Module 3

Learning Outcomes:
The Learner will be able to:
1. Identify major disorders affecting absorption
2. Apply knowledge on assessment to determine critical assessment cues in
clients with problems in absorption
3. Identify appropriate nursing diagnosis in clients with problems in
absorption
4. Create a nursing care plan with appropriate interventions for clients with
problems in absorption
5. Apply appropriate evaluation criteria to determine status of patients with
problems in absorption

MAJOR DISORDERS OF THE GASTROINTESTINAL TRACT AFFECTING

ABSORPTION

Malabsorption Syndrome
Data Base
A. Etiology and pathophysiology
1. Etiology unknown; possible hereditary factor
2. Nontropical sprue similar to celiac disease in children and is characterized by intolerance to gluten,
abnormalities in the structure of the small intestine, and malabsorption
3. Tropical sprue is endemic in the Indian subcontinent and the Caribbean and is thought to be due to
infection rather than diet
4. Intolerance to gluten results in blunting of the intestinal villi, which reduces absorptive surface of the
intestinal mucosa
5. Intolerance to lactose causes osmotic retention of water and results in cramping and diarrhea
B. Clinical findings
1. Subjective
a. Anorexia
b. Fatigability; weakness
c. Abdominal discomfort
2. Objective
a. Weight loss
b. Anemia (macrocytic)
c. Diarrhea
d. Steatorrhea
e. Visualization of the small bowel demonstrates flat, blunt villi
f. Tetany
g. Demineralization of the skeletal system
C. Therapeutic interventions
1. Tropical sprue may respond to a high-protein, normal-fat diet with supplemental vitamin B12, A, D, E, K,
folic acid, and iron; in addition, antibiotics such as tetracycline for at least 6 months
may be helpful
2. Nontropical sprue may respond to a high-protein, normal-fat, gluten-gliadin-free diet and vitamin
supplements of A, D, K, B complex, and folic acid, as well as iron and calcium
3. Whenever the disease does not respond to diet, corticosteroids may be used
4. Fluid and electrolyte imbalances must be resolved
Nursing Care of Clients with Malabsorption Syndrome
A. Assessment
1. History of symptoms and causative factors
2. History of bowel habits
3. Stool for diarrhea and steatorrhea
4. Presence and extent of bowel sounds
B. Analysis/Nursing Diagnoses
C. Planning/Implementation
1. Teach the client and family how to modify the diet to comply with medical management
2. Instruct family that rice, corn, and soy flours should be used in place of wheat, rye, barley, and oats
3. Inform the client of the importance of reading labels, because gluten-containing grains are added to
many products, and of the need to question the contents of foods in restaurants
4. Advise the client as to the importance of follow-up care for disease management
5. Provide an opportunity for the client and family to verbalize feelings about the illness
6. Observe the client for signs of electrolyte imbalance
7. Record weight on a regular basis
D. Evaluation/Outcomes
1. Maintains or regains weight appropriate for height, age, and frame
2. Reports decreased number of bowel movements
3. Maintains fluid and electrolyte balance
4. Client and family verbalize feelings
5. Follows dietary recommendations

Appendicitis
Data Base
A. Etiology and pathophysiology
1. Compromised circulation and inflammation of the vermiform appendix
2. Causes include obstruction by a fecalith, foreign body, or kinking
3. Inflammation may be followed by edema, necrosis, and rupture
B. Clinical findings
1. Subjective
a. Anorexia
b. Nausea
c. Right lower quadrant pain (McBurney's point)
d. Rebound tenderness
e. Abdominal distention and paralytic ileus if appendix is ruptured
2. Objective
a. Vomiting
b. Fever
c. Leukocytosis
C. Therapeutic interventions
1. Surgical removal of the appendix without delay to decrease the chance of rupture and the risk of
peritonitis
2. Prophylactic use of antibiotics postoperatively
3. Fluid and electrolyte maintenance
4. Analgesics for pain
Nursing Care of Clients with Appendicitis
A. Assessment
1. History of characteristics of pain and presence of nausea and vomiting
2. Presence of anorexia or the urge to pass flatus
3. Presence of rebound tenderness when palpating abdomen
4. Presence of tenderness/rigidity when palpating McBurney's point
5. Temperature for baseline data
6. Presence and extent of bowel sounds
B. Analysis/Nursing Diagnoses
C. Planning/Implementation
1. Provide emotional support because this condition is unanticipated and the individual needs to ventilate
any fear of surgery
2. Monitor fluid and electrolyte balance
3. Assess the client for signs of infection; maintain a semi-Fowler's position to help localize infection if the
appendix ruptures
4. Encourage early ambulation, if not contraindicated by the client's condition, to prevent complications
5. Assess the client's return of bowel function (bowel sounds, flatus, bowel movement)
D. Evaluation/Outcomes
1. States pain is alleviated
2. Maintains adequate fluid balance
3. Verbalizes feelings

Regional Enteritis
Data Base
A. Etiology and pathophysiology
1. Etiology unknown
2. Usually occurs in young adults, but can occur at any age
3. Inflammatory changes involving any part of the alimentary tract but usually demarcated segments of
the small bowel
4. Ulceration of the intestinal submucosa accompanied by congestion, thickening of the small bowel, and
fissure formations
5. Enlargement of regional lymph nodes
6. Fibrosis and narrowing of the intestinal wall
7. Abscesses and fistulas of the abdominal wall, bladder, and vagina
B. Clinical findings
1. Subjective
a. Pain in the lower right quadrant, cramping, and spasms
b. Nausea
c. Exacerbations related to emotional upsets or dietary indiscretions with milk, milk products, and fried
foods
2. Objective
a. Borborygmus (rumbling, gurgling sound in the intestines), flatulence
b. Weight loss
c. Fever
d. Electrolyte disturbance
e. Diarrhea
f. Gastrointestinal x-ray series to detect and outline the congested, thickened, fibrosed, and narrowed
appearance of the intestinal wall; also abscesses and fistulas, partial bowel obstruction, and ulceration of
the mucosa
g. Proctosigmoidoscopy is performed to exclude other diseases, such as ulcerative colitis and diverticulitis
h. Stools are examined for the presence of blood, fat, protein, parasites, or ova
i. Fecal fat test is performed to determine fat content, an abnormal amount of which is significant in
malabsorptive disorders or hypermotility
j. D-xylose tolerance test is performed to determine absorptive ability of upper intestinal tract
C. Therapeutic interventions
1. Nothing by mouth in the presence of vomiting
2. Clear fluid diet progressing to bland, low-residue, low-fat diet, but increased calories, proteins, vitamins
(especially vitamin K), and carbohydrates
3. Total parenteral nutrition (TPN) may be ordered when oral intake is inadequate
4. Medications such as:
a. Antiemetics
b. Vitamins and minerals
c. Anticholinergics
d. Antidiarrheals
e. Antiinflammatories
f. Antiinfectives
5. Surgery (resection of diseased part) if the client does not respond to medical therapy or if
complications such as obstruction, abscesses, or fistulas occur
Nursing Care of Clients with Regional Enteritis
A. Assessment
1. Increased bowel motility on auscultation
2. Weight for baseline data
3. History of frequency, color, and consistency of stools
4. Presence and extent of bowel sounds
B. Analysis/Nursing Diagnoses
C. Planning/Implementation
1. Monitor intake and output
2. Offer clear liquids hourly as ordered once the client ceases to experience nausea and vomiting
3. Encourage high-calorie, high-protein, high-carbohydrate diet supplemented with vitamins and
potassium as ordered
4. Assist with total parenteral nutrition (TPN) if ordered
5. Offer small, frequent feedings considering client preference, types of food allowed, and esthetic factors
6. Record weight daily
7. Observe for signs of complications such as elevated temperature, increasing nausea and vomiting,
abdominal rigidity
8. Communicate concern and awareness regarding the client's discomfort and emotional lability during
exacerbations of this chronic illness
9. Teach the client:
a. To avoid taking laxatives and salicylates that irritate the intestinal mucosa
b. How to take antidiarrheals and mucilloid drugs effectively and the observations to make during their
use
c. Skin care if the perineal area is irritated
d. The importance of seeking help early when exacerbations occur
D. Evaluation/Outcomes
1. Reports a reduction in pain
2. Has a decrease in the number of bowel movements
3. Maintains adequate nutritional status
4. Maintains fluid and electrolyte balance
5. Maintains perianal skin integrity

Ulcerative Colitis
Data Base
A. Etiology and pathophysiology
1. May be caused by emotional stress, an autoimmune response, or a genetic predisposition
2. Edema of the mucous membrane of the colon leads to bleeding and shallow ulcerations
3. Abscess formation occurs, and the bowel wall shortens and becomes thin and fragile
4. Associated with increased risk of colon cancer
B. Clinical findings
1. Subjective
a. Weakness, debilitation
b. Anorexia
c. Nausea
2. Objective
a. Dehydration with tenting of skin (poor skin turgor)
b. Passage of bloody, purulent, mucoid, watery stools
c. Anemia
d. Low-grade fever
C. Therapeutic interventions
1. Dietary management
a. Diet plays a major role in the management of colitis; emphasis has changed from a low-residue diet to
a more liberal diet (restricted roughage may be useful during more acute attacks of severe cramps,
diarrhea, and bleeding, but seems to have little effect on preventing relapses); supplementing diet with
raw bran has been shown to be effective in controlling bouts of diarrhea and constipation
b. If tolerated, unrestricted fluid intake; high-protein, high-calorie diet; avoidance of food allergens,
especially milk
2. Pharmacologic management
a. Antiemetics
b. Anticholinergics
c. Corticosteroids
d. Antibiotics
e. Sedatives, analgesics, and tranquilizers
f. Antidiarrheals
3. Replacement of fluids and electrolytes that are lost because of diarrhea
4. A temporary ileostomy, a partial colectomy, or a total colectomy with a permanent ileostomy may be
performed when:
a. No response to medical treatment is evident
b. Course of the disease is downhill
c. Massive hemorrhage or colonic obstruction occurs
d. Cancer is suspected
Nursing Care of Clients with Ulcerative Colitis
A. Assessment
1. Localized areas of tenderness found over diseased bowel on palpation
2. History of patterns and characteristics of bowel elimination
3. Feces for color, consistency, and characteristics
4. Temperature and weight for baseline data
5. Presence and extent of bowel sounds
B. Analysis/Nursing Diagnoses
C. Planning/Implementation
1. Instruct client to adhere to the following dietary program
a. Eat small, frequent feedings of high-protein, high-calorie foods (low fat helps decrease steatorrhea,
which is common with ileal involvement; if steatorrhea is present, vitamins A and E may be required as
supplements)
b. Avoid irritating spices such as red or black pepper
c. Replace iron, calcium, and zinc losses with supplements; if there is ileal involvement, intramuscular
injections of vitamin B12 may be prescribed monthly to reduce anemia
d. Avoid all food allergens, especially milk (milk has been implicated as a direct cause of colitis in infants
and is often associated with diarrhea in adults); milk may be reintroduced when client is relatively
asymptomatic; however, lactose intolerance is common in this condition and dairy restrictions may be
permanent (some lactose-intolerant individuals can manage yogurt, buttermilk, and hard cheeses; lactase
enzyme preparations are available that can be added to milk products to hydrolyze lactose)
2. Teach importance of diet in controlling and/or minimizing symptoms
3. Involve the client in dietary selection, recognizing preferences as much as possible
4. Initiate accurate administration and recording of fluid, electrolyte, or blood replacements as ordered by
the physician
5. Plan nursing care to allow the client complete bed rest and the maximum number of rest periods
6. Provide gentle, thorough perineal care as required
7. Observe for complications such as rectal hemorrhage, fever, dehydration
8. Allow the client and family time to verbalize feelings and participate in care
9. If an ileostomy is performed, help the client accept the changes of body image and function involved;
usual activities can be resumed but contact sports must be avoided
10. Anticipate that stress can influence peristalsis
D. Evaluation/Outcomes
1. Maintains or regains weight
2. Reports decrease in pain
3. Adheres to medical regimen
4. Maintains skin integrity
5. Establishes an acceptable pattern of soft, formed bowel movements
6. Client or family member demonstrates ability to perform ostomy care

Crohn's Disease
Data Base
A. Etiology and pathophysiology
1. Although the causative mechanisms are unknown, there are various theories involving genetic
predisposition, autoimmune reaction, or environmental causes
2. Cobblestone ulcerations form along the mucosal wall of the terminal ileum, cecum, and ascending
colon, which form scar tissue and inhibit food and water absorption in the area
3. Ulcerations may perforate through the intestinal wall and form fistulas with adjoining organs
B. Clinical findings
1. Subjective
a. Severe pain in the right lower quadrant
b. Malaise
2. Objective
a. Moderate fever
b. Elevated WBCs
c. Mild diarrhea with mucus but no blood
d. Anemia
C. Therapeutic interventions
1. High-calorie, high-protein diet
2. Vitamin supplements, including B12, if a large portion of ileum is involved; usually administered
parenterally to control dosage
3. Pharmacologic management
a. Anticholinergics
b. Analgesics
c. Intestinal antibiotics
d. Immunosuppressives
4. Surgery when fistulas or intestinal obstruction occurs; the involved area of intestine is removed and the
ends are anastomosed, if possible; an ostomy is indicated if large areas of intestine are involved
Nursing Care of Clients with Crohn's Disease
A. Assessment
1. Weight and temperature for baseline data
2. Feces for color, consistency, and steatorrhea
3. Tenderness and guarding of the abdomen, especially in the right lower quadrant
4. Presence and extent of bowel sounds
B. Analysis/Nursing Diagnoses
C. Planning/Implementation
1. Provide an emotionally therapeutic environment in which client can communicate concerns and
stresses resulting from this illness
2. Instruct client regarding dietary restrictions and modifications
3. Observe client for signs of fluid and electrolyte imbalances
D. Evaluation/Outcomes
1. Reports decreased frequency of stool
2. Maintains or regains weight
3. Describes decrease in pain
4. Complies with treatment regimen
5. Reports reduced feelings of stress
6. Remains free from infection
7. Client or family member demonstrates ability to perform ostomycare