Gastrointestinal Tract Visualization

This Nursing lecture provides a graphical review of the different operations and diagnostic tests used in the study of the Gastrointestinal tract. This nursing lecture includes nursing interventions and management for each particular GIT operation.

1. GI tract Visualization http://nursinglectures.blogspot.com
2. GIT Visualization
   • Barium Swallow- UGIS
   • Pretest: written consent, NPO the night
   • Intratest: administer barium orally, then followed by X-ray
   • Post-test: Laxative for constipation, increased fluids, assess for intestinal obstruction , warn that stool is light colored!
3. 
   
4. 
   
5. GIT Visualization
   • Barium Enema- LGIS
   • Pretest: Informed consent, NPO the night, Enema the morning
   • Intratest: Position on LEFT side, administer enema, then X-ray follow
   • Post-test: Cleansing enema , Laxative for constipation, assess for intestinal obstruction
6. 
   
7. Barium Enema
8. GIT Visualization
   • Esophagogastroscopy
   • Pretest: Informed consent, NPO for 8 hours, warn that gag reflex is abolished
   • Intratest: Position on LEFT side during scope insertion
   • Post-test: NPO until gag returns. Monitor for complications
9. 
   
10. GIT Visualization
    • Anoscopy, proctoscopy, proctosigmoidoscopy, colonoscopy
    • Pretest: Consent, NPO, and enema administration the morning
    • Intratest: Position on the LEFT side during scope insertion
    • Post-test: Monitor for complications
11. 
    
12. Gallbladder
    • Oral cholescystogram
    • PTC
    • ERCP
    • Ultrasound
13. IV Cholecystogram
    • X-ray visualization of the gallbladder after administration of contrast media intravenously
    • Pre-test: Allergy to iodine and sea-foods
    • Intra-test: ensure patent IV line
    • Post-test: increase fluid intake to flush out the dye, Assess for delayed hypersensitivity reaction to the dye like chills and N/V
14. 
    
15. Oral Cholecystogram
    • X-ray visualization of the gallbladder after administration of contrast media
    • Done 10 hours after ingestion of contrast tablets
    • Done to determine the patency of biliary duct
16. 
    
17. 
    
18. Endoscopic retrograde cholangiopancreatography
    • Examination where a flexible endoscope is inserted into the mouth and via the common bile duct and pancreatic duct to visualize the structures
    • Iodinated dye can also be injected after for the x-ray procedure
19. Endoscopic retrograde cholangiopancreatography
    • Pre-test: consent, NPO for 12 hours, Allergy to sea-foods, Atropine sulfate
    • Intra-test: Gag reflex is abolished, Position on LEFT side
    • Post-test: NPO until gag reflex returns, Position side lying and monitor for perforation and hemorrhage
20. 
    
21. 
    
22. 
    
23. Percutaneous Transhepatic Cholangiogram
    • Under fluoroscopy, the bile duct is entered percutaneously and injected with a dye to observe filling of hepatic and biliary ducts
24. 
    
25. Ultrasound of the liver, gallbladder and pancreas
    • Consent MAY be needed
    • Place patient on NPO!!!
    • Laxative may be given to decrease the bowel gas
26. • HIATAL HERNIA
    • Protrusion of the esophagus into the diaphragm thru an opening
    • Two types- Sliding hiatal hernia (most common) and Axial hiatal hernia
    • ASSESSMENT
    • Heartburn
    • Regurgitation
    • Dysphagia
    • 50%; without symptoms
    • DIAGNOSTIC TEST
    • Barium swallow and fluoroscopy.
    • NURSING INTERVENTIONS
    • Provide small frequent feedings
    • AVOID reclining for 1 hour after eating
    • Elevate the head of the head on 8 –inch block
    • Provide pre-op and post-op care
27. Hiatal hernia – X-ray Hiatal hernia
28. • Sliding Hiatal Hernia
    • Causes:
    • Muscle weakness in the esophageal hiatus:
    • Aging process
    • Congenital muscle weakness
    • Obesity
    • Trauma
    • Surgery
    • Prolonged increases in intra-abdominal pressure
29. Sliding Hiatal Hernia
30. • Paraesophageal / Rolling Hernias
    • Cause: anatomic defect.
31. • Management
    • Medications
    • Antacids
    • Antiemetics
    • Histamine Receptor Antagonist
    • Gastric Acid Secretion Inhibitor
    • AVOID; These drugs lowers the LES (lower esophageal sphincter) pressure:
    • Anticholinergics
    • Xanthine derivatives
    • Ca-channel blockers
    • Diazepam
32. GASTROESOPHAGEAL REFLUX DISEASE
33. • Gastro-esophageal reflux (GERD)
    • Backlow
    • incompetent LES
    • May mimic ANGINA or MI
    • ASSESSMENT (for GERD)
    • Heartburn
    • Dyspepsia
    • Regurgitation
    • Epigastric pain
    • Dysphagia
    • Ptyalism
34. • Diagnostic test
    • Endoscopy or barium swallow
    • Gastric ambulatory pH analysis
35. 
    
36. • NURSING INTERVENTION
    • Provide small frequent feedings
    • AVOID reclining for 1 hour after eating
    • Elevate the head of the head on 8 –inch block
    • Provide pre-op and post-op care
37. Gastritis
38. Conditions of the Stomach
    • GASTRITIS
    • Inflammation of the gastric mucosa
    • May be Acute or Chronic
    • Etiology: Acute- bacteria, irritating foods, NSAIDS, alcohol
    • Etiology: Chronic- Ulceration, bacteria, Autoimmune disease, diet, alcohol, smoking
39. Conditions of the Stomach
    • PATHOPHYSIOLOGY OF Gastritis
    • Insults  cause gastric mucosal damage  inflammation, hyperemia and edema  superficial erosions  decreased gastric secretions, ulcerations and bleeding
40. Conditions of the Stomach
    • ASSESSMENT
    • (Acute)
    • Dyspepsia
    • Headache
    • Anorexia
    • Nausea/Vomiting
    • ASSESSMENT (Chronic)
    • Pyrosis
    • Singultus
    • Sour taste in the mouth
    • Dyspepsia
    • N/V/anorexia
    • Pernicious anemia
41. Conditions of the Stomach
    • DIAGNOSTIC PROCEDURE
    • EGD- to visualize the gastric mucosa for inflammation
    • Low levels of HCl
    • Biopsy to establish correct diagnosis whether acute or chronic
42. Conditions of the Stomach
    • NURSING INTERVENTIONS
    • 1. Give BLAND diet
    • 2. Monitor for signs of complications like bleeding, obstruction and pernicious anemia
    • 3. Instruct to avoid spicy foods, irritating foods, alcohol and caffeine
43. Conditions of the Stomach
    • NURSING INTERVENTIONS
    • 4. Administer prescribed medications- H2 blockers, antibiotics, mucosal protectants
    • 5. Inform the need for Vitamin B12 injection if deficiency is present
44. Gastritis
45. Acute Gastritis Chronic Gastritis
46. PEPTIC ULCER DISEASE
47. Conditions of the Stomach
    • PEPTIC ULCER DISEASE
    • An ulceration of the gastric and duodenal lining
    • Gastric ulcer and Duodenal ulcer
    • Most common Peptic ulceration: anterior part of the upper duodenum
48. Conditions of the Stomach
    • PATHOPHYSIOLOGY of PUD
    • Disturbance in acid secretion and mucosal protection
    • Increased acidity or decreased mucosal resistance  erosion and ulceration
49. Duodenal Ulcer Gastric Ulcer Pain occurs 90 min to 3h after meals; wakes up patient midnight to 3 AM Commonly pain occurs within a short time of food intake Relieved by food, antacids and H2 blockers; is not associated with vomiting (if atypical features occur think of complications) High gastric acid levels Commonly accompanied by nausea, vomiting with food intake and a variable response to medications Low gastric acid levels H. pylori +++ H. pylori +++ Does not represent a malignancy Malignancy + Usually not accompanied by a high complication rate 25% will be accompanied by significant bleeding; higher mortality and morbidity
50. DUODENAL / GASTRIC ULCER
    • Age: 30-60
    • M:F: 2-3:1
    • 80%- duodenal
    • Hypersecretion of HCL
    • (+) weight gain
    • Pain occurs 2-3 p.c .; often awakened between 1-2 am; ingestion of food relieves pain
    • 50 and over
    • 1:1
    • 15% GU
    • N-hyposecretion of HCl
    • Weight loss
    • Pain occurs ½ hrs pc ; rarely occurs at night; relieved by vomiting ; ingestion of food does not help, sometimes inc pain
51. DUODENAL / GASTRIC ULCER
    • DU
    • Vomiting uncommon
    • Hge less common; melena more common
    • More likely to perforate
    • Malignancy rare
    • Risk factors:
    • a. H. pylori
    • b. Alcohol/Smoking
    • c. Cirrhosis
    • d. Stress
    • GU
    • Vomiting common
    • Hge more likely; hematemesis more common
    • Occasionally
    • Risk factors
    • a. H. pylori
    • b. Gastritis
    • c. Alcohol/Smoking
    • d. NSAIDs
    • e. Stress
52. PUD
    • Laboratory:
    • CBC
    • Endoscopy
    • Gastric acid analysis
    • UGIS
53. 
    
54. 
    
55. • Medical management
    • Supportive
    • Drug therapy
    • Nursing Interventions:
    • Administer medications as ordered
    • Provide nursing care for the client with ulcer surgery.
    • Prepare the client for diagnostic procedure for barium swallow and EGD.
56. • Provide client teaching and discharge planning
    • Prepare the patient for surgery if warranted. Usually, the indication includes- unresponsive ulcer healing for 12-16 weeks, life-threatening hemorrhage and perforation.
57. 
    
58. Ulcer Surgery
59. 
    
60. • Ulcer Surgery
    • Surgery is performed when peptic ulcer disease does not respond to medical management.
    • Types
    • Vagotomy:
    • Antrectomy:
    • Pyloroplasty:
    • Gastroduodenostomy (Billroth I):
    • Gastrojejunostomy (Billroth II):
    • Gastrectomy: removal of 60%-80% of the stomach
    • Esophagojejunostomy (total gastrectomy): removal of the entire stomach with a loop of jejunum anastomosed to the esophagus
61. Nursing Interventions
    • Relieving pain
    • Reducing anxiety
    • Maintaining optimal nutritional status
    • Monitoring and managing potential complications
    • Hemorrhage
    • Perforation and penetration
    • Pyloric obstruction
62. Conditions of the Stomach
    • SURGICAL PROCEDURES FOR PUD
    • Post-operative Nursing management
    • 1. Monitor VS
    • 2. Post-op position: FOWLER’S
    • 3. NPO until peristalsis returns
    • 4. Monitor for bowel sounds
    • 5. Monitor for complications of surgery
63. Conditions of the Stomach
    • Post-operative Nursing management
    • 6. Monitor I and O, IVF
    • 7. Maintain NGT
    • 8. Diet progress: clear liquid  full liquid  six bland meals
    • 9. Manage DUMPING SYNDROME
64. • DUMPING SYNDROME
    • A group of unpleasant vasomotor and GI symptoms caused by rapid emptying of gastric content into the jejunum.
    • Associated with the presence of hyperosmolar chyme
65. • Early signs and symptoms (5 to 30 minutes p.c.). Weakness, tachycardia, dizziness, diaphoresis, pallor, feeling of fullness or discomfort. Nausea and explosive diarrhea
    • Rapid emptying of hypertonic food from the stomach
    • Distention of the jejunum causing early symptoms
    • Fluid shift from the bloodstream into the jejunum
    • Decreased blood volume
    • Shock – like manifestations
66. Late signs and symptoms (2 to 3 hrs. p.c.) Sudden hyperglycemia Increased insulin secretion Reactive HYPOGLYCEMIA
67. 
    
68. • MANAGEMENT OF DUMPING SYNDROME
    • Eat in a low fowler’s position
    • Lie down after a meal (left side)
    • Moderate fat, high protein diet. Fats slows down gastric motility, proteins increase colloidal osmotic pressure and prevents shifting of plasma
69. MANAGEMENT OF DUMPING SYNDROME
    • Small frequent feedings
    • Limit carbohydrates, no simple sugars
    • Give fluids 1 hr before and after meals
    • Avoid very hot and cold foods and beverages
    • Anticholinergic or antispasdomic medications are given
70. Inflammatory Bowel Disease: Crohns and Ulcerative colitis
71. 
    
72. 
    
73. CHRONIC INFLAMMATORY BOWEL DISORDERS A.Regional ENTERITIS (Crohn’s Disease) B. Ulcerative Colitis
    • Transmural
    • Mucous ulceration
    • Ileum/ascending colon
    • Rectum/ lower colon
    Cause
    • Unknown
    • Unknown
    • Jewish
    • Familial
    • Environmental
    • Jewish
    • Emotional stress
    Age
    • 20-30 years
    • 40-60 years
    • 15-40 years
    Bleeding
    •  ; stool with pus and mucus
    • Severe; stool with blood, pus and mucus
74. Perianal involvement
    • Severe
    • Mild
    Fistulas
    • Common
    • Rare
    Rectal involvement
    • 20%
    • 100%
    Diarrhea
    • 5-6 soft stool/ day
    • 20-30 watery stool/ day
    Abdominal pain
    • +
    • +
75. Weight loss
    • +
    • +
    Intervention
    • TPN
    • Steriods
    • Azulfidine (Sulfasalazine)
    • Ileostomy
    • Colectomy
    • Diet
    • TPN
    • Steriods
    • Azulfidine (Sulafasalazine)
    • Ileostomy/
    • Proctocolectomy
76. • Nursing Interventions for Crohn’s and UC
    • Maintain NPO during the active phase
    • Monitor for complications like severe bleeding, dehydration, electrolyte imbalance
    • Monitor bowel sounds, stool and blood studies
    • Restrict activities
    • Administer IVF, electrolytes and TPN if prescribed
77. • Instruct the patient to AVOID gas-forming foods, MILK products and foods such as whole grains, nuts, RAW fruits and vegetables especially SPINACH, pepper, alcohol and caffeine.
78. • Diet progression- clear liquid  LOW residue, high protein diet
    • Administer drugs- anti-inflammatory, antibiotics, steroids, bulk-forming agents and vitamin/ iron-supplements
79. Crohn’s Disease: Anatomic Distribution Small bowel alone (33%) Colon alone (20%) Ileocolic (45%) Least Most Freq of involvement
80. Pathophysiology of IBD - pt. 1 fbg06
81. Pathophysiology of IBD - pt. 2 fbg06
82. APPENDICITIS
83. • Appendicitis
    • Inflammation of the vermiform appendix that prevents mucus from passing into the cecum
84. PATHOPHYSIOLOGY Obstruction of the appendix lumen Mucosal inflammation and bacterial proliferation Increased intra-luminal Pressure Lymphoid swelling Decreased venous drainage Thrombosis Bacterial invasion Abscess Gangrene Perforation (24 to 36 hours) Peritonitis
85. • Assessment findings
    • Acute abdominal pain that usually starts in the epigastric or umbilical region
    • Mc Burney’s Point
    • initially intermittent then become steady and severe over a short period.
    • Appendicitis “signs”
    • Rebound tenderness
    • Psoas sign (lateral position with right hip is palpated)
    • Rovsing’s sign (right quadrant pain when the left is palpated)
    • Obturator sign (pain on external rotation of the right thigh)
86. 
    
87. • Nursing Interventions
    • Administer antibiotics/ antipyretics as ordered
    • prevent perforation of the appendix; don’t give enemas or cathartics or use heating pad
88. • Surgical procedure= APPENDECTOMY
    • If appendicitis ruptured (peritonitis): with penrose drains; Position: semi-fowler’s position to localize inflammation within the pelvic area
    • Resume all normal activities within 2 to 4 weeks
    • In addition to routine post-op care
    • Monitor NG tube (usually with low suction)
    • Monitor penrose drains
    • Position in semi-fowler’s or lying on right side to facilitate drainage
    • Administer antibiotics as ordered
89. DIVERTICULITIS
90. • DIVERTICULITIS
    • Diverticulum is outpouching of the mucosal lining of the GI tract, commonly in the colon.
    • Diverticula/ diverticulosis are multiple outpouching
    • Diverticulitis is acute inflammation and infection commonly caused by trapped fecal material and bacteria
    • Causes: Low fiber diet, chronic constipation and obesity
91. 
    
92. Low fecal volume in the colon Increased intraluminal pressure Decreased muscle strength in the colon wall Herniation/Outpoutching of mucous membrane Entrapment of fecal material and bacteria Inflammation and infection Scarring Abscess Bleeding Perforation Peritonitis Decreased muscle strength in the colon wall
93. CONDITIONS OF THE LARGE INTESTINE
    • ASSESSMENT findings for D/D
    • 1. Left lower Quadrant pain
    • 2. Flatulence
    • 3. Bleeding per rectum
    • 4. nausea and vomiting
    • 5. Fever
    • 6. Palpable, tender rectal mass
94. CONDITIONS OF THE LARGE INTESTINE
    • NURSING INTERVENTIONS
    • 1. Maintain NPO during acute phase
    • 2. Provide bed rest
    • 3. Administer antibiotics, analgesics like meperidine (morphine is not used) and anti-spasmodics
    • 4. Monitor for potential complications like perforation, hemorrhage and fistula
    • 5. Increase fluid intake
95. CONDITIONS OF THE LARGE INTESTINE
    • NURSING INTERVENTIONS
    • 6. Avoid gas-forming foods or HIGH-roughage foods containing seeds, nuts to avoid trapping
    • 7. introduce soft, high fiber foods ONLY after the inflammation subsides
    • 8. Instruct to avoid activities that increase intra-abdominal pressure
96. INTESTINAL OBSTRUCTION
97. CONDITIONS OF THE LARGE INTESTINE
    • DIAGNOSTIC STUDIES
    • 1. If no active inflammation, COLONOSCOPY and Barium Enema
    • 2. CT scan is the procedure of choice!
    • 3. Abdominal X-ray
98. Intestinal Obstruction
    • 2 Types:
    • Mechanical
    • Functional
99. Small Bowel Obstruction
    • Intestinal contents, fluid, gas accumulate above the IO abdominal distention & retention of fluid absorption of fluids stimulates more gastric secretion pressure w/n intestinal lumen venous & arteriolar capillary pressure edema, congestion rupture
100. Nursing Assessment
     • Crampy abdominal pain wavelike and colicky
     • (+) blood and mucus; (-) fecal (-) flatus
     • (+) vomiting
     • Obstruction complete reverse peristalsis
     • Ileal obstruction fecal vomiting
     • Distended abdomen
     • Signs of DHN
101. Medical Management
     • NGT
     • IVF
     • Surgery
102. LARGE BOWEL OBSTRUCTION
103. PERITONITIS
104. • Peritonitis
     • Local or generalized inflammation of part or all of the parietal and visceral surfaces of the abdominal cavity.
     • Initial response: edema, vascular congestion, hypermotility of the bowel and outpouring plasma-like fluid from the extracellular, vascular and interstitial compartments into the peritoneal space.
     • .
105. • Later response: abdominal distention leading to respiratory compromise, hypovolemia results in decreased urinary output.
     • Intestinal motility gradually decrease and progresses to paralytic ileus
106. Inflammation Adhesions Abscess Intestinal Obstruction Fluid shift into abdominal cavity (300-500 ml.)  Peristalsis Bowel distended with gas & fluid
     • Hypovolemia
     • Electrolyte imbalance
     • Dehydration
     • Shock
     Pathophysiology
107. • Medical Management
     • Fluid, colloid and electrolyte
     • O2 therapy
     • Antibiotics
     • Surgery
108. Nursing Management
     • Position on side with knees flexed
     • Monitor VS; I and O
     • Observe drainage
     • SIGNS THAT PERITONITIS IS IMPROVING:
     • 1. temperature
     • 2. pulse
     • 3. softening of the abdomen
     • 4. (+) bowel sounds (+) bowel movement
     • 5. (+) flatus
109. 
     
110. 
     
111. • Nursing Interventions
     • Assess respiratory status for possible distress.
     • Assess characteristics of abdominal pain and changes overtime.
     • Administer medications as ordered.
     • Perform frequent abdominal assessment.
     • Monitor and maintain fluid and electrolyte balance; monitor for sings of septic shock.
     • Maintain patency of NG or intestinal tubes.
     • Place client in Fowler’s position to localize peritoneal contents.
     • Provide routine pre-and post-op care if surgery ordered.
112. HEMORRHOIDS
113. • HEMORRHOIDS
     • These are dilated blood vessels beneath the lining of the skin in the anal canal
     • Two types of Hemorrhoids exist
     • External Hemorrhoids: occur below the anal sphincter
     • Internal Hemorrhoids: occur above the anal sphincter
     • Causes
     • Chronic constipation
     • Pregnancy
     • Obesity
     • Prolonged sitting and standing
     • Wearing constricting clothes
     • Disease conditions like liver cirrhosis, RSCHF (right-sided CHF)
114. • Assessment
     • Constipation in an effort to prevent pain or bleeding associated with defecation.
     • Anal pain.
     • Rectal bleeding (usually bright red-hematochezia)
     • Internal hemorrhoids may prolapse, usually painless. External hemorrhoids are usually painful.
115. 
     
116. 
     
117. • Nursing Management
     • High fiber diet, liberal fluid intake
     • Bulk laxatives
     • Hot Sitz Bath; warm compress, witch hazel cream can be applied to decrease size.
     • Local anesthetic application- Nupercaine.
118. • Surgery
     • Hemorrhoidectomy
     • Sclerotheraphy (5% phenol in oil)
     • Cryosurgery
     • Rubber-band ligation; done only if hemorrhoids are INTERNAL
     • Pre-op Care
     • Low residue diet to reduce the bulk of stool.
     • Stool softeners.
119. • Post –op Care
     • Promotion of comfort
     • Analgesics as prescribed
     • Post-op position: Side-lying position or prone position
     • Hot sitz bath 12-24 hours post-op to promote comfort and hasten healing
     • Promotion of elimination
     • Stool softeners are given as prescribed.
     • Analgesic before initial defecation
     • Encourage the client to defecate as soon as the urge occurs
     • Enema as prescribed, using small-bore rectal tube
120. • Anal Fissure
     • An elongated laceration between the anal canal and the perianal skin.
     • Anal Absess
     • Results from the obstruction of gland ducts in the anorectal region by feces, leading to infection.
     • Anal Fistula
     • Involves development of an abnormal communication between the anal canal and skin outside the anus.
     • Caused by rupture and drainage of an abscess.
121. Conditions of the Accessory Organs
122. The Gallbladder Conditions of the Accessory organs
123. CONDITION OF THE GALLBLADDER
     • Cholecystitis
     • Inflammation of the gallbladder
     • Can be acute or chronic
124. CONDITION OF THE GALLBLADDER
     • Cholecystitis
     • Acute cholecystitis usually is due to gallbladder stones
125. CONDITION OF THE GALLBLADDER
     • Cholecystitis
     • Chronic cholecystitis is usually due to long standing gall bladder inflammation
126. 
     
127. Cholelithiasis
     • Formation of GALLSTONES in the biliary apparatus
128. 
     
129. Predisposing FACTORS
     • “ F”
     • Female
     • Fat
     • Forty
     • Fertile
     • Fair
130. 
     
131. Pathophysiology
     • Supersaturated bile, Biliary stasis
     • Stone formation
     • Blockage of Gallbladder
     • Inflammation, Mucosal Damage and WBC infiltration
132. CONDITION OF THE GALLBLADDER
     • ASSESSMENT findings for cholecystitis
     • 1. Indigestion, belching and flatulence
     • 2. Fatty food intolerance
133. CONDITION OF THE GALLBLADDER
     • ASSESSMENT findings for cholecystitis
     • 3. Epigastric pain that radiates to the scapula or localized at the RUQ
     • 4. Mass at the RUQ
134. CONDITION OF THE GALLBLADDER
     • ASSESSMENT findings for cholecystitis
     • 5. Murphy’s sign
     • 6. Jaundice
     • 7. dark orange and foamy urine
135. CONDITION OF THE GALLBLADDER
     • DIAGNOSTIC PROCEDURES
     • 1. Ultrasonography- can detect the stones
     • 2. Abdominal X-ray
     • 3. Cholecystography
136. CONDITION OF THE GALLBLADDER
     • DIAGNOSTIC PROCEDURES
     • 4. WBC count increased
     • 5. Oral cholecystography cannot visualize the gallbladder
     • 6. ERCP: reveals inflamed gallbladder with gallstone
137. CONDITION OF THE GALLBLADDER
     • NURSING INTERVENTIONS
     • 1. Maintain NPO in the active phase
     • 2. Maintain NGT decompression
138. CONDITION OF THE GALLBLADDER
     • NURSING INTERVENTIONS
     • 3. Administer prescribed medications to relieve pain. Usually Demerol (MEPERIDINE)
     • Codeine and Morphine may cause spasm of the Sphincter  increased pain. Morphine cause MOREPAIN
139. CONDITION OF THE GALLBLADDER
     • 4. Instruct patient to AVOID HIGH- fat diet and GAS-forming foods
     • 5. Assist in surgical and non-surgical measures
     • 6. Surgical procedures- Cholecystectomy, Choledochotomy, laparoscopy
140. CONDITION OF THE GALLBLADDER
     • PHARMACOLOGIC THERAPY
     • Analgesic- Meperidine
     • Chenodeoxycholic acid= to dissolve the gallstones
     • Antacids
     • Anti-emetics
141. 
     
142. 
     
143. CONDITION OF THE GALLBLADDER
     • Post-operative nursing interventions
     • 1. Monitor for surgical complications
     • 2. Post-operative position after recovery from anesthesia- LOW FOWLER’s
144. CONDITION OF THE GALLBLADDER
     • Post-operative nursing interventions
     • 3. Encourage early ambulation
     • 4. Administer medication before coughing and deep breathing exercises
     • 5. Advise client to splint the abdomen to prevent discomfort during coughing
145. CONDITION OF THE GALLBLADDER
     • Post-operative nursing interventions
     • 6. Administer analgesics, antiemetics, antacids
     • 7. Care of the biliary drainageor T-tube drainage
     • 8. Fat restriction is only limited to 4-6 weeks. Normal diet is resumed
146. T-tube
147. 
     
148. Cholecystectomy/ Choledochostomy/ Choledochotomy
149. • Cholecystectomy/Choledochostomy/Choledochotomy
     • Open Cholecystectomy:
     • Choledochostomy:
     • Laparoscopic Cholecystectomy
     • Choledochotomy:
150. Pancreatitis
151. Pancreatic secretions
     • 1. Bicarbonate- to neutralize the acidic chyme from the stomach
     • 2. Pancreatic amylase- for carbohydrate digestion
152. Pancreatic secretions
     • 3. Pancreatic lipase- for fat digestion
     • 4. Trypsin and chymotrypsin- for protein digestion
153. 
     
154. Fig. 16.22
     
155. CONDITION OF THE PANCREAS
     • Pancreatitis
     • Inflammation of the pancreas
     • Can be acute or chronic
156. CONDITION OF THE PANCREAS
     • Pancreatitis
     • Etiology and predisposing factors
     • Alcoholism
     • Hypercalcemia
     • Trauma
     • Hyperlipidemia
157. CONDITION OF THE PANCREAS
     • Pancreatitis
     • Etiology and predisposing factors
     • Biliary tract disease - cholelithiasis
     • Bacterial disease
     • PUD
     • Mumps
158. 
     
159. CONDITION OF THE PANCREAS
     • PATHOPHYSIOLOGY of acute pancreatitis
     • Self-digestion of the pancreas by its own digestive enzymes principally TRYPSIN
160. CONDITION OF THE PANCREAS
     • PATHOPHYSIOLOGY of acute pancreatitis
     • Spasm, edema or block in the Ampulla of Vater  reflux of proteolytic enzymes  auto digestion of the pancreas  inflammation
161. CONDITION OF THE PANCREAS
     • PATHOPHYSIOLOGY of acute pancreatitis
     • Autodigestion of pancreatic tissue
     • Hemorrhage, Necrosis and Inflammation
     • KININ ACTIVATION will result to increased permeability
     • Loss of Protein-rich fluid into the peritoneum
     • HYPOVOLEMIA
162. CONDITION OF THE PANCREAS
     • ASSESSMENT findings
     • 1. Abdominal pain- acute onset, occurring after a heavy meal or alcohol intake
     • 2. Abdominal guarding
163. CONDITION OF THE PANCREAS
     • ASSESSMENT findings
     • 3. Bruising on the flanks and umbilicus
     • 4. N/V, jaundice
     • 5. Hypotension and hypovolemia
     • 6. Signs of shock
164. CONDITION OF THE PANCREAS
     • DIAGNOSTIC TESTS
     • 1. Serum amylase and serum lipase
     • 2. Ultrasound
     • 3. WBC
     • 4. Serum calcium
     • 5. CT scan
     • 6. Hemoglobin and hematocrit
165. CONDITION OF THE PANCREAS
     • NURSING INTERVENTIONS
     • 1. Assist in pain management. Usually, Demerol is given . Morphine is AVOIDED
     • 2. Assist in correction of Fluid and Blood loss
166. CONDITION OF THE PANCREAS
     • NURSING INTERVENTIONS
     • 3. Place patient on NPO to inhibit pancreatic stimulation
     • 4. NGT insertion to decompress distention and remove gastric secretions
     • 5. Maintain on bed rest
167. CONDITION OF THE PANCREAS
     • NURSING INTERVENTIONS
     • 7. Position patient in SEMI-FOWLER’s to decrease pressure on the diaphragm
     • 8. Deep breathing and coughing exercises
     • 9. Provide parenteral nutrition
168. CONDITION OF THE PANCREAS
     • NURSING INTERVENTIONS
     • 10. Introduce oral feedings gradually- HIGH carbo, LOW FAT
     • 11. Maintain skin integrity
     • 12. Manage shock and other complications
169. Damage to pancreatic cells Inflammation Edema of the Pancreas and Pancreatic duct Obstruction to the Flow of Pancreatic Enzyme Activation of Pancreatic Enzymes inside Pancreas AUTODIGESTION of the Pancreas Fatty Necrosis, Ulceration, Hemorrhage, Infection Pathophysiology
170. CHRONIC PANCREATITIS
     • NURSING ASSESSMENT:
     • Abdominal pain
     • LUQ mass
     • Steatorrhea and foul smelling stools
     • Weight loss
     • Muscle wasting
     • Jaundice
     • S/Sx DM
171. • NIRSING INTERVENTION
     • Diet: fat/CHON limited
     • Avoid heavy meals/alcohol
     • Supplemental vitamins
     • Pancreatic enzyme
     • Insulin
172. • Notify MD: increased steatorrhea, abdominal distention, cramping, and skin breakdown
173. Hepatitis
174. • Hepatitis
     • Infectious inflammation of the liver parenchyma caused by bacteria, viruses and other microorganisms.
     • Viral hepatitis is caused by systemic viral infections that predominantly affect the hepatocytes and cause an increase in transaminases. ALT is excreted mainly by the hepatocytes whereas AST may be excreted anywhere in the GI tract in addition to the liver. ALT is specific for hepatocyte damage; thus in viral hepatitis ALT>AST, unlike ethanol heapatitis which the opposite is true. Viral hepatitis is one of the three causes of transaminase elevation>1,000 (the other two being toxins- acetaminophen and shock liver). Cirrhosis can develop as a result of chronic hepatitis that occurs with hepatitis B and C. Fulminatic hepatic failure with massive hepatic necrosis is rare but can occur with all viral hepatitides. Viral hepatitides are caused by RNA viruses, except hepatitis B, which are caused by DNA virus.
     • There is wide spread inflammation of the liver tissue with liver cell damage due to hepatic cell degeneration and necrosis; proliferation and enlargement of the Kuppfer cells; inflammation of the perportal areas (may cause interruption of the bile flow).
175. • Viral Hepatitis A
     • Single-stranded RNA virus transmitted via fecal-oral route predominantly. Poor hygiene or contaminated food and shellfish increase risk of transmission. There is no transplacental transmission. It carries the risk of fulminant hepatitis. There is incubation period: 15-45 days.
     • Viral Hepatitis B
     • Hepatitis B is caused by a DNA virus, identified in all body fluids, blood, saliva, synovial fluid, breast milk, ascites, cerebral spinal fluid, etc. Transmitted by blood and body fluids (saliva, semen, vaginal secretions): often from contaminated needles among IV drug abusers; intimate/ sexual contact. Hepatitis B accounts for 50% of cases of fulminant hepatitis. In an adult who develops acute hepatitis B, there is approximately 10% chance that it will progress into chronic hepatitis; in the neonate the chance is 90% for chronic hepatitis. Incubation period is very long: 1-6 months.
176. • Viral Hepatitis C
     • This is caused by a single-stranded RNA virus that is generally transmitted predominantly by blood products. Currently it is the most common hepatitis among IV drug abusers and in prisons. Before 1990 it accounted for 90% of transfusion hepatitis. Risk for sexual transmission is present but much lower that with hepatitis B (<5%).>
177. 
     
178. • Viral Hepatitis D
     • Caused by an RNA virus that affects either simultaneously with hepatitis B or as a super-infection in a person with chronic hepatitis B. Hepatitis D infection cannot occur unless there is current and ongoing replication of the hepatitis B virus. Overall this infection carries the highest risk among acute viral hepatitis for fulminant disease; the risk is even greater in super-infection. Predominantly seen in patients exposed to blood products (drug addicts and hemophiliacs). If anti-HBs antibodies are present, then that person is immune to hepatitis B and D.
     • Viral Hepatitis E
     • Similar to hepatitis A with fecal or oral transmission, there is no chronic form. The risk of fulminant disease has been described mainly in preganant patients.
179. 
     
180. 
     
181. • Assessment findings
     • Preicteric stage
     • Anorexia, nausea and vomiting, fatigue, constipation or diarrhea, weight loss.
     • Right upper quadrant discomfort, hepatomegaly, splenomegaly, lymphadenopathy.
     • Icteric stage
     • Fatigue, weight loss, light-colored stools, dark urine.
     • Continued heapatomegaly with tenderness, lymphatomegaly, splenomegaly
     • Jaundice, pruritus.
     • Posticteric stage
     • Fatigue, but an increased sense of weel-being, hepatomegaly gradually decreasing
182. • Pathophysiology of Viral Hepatitis
     • There is Diffuse Inflammatory Infiltration of Hepatic Tissue with Mononuclear Cells and local, spotty or single cell necrosis
     • Preicteric (prodromal phase)- lasts for 1 week. Assessment: Elevated temperature and chills, nausea and vomiting, dyspnea, anorexia (the major manifestation) headache, arthralgia, tenderness in RUQ, weakness, general malaise, weight loss, hepatomegaly and lymphadenopathy.
     • Icteric Phase: Starts with the onset of jaundice, it reaches its intensity in 2 weeks and lasts from 4 to 6 weeks= worsening of anorexia, anausea and vomiting, dyspnea, weakness and malaise and liver tenderness increases.
     • Posticteric Phase: Begins with the disappearance of jaundice, normally lasts for several weeks up to 4
183. • Decrease Ammonia formation
     • Restrict protein in the diet
     • Duphalac (lactulose)
     • Neomycin sulfate
     • Tap water or NSS enema
     • Avoid sedatives and paracetamol.
     • Avoid ASA.
     • Avoid Hypokalemia
184. • Diagnostic tests
     • All 5 types of hepatitis
     • SGPT, SGOT or AST, alkaline, phosphatase, bilirubin, ESR: all increased (preicteric)
     • Leukocytes, lymphocytes, neutrophils: all decreased (pericteric)
     • Prolonged PT
     • Hepatitis A
     • Hepatits A virus (HAV) in stool before onset of disease
     • Anti-HAV (IgM): positive in acute infection; indicating a recent exposure.
     • Anti-HAV (IgG) appears soon after onset of jaundice; indicates previous exposure and life-long immunity.
185. • Hepatitis B
     • HBsAG (surface antigen): positive, develops 4-12 weeks after injection (in the acute phase.
     • Anti-HBsAG: negative in 80% of cases. If positive alone, indicates prior immunity via vaccination. If core antibody (anti-HBc) is also present his point toward a previous infection and immunity.
     • Anti-HBc: associated with infectivity, develops 2-16 weeks after infection
     • HBeAg: associated with infectivity and disappears before jaundice
     • Anti-HBe: present in carriers, represents low jaundice
     • Hepatitis C
     • Antibody to hepatitis C (anti-HCV) is usually posititve.
     • HCV RNA polymerase chain reaction is the most sensitive way to detect hepatitis C
186. • Nursing Interventions
     • Promote adequate nutrition.
     • Administer anti-emetics as ordered, 30 minutes before meals to decrease occurrence of nausea and vomiting
     • Provide small, frequent meals of a high-carbohydrate, moderate- to high-protein, high vitamin, high- calorie intake
     • Avoid very hot or very cold foods
     • Ensure rest/ relaxation: plan schedule for rest and activity periods, organize nursing care to minimize interruption.
     • Monitor/ relieve pruritus
     • Administer corticosteroids are ordered.
     • Institute isolation procedures are required: pay special attention to good hand-washing technique and adequate sanitation.
     • In hepatitis A administer immune serum globulin (ISG) early to exposed individuals as ordered.
187. • In hepatitis B
     • Screen donors for HBsAg.
     • Use disposable needles an syringes.
     • Instruct client/ others to avoid sexual intercourse while disease is active.
     • Administer ISG to exposed individuals as ordered.
     • Administer hepatitis B immunoglobulin (HBIG) as ordered to provide temporary and passive immunity to exposed individuals.
     • To produce active immunity, administer hepatitis B vaccine to those individuals at high risk.
     • In non-A, non-B: use disposable needles and syringes; ensure adequate sanitation.
     • Provide client teaching and discharge planning concerning
     • Importance of avoiding alcohol
     • Avoidance of persons with known infections
     • Balance of activity and rest periods
     • Importance of not donating blood
     • Dietary modifications
     • Recognition and reporting of signs of inadequate convalescence: anorexia, jaundice, increasing liver tenderness/ discomfort.
     • Techniques/ importance of good personal hygiene
188. • General Preventive Measures
     • Hand washing by all persons
     • Feces, urine, blood and other fluids are considered potentially infectious and should be disposed properly.
     • Contaminated needles and other equipment that comes in contact with infected blood and body fluids, disposable and non-disposable needles, syringes and other equipment used in patient care must be handled with great care; discarded in appropriate containers.
     • Preventive Measures Used with Persons with Known Hepatitis
     • For clients with known hepatitis A, enteric precautions should be implemented
     • For clients with Hepatits B; non-A, non-B hepatitis; blood and body fluid precaution should be observed
     • Instruct clients with viral hepatitis not to donate blood.
     • Advise client with acute hepatitis B; non-A, non-B hepatitis or delta hepatitis not to have intimate sexual contact during the period of infection.
189. • Summary of Collaborative Management in Viral Hepatitis
     • Promotion of rest to relieve fatigue
     • Maintenance of food and fluid intake
     • 3,000 ml/day of fluids for fever and vomiting; monitor I and O, weight
     • Well-balanced diet; encourage fruit juices and carbonated beverages
     • Fats may need to be restricted
     • Alcoholic beverages should be avoided
     • Prevention of injury
     • Prolonged prothrombin time leads leads to bleeding tendencies
     • Monitor urine and stools for fresh or old blood; the skin for petechiae
     • Monitor prpthrombin time, hematocrit and hemoglobin
     • Plan so that all blood samples are collected at one time to avoid several punctures
     • Avoid parenteral injections, if possible
190. • Apply pressure to injection sites and venipuncture sites for minutes
     • Advise client to use soft toothbrush or swabs
     • Administer vitamin K as ordered
     • Provision of comfort measures
     • Relaxing baths, bakrubs, fresh linens and quiet dark environment
     • Relieve pruritus through the following measures:
     • Use of cool, light, non- restrictive clothing
     • Use of soft, dry, clean bedding, use of warm baths
     • Application of emollient creams and lotions to dry skin
     • Maintenance of cool environment
     • Administration of antihistamines as ordered
     • Use of diversional activities, e.g. reading, TV and radio
191. Cirrhosis of the Liver
192. LIVER Normal Function 1. Stores glycogen 2. Synthesizes proteins 3. Synthesizes globulins 4. Synthesizes Clotting factors 5. Secreting bile 6. Converts ammonia to urea 7. Stores Vitamims and minerals 8. Metabolizes estrogen
193. • Liver function test:
     • AST aspartate aminotransferase formerly SGOT 4.8 - 19 U/L
     • ALT alanine aminotransferase formerly SGPT 2.4 - 7 U/L highly specific
194. Liver Biopsy
195. Jaundice
     • a symptom of a disease
     • yellow pigmentation of the skin
     • due to accumulation of bilirubin pigment
     • usually observed first in the sclera
     • kernicterus (brain) fatal
196. 
     
197. Hemolytic Jaundice
     • due to:
     • rapid RBC destruction increased in indirect, unconjugated or B2
     • due to transfusion reaction or EBF
198. Obstructive Jaundice
     • due to:
     • biliary atresia
     • inflammation of the biliary tract
     • tumors
     • cholestatic agent
     • total bilirubin is increased
     • bile is dammed into the liver and reabsorbed into the circulatory
     • s/sx:
     • deep orange, foamy urine
     • dark tea colored urine
     • clay colored stool
     • severe itchiness
     • steatorrhea
199. Hepatic Jaundice
     • due to:
     • Diseased liver (hepatitis or cirrhosis)
     • Inability of the liver to clear normal amount of bilirubin from the blood
     • Increased bilirubin and albumin
200. Jaundice Management:
     • Control pruritus
     • calamine
     • baking soda
     • NaHCO3
     • Antihistamine
     • Soothing baths
     • Drug
     • Cholestyramine = it binds bile salts in the intestine and eliminated via feces.
     • Look for the cause and manage it
201. • Cirrhosis of the Liver
     • Chronic, progressive disease characterized by inflammation, fibrosis and degeneration of the liver parenchymal cells
     • Destroyed liver cells are replaced by scar tissue, resulting in architectural changes and malfunction of the liver
202. • Types
     • Laennec’s cirrhosis: associated with alcohol abuse and malnutrition
     • Biliary cirrhosis: associated with biliary obstruction
     • Post necrotic cirrhosis
     • Cardiac cirrhosis
203. Pathogenesis:
     • repeated destruction of hepatic cell  scar tissue formation (fibrotic)  regeneration of liver cell follows  another destruction will occur  cycle (scarring and regeneration) will be repeated until hepatocytes becomes fibrotic and liver function is compromised
204. 
     
205. 
     
206. Pathophysiology Alcohol abuse Leonnec’s Cirrhosis Malnutrition Infection Postnecrotic Cirrhosis Drugs Biliary Obstruction- Biliary Cirrhosis RSCHF- Cardiac Cirrhosis Destruction of HEPATOCYTES FIBROSIS/SCARRING Obstruction of blood flow Increase Pressure in the venous and sinusoidal channels Fatty infiltration FIBROSIS/SCARRING PORTAL HYPERTENSION } }
207. • Assessment of Liver Cirrhosis
     • Portal HPN and the consequences are:
     • Hepatomegaly = initially then the liver shrinks in size as fibrosis replaces the liver parenchyma
     • Splenomegaly = due to increased backpressure of the blood
     • Caput medusae (dilated veins over the abdomen)
     • Spider angioma (telangiectasia / dilated capillaries over the face and the anterior trunk) = due to increased estrogen.
     • Palmar erythema . This is also due to estrogen level in males.
208. • PORTAL HYPERTENSION
     • Esophageal varices
     • Fluid extravasation
     • Ascites and edema
209. •  collateral circulation
     • vein distention (angioma)
     • hemorrhoids
     • spiderangioma (red dot)
     • palmar erythema
     • telangiectasia (permanent)
     • esophageal varices
210. Caput Medusae
211. ASCITES
     • HYPOALBUMINEMIA
     • DECREASED METABOLISM OF ALDOSTERONE
212. • Males (increased estrogen) will result to:
     • Gynecomastia
     • Decreased libido
     • Impotence
     • Fall of body hair
     • Atrophy of testicles
     • Females (Increased androgen)
     • Hirtuism
     • Acne
     • Deepening of voice
     • Virilism
213. Esohageal Varices
214. • Esophageal Varices
     • Definition:
     • ETIOLOGY:
     • Emergency condition
     • ASSESSMENT findings for EV
     • Hematemesis
     • Melena
     • Ascites
     • Jaundice
     • hepatomegaly/splenomegaly
     • Signs of Shock
215. • DIAGNOSTIC PROCEDURE
     • Esophagoscopy to locate the bleeding site
216. CONDITION OF THE ESOPHAGUS
     • NURSING INTERVENTIONS FOR EV
     • 1. Monitor VS strictly. Note for signs of shock
     • 2. Monitor for LOC
     • 3. Maintain NPO
217. CONDITION OF THE ESOPHAGUS
     • NURSING INTERVENTIONS FOR EV
     • 4. Monitor blood studies
     • 5. Administer O2
     • 6. prepare for blood transfusion
218. CONDITION OF THE ESOPHAGUS
     • INTERVENTIONS FOR EV
     • 7. prepare to administer Vasopressin and Nitroglycerin
     • 8. Assist in NGT and Sengstaken-Blakemore tube insertion for balloon tamponade
219. CONDITION OF THE ESOPHAGUS
     • NURSING INTERVENTIONS FOR EV
     • 9. Prepare to assist in surgical management:
     • Endoscopic sclerotherapy
     • Variceal ligation
     • Shunt procedures
220. • If bleeding esophageal varices occur:
     • Place in semi-Fowler’s position to prevent aspiration
     • Suction the mouth
     • Administer vasopressin as ordered
     • Gastric lavage with tap water (room temperature saline) as ordered.
     • Sclerotherapy
     • Balloon tamponade with the use of Sengstaken – Blakemore tube
     • Variceal band ligation
     • Portasystemic shunting
     • Portacaval
     • Splenorenal
     • Mesocaval
221. • Nursing Interventions
     • Provide sufficient rest and comfort.
     • Bed rest with bathroom privileges.
     • Encourage gradual, progressive, increasing activity with planned rest periods.
     • Institute measures to relieve pruritus.
     • Bath with tepid water followed by application of an emollient lotion.
     • Provide cool, light, nonrestrictive clothing.
     • Keep nails short to
     • Apply cool, moist compresses to pruritic areas.
     • Promote nutritional intake.
     • Small frequent feedings.
     • Promote a high calorie, low to moderate protein, high carbohydrate, low fat diet, with supplemental vitamin therapy (vitamins A, B-complex, C, D, K and folic acid)
     • Prevent infection
     • Frequent turning and skin care.
     • Reverse isolation for clients with severe leucopenia
     • Monitor WBC.
222. • Monitor/prevent bleeding.
     • Administer diuretics as ordered.
     • Provide client teaching and discharge planning concerning.
     • Avoidance of hepatotoxic agents ( sedatives, opiates, or OTC drugs detoxified by the liver).
     • Avoid infections, DHN, Fever
     • Avoidance of all alcohol.
     • Avoidance of straining at stool, vigorous blowing of nose and coughing to decrease the incidence of bleeding.
223. 
     
224. Liver physiology and Pathophysiology Normal Function Abnormality in function 1. Stores glycogen = Hypoglycemia 2. Synthesizes proteins = Hypo-proteinemia 3. Synthesizes globulins =Decreased Antibody formation  risk for INFECTION 4. Synthesizes Clotting factors = Bleeding tendencies 5. Secreting bile = Jaundice and pruritus 6. Converts ammonia to urea =Hyper-ammonemia 7. Stores Vitamims and minerals =Deficiencies of Vit and min 8. Metabolizes estrogen = Gynecomastia, testes atrophy
225. • HEPACTIC ENCEPHALOPATHY
     • Is due to increased AMMONIA levels. The liver cannot convert ammonia by products of protein metabolism into Urea Hepatic coma
     • The initial manifestations are BEHAVIORAL changes and MENTAL changes.
     • Advance Stage :
     • Asterixis –
     • Confusion / disorientation
     • Delirium / hallucination
     • Fetor hapaticus
226. • Summary of Collaborative Management
     • Rest. To reduce metabolic demands of the liver.
     • Diet
     • Early stage
     • High calorie, HIGH carbohydrates, LOW protein that is restricted to complete protein only, moderate fats.
     • Late stage
     • HIGH calorie, HIGH carbohydrates, LOW protein.
     • Skin care
     • Avoid trauma/injury
     • Prevent infection
227. • Decrease Ammonia formation
     • Restrict protein in the diet
     • Duphalac (lactulose)
     • Neomycin sulfate
     • Colchicine
     • Tap water or NSS enema
     • Avoid sedatives and paracetamol.
     • Avoid ASA.
     • Avoid Hypokalemia
228. • Manage Ascites
     • Monitor weight, intake and output, abdominal girth
     • Restrict sodium and fluid intake
     • Administer diuretics as ordered
     • Initially, K – sparring diuretic
     • Later, K- wasting diuretic
     • Administer albumin / IV as ordered assist in paracentesis
229. Abdominal Paracentesis
     • Withdrawal of fluid from the peritonealspace
     • Purpose: diagnostic and therapeutic
     • Pretest: consent, empty bladder
     • Position: sitting
     • Site: midway between the umbilicus and symphysis
230. Abdominal Paracentesis
     • Intratest: 1,500 ml maximum amount collected at one time, Monitor VS
     • Post-test : monitor VS, bleeding complication
     • Measure abdominal girth and weight
231. 
     
232. COLORECTAL CANCER
233. • COLORECTAL CANCER
     • Cause: Unknown
     • Predisposing factors:
     • Age above 40 years
     • Diet
     • Low in fiber
     • High in fat, protein and refined carbohydrates
     • Obesity
     • History of IBD, familial polyposis or colon polyps
     • Family history of colon cancer
     • Most common site: Rectosigmoid area (70%)
234. • Assessment
     • Ascending (right) Colon Cancer
     • Occult blood in stool
     • Anemia
     • Anorexia and weight loss
     • Abdominal pain above umbilicus
     • Palpable mass
     • Distal colon/ Rectal cancer
     • Bright rectal bleeding
     • Changed bowel habits
     • Constipation or Diarrhea
     • Pencil or ribbon- shaped stool
     • Tenesmus
     • Sensation of incomplete bowel emptying
235. • Duke’s Classification of Colorectal Cancer
     • Stage A: confined to bowel mucosa, 80-90% 5 –year survival rate
     • Stage B: invading muscle wall
     • Stage C: lymph node involvement
     • Stage D: metastases or locally respectable tumor, less than 5%- 5- year survival rate.
236. 
     
237. • Guidelines for Early Detection of Colorectal Cancer
     • Digital rectal examination yearly after age 40-45
     • Occult blood test yearly after age 50
     • Protosigmoidoscopy every 5 years after age 50, following 2 negative results of yearly examination
     • Collaborative Management
     • Surgery
     • Hemicolectomy
     • Abdomino-Perineal Resection (APR) for rectosigmoid cancer
     • Chemotherapy
     • Fluorouracil is the most effective drug for colorectal cancer
     • Radiotherapy
     • Adjuvant therapy for rectal cancer
238. • Medical Management: chemotherapy, radiation therapy, bowel surgery
     • Colonic surgery
     • Pre-op care
     • Provide psychosocial support
     • Through bowel cleansing
     • Diet modification
     • Low residue diet 3 to days preop, to reduce the bulk of the stool in the colon
     • Clear liquid diet 24 hours preop
     • Mechanical cleansing
     • Laxatives as ordered
     • Cleansing enema as ordered
     • Pharmacologic suppression of colon bacteria
     • Neomycin sulfate tablets to reduce bacterial flora. (it is poorly absorbed in the colon, thereby enhance excretion of colonic bacteria).
     • Vitamin C and K supplement because these are lost during repeated enema administration.
239. • Type of Colostomies
     • Ascending Colostomy
     • Stoma is on the right abdomen
     • Fecal drainage is watery
     • Transverse (Double-Barreled) Colostomy
     • The right stoma is also called proximal stoma; closest to the small intestine; drains semi-formed feces.
     • The left stoma is also called distal stoma; drains mucus
     • Transverse Loop Colostomy
     • Has 2 openings in the transverse colon, but one stoma
     • Indicated in IBD’s
     • Descending and Sigmoid Colostomy
     • Stoma on the left abdomen
     • Fecal drainage is well-formed
240. • Post-op Care
     • Managing the perineal wound (APR)
     • May require up to 6 months to completely heal
     • Wound irrigations with normal saline and absorbent dressings until wound closes .
     • Drainage is initially copious and sero-sanguinous, to be drained at regular basis to prevent infection and abscess formation
     • T-binder is used to secure perineal dressing
     • Sitz baths once the patient is ambulatory
     • Foam pads or soft pillows to promote comfort when sitting
     • Side-lying position during sleep
     • Stoma Monitoring
     • The stoma is pinkish to cherry red and with slight edema for 5-7 days
     • Dark, dusky , or brown –black stoma indicates ischemia and necrosis
     • The stoma should protrude by ½ to ¾ inch over abdomen
     • Flatus and fecal drainage usually begin in 3 to 6 days, as peristalsis returns
     • Empty the pouch when it is 1/3 to ½ full of stool
     • Loop colostomy is opened 48-72 hours post-op, with cautery at bedside.
241. • Teaching for Self-care
     • Stoma Care
     • Gently encourage the client to look at the stoma
     • Inform that the stoma has no touch of pain sensation
     • Instruct to report immediately any purple or black discoloration of stoma.
     • Cleanse the stoma initially with antiseptic
     • Skin Care
     • Wash the skin with warm water, pat dry.
     • Assess skin for signs of irritation or infection
     • When pouch seal leaks, change pouch immediately
     • Use skin barrier to protect the peristomal skin from liquid stool e.g. karaya preparation.
     • Skin infection caused by Candida Ablicans is treated with nystatin (Mycostatin) powder.
242. • Colostomy Irrigation
     • Initially colostomy irrigation is done to stimulate peristalsis, subsequent irrigations are done to promote evacuation of feces at a regular and convenient time
     • Recommendation with sigmoid colostomy
     • Initiated 5 to 7 days Post-op
     • Done in semi-Fowler’s position; then sitting on a toilet bowl once ambulatory
     • Use warm normal saline solution
     • Initially, introduce 200 ml. of NSS then 500 to 1,000 ml. Subsequently
     • Dilate stoma with lubricated gloved finger before insertion of catheter
     • Lubricate catheter before insertion
     • Insert 2 to 4 inches of the catheter into the stoma
     • Height of solution is 18 inches above the stoma
     • If abdominal cramps occur during introduction of solution, temporarily stop the flow of solution until peristalsis relaxes
     • Allow the catheter to remain in place for 5 to 10 minutes for better cleansing effect; then remove catheter to drain for 15 to 20 minutes
     • Clean the stoma, apply stoma, apply new pouch
243. • Managing Odor
     • Avoid Gas – forming and foul odor foods, e.g. dairy products, highly seasoned foods, fish, cabbage, celery, cauliflower, eggs, carbonated beverages, nuts.
     • Rinse pouch with tepid water or weak vinegar solution
     • Place deodorant tablet or small amount of mouthwash or a piece of charcoal into the pouch
     • Do not use pulverized ASA- it causes irritation of the stoma and damages the colostomy appliance.
244. • Supporting a Positive Self-Concept
     • Encourage to view the stoma
     • Encourage to verbalize feelings, fears and concern about stoma
     • Encourage to participate in colostomy care.
     • Encourage gradually resume all usual activities
     • Avoid tight belts or waistbands over the stoma
     • Advise to always carry colostomy supplies when traveling
     • Resolving grief
     • Encourage client to express feelings of loss
     • Explore client’s usual coping strategies for handling grief
     • Preventing Sexual Dysfunction
     • Explore positions that minimizes stress and pressure on the pouch
     • Empty and clean the pouch before sexual activity
     • Use smaller – sized pouch or pouch cover during sexual activity
     • Use of a binder of special underwear to hold the pouch secure
245. • Home care instructions for colostomy.
     • Instruct the colostomy patient to change the stoma appliance as needed, to wash the stoma site with warm and mild soap every 2-3 days and to change the adhesive layer as needed. These measures will prevent irritation and excoriation .
     • Discuss dietary restrictions and suggestions to prevent blockage of the stoma, diarrhea, flatus, and odor. Tell patient to start on low fiber diet initially and then gradually introduce fiber foods.
     • Corn, dried beans, onions, cabbage, fish, spicy dishes and some antibiotics can cause odor. Apples, melons, avocados and cantaloupe are additional foods that can cause excessive gas.
     • Advise to drink liberal amount of fluids especially in hot weather and diarrhea.