Bowel evacuation-pus, mucus,blood Stools scanty and hard painful defecation with defecation Assess for abrupt onset

7. Problem of the Lower GI Tract Assessment con’t.. Assess for complications Dehydration, bleeding tendency Abscesses and strictures Hemorrhoids and anal fissures Magnesium and calcium imbalances Perforation, peritonitis Evaluate results of client’s Hx & diagnostic tests Medical Hx.,Clinical Manifestations, Lower GI series, Stool and blood exam. Sigmoidoscopy

8. Implementation Problem of the Lower GI Tract Implementation Major objective-prevent acute episodes & manage complications Maintain nutritional status High-protein, high-calorie, high-fiber diet Avoid certain spices (pepper), gas-forming foods and milk product. All foods should be cooked to reduce cramping and diarrhea. Vitamins (A&E), minerals(zinc, calcium & magnesium) and iron supplements Eating may increase diarrhea and anorexia

9. Problem of the Lower GI Tract Implementation con’t…. Replace fluid & electrolytes loss due to diarrhea. 3 to 4 liters a day KCL may need to be added Correct psychological disturbances Allow pt. to ventilate feeling Avoid emotional probing during period of acute illness Help pt. Live with chronic disease

10. Problem of the Lower GI Tract Implementation con’t … Administer drugs as ordered. Steroid therapy for inflammation Anti-infectives-sulfa-to reduce severity of attack. Immunosuppressive Tranquilizers- to relieve anxiety Anticholinergics- relieve cramp Maintain bed rest during acute phase

11. Problem of the Lower GI Tract CharacteristicUlcerative Colitis Crohn’s Disease AgeYoung to middle Age Young LocationStarts distally & spreads in a cont. pattern up to the colon Occurs anywhere along GI tract in characteristic skip lesions; most frequent site is terminal ileum DistributionContinuousSegmental PerforationCommon

12. Problem of the Lower GI Tract CharacteristicUlcerative Colitis Crohn’s Disease Depth of involvement Mucosa & submucosa Entire thickness of bowel wall Small bowel involvement MinimalCommon MalabsorptionMinimal incidence Common DiarrheaPossibleCommon

13. Problem of the Lower GI Tract Abdominal Crampy pain PossibleCommon Fever(intermittent)During acute Attacks Common Weight lossCommonSevere Cobblestoning of mucosa RareCommon CarcinomaIncreased after 10 yrs. Slightly greater than gen. Pop. Recurrence after surgery Cure with colectomy 70% or more recurrence

14. Disorders of Liver, Biliary & Pancreatic Function Physical Examination Palpation of the abdomen to determine tenderness, size, & shape of liver and spleen. Visual inspection for ascites, venous networks, and jaundice.

15. Disorders of Liver, Biliary & Pancreatic Function Hepatic Failure Viral Hepatitis- inflammation of the liver. 1. Transmission: a. oral-anal route b. Blood transfusion with infected serum or plasma. c. Contaminated equipment- syringes, needles. d. Contaminated milk, water, and food. e. antibodies persist in serum

16. Disorders of Liver, Biliary & Pancreatic Function Prevention Good handwashing Good personal hygiene Control and screening of food handlers Passive immunization Incubation period: 20 to 50 days( short incubation period)

17. Disorders of Liver, Biliary & Pancreatic Function INCIDENCE More common in fall and winter months. Usually found in children and young adults Client is infectious 3 weeks prior to and 1 week after developing jaundice. Clinical recovery: 3 to 16 weeks.

18. Disorders of Liver, Biliary & Pancreatic Function Hepatitis B-Transmission Oral or parenteral route with infusion, ingestion or inhalation of a blood of an infected person. Contaminated needles, syringes, dental instruments. Oral or sexual contact. High risk individuals includes homosexual, IV drug abusers, medical workers. * Ranked as the 5 th leading cause of death.

19. Disorders of Liver, Biliary & Pancreatic Function Prevention Screen blood donors for HB3 AG. Registration of all carriers Active immunization- Hepatavax Type C: 1. Transmission-contaminated blood 2. Usual incubation period-7 to 8 weeks.

20. Disorders of Liver, Biliary & Pancreatic Function Hepatitis D-Transmission Same as Hepatitis B Hepatitis D- transmitted through oral- fecal contaminated water; course of illness resembles hepatitis A

21. Disorders of Liver, Biliary & Pancreatic Function Assessment Assess preicteric phase 1. Lethargy and malaise 2. Anorexia, nausea,& vomiting 3. Headache 4. Abdominal tenderness and pain 5. Diarrhea or constipation 6. Low-grade temperature Assess icteric phase 1. Dark urine and clay-colored stools 2. Jaundice 3. Pruritus

22. Disorders of Liver, Biliary & Pancreatic Function Implementation Wash your hands, wear gloves Use disposable equipment or sterilized reusable equipment. Provide diet-high calorie Bedrest Instruct client and family stress never to offer to be a blood donor/ encourage gamma globulin for close contacts. Restricted use of alcohol Abstain from sexual activity during communicable period.

23. Cirrhosis Definition Cirrhosis-progressive disease of the liver characterized by diffuse damage to the cell with fibrosis and nodular regeneration. 1. Laennec’s portal (alcoholic/nutritional) a. Most common in the U.S. b. Scar tissue surrounds the portal areas. c. Characterized by destruction of hepatic tissue, increased fibrous tissue( early hepatic stage ),in late stage, it is small and nodular.

24. Cirrhosis Types Postnecrotic cirrhosis- a sequela to viral hepatitis. Liver decreased in size with nodules and fibrous tissue. Biliary cirrhosis- Inflammation of intrahepatic bile duct as a result of chronic biliary obstruction and infection in the liver and common bile duct. There is increased skin pigmentation resembling a deep tan, jaundice and pruritus.

25. Cirrhosis Types Cardiac- Right-sided CHF. Liver is swollen and changes are reversible if CHF is treated effectively. Some fibrosis occurs with long standing CHF. Nonspecific, metabolic cirrhosis - Metabolic problems, infectious disease, infiltrative diseases, GI diseases.Portal and liver fibrosis may develop;liver is enlarged and firm.

26. Cirrhosis Causes Repeated destruction of hepatic cells, replacement with scar tissue and regeneration of liver cells. Insidious onset with progression over a period of years. Occurs twice as often in males, primarily affects 40 to 60 year old age group.

27. Cirrhosis Clinical Progression Hepatomegaly-due to accumulation of fat in the cell. Anorexia, weight loss, fatigue, jaundice Portal Hypertension-leads to esophageal varices Peripheral edema and ascites- accompanied by hormone imbalance Hepatic coma

28. Cirrhosis Assessment Evaluate client’s hx. Of failing health,weakness, gastrointestinal distress, fatigue, weight loss, & low resistance to infection. Assess for ascites due malnutrition, portal hypertension, low albumin Check for hematemesis Palpate liver Assess for esophageal varices, hemorrhoids from portal hypertension. Evaluate skin manifestations- spider angiomas Assess for precoma state-tremor, delirium & dysarthia.

29. Cirrhosis Complications Portal Hypertension-pressures within the the portal venous system become elevated as liver damages obstructs the free flow of blood through the organ. Characteristics: Causes congestion of the spleen, pancreas and GI Tract. As the body compensates for increased pressure in the hepatic system, collateral circulation develop.

30. Cirrhosis Complications Ascites-results of portal hypertension, decreased synthesis of the albumin, increased level of aldosterone, obstruction of hepatic lymph flow. LVP- removal of 5 liters or more ascitic fluid during a single tx. Albumin IV is given simultaneously. PVS-one end of the catheter is implanted in the peritoneal cavity & the tube is channeled through SC tissue to the SVC, where the catheter is implanted. The valve opens when there is a pressure differential > than 3 mm of H20 bet. The peritoneal cavity & the vein in the thoracic cavity.

31. Cirrhosis Complications Esophageal Varices- the increased portal venous pressures causes the blood- to be forced into these vessels & they become fragile & tortuous. Increased as a result of coughing, vomiting, sneezing, or straining during defecation. Bleeding may occurs by mechanical trauma- ingestion of coarse foods and acidic pepsin erosion.

32. Cirrhosis Treatments Gastric lavage-monitor frequently Pharmacologic therapy- Administration of vasopression,Propranolol (inderal)- beta blocker- reduce portal pressure & thus decrease pressure & esophageal bleed,and Sandostatin-lowers portal pressure by causing vasoconstriction & thus stop blleding. Side effect-abd. cramping & pallor. Used cautiously in persons with CAD-causes coronary vasoconstriction.

33. Cirrhosis Treatments Endoscopic Sclerotherapy- sclerosing agents (Na morrhuate- 5ml) injected into the varices. Causes thrombosis and sclerosis of the vessel and hemostasis in 3 to 5 minutes. If hemostasis does not occur- a second injection is given. Monitor for perforated esophagus, asp. Pneumonia, pleural effusion. Fever is common for several days.

34. Cirrhosis Treatments Balloon Tamponade- (Sengstaken-Blakemore) is inserted. Maintain proper position, care of the mouth and nares, frequent oral suctioning and providing comfort measures. Shunts-Transjugular Intrahepatic Portosystemic shunt- (TIPS) shunt created bet. The hepatic and portal veins & kept open by placement of a metal stent. This decompresses the portal system and reduces portal HTN enough to control bleeding. ADV. Non-invasive.

35. Cirrhosis Treatments Surgical Shunts-last measures to treat esophageal varices. Portal blood is being shunted away from the liver-toxins are not being metabolized. Risk for PSE-portal systemic encephalopathy @ 25% to 100%. Administartion of fresh whole blood- has more coagulation factors-avoid increase of NH3.

36. Cirrhosis Complications Portal-systemic Encephalopathy-result of rising levels of toxic substances normally metabolized & excreted by the liver. Treatments: Eliminating or restricting protein intake Increase Carb. Intake to decrease metabolism of endogenous proteins. Administering intestinal abx. Such as neomycin to kill bacteria in the GI tract. Administering lactulose- decreasing the PH of the bowel-promotes excretion of NH3 in the stool.

37. Stages of PSE Stage 1 Prodromal Stage 2 Impending Stage 3 Stuporous Stage 4 Coma Change in sleep pattern LethargyConfused Disoriented Unconscious Slow response Irritable Asterixis-ParanoiaFetor hepaticus(m usty sweet breath odor) TremorsSlurred speech

38. Cirrhosis Complications Hepatorenal Syndrome- sudden onset of oliguria and azotemia- end-stage of liver disease. The patient complains of anorexia,fatique, & weakness. Fluid retention leads to hyponatremia & dearease in urine osmolality. Fluid and lytes management Liver transplantation Hemodialysis for hyperkalemia and fluid overload.

39. Cirrhosis Implementation Assist in maximizing liver function. Diet: ample protein and carbohydrates Restrict salts and fluids Multivitamin Diuretics- spironolactones Antacids- decrease gastric distress. Eliminate hepatotoxin intake Completely restrict use of alcohol avoid sedatives and opiates Avoid all known hepatotoxic drugs

40. Cirrhosis Implementation Prevent infection by adequate rest. Administer plasma proteins as ordered Monitor intake and output Provide skin care and control pruritus Evaluate client’s response to diet therapy Evaluate LOC, personality changes, signs of increasing stupor. Prevent and control complications: ascites, bleeding esophageal varices, anemia.