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Medical Surgical Nursing:Gastrointestinal Disorder
Medical Surgical Nursing:Gastrointestinal Disorder
Medical Surgical Nursing:Gastrointestinal Disorder
Lecture Note
Chronic Inflammatory Bowel Disease
(IBD)
It is used to designate two chronic
inflammatory GI disorders:
1) Regional enteritis (Crohn's Disease)
2) Ulcerative Colitis:-It is very serious
and high mortality rate.
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Regional enteritis (Crohn's Disease)
Epidemiology;
commonly occurs in adolescents or
young adults.
It is more common in older women
population (50 and 80).
Most common affected areas are the
distal ileum and colon.
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Cont…d
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Cont…d
Clinical Manifestations
Insidious onset
Prominent lower right quadrant
abdominal pain (crampy).
Diarrhea
Weight loss
Malnutrition
Secondary anemia
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Cont…d
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Cont…d
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Cont…d
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Cont…d
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Cont…d
Intestinal biopsy
CT scan ( for bowel thickness and fistula
formation identification)
CBC
ESR
Albumin and protein levels
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Complications
Intestinal obstruction/stricture formation.
Perianal disease.
Fluid and electrolyte imbalances.
Malnutrition.
Fistula.
Abscess formation.
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Ulcerative Colitis
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Cont…d
C/M
Diarrhea (10 t0 20 liquid stools daily)
Abdominal pain
Intermittent tenesmus
Rectal bleeding
Hypocalcemia
Anemia
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Cont…d
Anorexia
Weight loss
Fever
Vomiting
Dehydration
Rebound tenderness may occur in the
right lower quadrant.
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Cont…d
Extraintestinal symptoms;
Skin lesions (eg, erythema
nodosum)
Eye lesions (eg, uveitis)
Joint abnormalities (eg, arthritis),
Liver disease.
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Cont…d
Diagnostic evaluation
Careful steel exam;
to r/o amoeba (dysentry)
is positive for blood
CBC
Low hgb & Hct level
Elevated WBC
Sigmoidoscopy & barium enema
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Cont…d
CT scanning
Magnetic resonance imaging
Ultrasound
Abdominal x-ray
Barium enema
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Cont…d
Complication
Perforation
Hemorrhage
Malignant neoplasm
Toxic mega colon
Osteoporosis
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Medical Management of Chronic
Inflammatory Bowel Disease
Management depends on the disease location,
severity, and complications.
The goal of the management is: -
1.To reduce the inflammation
2.To suppress in appropriate immune response
3.To provide rest for the diseased bowel
4.To improve quality of life and
5.To prevent complications
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Cont…d
Nutritional therapy
Advice to have a low residual, high protein,
high-calorie diet with supplemental vitamin
therapy & iron supplement.
Advice to take oral fluids/ IV fluids as
tolerated.
Advice to avoid any food (milk) which
exacerbate diarrhea.
Advice to avoid smoking and cold foods.
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Cont…d
Pharmacologic therapy
Sedatives
Anti-diarrheal/ anti peristaltic
Amino salicylate (eg, sulfasalazine)
Corticosteroids (eg, prednisone)
Antibiotics (sulfapyridine, metronidazole)
Immunomodulators (eg, azathioprene, 6-
mercaptopurine, methotrexate, cyclosporin)
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Cont…d
Surgical management
The surgical procedure is termed as
proctocolectomy with ileostomy.
Indication includes;
Profuse bleeding
Perforation/Stricture forming ulcers.
Development of cancer
Lake of improvement with medical
managements.
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Cont…d
Nursing management
Education about diet, medications,
about management of the ostomy and
referral to support groups.
Careful monitoring, parenteral
nutrition, fluid replacement.
Emotional support if surgery is done.
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Comparison between UC and RE
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Intestinal obstruction
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Cont…d
Paralytic ileus
Hernia
Gallstones ileus
Tumor
Ascaris bolus
Intusscusption (It is the small bowel
telescopes, as if it were swallowing itself
by invagination. It is the commonest
problem in infants.)
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Intusscusption
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Cont…d
C/M of SBO
Sudden Colicky pain intermittent with
10 -20 minute Interval.
Initial Vomiting
Normal Stool may be passed or
bloody.
Restless, dehydration &cry
Distention is late
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Cont…d
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Cont…d
SBO LBO
Abdominal crampy Abdominal crampy
Vomiting early S/S Constipation is
Constipation late early S/S
sign
Grossly distended
Abdominal
abdomen
distention
Fecal vomiting
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Cont..d
SBO… LBO…
Diagnostic method- Diagnostic method-Hx &
Hx & P/E. P/E.
Abdominal X-ray Abdominal x-rays reveals
indicates abnormal abnormally distended
quantities of gas &/or colon.
air in the bowel.
Colonoscopy may be
Decompression of the
bowel through NG performed to untwist &
tube. decompress the bowel in
high colon obstruction.
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Cont…d
SBO… LBO…
IV fluid ( N/S or R/L ) In lower bowel
administered to replace obstruction rectal tube
electrolyte and water. may be used for
Surgical Intervention is decompression.
needed. Surgical Intervention if it
More severe because is caused by tumor
most of the GI content Iv fluid administration.
are absorbed in this part. Minor unless necrosis
occurred.
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Cont…d
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Cont…d
Abdomen
Distended
Mild tenderness on palpation
Visible loop but not always
Tympanic on percussion
Bowel sound may be absent or increase
Empty rectum or hard stool
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Cont…d
CBC
Hgb
V/A
Abdominal x-ray
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Cont…d
Medical Management:
A) General Management
Keep the patient NPO
NG tube should be inserted for small bowel
obstruction to aspirate intestinal content.
Secure IV line ( Normal Saline or ringer
Lactate )
Triple antibiotic ( Ampicillin,
Gentamycin,& CAF )
Sedation
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Cont…d
B) Specific RX
Sigmoid Volvulus :-
Rectal tube is inserted for deflation but
contraindicated if gangrenous.
Laparatomy.
1) If loop is viable= de-rotation
2) If gangrenous= resection &
Colostomy
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Hernias
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Cont…d
Predisposing factors:-
Constipation
Ascites
Previous abdominal surgery
Lifting heavy load
Chronic Cough
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Classifications of hernias
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Cont…d
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Cont…d
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Cont…d
2. Based on severity
i) Reducible Hernia :- The protruding
mass can be replaced in abdomen.
ii) Irreducible Hernia :- The protruding
mass cannot be moved back into
abdomen.
iii) Incarcerated: - An irreducible hernia
in which the intestinal flow is completely
obstructed.
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Cont…d
Treatment
1) Mechanical ( reducible hernia only)
A truss is an appliance having a pad
that is held snugly in the hernial
orifice.
Does not cure a hernia - it prevents
abdominal contents from entering
hernial sac.
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Cont…d
2) Surgical
Recommended to correct the hernia before
a strangulation occurs which then becomes
on emergency situation.
I. Hernial Sac, is dissected free
II.Contents of sac, are replaced in abdominal
cavity.
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Cont…d
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Disorders of the rectum
1) Haemorrhoids
Def: - It is an enlarged & congested patch of
mucosa & sub-mucosa at anorectal junction or
Are dilated portions of veins in the anal canal.
Sites: - at 3, 7, 11 O'clock, on lithotomy position.
Hemorrhoid based on its site:-
1) Internal hemorrhoid (if it is above internal
sphincter.)
2) External ( if it is outside external sphincter)
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Cont…d
C/F
Bright red blood occurring at the end of
defecation (Late)
Mass Per-rectum
Peri-anal Discomfort
Pruritus
Mucosal Discharge
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Cont…d
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Classification of heamorhoids based
on its stage(severity)
a) 1st degree:- Bleed but no prolapsed
b) 2nd degree :- Prolapsed but reduce
spontaneously
c) 3rd degree :- but need manual
replacement
d) 4th degree :- not returned.
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Cont…d
Etiology: - idiopathic
Predisposing factor:-
Chronic Constipation
Excessive use of purgative
Pelvic masses ( Pregnancy )
Portal HTN
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Cont…d
Rx:
Regulating bowel by laxatives
Avoid Constipation
Advice high - residue diet that
contain fruit.
Sitz bath
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Cont…d
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Cont…d
B) Cryosurgical Hemorrhoidectomy
Involves freezing the tissue of the hemorrhoid
for a sufficient time to cause necrosis.
Not used widely because the discharge is very
foul-smelling & wound healing is prolonged.
C) Hemorrhoidectomy, or surgical excision, can
be performed to remove all of the redundant
tissue involved in the process.
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Ano-rectal Abscess
Def:
It is an infection in the para-rectal
spaces.
Risk Factors:
Regional enteritis
Immuno-defcient States (HIV/AIDS)
Many of these abscesses will result in
fistulas.
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Cont…d
C/M:
Abscess may occur in a variety of spaces in
& around the rectum.
Pain
Foul - Smelling pus
In Superficial abscess, (Swelling, redness &
tenderness).
Deeper abscess ( Fever, abdominal Pain )
Fistula
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Cont…d
Mx :
1) Palliative Rx;
Sitz Bath
Analgesics
2) Surgical Rx:-
Incision & drainage
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Anal fistula
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Cont…d
C/M
Pus or stool may leak constantly from the
cutaneous opening
Passage of flatus or feces from the vaginal or
bladder depending on the fistulas tract.
Fever
Mgx
Surgery is always recommended
Fistulectomy (excision of the fistulous tract)
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Anal fissure
Def:
It is a longitudinal tear or ulceration in the
lining of the anal canal
Cause:
Trauma of passing a large firm stool
Persistent tightening of the anal canal secondary
to stress or anxiety (leading to Constipation)
Child birth
Trauma
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Cont…d
C/M
Extremely Painful Defecation
Burning
Bleeding
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Cont…d
Mgx
Increase water intake
Sitz bath
Emollient Suppositories
Corticosteroid Suppositories (Relieve
Discomfort)
Surgery
*Most of the fissures will heal by conservative
measures.
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Cancer of the large intestine:
Colon & Rectum
Tumors of the small intestine are rare;
conversely tumors of the colon &
rectum are relatively common.
Cause: - Unknown
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Percentage distribution of colorectal
cancer
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Cont…d
Risk factors:-
Age: - incidence increases with age (most
patients are over age 55). It is the most
common cancer in old age except for
prostates cancer in men.
Family history of colon cancer
Chronic inflammatory bowel disease
Polyp
A diet high in fat, protein, & beef & low in
fiber
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Cont…d
C/M
It is determined by the location, stage of
cancer & function of the intestinal
segment.
Unexplained anemia
Anorexia
Weight loss
Fatigue
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Cont…d
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Cont…d
Diagnostic Evaluation
Fecal occult blood testing
Barium enema
Procto-sigmoidoscopy
Colonoscopy
Biopsy or cytology smears.
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Cont…d
Medical Mgx
The patient with symptoms of
intestinal obstruction is treated with
IV fluids & nasogastric Suction.
Treatment depends on the stage of
the disease & related complications.
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Cont…d
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Cont…d
Radiation Therapy
Surgical Removal
It is primary treatment
Indicated for most class A- lesions & all class- B
and C.
Segmental Resection with anastomosis
Temporary Colostomy followed by segmental
resection & anastomosis
Permanent Colostomy or ileostomy
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Cont…d
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Nursing Care for Patient with
Colostomy
Colostomy;
Is the surgical creation of an opening
(stoma) into the colon.
It can be temporary or permanent
divertion.
It allows for the drainage or evacuation
of colon contents to the outside of the
body.
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Cont…d
Colostomy Irrigation;
It is washing out of the intestinal content
through the stoma.
Indication
a) It is done to permit escape of feces when
there is an obstruction of the large bowel
or a known lesion, such as cancer, that
will eventually cause an obstruction.
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Cont…d
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