NCM112 LECTURE

MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

TOPIC OUTLINE: esophageal strictures, adenocarcinoma, and pulmonary
complications.
ALCON, MARY GRACE
AQUINO, JVY MARIE ASSESSMENT AND DIAGNOSTIC FINDINGS
AZUTEN, ZYZA-ZHOLEY
BALLESTA, ERIKA  History
BORJA, RIVERT JAMES  Ambulatory pH monitoring (gold standard for the
CARTUJANO, DAZLYNE diagnosis of GERD or a PPI trial.
CASTERAL, EILEITHIA CHYAVANNA
CORPUZ, MARK ANTHONY Note: Ambulatory pH monitoring involves transnasal
DERY, JOHN BRYAN catheter placement or endoscopic wireless capsule
TACCAD, HANNAH placement for approximately 24 hours.
TALOSIG, KEZIAH
SOMERA, KARLA MAE  Endoscopy or barium swallow is used to evaluate
damage to the esophageal mucosa and rule out strictures
I. DISTURBANCES IN INGESTION and hernias.
1.1. GERD
1.2. Hiatal hernia MANAGEMENT
1.3. Achalasia
II. DISTURBANCES IN DIGESTION  Educating the patient to avoid situations that decrease
2.1. Nausea and vomiting lower esophageal sphincter pressure or cause
2.2. Gastrointestinal bleeding esophageal irritation.
2.3. Gastritis  Lifestyle modifications include tobacco cessation, limiting
2.4. Peptic ulcer alcohol, weight loss, elevating the head of the bed,
III. DISTURBANCES IN ABSORPTION AND avoiding eating before bed, and altering the diet
ELIMINATION
 If medical management is unsuccessful, open or
3.1. Disorders of intestinal motility
laparoscopic Nissen fundoplication which involves
3.2. Malabsorption syndrome
wrapping of a portion of the gastric fundus around the
3.3. Structural obstructive bowel disorder
sphincter area of the esophagus.

I. DISTURBANCES IN INGESTION COMMONLY USED TO MANAGE GERD

 Antacids/Acid Neutralizing agents (e.g. calcium

GASTROESOPHAGEAL REFLUX DISEASE (GERD)
 A fairly common disorder marked by backflow of gastric
or duodenal contents into the esophagus that causes
troublesome symptoms and/or mucosal injury to the
esophagus.
 Excessive reflux may occur because of an incompetent
lower esophageal sphincter, pyloric stenosis, hiatal
hernia, or a motility disorder.
 “Increase with aging” and is seen in patients with irritable
bowel syndrome and obstructive airway disorder
exacerbations (e.g., asthma, COPD, cystic fibrosis)
peptic ulcer disease, and angina.
NOTE: GERD is associated with tobacco use, coffee
drinking, alcohol consumption, and gastric infection with
Helicobacter pylori.
CLINICAL MANIFESTATIONS
 Pyrosis (heartburn, a burning sensation in the esophagus
that is noncardiac in nature)
 Regurgitation
 Dyspepsia (indigestion)
 Dysphagia or odynophagia
 Hypersalivation
 Esophagitis
Note: GERD can result in dental erosion, ulcerations in
the pharynx and esophagus, laryngeal damage,
carbonate, aluminum hydroxide, magnesium hydroxide
and simethicome, alginate
 Histamine-2 (H2) receptor antagonists (e.g.
famotidine, cimetidine)
 Prokinetic agents (metoclopramide)
 Proton pump inhibitors (PPIs) (First-line drugs used.
e.g. Pantoprazole, Omeprazole, Esomeprazole,
Lansoprazole, Rabeprazole, Dexlansopraz)
 Reflux inhibitors (Bethanechol chloride)
 Surface agents/Alginate-based barriers (Sucralfate)
 Inhibitors of transient lower esophageal sphincter
relaxations (TLESRs) (Baclofen)
HIATAL HERNIA
 Occurs when the opening in the diaphragm through
which the esophagus passes becomes enlarged,
and part of the upper stomach moves up into the
lower portion of the thorax.
TYPES OF HIATAL HERNIA
 Sliding Hiatal Hernia (Type 1)
o happens when stomach and esophagus
slide into and out of chest through the
hiatus.
o mainly don’t bring on any symptoms and
might not require treatment.
 Fixed Hiatal Hernia
o some portion of stomach pushes through
diaphragm and remains there.

BSN 3B | PBL GROUP 1 1

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

o there is a risk that blood supply to stomach
could get blocked.  Barrium swallow - The test involves swallowing a
chalky-tasting, thick mixture of barium while X-rays
RISK FACTORS are taken. The barium shows the outline of the
esophagus and lower esophageal sphincter (LES)
 Those over the age of 50
 Pregnant women  CT scan of the chest - performing a chest CT scan
 Obesity in a timely fashion in patients with prolonged
 More common in women than men complaints such as chest discomfort, dysphagia, or
eating disorders, is highly important to avoid a
CLINICAL MANIFESTATIONS delayed diagnosis of achalasia.

 Acid reflux that deteriorates when you lean over or
lie down
 Epigastric pain or chest pain
 Problem swallowing
 Belching
ASSESSMENT AND DIAGNOSTIC FINDINGS
 X-ray
 Barium swallow
 Esophagogastroduodenoscopy (EGD)
 Esophageal manometry
 Chest CT Scan
NURSING MANAGEMENT
 Frequent, small feedings that can pass easily
through the esophagus.
 The patient is advised not to recline for 1 hour after
eating, to prevent reflux or movement of the hernia.
 Elevate the head of the bed on 4 to 8 inch to prevent
the hernia from sliding upward.
 Hiatal hernia may not be avoided completely,
however, certain measure can be taken from
exacerbating a hernia by losing weight, avoiding
lifting of heavy items, avoiding tight belts and
abdominal exercises.
ACHALASIA
 condition in which the muscles of the lower part of
the esophagus fail to relax, preventing food from
passing into the stomach.
 absent or ineffective peristalsis of the distal
esophagus accompanied by failure of the
esophageal sphincter to relax in response to
swallowing.
 may progress slowly
 occurs most often in people between ages 20 and 40
and ages 60 and 70 years
CLINICAL MANIFESTATIONS
 dysphagia
 report non cardiac chest or epigastric pain
 pyrosis (heartburn)
ASSESSMENT AND DIAGNOSTIC FINDINGS
 Xray - show esophageal dilation above the
narrowing at the lower gastroesophageal sphincter,
which is called a birds beak deformity.
 Endoscopy - reveals a dilated esophagus that
contains retained food; it may also reveal
inflammation, small ulcers caused by residual food or
pills, and candida (yeast) infection.
 High-resolution manometry - considered the gold
standard for the diagnosis of achalasia; primary
method used to evaluate esophageal motor function;
Displayed and interpreted by esophageal pressure
topography (EPT), HRM/ EPT provides a detailed
assessment of esophageal function.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 Patient is instructed to eat slowly and to drink fluids
with meals.
 Injection of botulinum toxin into quadrants of the
esophagus via endoscopy has been helpful because
it inhibits the contraction of smooth muscle.
 May be treated conservatively by pneumatic
dilation to stretch the narrowed area of the
esophagus.
 May be treated surgically by esophagomyotomy,
called a Heller myotomy, which involves cutting the
esophageal muscle fibers.
 A complete lower esophageal sphincter
myotomy is usually performed laparoscopically, with
or without a fundoplication (antireflux procedure that
minimizes the incidence of GERD).
 A newer technique, an endoscopic myotomy (per-
oral endoscopic myotomy [POEM]) provides an
alternative procedure that has been adopted by
many high-volume achalasia centers.
II. DISTURBANCES IN DIGESTION
NAUSEA AND VOMITING
 symptoms of different conditions such as stomach
flu, food poisoning, motion sickness, overeating,
blocked intestine, illness, concussion, or brain
injury, appendicitis, and migraines.
 Nausea: uneasiness of the stomach that often
accompanies the urge to vomit
 Vomiting: forcible voluntary or involuntary emptying
("throwing up") of stomach contents through the
mouth - can occur in both children and adults

BSN 3B | PBL GROUP 1 2

NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
CAUSES
 Adults - a result of a viral infection and food
poisoning, and occasionally a result of motion
sickness and illnesses in which the person has a
high fever
 Children - viral infection, food poisoning, motion
sickness, overeating or feeding, coughing, and
illnesses in which the child has a high fever.
PREVENTION
 Nausea
o Eating small meals throughout the day
instead of three large meals
o Eating slowly
o Avoiding hard-to-digest foods
o Consuming foods that are cold or at room
temperature to avoid becoming nauseated
from the smell of hot or warm food
o Resting after eating and keeping your
head elevated about 12 inches above your
feet helps reduce nausea.
o If you feel nauseated when you wake up in
the morning, eat some crackers before
getting out of bed or eat a high protein
snack (lean meat or cheese) before going
to bed.
o Drink liquids between (instead of during)
meals, and drink at least six to eight 8-
ounce glasses of water a day to prevent
dehydration.
o Try to eat when you feel less nauseated.
 Vomiting
o consuming small amounts of clear,
sweetened liquids such as soda pop, fruit
juices (except orange and grapefruit
because these are too acidic) and
popsicles.
o Drinks containing sugar calm the stomach
better than other liquids.
o Rest either in a sitting position or in a
propped lying position.
o Activity may worsen nausea and may lead
to vomiting.
MANAGEMENT
 Nausea
o Drink clear or ice-cold drinks.
o Eat light, bland foods (such as saltine
crackers or plain bread).
o Avoid fried, greasy, or sweet foods.
o Eat slowly and eat smaller, more frequent
meals.
o Do not mix hot and cold foods.
o Drink beverages slowly.
o Avoid activity after eating.
o Avoid brushing your teeth after eating.
o Choose foods from all the food groups as
you can tolerate them to get adequate
nutrition.
 Vomiting
BSN 3B | PBL GROUP 1
o Drinking gradually larger amounts of clear
liquids
o Avoiding solid food until the vomiting
episode has passed
o Resting
o Temporarily discontinuing all oral
medications, which can irritate the
stomach and make vomiting worse
 ** Vomiting and diarrhea > 24 hrs: oral
rehydrating solution to prevent and treat
dehydration
 Note: Consult physician if vomiting lasts for more
than one week
GASTROINTESTINAL BLEEDING
 Gastrointestinal (GI) bleeding is a symptom of a disorder in
your digestive tract. It can occur from any part of the GI
tract that runs from your mouth to your anus. The blood
often appears in stool or vomit but isn't always visible,
though it may cause the stool to look black or tarry. The
level of bleeding can range from mild to severe and can be
life-threatening.
 Sophisticated imaging technology, when needed, can
usually locate the cause of the bleeding. Treatment depends
on the source of the bleeding.
CAUSES
 Gastrointestinal bleeding can occur either in the upper or
lower gastrointestinal tract. It can have a number of causes.
 Upper GI bleeding
o Peptic ulcer. This is the most common cause of
upper GI bleeding. Peptic ulcers are sores that develop
on the lining of the stomach and upper portion of the
small intestine. Stomach acid, either from bacteria or
use of anti-inflammatory drugs, damages the lining,
leading to formation of sores.
o Tears in the lining of the tube that connects your
throat to your stomach (esophagus). Known as
Mallory-Weiss tears, they can cause a lot of bleeding.
These are most common in people who drink alcohol to
excess.
o Abnormal, enlarged veins in the esophagus
(esophageal varices). This condition occurs most
often in people with serious liver disease.
o Esophagitis. This inflammation of the esophagus is
most commonly caused by gastroesophageal reflux
disease (GERD).
 Lower GI bleeding
o Diverticular disease. This involves the development of
small, bulging pouches in the digestive tract
(diverticulosis). If one or more of the pouches become
inflamed or infected, it's called diverticulitis.
o Inflammatory bowel disease (IBD). This includes
ulcerative colitis, which causes inflammation and sores
in the colon and rectum, and Crohn's disease, and
inflammation of the lining of the digestive tract.
o Tumors. Noncanerous or cancerous tumors of the
esophagus, stomach, colon or rectum can weaken the
lining of the digestive tract and cause bleeding.
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 NCM112 LECTURE
MEDICAL-SURGICAL NURSING
o Colon polyps. Small clumps of cells that form on
the lining of your colon can cause bleeding. Most
are harmless, but some might be cancerous or can
become cancerous if not removed.
o Hemorrhoids. These are swollen veins in your
anus or lower rectum, similar to varicose veins.
o Anal fissures. These are small tears in the lining
of the anus.
o Proctitis. Inflammation of the lining of the rectum
Healthcare providers perform a thorough assessment that starts with
can cause rectal bleeding.
you describing your symptoms. To identify the source of the bleed
and how severe it is, you will need to undergo testing.
TYPES OF GI BLEEDING
 Acute: Sudden, severe bleeding that’s a sign of a
medical emergency.
 Chronic: Bleeding that comes and goes over a long
time.
 Occult: Bleeding is not visible as it is microscopic, but
you can see signs of GI blood loss (such as low blood
counts) on laboratory testing.
 Overt: Visible signs of a GI bleed, including abnormal
colors or substances in your feces (poop). You may
also vomit blood.
 Obscure: When standard endoscopy testing does not
reveal a source of GI bleeding.
SYPMTOMS
Signs and symptoms depend on the location of the bleed, which
can be anywhere on the GI tract, from where it starts — the
mouth — to where it ends — the anus — and the rate of
bleeding.
Overt bleeding might show up as:
 Vomiting blood, which might be red or might be dark
brown and resemble coffee grounds in texture
 Black, tarry stool
 Rectal bleeding, usually in or with stool
With occult bleeding, you might have:
 Lightheadedness
 Difficulty breathing
 Fainting
 Chest pain
 Abdominal pain
Symptoms of shock
If your bleeding starts abruptly and progresses rapidly, you could
go into shock. Signs and symptoms of shock include:
 Drop in blood pressure
 Not urinating or urinating infrequently, in small amounts
 Rapid pulse
 Unconsciousness
Acute GI bleed symptoms come on suddenly and are often
severe. It’s important to seek immediate medical care if you
notice:
 Dizziness or faintness (syncope).
 Difficulty urinating.
BSN 3B | PBL GROUP 1
 Rapid pulse, which can make you feel anxious or like your
heart is fluttering.
 Shock, which occurs when there isn’t enough blood flow to
your organs.
HOW IS GI BLEEDING DIAGNOSED
WHAT TYPES OF TESTING MIGHT NEED
 Blood tests check for signs of GI bleeds, such as anemia,
using a sample of your blood.
 Fecal occult blood test (FOBT) is a lab test that checks for
signs of blood in a poop sample.
 CT scan is a sophisticated imaging study that uses
technology to produce 3D, enhanced views of your
intestines.
 GI X-rays take images of your upper or lower digestive tract
to check for signs of a bleed or other conditions. The tests
use a barium contrast solution that makes it easier to see
the digestive tract on the X-ray.
 Upper endoscopy is a procedure to examine symptoms of
an upper GI bleed. It uses a long tube with a camera and
light at the tip (endoscope).
 Balloon enteroscopy is like an endoscopy. It uses long
tubes and a camera. Tiny balloons at the endoscope tip
inflate to help providers examine hard-to-reach small bowel.
 Colonoscopy or sigmoidoscopy is a procedure to
examine signs of a lower GI bleed. The test uses
endoscopes that are passed through the anus.
PREVENTION
 Taking nonsteroidal anti-inflammatory medicines
(NSAIDs) and aspirin only when necessary.
 Limiting alcohol use.
 Quitting tobacco if you regularly use it.
 Getting treatment to keep symptoms of GI conditions, like
diverticulitis, well managed.
 Checking for infections like helicobacter pylori, if one is at
risk, which can cause ulcers.
GASTRITIS
 inflammation of the gastric or stomach mucosa.
 a common GI problem, and affects women and men
about equally.
 may be acute, lasting several hours to a few days, or
chronic, resulting from repeated exposure to irritating
agents or recurring episodes of acute gastritis.
 A more severe form of acute gastritis is caused by
the ingestion of strong acid or alkali, which may
cause the mucosa to become gangrenous or to
perforate. Scarring can occur, resulting in pyloric
stenosis (narrowing or tightening) or obstruction.
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MEDICAL-SURGICAL NURSING
CLASSIFICATIONS

 EROSIVE - most often caused by local irritants

such as aspirin and other nonsteroidal anti-
inflammatory drugs (NSAIDs) (e.g., ibuprofen);
corticosteroids; alcohol consumption; and
gastric radiation therapy.
 NON – EROSIVE - most often caused by an
infection with a spiral-shaped gram-negative
bacterium, Helicobacter pylori (H. pylori). It is
estimated that 50% of individuals globally are
infected with H. pylori.
 ACUTE GASTRITIS - may develop in acute
illnesses, especially when the patient has had
major traumatic injuries, burns, severe infection,
lack of perfusion to the stomach lining, or major
surgery. This type of acute gastritis is often
referred to as stress-related gastritis or ulcer.
 CHRONIC GASTRITIS - often classified
according to the underlying causative
mechanism, which most often includes an
infection with H. pylori. Chronic H. pylori
gastritis is implicated in the development of
peptic ulcers, gastric adenocarcinoma (cancer),
and gastric mucosa–associated lymphoid tissue
lymphoma.
 may also be caused by a chemical gastric
injury (gastropathy) as the result of long-term
drug therapy (e.g., aspirin and other NSAIDs) or
reflux of duodenal contents into the stomach,
which most often occurs after gastric surgery
(e.g., gastrojejunostomy,

BSN 3B | PBL GROUP 1 5

NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
gastroduodenostomy). Autoimmune disorders such as
Hashimoto thyroiditis, Addison disease, and Graves
disease are also associated with the development of
chronic gastritis.
PATHOPHYSIOLOGY
 Gastritis is defined by a breakdown of the mucosal
barrier, which normally protects stomach tissue from
digestive juices (e.g., hydrochloric acid [HCl] and
pepsin). The compromised mucosal barrier allows
corrosive HCl, pepsin, and other irritating agents (e.g.,
alcohol, NSAIDs, H. pylori) to encounter the gastric
mucosa, resulting in inflammation. This inflammation
is usually brief and self-limiting in acute gastritis. The
edematous stomach mucosa is caused by
inflammation and hyperemic (fluid and blood
congested) as well as undergoing superficial erosion.
Erosive illness can cause superficial ulceration, which
can lead to hemorrhage. Chronic gastritis is caused
by recurrent or persistent assaults that cause chronic
inflammatory alterations and finally atrophy (or
thinning) of the stomach tissue (Norris, 2019).
CLINICAL MANIFESTATIONS
The patient with acute gastritis may have a rapid onset of
symptoms, such as:
 epigastric pain or discomfort
 dyspepsia (indigestion; upper abdominal discomfort
associated with eating)
 anorexia
 hiccups
 nausea and vomiting, which can last from a few
hours to a few days.
Erosive gastritis may cause:
 bleeding, which may manifest as blood in vomit or as
melena (black, tarry stools; indicative of occult blood
in stools) or hematochezia (bright red, bloody stools)
The patient with chronic gastritis may complain of:
 fatigue
 pyrosis (a burning sensation in the stomach and
esophagus that moves up to the mouth; heartburn)
 after eating, belching, a sour taste in the mouth,
halitosis
 early satiety
 anorexia
 nausea and vomiting.
BSN 3B | PBL GROUP 1
NOTE: Some patients may have only mild epigastric
discomfort or report intolerance to spicy or fatty foods or
slight pain that is relieved by eating (Akiva & Greenwald,
2019). Patients with chronic gastritis may not be able to
absorb vitamin B12 because of diminished production of
intrinsic factor by the stomach’s parietal cells due to
atrophy, which may lead to pernicious anemia. Some
patients with chronic gastritis have no symptoms.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 The definitive diagnosis of gastritis is determined by
an ENDOSCOPY AND HISTOLOGIC
EXAMINATION OF A TISSUE SPECIMEN
OBTAINED BY BIOPSY.
 A COMPLETE BLOOD COUNT (CBC) may be
drawn to assess for anemia as a result of
hemorrhage or pernicious anemia.
MEDICAL MANAGEMENT
 The gastric mucosa is capable of repairing itself after
an episode of acute gastritis. As a rule, the patient
recovers in about 1 day, although the patient’s
appetite may be diminished for an additional 2 or 3
days. Acute gastritis is also managed by instructing
the patient to refrain from alcohol and food until
symptoms subside. When the patient can take
nourishment by mouth, a nonirritating diet is
recommended. If the symptoms persist, intravenous
(IV) fluids may need to be given. If bleeding is
present, management is similar to the procedures
used to control upper GI tract hemorrhage.
 Therapy is supportive and may include nasogastric
(NG) intubation, antacids, histamine-2 receptor
antagonists (H2 blockers) (e.g., famotidine,
cimetidine), proton pump inhibitors (e.g.,
omeprazole, lansoprazole), and IV fluids (Wehbi
et al., 2019).
 Fiberoptic endoscopy may be necessary.
 A gastric resection or a gastrojejunostomy
(anastomosis of jejunum to stomach to detour
around the pylorus) may be necessary to treat gastric
outlet obstruction, also called pyloric obstruction, a
narrowing of the pyloric orifice, which cannot be
relieved by medical management.
 Chronic gastritis is managed by modifying the
patient’s diet, promoting rest, reducing stress,
recommending avoidance of alcohol and
NSAIDs, and initiating medications that may
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NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
include antacids, H2 blockers, or proton pump
inhibitors (Akiva & Greenwald, 2019).
 H. pylori may be treated with select drug
combinations which typically include a proton
pump inhibitor, antibiotics, and sometimes
bismuth salts.
NURSING MANAGEMENT
 REDUCING ANXIETY - The patient may be anxious
because of pain and planned treatment modalities.
The nurse uses a calm approach to assess the
patient and to answer all questions as completely as
possible.
 PROMOTING OPTIMAL NUTRITION - The nurse
discourages the intake of caffeinated beverages,
because caffeine is a central nervous system
stimulant that increases gastric activity and pepsin
secretion. The nurse also discourages alcohol use.
Discouraging cigarette smoking is important. The
level of nicotine measured in gastric acid can be 10
times greater than arterial blood and 80 times greater
than venous blood. Nicotine will increase secretion of
gastric acid and will also interfere with the mucosal
barrier in the GI tract (Berkowitz, Schultz, Salazar, et
al., 2018). When appropriate, the nurse initiates and
refers the patient for alcohol counseling and smoking
cessation programs.
 PROMOTING FLUID BALANCE - Daily fluid intake
and output are monitored to detect early signs of
dehydration (minimal fluid intake of 1.5 L/day, urine
output of less than 1 mL/kg/h). If food and oral fluids
are withheld, IV fluids (3 L/day) usually are
prescribed and a record of fluid intake plus caloric
value (1 L of 5% dextrose in water = 170 calories of
carbohydrate) needs to be maintained. Electrolyte
values (sodium, potassium, chloride) are assessed
every 24 hours to detect any imbalance. The nurse
must always be alert to any indicators of hemorrhagic
gastritis, which include hematemesis (vomiting of
blood), tachycardia, and hypotension. All stools
should be examined for the presence of frank or
occult bleeding. If these occur, the primary provider
should be notified, and the patient’s vital signs are
monitored as the patient’s condition warrants.
 RELIEVING PAIN - The nurse must regularly assess
the patient’s level of pain and the extent of comfort
achieved through the use of medications and
avoidance of irritating substances.
PROMOTING HOME, COMMUNITY-BASED, AND
TRANSITIONAL CARE
 The nurse evaluates the patient’s knowledge about
gastritis and develops an individualized education plan
that includes information about stress management, diet,
and medications. Dietary instructions take into account the
patient’s daily caloric needs as well as cultural aspects of
food preferences and patterns of eating. The nurse and
patient review foods and other substances to be avoided
(e.g., spicy, irritating, or highly seasoned foods; caffeine; without an identifiable cause. Many patients with peptic ulcers
nicotine; alcohol).
BSN 3B | PBL GROUP 1
 The nurse reinforces previous education and conducts
ongoing assessment of the patient’s symptoms and
progress. Patients with malabsorption of vitamin B12 need
information about lifelong vitamin B12 injections; the nurse
may instruct a family member or caregiver how to
administer the injections or make arrangements for the
patient to receive the injections from the primary provider.
Finally, the nurse emphasizes the importance of keeping
follow-up appointments with the primary provider
PEPTIC ULCER
 A peptic ulcer is an excavation (hollowed-out area)
that forms in the mucosa of the stomach, in the
pylorus, in the duodenum, between the stomach and
the jejunum, or in the esophagus.
 Erosion of a circumscribed area of mucosa is the
cause and this erosion may extend as deeply as the
muscle layers or through the muscle to the
peritoneum.
 A peptic ulcer may be referred to as a gastric,
duodenal, or esophageal ulcer, depending on its
location.
 Peptic ulcers are more likely to occur in the
duodenum than in the stomach. As a rule, they occur
alone but they may occur in multiples.
 Chronic gastric ulcers tend to occur in the lesser
curvature of the stomach, near the pylorus.
Esophageal ulcers occur as a result of the backward
flow of HCl from the stomach into the esophagus
(GERD).
 Most peptic ulcers result from infection with H. pylori,
which may be acquired through ingestion of food and
water.
RISK FACTORS
 The use of NSAIDs, such as ibuprofen and
aspirin, represents a major risk factor for peptic
ulcers. Studies report that both NSAIDs and H. pylori
impair the protective gastric mucosa, and the failure
of the GI tract to repair the mucosa may result in
ulceration.
 It is believed that smoking and alcohol consumption
may be risks, although the evidence is inconclusive.
 Familial tendency also may be a significant
predisposing factor. People with blood type O are
more susceptible to the development of peptic ulcers
than are those with blood type A, B, or AB.
 Peptic ulcer disease is also associated with
Zollinger-Ellison syndrome. (ZES is a rare condition
in which benign or malignant tumors form in the
pancreas and duodenum that secrete excessive
amounts of the hormone gastrin.) The excessive
amount of gastrin results in extreme gastric
hyperacidity and severe peptic ulcer disease.
CLINICAL MANIFESTATIONS
Symptoms of peptic ulcer disease may last for a few days,
weeks, or months and may disappear only to reappear, often
have no signs or symptoms.
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NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
 Complains of dull, gnawing pain or a burning
sensation in the mid epigastrium or the back.
 Pyrosis
 Vomiting
 Constipation
 Diarrhea
 Bleeding
o These symptoms are often accompanied by
sour eructation (burping), which is common
when the patient’s stomach is empty.
 The pain associated with gastric ulcers most
commonly occurs immediately after eating.
 The pain associated with duodenal ulcers most
commonly occurs 2 to 3 hours after meals.
o Patients with duodenal ulcers are more
likely to express relief of pain after eating
or after taking an antacid than patients
with gastric ulcers.
Peptic ulcer perforation results in the sudden onset of signs
and symptoms. The patient often reports:
 Severe, sharp upper abdominal pain, which may be
referred to the shoulder.
 Extreme abdominal tenderness
 Nausea or vomiting
 Hypotension and tachycardia may occur, indicating
the onset of shock
ASSESSMENT AND DIAGNOSTIC FINDINGS
 Physical examination: pain, epigastric tenderness,
or abdominal distention.
 Upper endoscopy: is the preferred diagnostic
procedure as it allows direct visualization of
inflammatory changes, ulcers, and lesions.
o H. pylori infection may be determined by
endoscopy and histologic examination of a
tissue specimen obtained by biopsy, or a
rapid urease test of the biopsy specimen.
 Less invasive diagnostic measures for H. pylori
include serologic testing, stool tests, and breath
tests.
MANAGEMENT
 Once the diagnosis is established, the patient is
informed that the condition can be managed.
Recurrence may develop; however, peptic ulcers
treated with antibiotics to eradicate H. pylori have a
lower recurrence rate than those not treated with
antibiotics. The goals are to eradicate H. pylori as
indicated and to manage gastric acidity.
PHARMACOLOGIC THERAPY
 Antibiotics
 Proton pump inhibitors,
 Bismuth salts
o To suppress or eradicate H. pylori
Recommended combination drug therapy is typically
prescribed for 10 to 14 days and may include triple therapy
BSN 3B | PBL GROUP 1
with two antibiotics plus a proton pump inhibitor or quadruple
therapy with two antibiotics plus a proton pump inhibitor and
bismuth salts.
 The patient is advised to adhere to and complete the
medication regimen to ensure complete healing of
the ulcer.
 The patient also is advised to avoid the use of
NSAIDs.
 Maintenance dosages of H2 blockers are usually
recommended for 1 year.
 Patients with ZES: may be controlled with proton
pump inhibitors. Octreotide, a medication that
suppresses gastrin levels, also may be prescribed.
They will also require periodic endoscopy to evaluate
the effectiveness of medication therapy.
 Patients at high risk for stress ulcers (e.g., patients
who are mechanically ventilated for more than 48
hours): may be treated prophylactically with either H2
blockers or proton pump inhibitors, and
cytoprotective agents (e.g., misoprostol,
sucralfate).
SMOKING CESSATION
 Smoking decreases the secretion of bicarbonate
from the pancreas into the duodenum, resulting in
increased acidity of the duodenum.
 Continued smoking is also associated with delayed
healing of peptic ulcers.
DIETARY MODIFICATION
The intent of dietary modification for patients with peptic ulcers
is to avoid oversecretion of acid and hypermotility in the GI
tract. These can be minimized by:
 Avoiding extremes of temperature in food and
beverages and overstimulation from the
consumption of alcohol, coffee (including
decaffeinated coffee, which also stimulates acid
secretion), and other caffeinated beverages.
 Eating three regular meals a day. (it neutralizes acid)
 Small, frequent feedings are not necessary as long
as an antacid or an H2 blocker is taken.
 Diet compatibility becomes an individual matter: The
patient eats foods that are tolerated and avoids those
that produce pain.
SURGICAL MANAGEMENT
Surgery is usually recommended for patients with intractable
ulcers (those failing to heal after 12 to 16 weeks of medical
treatment), life-threatening hemorrhage, perforation, or
obstruction and for those with ZES that is unresponsive to
medications
 Vagotomy: severing of the vagus nerve.
o Decreases gastric acid by diminishing
cholinergic stimulation to the parietal cells,
making them less responsive to gastrin.
o May be performed via an open surgical
approach or laparoscopy.
8
NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
o May be performed to reduce gastric acid
secretion.
o A drainage type of procedure (see
pyloroplasty) is usually performed to assist
with gastric emptying (because there is total
denervation of the stomach).
o Some patients experience problems with
feeling of fullness, dumping syndrome,
diarrhea, and gastritis.
 Truncal Vagotomy: Severs the right and left vagus
nerves as they enter the stomach at the distal part of
the esophagus; most commonly used to decrease
acid secretions.
 Selective vagotomy: Severs vagal innervation to
the stomach but maintains innervation to the rest of
the abdominal organs.
 Antrectomy (Billroth I gastroduodenostomy):
Removal of the lower portion of the antrum of the
stomach (which contains the cells that secrete
gastrin) as well as a small portion of the duodenum
and pylorus. The remaining segment is anastomosed
to the duodenum. May be performed in conjunction
with a truncal vagotomy.
 Billroth II (gastrojejunostomy): Removal of lower
portion (antrum) of stomach with anastomosis to
jejunum. Dotted lines show portion removed
(antrectomy). A duodenal stump remains and is
oversewn.
III. DISTURBANCES IN ABSORPTION AND
ELIMINATION
DISORDERS OF INTESTINAL MOTILITY
FECAL (BOWEL) INCONTINENCE
 Fecal incontinence, also known as bowel
incontinence, is a condition characterized by the
inability to control bowel movements, resulting in the
involuntary passage of feces. It can range from
occasional leakage to a complete loss of bowel
control. Fecal incontinence can significantly impact a
person's quality of life and emotional well-being.
Causes:
 Muscle or nerve damage: Damage to the muscles or
nerves that control bowel movements can lead to
fecal incontinence. Causes of such damage include
childbirth injuries, rectal surgery, spinal cord injury,
multiple sclerosis, and nerve diseases.
 Diarrhea: Chronic diarrhea can overwhelm the
rectum's ability to hold stool, leading to fecal
incontinence. Conditions such as inflammatory
bowel disease, irritable bowel syndrome, and
infections can cause diarrhea.
 Constipation: Severe or chronic constipation can
weaken the muscles and nerves in the rectum,
BSN 3B | PBL GROUP 1
making it difficult to control bowel movements. Over
time, this can lead to fecal incontinence.
 Rectal prolapse: When the rectum slips out of place
and protrudes through the anus, it can cause
difficulty in holding stool, resulting in fecal
incontinence.
 Pelvic floor dysfunction: Weakening or damage to
the muscles and ligaments that support the pelvic
organs can contribute to fecal incontinence.
 Psychological factors: Emotional distress, such as
chronic stress or anxiety, can affect bowel function
and contribute to fecal incontinence.
CLINICAL MANIFESTATIONS
 Involuntary leakage: The primary symptom of fecal
incontinence is the unintentional passage of stool.
This can range from occasional minor leakage to
complete loss of bowel control.
 Urgency: Individuals with fecal incontinence often
experience a sudden, strong urge to have a bowel
movement. The urgency may be difficult to control,
resulting in accidents.
 Diarrhea or loose stools: Fecal incontinence can
be associated with loose stools or diarrhea, which
can further contribute to the difficulty in maintaining
control.
 Difficulty with gas control: In addition to stool
leakage, some individuals with fecal incontinence
may also have trouble controlling the release of gas
(flatulence).
 Skin irritation: Frequent contact of stool with the
skin can cause skin irritation, leading to redness,
soreness, itching, or even skin breakdown (ulcers).
 Emotional distress: Fecal incontinence can
significantly impact an individual's quality of life,
leading to embarrassment, social isolation, and
emotional distress.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 Medical History: A thorough medical history is
essential to identify potential risk factors and
underlying conditions contributing to fecal
incontinence. Factors such as previous surgeries,
pelvic floor trauma, neurological disorders,
inflammatory bowel disease, and medications can
provide important clues.
 Physical Examination: A comprehensive physical
examination is necessary to assess the overall
health of the patient and identify any physical
abnormalities that may be contributing to fecal
incontinence. Examination of the abdomen, anus,
and rectum may reveal signs of structural
abnormalities, anal sphincter dysfunction, or nerve
damage.
 Anal Manometry: Anal manometry measures the
pressures within the anal canal and helps evaluate
the function of the anal sphincter muscles. This test
can identify sphincter weakness or dysfunction,
which may be a contributing factor to fecal
incontinence.
9
NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
 Endoanal Ultrasound: Endoanal ultrasound is a
diagnostic imaging technique that uses sound waves
to create images of the anus and rectum. It can help
identify structural abnormalities, such as sphincter
defects, fistulas, or tumors, which may contribute to
fecal incontinence.
 Bowel Diary: Keeping a bowel diary can provide
valuable insights into the frequency, consistency,
and circumstances surrounding episodes of fecal
incontinence. This record helps identify patterns,
triggers, and potential factors contributing to the
condition, assisting in the development of
appropriate treatment plans.
MANAGEMENT AND TREATMENT
 Dietary Modifications: Making changes to your diet
can help regulate bowel movements and reduce the
likelihood of incontinence episodes. This may involve
increasing fiber intake to promote regularity and
avoiding foods that can worsen symptoms, such as
caffeine, alcohol, spicy foods, and greasy/fried foods.
 Medications: Depending on the underlying cause of
fecal incontinence, certain medications may be
prescribed. For example, antidiarrheal medications
can help control loose stools, while laxatives or stool
softeners can address constipation-related issues.
Other medications may be used to improve anal
sphincter muscle function or reduce inflammation.
 Bowel Training: Bowel training involves establishing
a regular bowel movement routine to promote better
control. This typically involves attempting to have a
bowel movement at the same time each day, ideally
following a meal. Over time, this can help regulate
bowel movements and reduce the risk of accidents.
 Surgical Interventions: In severe cases of fecal
incontinence that do not respond to other treatments,
surgery may be considered. Surgical options include
sphincteroplasty (repair of the anal sphincter
muscles), artificial sphincter implantation, or
colostomy (creating an opening in the abdomen for
stool to exit the body).
NURSING INTERVENTIONS
Assessment and Evaluation:
 Conduct a thorough assessment to determine the
underlying cause of fecal incontinence, such as
diarrhea, constipation, neurological disorders, or
sphincter dysfunction.
 Evaluate the patient's bowel habits, dietary intake,
and medication history.
 Assess the patient's cognitive and physical abilities,
including mobility and manual dexterity.
Education and Lifestyle Modifications:
 Educate the patient and their caregivers about the
condition, its causes, and potential treatment
options.
 Provide information on dietary modifications, such as
increasing fiber intake, drinking enough fluids, and
BSN 3B | PBL GROUP 1
avoiding foods that worsen bowel symptoms (e.g.,
spicy or greasy foods).
 Encourage regular exercise, as it can improve bowel
function.
 Promote healthy bowel habits, including maintaining
a consistent toileting schedule and allowing
adequate time for bowel movements.
Bowel Training:
 Develop a structured bowel training program tailored
to the patient's needs and capabilities.
 Help the patient establish a regular toileting routine,
preferably after meals or at times when bowel
movements are more likely to occur.
 Use relaxation techniques, such as deep breathing
exercises, to help the patient relax during bowel
movements.
 Encourage the patient to sit on the toilet for an
appropriate amount of time, even if a bowel
movement does not occur immediately.
 Provide positive reinforcement and praise for
successful bowel movements and adherence to the
bowel training program.
Medication Management:
 Collaborate with the healthcare team to determine if
medication is appropriate for the patient's condition.
 Administer prescribed medications as ordered, such
as antidiarrheal agents, stool softeners, or
medications to improve sphincter control.
 Monitor the patient for any side effects or adverse
reactions to the medications.
Skin Care and Hygiene:
 Ensure meticulous perineal hygiene after bowel
movements to prevent skin irritation and breakdown.
 Provide gentle cleansing using mild soap and warm
water, followed by thorough drying.
 Apply a moisture barrier cream or ointment to protect
the skin from exposure to stool.
Assistive Devices and Products:
 Evaluate the need for assistive devices, such as
adult diapers, pads, or fecal collection devices, to
manage episodes of fecal incontinence.
 Assist the patient in selecting appropriate products
and ensuring proper usage.
Emotional Support and Counseling:
 Recognize the emotional impact of fecal
incontinence on the patient's self-esteem and overall
well-being.
10
NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
IRRITABLE BOWEL SYNDROME
 Irritable Bowel Syndrome (IBS) is a common
gastrointestinal disorder that affects the functioning
of the large intestine (colon). It is a chronic condition
characterized by a group of symptoms that can vary
from person to person and may include abdominal
pain, bloating, cramping, diarrhea, constipation, or
alternating episodes of both.
 The exact cause of IBS is not fully understood, but it
is believed to involve a combination of factors such
as abnormal muscle contractions in the colon,
heightened sensitivity to intestinal pain, changes in
the gut microbiota, and certain psychological or
emotional factors. It is important to note that IBS is
not a life-threatening condition and does not lead to
more serious diseases such as inflammatory bowel
disease or colon cancer.
RISK FACTORS
 Gender: Women are more likely to develop IBS than
men. Hormonal fluctuations, particularly during
menstruation, may contribute to this increased risk.
 Age: IBS can occur at any age, but it commonly
begins during adolescence or early adulthood. It
tends to affect younger individuals more frequently.
 Family History: There is evidence to suggest that
IBS may have a genetic component. If you have a
close family member with IBS, you may have a
higher risk of developing the condition.
 Psychological Factors: Emotional stress, anxiety,
depression, and other psychological conditions are
associated with a higher risk of IBS. Stress can
exacerbate symptoms and make them more
challenging to manage.
 Gastrointestinal Infections: Certain
gastrointestinal infections, such as bacterial
gastroenteritis, can trigger the onset of IBS
symptoms in some individuals. This is known as
post-infectious IBS.
CLINICAL MANIFESTATIONS
 Abdominal pain or discomfort: This is one of the
hallmark symptoms of IBS. The pain or discomfort is
usually located in the lower abdomen and may be
described as cramping, sharp, or dull. The severity
and frequency of the pain can vary.
 Altered bowel habits: IBS can cause changes in
bowel movements. Some individuals with IBS
experience diarrhea, with loose or watery stools.
Others may have constipation, with infrequent bowel
movements and difficulty passing stool. Some
people may alternate between episodes of diarrhea
and constipation.
 Changes in stool appearance: The appearance of
the stool can change in IBS. It may be loose, hard,
lumpy, or have a mucous coating. Some individuals
may notice changes in the color of their stool as well.
 Bloating and distension: Many people with IBS
experience bloating, which is a sensation of
BSN 3B | PBL GROUP 1
increased abdominal fullness or tightness. The
abdomen may appear visibly distended or swollen.
 Excessive gas (flatulence): IBS can cause
increased gas production in the intestines, leading to
excessive flatulence.
 Urgency and feeling of incomplete bowel
movement: Some individuals with IBS may
experience a sudden and urgent need to have a
bowel movement, often accompanied by a feeling of
incomplete evacuation.
 Fatigue and sleep disturbances: IBS can be
associated with fatigue and sleep disturbances,
which may be a result of disrupted bowel function,
pain, or psychological factors.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 Patient History: The healthcare provider will begin
by taking a detailed history of the patient's
symptoms. The key symptoms of IBS include
abdominal pain or discomfort that is relieved by
bowel movements, changes in bowel habits (such as
diarrhea, constipation, or both), bloating, and
excessive gas. The duration, frequency, and severity
of symptoms will be evaluated.
 Rome Criteria: The Rome criteria are widely used
guidelines for diagnosing functional gastrointestinal
disorders, including IBS. According to the Rome IV
criteria, IBS is diagnosed when the patient
experiences recurrent abdominal pain or discomfort
for at least three days per month in the past three
months, associated with two or more of the following:
improvement with defecation, onset associated with
a change in frequency of stool, or onset associated
with a change in form (appearance) of stool.
 Physical Examination: A physical examination is
usually performed to assess the patient's overall
health and to rule out other underlying conditions.
During the examination, the healthcare provider may
check for any abdominal tenderness, signs of
inflammation, or other relevant findings.
 Diagnostic Tests: Diagnostic tests are typically
used to rule out other conditions that may present
with similar symptoms. The choice of tests may vary
depending on the individual patient's symptoms and
risk factors. Common tests may include:
 Stool analysis: This may be done to rule out
infections, parasites, or other abnormalities in the
stool.
 Blood tests: Blood tests can help identify any signs
of inflammation, check for anemia, and evaluate
thyroid function.
 Colonoscopy or sigmoidoscopy: These
procedures involve the insertion of a flexible tube
with a camera into the colon or sigmoid colon to
visualize the intestinal lining and rule out other
gastrointestinal conditions.
 Imaging tests: In certain cases, imaging tests such
as abdominal ultrasound or computed tomography
(CT) scan may be ordered to evaluate the digestive
organs and rule out other conditions.
11
NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
MANAGEMENT AND TREATMENT
 Dietary changes: Many individuals with IBS find
relief by making changes to their diet. This may
involve identifying and avoiding trigger foods that can
worsen symptoms. Common trigger foods include
spicy foods, fatty foods, caffeine, alcohol, and certain
types of carbohydrates like those found in wheat,
onions, garlic, and legumes. A low-FODMAP diet,
which restricts certain types of carbohydrates, has
shown to be effective for some people with IBS.
 Fiber supplementation: For some individuals,
increasing dietary fiber can help regulate bowel
movements and reduce symptoms. However, for
others, high-fiber diets may worsen symptoms. It's
important to work with a healthcare professional to
determine the right approach for you. Soluble fiber
sources, such as psyllium husk, may be better
tolerated by some individuals.
 Medications: Various medications can be
prescribed to manage specific symptoms of IBS.
These include antispasmodics, which help relieve
abdominal pain and cramping, and antidiarrheal
medications, which can be used to control diarrhea.
In some cases, low-dose tricyclic antidepressants or
selective serotonin reuptake inhibitors (SSRIs) may
be prescribed to alleviate pain and regulate bowel
movements.
 Stress management: Stress and anxiety can
worsen IBS symptoms. Techniques such as deep
breathing exercises, mindfulness meditation, regular
physical exercise, and engaging in activities that
promote relaxation can help manage stress levels
and improve symptoms.
 Probiotics: Probiotics are beneficial bacteria that
can help restore the natural balance of gut flora.
Some studies have suggested that certain strains of
probiotics can reduce symptoms of IBS, although
results can vary. It's advisable to consult with a
healthcare professional before starting any probiotic
regimen.
 Alternative therapies: Some individuals find relief
from symptoms through alternative therapies such as
acupuncture, hypnotherapy, or herbal supplements.
However, evidence for their effectiveness in treating
IBS is limited, and it's important to approach these
therapies with caution and consult with a qualified
practitioner.
 Education and support: Learning about IBS and
understanding its nature can be empowering.
Support groups or counseling can provide valuable
information, coping strategies, and emotional
support.
NURSING INTERVENTIONS
 Assess and document symptoms: Regularly
assess the patient's gastrointestinal symptoms, such
as abdominal pain, bloating, diarrhea, or
constipation. Keep a record of the frequency,
duration, and intensity of symptoms to help identify
BSN 3B | PBL GROUP 1
triggers and evaluate the effectiveness of
interventions.
 Provide education: Educate the patient about IBS,
its causes, and potential triggers. Discuss dietary
modifications, stress management techniques, and
lifestyle changes that may help manage symptoms.
Provide written materials and resources for further
information.
 Dietary modifications: Collaborate with a
registered dietitian to develop an individualized diet
plan for the patient. Discuss trigger foods to avoid,
such as caffeine, fatty foods, spicy foods, and gas-
producing foods. Encourage the patient to maintain
a food diary to identify specific triggers.
 Stress management: Help the patient develop
effective stress management strategies, such as
deep breathing exercises, meditation, yoga, or
engaging in hobbies and activities that promote
relaxation. Encourage regular exercise, which can
help reduce stress and improve bowel function.
 Medication management: Assist with medication
administration as prescribed by the healthcare
provider. This may include antispasmodics,
laxatives, fiber supplements, or medications for
diarrhea or constipation. Educate the patient about
the purpose, potential side effects, and proper
administration of each medication.
 Encourage regular bowel habits: Advise the
patient to establish a regular bowel routine by
promoting consistent meal times, encouraging
regular exercise, and providing access to bathroom
facilities. Ensure privacy and comfort in the bathroom
environment.
 Emotional support: Recognize the emotional
impact of IBS on the patient's quality of life. Provide
emotional support and reassurance, allowing the
patient to express concerns and frustrations. Offer
counseling or referral to a mental health professional,
if needed.
CONSTIPATION
 is defined as fewer than three bowel movements
weekly or bowel movements that are hard, dry, small,
or difficult to pass.
 People more likely to become constipated are
women, particularly pregnant women, patients who
recently had surgery, older adults, non-Caucasians,
and people with a history of irritable bowel syndrome.
 Notably, constipation is a symptom and not a
disease; however, constipation can indicate an
underlying disease or motility disorder of the GI tract.
 This subjective problem occurs when a person’s
bowel elimination pattern is not consistent with what
they consider normal.
 Constipation can be caused by certain medications,
such as anticholinergic agents, antidepressants,
anticonvulsants, antispasmodics (muscle relaxants),
calcium channel antagonists, diuretic agents,
12
NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
opioids, aluminum- and calcium-based antacids, and
iron preparations.
 the urge to defecate. Constipation is also a result of
dietary habits (i.e., low consumption of fiber and
inadequate fluid intake), lack of regular exercise, and
a stressfilled life.
PATHOPHYSIOLOGY
 The pathophysiology of constipation is poorly
understood, but it is thought to include interference
with one of three major functions of the colon:
mucosal transport (i.e., mucosal secretions facilitate
the movement of colon contents), myoelectric activity
(i.e., mixing of the rectal mass and propulsive
actions), or the processes of defecation (e.g., pelvic
floor dysfunction). There are four classes of
constipation, based upon their underlying
pathophysiologic mechanisms:
 Functional constipation, which involves normal
transit mechanisms of mucosal transport. This type
of constipation is most common and can be
successfully treated by increasing intake of fiber and
fluids.
 Slow-transit constipation, which is caused by
inherent disorders of the motor function of the colon
(e.g., Hirschsprung disease), and is characterized by
infrequent bowel movements.
 Defecatory disorders, which are caused by
dysfunctional motor coordination between the pelvic
floor and anal sphincter. Dyssynergic constipation is
a common cause of chronic constipation and is
caused by an inability to coordinate the abdominal,
pelvic floor, and rectoanal muscles to defecate.
Anismus is a term used to describe pelvic floor
dysfunction and constipation. This can cause not
only constipation but also fecal incontinence.
 Opioid-induced constipation, which includes new
or worsening symptoms that occur when opioid
therapy is initiated, changed, or increased and must
include two or more symptoms of functional
constipation.
 The urge to defecate is stimulated normally by rectal
distention that initiates a series of four actions:
stimulation of the inhibitory rectoanal reflex,
relaxation of the internal sphincter muscle, relaxation
of the external sphincter muscle and muscles in the
pelvic region, and increased intra-abdominal
pressure. Interference with any of these processes
can lead to constipation
 When the urge to defecate is ignored, the rectal
mucous membrane and musculature become
insensitive to the presence of fecal masses, and
consequently a stronger stimulus is required to
produce the necessary peristaltic rush for defecation.
 The initial effect of fecal retention is to produce
irritability of the colon, which at this stage frequently
goes into spasm, especially after meals, giving rise
to colicky midabdominal or low abdominal pains.
 After several years of this process, the colon loses
muscular tone and becomes essentially
BSN 3B | PBL GROUP 1
unresponsive to normal stimuli (similar to an
overstretched balloon).
 Atony or decreased muscle tone occurs with aging.
This may lead to constipation because the stool is
retained for longer periods.
CLINICAL MANIFESTATION
 Fewer than three bowel movements per week
 Abdominal distention
 Abdominal pain and bloating
 Sensation of incomplete evacuation
 Straining at stool
 Elimination of small-volume, lumpy, hard, dry stools
 Low back pain
ASSESSMENT AND DIAGNOSTIC FINDING
 Patient’s history, physical examination
 Results of a barium enema or sigmoidoscopy
 Stool testing for occult blood
 Anorectal manometry
 Defecography
 X-ray
 Colonoscopy
 Lower GI endoscopoy
COMPLICATIONS
 Increased arterial pressure
 Straining at stool
 Increased intrathoracic pressure
 Decreased cardiac output
 Orthostasis
 Syncope
 Fecal incontinence
 Hemorrhoids
 Fissures
 Rectal prolapse
 Megacolon
MEDICAL MANAGEMENT
 Treatment targets the underlying cause of
constipation and prevention of recurrence. It includes
education, exercise, bowel habit training, increased
fiber and fluid intake, and judicious use of laxatives.
 Management may also include discontinuing laxative
use or replacing medications that could cause or
exacerbate constipation with other nonconstipating
medications.
 Patients can be educated to sit on the toilet with legs
supported and to utilize the gastrocolic reflex
(peristaltic movements of the large bowel occurring
five to six times daily that are triggered by distention
of the stomach) by attempting to defecate following a
meal and a warm drink.
 Routine exercise to strengthen abdominal muscles is
encouraged.
 Biofeedback is a technique that can be used to help
patients learn to relax the sphincter mechanism to
13
NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
expel stool. Biofeedback is an effective therapy for
patients with dyssynergic defecation and is
considered first-line therapy once anorectal
structural lesions have been excluded as the cause
for constipatio.
 Daily dietary intake of 25 to 30 g/day of fiber (soluble
and bulk forming) is recommended, especially for the
treatment of constipation in the older adult. It is
important to add fiber to the diet slowly in order to
avoid adverse effects such as abdominal cramping
and bloating.
NURSING MANAGEMENT
 Recognize the physiology of defecation and the
importance of responding to the urge to defecate.
 Understand the normal variations in patterns of
defecation.
 Establish a bowel routine, and be aware that having
a regular time for defecation (e.g., best time is after
a meal) may aid in initiating the reflex.
 Ensure proper dietary habits, such as eating high-
residue, high-fiber foods (e.g., fruits, vegetables);
adding fiber to the diet slowly with adequate fluid
intake; choosing dietary sources of fiber, which are
preferred over fiber supplements; adding bran daily
(must be introduced gradually); and increasing fluid
intake (unless contraindicated) to help prevent
constipation.
 Increase muscle strength through an exercise
regimen, increased ambulation, and abdominal
muscle toning to help propel colon contents.
 Perform abdominal toning exercises, including
contracting abdominal muscles 4 times daily and leg-
to-chest lifts 10 to 20 times each day.
 Use the normal position (semisquatting) to maximize
the use of abdominal muscles and force of gravity.
 Avoid overuse or long-term use of stimulant
laxatives.
DIARRHEA
 is an increased frequency of bowel movements
(more than 3 per day) with altered consistency (i.e.,
increased liquidity) of stool.
 It can be associated with urgency, perianal
discomfort, incontinence, nausea, or a combination
of these factors (NIDDK, 2016b). Any condition that
causes increased intestinal secretions, decreased
mucosal absorption, or altered motility can produce
diarrhea.
 Diarrhea can be classified as acute, persistent, or
chronic. Acute diarrhea is selflimiting, lasting 1 or 2
days; persistent diarrhea typically lasts between 2
and 4 weeks; and chronic diarrhea persists for
more than 4 weeks and may return sporadically.
 Acute and persistent diarrheas are frequently caused
by viral infections (e.g., norovirus). In addition, some
drugs can cause acute or persistent diarrhea,
including some antibiotics (e.g., erythromycin) and
BSN 3B | PBL GROUP 1
magnesium-containing antacids (e.g., magnesium
hydroxide).
 Chronic diarrhea may be caused by adverse effects
of chemotherapy, antiarrhythmic agents,
antihypertensive agents, metabolic and endocrine
disorders (e.g., diabetes, Addison disease,
thyrotoxicosis), malabsorptive disorders (e.g.,
lactose intolerance, celiac disease), anal sphincter
defect, Zollinger-Ellison syndrome, acquired immune
deficiency syndrome (AIDS), and by parasitic or
Clostridium difficile infections.
PATHOPHYSIOLOGY
 Acute and persistent diarrheas are classified as
either noninflammatory (large-volume) or
inflammatory (small-volume). Enteric pathogens that
are noninvasive (e.g., S. aureus, Giardia) do not
cause inflammation but secrete toxins that disrupt
colonic fluid transport.
 They cause noninflammatory diarrhea, which is
characterized by a large volume of loose, watery
stools. Other pathogens that invade the intestinal
mucosa and cause inflammatory changes typically
result in smaller volumes of stool that is bloody (e.g.,
dysentery). Organisms implicated may include
Shigella, Salmonella, and Yersinia species.
 Types of chronic diarrhea include secretory, osmotic,
malabsorptive, infectious, and exudative. Secretory
diarrhea is usually high-volume diarrhea.
 Often associated with bacterial toxins and
chemotherapeutic agents used to treat neoplasms, it
is caused by increased production and secretion of
water and electrolytes by the intestinal mucosa into
the intestinal lumen.
 Osmotic diarrhea occurs when water is pulled into
the intestines by the osmotic pressure of unabsorbed
particles, slowing the reabsorption of water.
 It can be caused by lactase deficiency, pancreatic
dysfunction, or intestinal hemorrhage.
 Malabsorptive diarrhea combines mechanical and
biochemical actions, inhibiting effective absorption of
nutrients.
 Low serum albumin levels lead to intestinal mucosa
swelling and liquid stool. Infectious diarrhea results
from infectious agents invading the intestinal
mucosa.
 Exudative diarrhea is caused by changes in mucosal
integrity, epithelial loss, or tissue destruction by
radiation or chemotherapy. Diarrhea may also be
caused by laxative misuse.
CLINICAL MANIFESTATION
 Abdominal cramps
 Distention
 Borborygmus (i.e., a rumbling noise caused by the
 movement of gas through the intestines)
 Anorexia
 Thirst
 Painful spasmodic contractions of the anus
14
NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
 Tenesmus
ASSESSMENT AND DIAGNOSTIC FINDING
 CBC
 Serum chemistries
 Urinalysis
 Routine stool examination
 Stool examinations for infectious or parasitic
organisms, bacterial toxins, blood, fat, electrolytes,
and white blood cells.
 Endoscopy
COMPLICATIONS
 Dehydration
 Cardiac arrhythmia
 Metabolic acidosis
 Muscle weakness
 Paresthesia
 Hypotension
 Anorexia
 Drowsiness
MEDICAL MANAGEMENT
 Management is directed at controlling symptoms,
preventing complications, and eliminating or treating  The patient should follow a perianal skin care routine
the underlying disease. Until the definitive cause is
discovered, infection control measures that restrict
the transmission of infectious organisms (e.g., C.
difficile–associated diarrhea) are warranted.
 Certain medications (e.g., antibiotics, anti-
inflammatory agents) and antidiarrheal agents (e.g.,
loperamide, diphenoxylate with atropine) may be
prescribed to reduce the severity of the diarrhea and
treat the underlying disease.
 In most cases, loperamide is the medication of
choice because it has fewer side effects than
diphenoxylate with atropine. Findings from a
systematic review supported the use of probiotics
(live organisms given to a host) in some forms of
diarrhea.
 The specific organisms used were Saccharomyces
boulardii (yeast) or lactic acid bacteria such as
Lactobacillus and Enterococcus lactic acid bacterium
species.
 Benefits include shortened duration of symptoms
and early improvement of symptoms; there were no
serious adverse effects reported.
NURSING MANAGEMENT
 The nurse assesses and monitors the characteristics
and pattern of diarrhea.
 A health history should address the patient’s
medication therapy, medical and surgical history,
and dietary patterns and intake.
 Reports of recent acute illness or recent travel to
another geographic area are important.
 Assessment includes abdominal auscultation and
palpation for tenderness. Inspection of the abdomen,
BSN 3B | PBL GROUP 1
mucous membranes, and skin is important to
determine hydration status.
 Stool samples are obtained for testing.
 The perianal area should also be assessed for skin
excoriation.
 During an episode of diarrhea, the patient is
encouraged to increase intake of liquids and foods
low in bulk until the symptoms subside.
 When the patient is able to tolerate food intake, the
patient should avoid caffeine, alcoholic beverages,
dairy products, and fatty foods for several days.
 Antidiarrheal medications such as diphenoxylate
with atropine or loperamide may be taken as
prescribed. Intravenous (IV) fluid therapy may be
necessary for rapid rehydration in some patients,
especially in older adults and in patients with
preexisting GI conditions (e.g., IBD).
 It is important to monitor serum electrolyte levels
closely.
 The nurse immediately reports evidence of
arrhythmias or a change in a patient’s level of
consciousness.
 The perianal area may become excoriated because
diarrheal stool contains digestive enzymes that can
irritate the skin.
to decrease irritation and excoriation.
DISORDERS OF MALABSORPTION
 Malabsorption is an umbrella term for a wide range of
disorders that affect your ability to absorb nutrients from
your food. (Especially major vitamins: A & B12,
minerals: iron & calcium, and nutrients:
carbohydrates, fats, and proteins)
 Malabsorption can lead to indigestion and even
malnutrition — not from a lack of eating enough nutrients,
but from an inability to absorb them.
 This can be grouped into the ff. categories:
 Mucosal (transport) disorders causing
generalized malabsorption (e.g., celiac
disease, Crohn’s disease, radiation enteritis)
 Luminal disorders causing malabsorption
(e.g., bile acid deficiency, ZollingerEllison
syndrome, pancreatic insufficiency, small bowel
bacterial overgrowth, or chronic pancreatitis)
 Lymphatic obstruction, interfering with the
transport of fat by-products of digestion into the
systemic circulation (e.g., neoplasms, surgical
trauma).
15
NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

 Hypothyroidism
 Migraine headaches,
 Osteopenia
 Anemia,
 Seizures
 Paresthesias in the hands and feet
 Red, shiny tongue

Some adults and children may have evidence:

 Ridges in the enamel of their adult teeth

 Discoloration or yellowing
 Dermatitis herpetiformis is a rash that is frequently
associated with celiac disease in adults; it manifests as
clusters of erythematous macules that develop into itchy
papules and vesicles on the forearms, elbows, knees,
face, or buttocks

CELIAC DISEASE NOTE:

 Celiac disease is a disorder of malabsorption caused by
an autoimmune response to the consumption of products
that contain the protein gluten leads to damage in the
small intestine.
 The villi help your body take in nutrients from food into
your bloodstream. Without the villi, your small intestine
can’t get enough nutrients, no matter how much food you
eat.
Children who have celiac disease may not grow at a normal
rate. In addition, diarrhea, steatorrhea, abdominal pain,
abdominal distention, flatulence, and weight loss are more
common manifestations in children than adults.
You may have celiac disease but not have any symptoms.
That is because the part of your small intestine that is not hurt
can still take in enough nutrients. But you may still be at risk
for problems of the disease.

ASSESSMENT AND DIAGNOSTIC FINDINGS

 Comprehensive assessment:
 Presenting s/s
 Family History
 Risk factor Assessment
 Definitive Diagnosis:
o Series of serologic tests:
 It is important that the patient continues
to consume gluten products during
testing, or there could be a false-
negative serologic finding.
RISK FACTORS  Immunoglobulin A (IgA) anti-tissue
transglutaminase (tTG), which is 90%
 European, Americans sensitive and 95% specific to celiac
 Have Type 1 Diabetes disease.
 Have Down Syndrome  Endoscopic Biopsy
 Have other autoimmune diseases o upper endoscopy with biopsies of the
 Who are infertile proximal small intestine
 Have irritable bowel syndrome with diarrhea  Blood Test
 Note: GERD can result in dental erosion, ulcerations MEDICAL MANAGEMENT
in the pharynx and esophagus, laryngeal damage,
esophageal strictures, adenocarcinoma, and  Education about the disease
pulmonary complications.  Life-long gluten-free diet
o Consultation with a dietitian
CLINICAL MANIFESTATION
o Avoid barley, rye, and wheat.
Adults can present with non-GI signs and symptoms of celiac o Many will have a secondary lactose
disease, which are highly variable and can include: intolerance.
o Approximately 70% of patients will
 Fatigue have clinical improvement within 2
 General malaise weeks.
 Depression  Monitoring:

BSN 3B | PBL GROUP 1 16

NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

o Repeat IgA anti-tissue
transglutaminase antibody at 6 and 12
months after diagnosis.
o Small bowel biopsy after 3–6 months
on a gluten-free diet
 Identify and treat any nutritional deficiencies (vitamin
and mineral supplements, as needed).
 Most common reason for treatment failure is incomplete
removal of gluten from the diet.
 Refractory disease:
o 5% of patients may not respond to a
gluten-free diet.
o Consider an alternative or concurrent
disease:
 Irritable bowel syndrome
 Small bowel bacterial
overgrowth
 Pancreatic insufficiency
 Microscopic colitis
o Glucocorticoids and
immunosuppressants may be
considered.

NURSING MANAGEMENT
 The nurse provides patient and family education
regarding adherence to a gluten-free diet, and how to
avoid other gluten products
 For instance, oats are not contraindicated in gluten-free
diets; however, many oat products are produced in
facilities that are cross-contaminated with wheat or
other contraindicated grains.
 Likewise, gluten-free foods prepared in restaurants or
dining areas that share preparatory space can become
gluten-contaminated
 For instance, gluten-free toast prepared in a toaster that
is also used for wheat-based toast can become gluten-
contaminated.
 Patients must become vigilant in asking restaurant and
dining hall staff about how gluten-free foods are
prepared
 Products that are not foods can also contain gluten.
Many generic and over-thecounter drugs can be
prepared with gluten gels. Toothpastes, communion
wafers, and some cosmetics (e.g., lipsticks) and art
supplies (e.g., modeling clay) can also contain gluten.
 Patients must understand how to carefully read labels
on both foods and nonfood products to determine if they
contain gluten. The U.S. Food and Drug Administration
(FDA) regulates and monitors the appropriate
application of gluten-free labels.
STRUCTURAL OBSTRUCTIVE BOWEL DISORDER
 Intestinal obstruction exists when blockage prevents
the normal flow of intestinal contents through the
intestinal tract. Two types of processes can impede
this flow:
 Mechanical obstruction
o Extrinsic lesions from outside the
intestines or intrinsic lesions within the
intestines can obstruct flow. Examples of
extrinsic lesions include adhesions,
hernias, and abscesses. Examples of
intrinsic lesions include intestinal tumors
(benign and cancerous), strictures (from
prior surgery or radiation), or intraluminal
lesions due to a defect in the bowel lumen
(e.g., intussusception).
 Functional or paralytic obstruction
o The intestinal musculature cannot propel
the contents along the bowel either due to
interruption of innervation or vascular
supply to the bowel. Examples are
amyloidosis, muscular dystrophy,
endocrine disorders such as diabetes, or
neurologic disorders such as Parkinson’s
disease. The blockage also can be
temporary and the result of the

BSN 3B | PBL GROUP 1 17

NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
manipulation of the bowel during surgery
(i.e., ileus).
 Obstruction can occur in the large or small intestine
and can be partial or complete.
 Severity depends on the region of bowel affected,
the degree to which the lumen is occluded, and
especially the degree to which the vascular supply
to the bowel wall is disturbed. Most obstructions
occur in the small intestine.
CAUSES
SMALL BOWEL OBSTRUCTION:
 Intestinal adhesions — bands of fibrous tissue in
the abdominal cavity that can form after abdominal
or pelvic surgery
 Hernias — portions of intestine that protrude into
another part of your body
 Tumor account for 90% of obstructions in the small
intestines
 Crohn’s Disease
 Intussusception — invagination or shortening of
the colon caused by the movement of one segment
of bowel into another.
 Volvulus — twisting of the colon
 Paralytic Ileus — muscle or nerve problems
disrupt the normal coordinated muscle contractions
of the intestines, slowing or stopping the movement
of food and fluid through the digestive system.
LARGE BOWEL OBSTRUCTION:
 Cancer (60%), Diverticular Disease (20%), and
Volvulus (5%)
 Benign Tumors
 Strictures
 Obstipation or Fecal Impaction
SMALL BOWEL OBSTRUCTION
PATHOPHYSIOLOGY
 Intestinal contents, fluid, and gas accumulate
proximal to the intestinal obstruction.
BSN 3B | PBL GROUP 1
 The abdominal distention and retention of fluid
reduce the absorption of fluids and stimulate more
gastric secretion. With increasing distention,
pressure within the intestinal lumen increases,
causing a decrease in venous and arteriolar
capillary pressure.
 Third-spacing offluids, electrolytes, and proteins into
the intestinal lumen occurs, resulting in decreased
circulating fluid volume and dehydration. With
continued intestinal distention and edema, perfusion
to the affected intestinal segment can be
compromised, leading to ischemia, necrosis, and
eventual rupture or perforation of the intestinal wall,
with resultant peritonitis (Bordeianou & Yeh, 2019;
Ramnarine, 2017).
CLINICAL MANIFESTATIONS
 Crampy pain that is wavelike and colicky due to
persistent peristalsis both above and below the
blockage
 Vomiting occurs － the patient may pass blood and
mucus but no fecal matter and no flatus.
 If the obstruction is complete, the peristaltic waves
initially become extremely vigorous and eventually
assume a reverse direction, with the intestinal
contents propelled toward the mouth instead of
toward the rectum.
 The signs of dehydration become evident: intense
thirst, drowsiness, oliguria generalized malaise,
aching, and a parched tongue and mucous
membranes.
 The abdomen becomes distended. The lower the
obstruction in the GI tract, the more marked the
abdominal distention; this may cause reflux
vomiting.
 Vomiting results in loss of hydrogen ions and
potassium from the stomach, leading to reduction
of chloride and potassium in the blood and to
metabolic alkalosis.
ASSESSMENT AND DIAGNOSTIC FINDINGS
 Diagnosis is based on the symptoms, physical
assessment findings, and the results of imaging
studies. Early in the process, bowel sounds are
high-pitched and hyperactive in an attempt to pass
the obstruction; later, bowel sounds will be
hypoactive.
 Abdominal x-ray and CT scan findings include
abnormal quantities of gas, fluid, or both in the
intestines and sometimes collapsed distal bowel.
 Laboratory studies (i.e.,electrolyte studies and a
CBC) reveal a picture of dehydration, loss of
plasma volume, and possible infection
 The approach to small bowel obstruction focuses on
confirming the diagnosis, identifying the etiology,
and determining the likelihood of strangulation.
MEDICAL MANAGEMENT
 Decompression of the bowel through insertion of an
NG tube is necessary for all patients with small
bowel obstruction; this may be tried for up to 3 days
for patients with partial obstructions, as resting the
18
NCM112 LECTURE
MEDICAL-SURGICAL NURSING
FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS
bowel in this manner can result in resolution of the
obstruction.
 Patients with adhesions, administration of
hypertonic water-soluble GI contrast media
(Gastrografin) may be of benefit in stimulating
peristalsis and determining the probability of
needing surgical intervention.
 The tube is clamped for 2 to 4 hours then an
abdominal x-ray is taken within 6 to 24 hours;
evidence of the dye in the large intestine is
predictive of resolution of obstruction without
surgical intervention.
NURSING MANAGEMENT
 Nursing management of the patient with a small
bowel obstruction who does not require surgery
includes:
o Maintaining the function of the NG tube
o Assessing and measuring the NG output
o Assessing for fluid and electrolyte
imbalance
o Monitoring nutritional status
o Assessing for manifestations consistent
with resolution (e.g., return of normal
bowel sounds, decreased abdominal
distention, subjective improvement in
abdominal pain and tenderness, passage
of flatus or stool).
o Reports discrepancies in the patient’s
intake and output, worsening of pain or
abdominal distention, and increased NG
output.
o If the patient’s condition does not improve,
the nurse prepares them for surgery. This
preparation includes preoperative
education as the patient’s condition
indicates. Nursing care of the patient after  Restoration of intravascular volume
surgical repair of a small bowel obstruction  Correction of electrolyte abnormalities
is similar to that for other abdominal
surgeries.
LARGE BOWEL OBSTRUCTION
 A large bowel obstruction results in an accumulation
of intestinal contents, fluid, and gas proximal to the
obstruction. It can lead to severe distention and
perforation unless some gas and fluid can flow back
through the ileocecal valve.
PATHOPHYSIOLOGY
 Large bowel obstruction, even if complete, may be
undramatic if the blood supply to the colon is not
disturbed. However, if the blood supply is cut off,
intestinal strangulation and necrosis occur; this
condition is life threatening.
 In the large intestine, dehydration occurs more
slowly than in the small intestine because the colon
can absorb its fluid contents and can distend to a
size considerably beyond its normal full capacity.
 Similar to small bowel obstruction, complications
include perforation, peritonitis, and sepsis.
BSN 3B | PBL GROUP 1
CLINICAL MANIFESTATIONS
 Large bowel obstruction differs clinically from small
bowel obstruction in that the symptoms develop and
progress relatively slowly.
 Patients with obstruction in the sigmoid colon or
the rectum, constipation may be the only symptom
for weeks.
 The shape of the stool is altered as it passes the
obstruction that is gradually increasing in size.
 Blood loss in the stool may result in iron
deficiency anemia..
 The signs of dehydration become evident: intense
thirst, drowsiness, oliguria generalized malaise,
aching, and a parched tongue and mucous
membranes.
 Weakness
 Weight loss
 Anorexia
 Abdomen becomes markedly distended.
 Loops of large bowel become visibly outlined
through the abdominal wall
 Crampy lower abdominal pain
ASSESSMENT AND DIAGNOSTIC FINDINGS
 Diagnosis is based on symptoms, physical
assessment findings, and on imaging studies. The
abdomen may be distended, bowel sounds may be
normal early in the obstruction, but later hypoactive
to absent, and the abdomen hyper resonant
 Abdominal x-ray and Abdominal CT or MRI
findings reveal a distended colon and pinpoint the
site of the obstruction.
MEDICAL MANAGEMENT
 NG aspiration and decompression are instituted
immediately
 A Colonoscopy may be performed to untwist and
decompress the bowel.
 A rectal tube may be used to decompress an area
that is lower in the bowel.
 As an alternative, a metal colonic stent may be
used as either a palliative intervention or as a
bridge to definitive surgery.
 The usual treatment is surgical resection to
remove the obstructing lesion.
 A temporary or permanent colostomy may be
necessary.
 An ileoanal anastomosis may be performed if
removal of the entire large bowel is necessary.
NURSING MANAGEMENT
 The nurse role is to:
 Monitor the patient for symptoms indicating that the
intestinal obstruction is worsening or resolving and
to provide emotional support and comfort.
 Administers IV fluids and electrolytes as prescribed
 If the patient’s condition does not respond to
nonsurgical treatment, the nurse prepares the
patient for surgery. This preparation includes
preoperative education as the patient’s condition
indicates. After surgery, routine postoperative
19
NCM112 LECTURE
MEDICAL-SURGICAL NURSING

FLUID DISTRUBANCES, ELECTROLYTE IMBALANCES, RENAL AND KIDNEY DISORDERS

nursing care is provided, including abdominal
wound care.

BSN 3B | PBL GROUP 1 20