CONCEPTS ON DISTURBANCES IN GASTROINTESTINAL TRACT

I. ANATOMY AND PHYSIOLOGY A. Functions of the gastrointestinal system 1. Process food substances. 2. Absorb the products of digestion into the blood. 3. Excrete unabsorbed materials. 4. Provide an environment for microorganisms to synthesi e nutrients! such as vitamin ". #. For ris$ factors associated %ith the gastrointestinal system! &. 'outh 1. (he mouth contains the lips! chee$s! palate! tongue! teeth! salivary glands muscles! and maxillary bones. 2. )aliva contains the amylase en yme *ptyalin+ that aids in digestion. ,. Esophagus 1. (he esophagus is a collapsible muscular tube about 1- inches long. 2. (he esophagus carries food from the pharynx to the stomach. .. (he stomach contains the cardia! fundus! the body! and the pylorus. 1. 'ucous glands a. 'ucous glands are located in the mucosa. b. 'ucous glands prevent autodigestion by providing an al$aline protective covering. 2. (he lo%er esophageal *cardiac+ sphincter prevents reflux of gastric contents into the esophagus. 3. (he pyloric sphincter regulates the rate of stomach emptying into the small intestine. 4. /ydrochloric acid $ills microorganisms brea$s food into small particles and provides a chemical environment that is re0uired by the gastric en ymes. #. Pepsin is the chief coen yme of gastric 1uice! %hich converts proteins into proteases and peptones. 2. 3ntrinsic factor is necessary for the absorption of vitamin &12. 4. 5astrin controls gastric acidity. E. )mall intestine 1. (he duodenum contains the openings of the bile and pancreatic ducts. 2. (he 1e1unum is about 6 feet long. 3. (he ileum is about 12 feet long. 4. (he small intestine terminates into the cecum. F. Pancreatic intestinal 1uice en ymes 1. Amylase digests starch to maltose. 2. 'altase reduces maltose to monosaccharide glucose 3. 7actase splits lactose into galactose and glucose. 4. )ucrase reduces sucrose to fructose and glucose. #. 8ucleoses split nucleic acids to nucleotides. 2. Entero$ifla)e activates trypsinogen to trypsin. 5. 7arge intestine 1. (he large intestine is about # feet long. 2. (he large intestine absorbs %ater and eliminates %astes. 3. 3ntestinal bacteria play a vital role in the synthesis of some & vitamins and vitamin ". 4. ,olon a. Ascending b. (ransverse c. .escending d. )igmoid e. 9ectum #. (he ileocecal valve prevents contents of large intestine from entering ileum. 2. (he anal sphincters guard the anal canal. /. Peritoneum 1. (he peritoneum lines the abdominal cavity. 2. (he peritoneum forms the mesentery that supports the intestines and blood supply. 3. 7iver 1. (he liver is the largest gland in the body %eighing 3 to 4 lb. 2. (he liver contains "upffer:s cells! %hich remove bacteria in the portal venous blood. 3. (he liver removes excess glucose and amino acids from the portal blood. 4. (he liver synthesi es glucose! amino acids! and fats. #. (he liver aids in the digestion of fats! carbohydrates! and proteins. 2. (he liver stores and filters blood *2-- to 4-- m7 of blood stored+. 4. (he liver stores vitamins A! .! and & and iron. 6. (he liver secretes bile to emulsify fats *#-- to 1--- m7 of bile a day+. ;. /epatic ducts a. (he hepatic ducts deliver bile to the gallbladder via the cystic duct. b. (he hepatic ducts deliver bile to the duodenum via the common bile duct. c. (he common bile duct opens into the duodenum! %ith the pancreatic duct at the ampulla of <ater.
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d. (he sphincter prevents the reflux of intestinal contents into the common bile duct and pancreatic duct. =. 5allbladder 1. (he gallbladder stores and concentrates bile. 2. (he gallbladder contracts to force bile into the duodenum during the digestion of fats. 3. (he cystic duct 1oins the hepatic duct to form the common bile duct. 4. (he sphincter of >ddi guards the entrance into the duodenum. #. (he presence of fatty materials in the duodenum stimulates the liberation of cholecysto$inin! %hich causes contraction of the gallbladder and relaxation of the sphincter of >ddi. ". Pancreas 1. Exocrine gland a. (he pancreas secretes sodium bicarboa? neutrali e the acidity of the stomach con?e?.u that enter the duodenum. b. Pancreatic 1uices contain en ymes for diges? carbohydrates! fats! and proteins. 2. Endocrine gland a. (he islets of 7angerhans secrete insulin b. 3nsulin is secreted into the bloodstream. important for carbohydrate metabolism. c. (he pancreas secretes glucagon to raise bic glucose levels. d. (he pancreas secretes somatostatin to exert hypoglycemic effect. II. GASTROINTESTINAL SYSTEM DIAGNOSTIC PROCEDURES Anoscopy! proctoscopy! and sigmoidoscopy ,holecystography Endoscopic retrograde cholangiopancreatography Fiberoptic colonoscopy 5astric analysis 7aparoscopy *peritoneoscopy+ 7iver biopsy 7o%er gastrointestinal tract study *barium enema+ Paracentesis )tool specimens @pper gastrointestinal fiberoscopy @pper gastrointestinal tract study *barium s%allo%+ A. @pper gastrointestinal tract study *barium s%allo%+ 1. .escription? An examination of the upper gastrotestinal tract under fluoroscopy after the client drin$s barium sulfate 2. Preprocedure? 8P> after midnight before the ca of the test 3. Postprocedure a. A laxative may be prescribed. b. 3nstruct the client to increase oral fluid inta$e to help pass the barium. c. 'onitor stools for the passage of barium *stools %ill appear chal$y %hite+ because barium can cause a bo%el obstruction. &. 7o%er gastrointestinal tract study *barium enema+ 1. .escription a. A fluoroscopic and radiographic examination of the large intestine is performed after rectal instillation of barium sulfate. b. (he study may be done %ith or %ithout air. 2. Preprocedure a. A lo%Aresidue diet for 1 to 2 days before the test b. A clear li0uid diet and a laxative the evening before the test c. 8P> after midnight before the day of the test d. ,leansing enemas on the morning of the test 3. Postprocedure a. 3nstruct the client to increase oral fluid inta$e to help pass the barium. b. Administer a mild laxative as prescribed to facilitate emptying of the barium. c. 'onitor stools for the passage of barium. d. 8otify the physician if a bo%el movement does not occur %ithin 2 days.

,. Gastri Ana!"sis 1. .escription a. 5astric analysis re0uires the passage of a nasogastric tube into the stomach to aspirate gastric contents for the analysis of acidity *p/+! appearance! and volumeB the entire gastric contents are aspirated! and then specimens are collected every 1# minutes for 1 hour. b. /istamine or pentagastrin may be administered subcutaneously to stimulate gastric secretions and may produce a flushed feeling. c. Esophageal reflux of gastric acid may be performed by ambulatory p/ monitoringB a probe is placed 1ust above the lo%er esophageal sphincter! is connected to an external recording device! and provides a computer analysis and graphic display of results. 2. Preprocedure a. Fasting for 6 to 12 hours is re0uired before the test. b. Avoid tobacco and che%ing gum for 2 hours before the test.
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c. 'edications that stimulate gastric secretions are %ithheld for 24 to 46 hours. 3. Postprocedure a. ,lient may resume normal activities. b. 9efrigerate gastric samples if not tested %ithin 4 hours. .. Upper Gastrointestina! #i$eros op" 1. .escription a. @pper gastrointestinal fiberoscopy also is $no%n as esophagogastroduodenoscopy. b. Follo%ing sedation! an endoscope is passed do%n the esophagus to vie% the gastric %all! sphincters! and duodenumB tissue specimens can be obtained. 2. Preprocedure a. (he client must be 8P> for 2 to 12 hours before the test. b. A local anesthetic *spray or gargle+ is administered along %ith mida olam *<ersed+ intravenously *provides conscious sedation and relieves anxiety+ 1ust before the scope is inserted. a. Atropine may be administered o reduce secretions! and glucagon may be administered to relax smooth muscle. c. ,lient is positioned on the left side to facilitate saliva drainage and to provide easy access of the endoscope. d. Air%ay patency is monitored during the test and pulse oximetry is used to monitor oxygen saturationB emergency e0uipment should be readily available. 3. Postprocedure a. ,lient must be 8P> until the gag reflex returns *1 to 2 hours+. b. 'onitor for signs of perforation *pain! bleeding! unusual difficulty s%allo%ing! elevated temperature+. c. 'aintain bedrest for the sedated client until alert. d. 7o enges! saline gargles! or oral analgesics can relieve minor sore throat! after the gag reflex returns. E. Anos op"% Pro tos op"% an& Sig'oi&os op" 1. .escription a. Anoscopy re0uires use of a rigid scope to examine the anal canalB client is placed in the $neeAchest position %ith the bac$ inclined at a 4#A degree angle. b. Proctoscopy and sigmoidoscopy re0uire use of a flexible scope to examine the rectum and sigmoid colonB client is placed on the left side %ith the right leg bent and placed anteriorly. c. &iopsies and polypectomies can be performed. 2. Preprocedure? Enemas are given until the returns are clear. 3. Postprocedure? 'onitor for rectal bleeding and signs of perforation. F. #i$eropti Co!onos op" 1. .escription a. ,olonoscopy is a fiberoptic endoscopy study in %hich the lining of the large intestine is visually examinedB biopsies and polypectomies can be performed. b. ,ardiac and respiratory function is monitored continuously during the test. c. ,olonoscopy is performed %ith the client lying on the left side %ith the $nees dra%n up to the chestB position may be changed during the test to facilitate passing of the scope. 2. Preprocedure a. Ade0uate cleansing of the colon is necessary! as prescribed by the physician. b. A clear li0uid diet is started at noon on the day before the test. c. ,onsult %ith the physician regarding medications that must be %ithheld before the test. d. ,lient is 8P> after midnight on the day before the test. e. 'ida olam *<ersed+ is administered intravenously to provide sedation. f. 5lucagon may be administered to relax smooth muscle. 3. Postprocedure a. Provide bedrest until alert. b. 'onitor for signs of perforation. c. 3nstruct the client to report any bleeding to the physician. 5. Laparos op" *peritoneoscopy+ is performed %ith a fiberoscopic laparoscope that allo%s direct visuali ation of organs and structures %ithin the abdomenB biopsies may be obtained. /. C(o!e "stograp(" 1. .escription? Performed to detect gallstones and to assess the ability of the gallbladder to fill! concentrate its contents! contract! and empty. 2. Preprocedure a. Assess allergies to iodine or seafood. b. ,ontrast agents such as iopanoic acid *(elepa0ue+! iodipamide meglumine *,holografin+! or sodium ipodate *>ragrafin+ may be administered 1- to 12 hours *evening before+ before the test. c. ,lient is 8P> after the contrast agent is administered. d. 3nstruct the client that if a rash! itching! hives! or difficulty in breathing occurs after ta$ing the contrast agent! to report to the emergency room. 3. Postprocedure a. 3nform the dient that dysuria is common because the contrast agent is excreted in the urine. b. A normal diet may be resumed *a fatty meal may enhance excretion of the contrast agent+.
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3. En&os opi Retrogra&e C(o!angiopan reatograp(" )ERCP* 1. .escription a. Examination of the hepatobiliary system is performed via a flexible endoscope inserted into the esophagus to the descending duodenumB multiple positions are re0uired during the procedure to pass the endoscope. b. 3f medication is administered before the procedure! the client is monitored closely for signs of respiratory and central nervous system depression! hypotension! oversedation! and vomiting. 2. Preprocedure a. ,lient is 8P> for several hours before the procedure. b. )edation is administered before the procedure. 3. Postprocedure a. 'onitor vital signs. b. 'onitor for the return of the gag reflex. c. 'onitor for signs of perforation or infection. =. Per +taneo+s Trans(epati C(o!angiograp(" 1. .escription a. (he examination involves the in1ection of dye directly into the biliary tree. b. (he hepatic ducts %ithin the liver! the entire length of the common bile duct! the cystic duct! and the gallbladder are outlined clearly. 2. Preprocedure a. ,lient is 8P>. b. )edating medication is administered. 3. Postprocedure a. 'onitor vital signs. b. 'onitor for signs of bleeding! peritonitis! and septicemiaB report the presence of pain immediately. c. Administer antibiotics as prescribed to reduce the ris$ of sepsis. ". Para entesis 1. .escription? (ransabdominal removal of fluid from the peritoneal cavity for analysis 2. Preprocedure a. >btain informed consent. b. /ave client void before the start of procedure to empty bladder and to move bladder out of the %ay of the paracentesis needle. a. 'easure abdominal girth! %eight! and baseline vital signs. b. 8ote that the client is positioned upright on the edge of the bed %ith the bac$ supported and the feet resting on a stool *Fo%ler:s position is used for the client confined to bed+. 3. Postprocedure a. 'onitor vital signs. b. 'easure fluid collected! describe! and record. c. 7abel fluid samples and send to the laboratory for analysis. d. Apply a dry sterile dressing to the insertion siteB monitor site for bleeding. e. 'easure abdominal girth and %eight. f. 'onitor for hypovolemia! electrolyte loss! mental status changes! or encephalopathy. g. 'onitor for hematuria caused by bladder trauma. h. 3nstruct the client to notify the physician if the urine becomes bloody! pin$! or red. 7. Li,er Biops" 1. .escription? A needle is inserted through the abdominal %all to the liver to obtain a tissue sample for biopsy and microscopic examination. 2. Preprocedure a. >btained informed consent. b. Assess results of coagulation tests *prothrombin time! partial thromboplastin time! platelet count+. c. Administer a sedative as prescribed. d. 8ote that the client is placed in the supine or left lateral position during the procedure to expose the right side of the upper abdomen. 3. Postprocedure a. Assess vital signs. b. Assess biopsy site for bleeding. c. 'onitor for peritonitis. d. 'aintain bed rest for several hours. e. Place client on the right side %ith a pillo% under the costal margin to decrease the ris$ of hemorrhage! and instruct the client to avoid coughing and straining. f. 3nstruct the client to avoid heavy lifting and strenuous exercise for 1 %ee$. Stoo! Spe i'ens 1. (esting of stool specimens includes inspecting the specimen for consistency and color and testing for occult blood. 2. (ests for fecal urobilinogen! fat! nitrogen! parasites! pathogens! food substances! and other substances may be performedB these tests re0uire that the specimen be sent to the laboratory. 3. 9andom specimens are sent promptly to the laboratory. #. Cuantitative 24A to 42A hour collections must be $ept refrigerated until they are ta$en to the laboratory.
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)ome specimens re0uire that a certain diet be follo%ed or that certain medications be %ithheldB chec$ agency guidelines regarding specific procedures.

NASOGASTRIC TUBES A. .escription 1. )hort tubes used to intubate the stomach 2. (ube inserted from nose to stomach &. (ypes of tubes 1. Le,in a. )ingleAlumen nasogastric tube b. @sed to remove gastric contents via intermittent suction or to provide tube feedings 2. Sa!e' S+'p a. A )alem sump is a doubleAlumen nasogastric tube %ith an air vent *pigtail+ used for decompression %ith continuous suction. b. Air vent is not to be clamped and is to be $ept above the level of the stomach. c. 3f lea$age occurs through the air vent! instill 3- m7 of air into the air vent and irrigate the main lumen %ith normal saline *8)+. ,. 3ntubation procedures 1. Place the client in high Fo%ler:s position. 2. 'easure from tip of nose to earlobe to xiphoid process to determine the length of insertion! and mar$ %ith tape. 3. 7ubricate tube about 3 inches %ith a %aterA soluble 1elly only oilAsoluble is not used because of the ris$ of pneumonia if the tube accidentally slips into the bronchus. 4. 3nstruct the client to bend the head for%ard! %hich closes the epiglottis and opens the esophagus. #. 3nsert into nostril and advance bac$%ard and through the nasopharynx. 2. /ave the client ta$e a sip of %ater! and advance the tube as the client s%allo%s. 4. .o not force the tube. 6. 3f the client experiences any respiratory distress *coughing or cho$ing+ during insertion! pull bac$ on the tube and %ait until the distress subsides. ;. Advance until reaching the taped mar$B tape tube in place %hen correct placement is confirmed. 1-. 3f feedings are prescribed! xAray confirmation should be done before feedings are initiated. 11. Follo%ing gastrointestinal intubation! the tube may be attached to continuous or intermittent suction! %ith a pressure not exceeding 2# mm /g as prescribed by the physician. .. Assessment of placement 1. 8ote that the most reliable method to determine placement is by radiography! %hich should be performed after initial placement. 2. Assess tube placement every 4 hours and before administering feedings or medications. 3. Assess tube placement by aspirating gastric conA A tents and measuring the p/! %hich should be 4 or less *p/ values greater than 2 indicate intestinal placement+. 4. 3nserting # to 1- m7 of air into the nasogastric tube and listening for the rush of air over the stomach %ith a stethoscope is an alternative method for assessing placement but is not as reliable as radiography or chec$ing gastric p/. E. Assessment of residual 1. ,hec$ residual volumes every 4 hours! before each feeding! and before giving medications. 2. Aspirate all stomach contents *residual+ and measure amount. 3. 9einstill residual feeding to prevent excessive fluid and electrolyte losses! unless the residual volume appears abnormal. F. 3rrigation 1. Perform irrigation every 4 hours to chec$ the patency of the tube. 2. Assess placement before irrigating. 3. 5ently instill 3- to #- m7 of %ater or 8) *depending on agency policy+ %ith an irrigation syringe. 4. Pull bac$ on the syringe plunger to %ithdra% the fluid to chec$ patencyB repeat if tube remains sluggish. 5. 9emoval of a nasogastric tube? As$ the client to ta$e a deep breath and holdB remove the tube slo%ly and 3 evenly over the course of 3 to 2 seconds *coil the tube around the hand %hile removing it+. GASTROINTESTINAL TUBE #EEDINGS A. (ubes 1. 8asogastric? nose to stomach 2. 8asoduodenalDnaso1e1unal? nose to duodenum or 1e1unum 3. 5astrostomy? stomach 4. =e1unostomy? 1e1unum &. (ypes of administration 1. &olus a. A bolus resembles normal meal feeding patterns. b. Administration consists of 3-- to 4-- m7 of formula given over a 3-A to 2-Aminute period every 3 to 2 hours. 2. ,ontinuous a. Feeding is administered continually for 24 hours. b. An infusion pump regulates the flo%.
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3. ,yclical a. Feeding is administered in the daytime or the nighttime for 6 to 12 hours. D b. An infusion pump regulates the flo%. c. Feedings at night allo% for more freedom during the day. ,. Administration of feedings 1. Position the client in high Fo%ler:s and on the right side if comatose. 2. Earm feeding to room temperature to prevent diarrhea and cramps. 3. Aspirate all stomach contents *residual+! measure the amount! and return the contents to the stomach to prevent electrolyte imbalances. 4. ,hec$ physician:s order and agency policy regarding residual amountsB usually if the residual is less than 1-- m7! feeding is administeredB largeAvolume aspirates indicate delayed gastric emptying and place the client at ris$ for aspiration. #. Assess tube placement by aspirating gastric contents and measuring the p/ *should be 4 or less+. 2. Assess bo%el soundsB hold feeding and notify the physician if bo%el sounds are absent. 4. @se a feeding pump for continuous or cyclic feedings. 6. For bolus feeding! leave the client in a high Fo%ler:s position for 3- minutes after feeding. ;. For a continuous feeding! $eep the client in a semiAFo%ler position at all times. .. Precautions 1. ,hange the feeding container and tubing every 24 hours. 2. .o not hang more solution than %ill be re0uired for a 4Ahour period to prevent bacterial gro%th. 3. ,hec$ the expiration date on the formula before administering. 4. )ha$e the formula %ell before inserting into container. #. Al%ays assess placement of the tube before feeding. 2. Al%ays assess bo%el soundsB do not administer any feedings if bo%el sounds are absent. 4. Add a drop of methyline blue to the feeding! particularly %ith clients %ho have endotracheal or tracheal tubesB suspect a tracheoesophageal fistula %hen blue gastric contents appear in tracheal excretion! and if this is noted! notify the physician immediately. 6. Administer feeding at prescribed rate or via gravity flo% *intermittent! bolus feedings+ %ith a 2-Am7 syringe %ith the plunger removed. ;. 5ently flush %ith 3- to #- m7 of %ater or normal saline *depending on agency policy+ %ith the irrigation syringe after the feeding. E. Prevention of complications 1. .iarrhea a. @se fiberAcontaining feedings. b. Administer feeding slo%ly and at room temperature. 2. Aspiration a. <erify tube placement. b. .o not administer feeding if residual is greater than 1-- m7 *chec$ physician:s order and agency policy+. c. "eep the head of the bed elevated. d. 3f aspiration occurs! suction as needed! assess respiratory rate! auscultate lung sounds! monitor temperature for aspiration pneumonia! and prepare to obtain chest radiograph. 3. ,logged tube a. @se li0uid forms of medication! if possible. b. Flush the tube %ith 3- to #- m7 of %ater or 8) *depending on agency policy+ before and after medication administration and before and after bolus feeding. c. Flush %ith %ater every 4 hours for continuous feeding. 4. <omiting a. Administer feedings slo%ly! and for bolus feedings! ma$e the feeding last for 3- minutes. b. 'easure abdominal girth. c. .o not allo% feeding bag to empty. d. .o not allo% air to enter the tubing. e. Administer feeding at room temperature. f. Elevate the head of the bed. g. Administer antiemetics as prescribed. h. 3f client vomits! place client in sideAlying position.

MEDICATIONS -IA NASOGASTRIC OR GASTROSTOMY TUBE A. ,rush medications or use elixir forms of medications. &. Ensure that the medication ordered can be crushed or that the capsule can be opened. ,. .issolve crushed medication or capsule contents in # to 1- m7 of %ater. .. ,hec$ placement and residual before instilling medications. E. .ra% up the medication into a catheter tip syringe! clear excess air! and insert medication into the tube. F. Flush %ith 3- to #- m7 of %ater or 8) *depending on agency policy+. 5. ,lamp the tube for 3- to 2- minutes *depending on medication and agency policy+. INTESTINAL TUBES A. .escription 1. (he intestinal tube is passed nasally into the small intestine.
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(he tube may be used to decompress the bo%el or to remove intestinal contents. (he tube enters the small intestine through the pyloric sphincter because of the %eight of a small bag of mercury at the end.

&. (ypes of tubes 1. ,antor or /arris 2. 'illerAAbbott ,. 3nterventions 1. Assess physician:s orders and agency policy for advancement and removal of tube. 2. Position client on the right side to facilitate passage of the mercury %eights %ithin the tube through the pylorus of the stomach and into the small intestine. 3. .o not secure the tube to the face %ith tape until has reached final placement *may ta$e several hours+ in the intestines. 4. 9adiography is performed to verify desired placement. #. 'onitor drainage from the tube. 2. 3f the tube becomes bloc$ed! notify the physicianB a small amount of air in1ected into the lumen may be prescribed to clear the tube. 4. Assess the abdomen and measure abdominal girth. 6. (o remove the tube! the mercury and air are removed from the balloon portion of the tube %ith a #Am7 syringeB the tube is removed gradually *2 inches every hour+ as prescribed by the physician. ;. .ispose of the mercury in the appropriate manner as per agency policy. ESOPHAGEAL AND GASTRIC TUBES A. .escription 1. @sed to apply pressure against esophageal veins to control bleeding 2. 8ot used if the client has ulceration or necrosis of the esophagus or has had previous esophageal surgery &. Sengstaken.B!ake'ore t+$e 1. (he )engsta$enA&la$emore tube is a tripleAlumen gastric tube %ith an inflatable esophageal balloon! an inflatable gastric balloon! and a gastric aspiration lumen. 2. (he gastric balloon applies pressure at the cardioesophageal 1unction to compress gastric varices directly and to decrease blood flo% to esophageal varicesB traction is applied to maintain the gastric balloon in place. 3. (he esophageal balloon directly compresses esophageal varices. 4. 3f bleeding is not stopped %ith inflation of the gastric balloon! the esophageal balloon is inflated to 2# to 4# mm /g. #. A radiograph of the upper abdomen and chest confirms placement. 2. 5astric contents are aspirated by gastric lavage or intermittent suction via the gastric aspiration port. 4. Eith the )engsta$enA&la$emore tube! a nasogastric tube also is inserted in the opposite naris to collect secretions that accumulate above the esophageal balloon. ,. Minnesota t+$e 1. FourAlumen gastric tube 2. A modified )engsta$enA&la$emore tube %ith an additional lumen for aspirating esophagopharyngeal secretions .. 3nterventions 1. ,hec$ patency and integrity of all balloons before insertion. 2. 7abel each lumen. 3. Place the client in the upright or Fo%ler:s position for insertion. 4. 3mmediately after insertion! prepare for radiography to verify placement. #. 'aintain head elevation once the tube is in place. 2. .oubleAclamp the balloon ports to prevent air lea$s. 4. "eep s issors at the bedside at all timesB monitor for respiratory distress! and if it occurs! cut tubes to deflate balloons. 6. (o prevent ulceration or necrosis of the esophagus! release esophageal pressure as prescribed and per agency policy. ;. 'onitor for increased bloody drainage! %hich may indicate persistent bleeding. 1-. 'onitor for signs of esophageal rupture! %hich includes a drop in blood pressure! increased heart rate! and bac$ and upper abdominal painB esophageal rupture is an emergency and must be reported to the physician immediately. LA-AGE TUBES A. .escription? @sed to remove toxic substances from the stomach &. (ypes of tubes 1. La,a +ator a. (he 7avacuator is an orogastric tube %ith a large suction lumen and a smaller lavageDvent lumen that provides continuous suction. b. 3rrigation solution enters the lavage lumen %hile stomach contents are removed through the suction lumen. 3. E/a!&0s? 9eusable singleAlumen large tube used for rapid oneAtime irrigation and evacuation 4. 3nability to pass a smallAgauge *such as a 8o. # French+ orogastric feeding tube via the mouth into the stomach. ,. 3nterventions preoperatively 1. 3nfant may be placed in an incubator or radiant %armer in %hich humidified oxygen is administered *intubation and mechanical ventilation may be necessary if respiratory distress occurs+. 2. 'aintain an 8P> status. 3. 'aintain 3< fluids as prescribed. 4. )uction accumulated secretions from the mouth and pharynx.
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A doubleAlumen catheter is placed into the upper esophageal pouch and attached to intermittent or continuous lo% suction to $eep the pouch empty of secretionsB it is irrigated %ith normal saline as prescribed to prevent clogging. 'aintain in an upright position to facilitate drainage and to prevent aspiration of gastric secretions. A gastrostomy tube may be placed and is left open so that air entering the stomach through the fistula can escape! minimi ing the danger of regurgitation. Administer broadAspectrum antibiotics as prescribed because of the high ris$ for aspiration pneumonia.

.. 3nterventions postoperatively 1. 'onitor respiratory status. 2. 'aintain 3< fluids! antibiotics! and parenteral nutrition as prescribed. 3. 'onitor inta$e and output and %eight daily. 4. 3nspect surgical site. #. Provide care to the chest tube if in place. 2. Assess for signs of pain. 4. Assess for dehydration and possible fluid overload. 6. 'onitor for anastomotic lea$s as evidenced by purulent chest drainage! increased temperature! and an increased %hite blood cell count. ;. (he doubleAlumen catheter is attached to lo% suction. 1-. 3f a gastrostomy tube is present! it is attached to gravity drainage until the infant can tolerate feedings *usually the fifth to seventh day postoperatively+. 11. &efore oral feedings and removal of the chest tube! a barium s%allo% is performed to verify the integrity of the esophageal anastomosis. 12. &efore feeding! the gastrostomy tube is elevated and secured above the level of the stomach to allo% gastric secretions to pass to the duodenum and s%allo%ed air to escape through the open gastrostomy tube. 13. Feedings through the gastrostomy tube may be prescribed until the anastomosis is healed. 14. >ral feedings are begun %ith sterile %ater follo%ed by fre0uent small feedings of formula. 1#. (he gastrostomy tube may be removed before discharge or may be maintained for supplemental feedings at home. 12. 3f the infant is a%aiting esophageal replacement! a cervical esophagostomy may be performed. 14. Assess cervical esophagostomy site for redness! brea$do%n! or exudate *continued discharge or saliva can cause s$in brea$do%n+B remove drainage fre0uently and apply a protective ointment! a barrier dressing! andDor a collection device. 16. 3f the infant is a%aiting esophageal replacement! nonnutritive suc$ing is provided by a pacifierB infants %ho remain 8P> for extended periods and have not received oral stimulation fre0uently may have difficulty eating by mouth after surgery and develop oral hypersensitivity and food aversion. 1;. 3nstruct the parents in the techni0ues of suctioning! gastrostomy tube care and feedings! and s$in site care as appropriate. 2-. 3nstruct parents to identify behaviors that indicate the need for suctioning! signs of respiratory distress! and signs of a constricted esophagus *poor feeding! dysphagia! drooling! or regurgitated undigested food+. RIS1 #ACTORS ASSOCIATED 2ITH THE GASTROINTESTINAL SYSTEM Family history of gastrointestinal disorders ,hronic laxative (obacco use ,hronic alcohol use ,hronic high stress levels Allergic reactions to food or medications ,hronic use of aspirin or nonsteroidal antiAinflammatory drugs 7ongAterm gastrointestinal conditions such as ulcerative colitis that may predispose to colorectal cancer Previous abdominal surgery or trauma! %hich may lead to adhesions 8eurological disorders that can impair movement! particularly %ith che%ing and s%allo%ing ,ardiac! respiratory! and endocrine disorders that may lead to constipation .iabetes mellitus! %hich may predispose to oral candidal infections PEDIATRIC GASTROINTESTINAL TRACT DISORDERS CLE#T LIP AND CLE#T PALATE 1. ,left lip or cleft palate is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development 2. (he defects involve abnormal openings in the lip or palate that may occur unilaterally or bilaterally and are readily apparent at birth. 3. ,auses include genetic! hereditary and environmental factorsB exposure to radiation or rubella virusB chromosome abnormalitiesB and teratogenic factors. 4. ,losure of cleft lip defect precedes that of the palate and is performed usually during the first %ee$s of life. #. ,left palate repair is performed sometime bet%een 34 an& 35 'ont(s o6 age to allo% for the palatal changes that ta$e place %ith normal gro%thB a cleft palate is closed before the child develops faulty speech habits. &. Assessment 1. ,left lip can range from a slight notch to a complete separation from the floor of the nose. 2. ,left palate can include nasal distortion! midline or bilateral cleft! and variable extension from the uvula and soft and hard palate.
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,. 3nterventions 1. Assess the ability to suc$! s%allo%! handle normal secretions! and breathe %ithout distress. 2. Assess fluid and calorie inta$e daily and monitor %eight. 3. 'odify feeding techni0uesB plan to use speciali ed feeding techni0ues! obturators! and special nipples and feeders. 4. /old the child in an upright position and direct the formula to the side and bac$ of the mouth to prevent aspirationB feed small amounts gradually and burp fre0uently. #. Position on side after feeding. 2. "eep suction e0uipment and bulb syringe at bedside. 4. Encourage breastAfeeding if appropriate. 6. (each the parents special feeding or suctioning techni0ues. ;. (each the parents the ESSR *enlarge! stimulate suc$ing! s%allo%! rest+ method of feeding ESSR Met(o& o6 #ee&ing ENLARGE the nipple STIMULATE the suc$ reflex S2ALLO2 REST to allo% the child to finish s%allo%ing %hat has been placed in the mouth. 1-. Encourage the parents to describe their feelings related to the deformity. .. 3nterventions postoperatively 1. ,left lip repair a. A lip protector device may be taped securely to the chee$s to prevent trauma to the suture line. c. Position the child on the si&e !atera! to the repair or on the bac$B avoid the prone position to prevent rubbing of the surgical site on the mattress. d. After feeding! cleanse the suture line of formula or serosanguineous drainage %ith a cottonA tipped s%ab dipped in salineB apply antibiotic ointment if prescribed. 2. ,left palate repair a. ,hild is allo%ed to lie on the abdomen. b. Feedings are resumed by bottle! breast! or cup. c. >ral pac$ing may be secured to the palate *removed in 2 to 3 days+. e. .o not allo% the child to brush his or her teeth. f. 3nstruct the parents to avoid offering hard food items to the child! such as toast or coo$ies. 3. )oft elbo% or 1ac$et restraints may be used *chec$ agency policies and procedures+ to $eep the child from touching the repair siteB remove restraints at least every 2 hours to assess s$in integrity and allo% for exercising the arms. 4. Avoid contact %ith sharp ob1ects near the surgical site. #. Avoid the series of oral suction or placing ob1ects in the mouth such as a tongue depressor! thermometer! stra%s! spoons! for$s! or pacifiers. 2. Provide analgesics for pain. 4. 3nstruct the parents in feeding techni0ues and in the care of the surgical site. 6. 3nstruct the parents to monitor for signs of infection at the surgical site! such as redness! s%elling! or drainage. ;. Encourage the parents to hold the child. 1-. 3nitiate appropriate referrals for speech impairment or languageAbased learning difficulties.

ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL #ISTULA )TE#* A. .escription 1. (he esophagus terminates before it reaches the stomach or a fistula is present that forms an unnatural connection %ith the trachea. 2. (he condition causes oral inta$e to enter the lungs or a large amount of air to enter the stomach! and cho$ing! coughing! and severe abdominal distention can occur. 3. Aspiration pneumonia and severe respiratory distress %ill develop! and death %ill occur %ithout surgical intervention. 4. (reatment includes maintenance of a patent air%ay! prevention of pneumonia! gastric or blind pouch decompression! supportive therapy! and surgical repair. &. Assessment 1. Frothy saliva in the mouth and nose and drooling 2. (he 78 Cs9F o+g(ing and (oking during feedings and unexplained "anosis 3. 9egurgitation and vomiting 4. Abdominal distention #. 3nability to pass a smallAgauge *such as a 8o. # French+ orogastric feeding tube via the mouth into the stomach. 3nterventions preoperatively 1. 3nfant may be placed in an incubator or radiant %armer in %hich humidified oxygen is administered *intubation and mechanical ventilation may be necessary if respiratory distress occurs+. 2. 'aintain an 8P> status. 3. 'aintain 3< fluids as prescribed. 4. )uction accumulated secretions from the mouth and pharynx.

kenpogi

#. 2. 4. 6.

A doubleAlumen catheter is placed into the upper esophageal pouch and attached to intermittent or continuous lo% suction to $eep the pouch empty of secretionsB it is irrigated %ith normal saline as prescribed to prevent clogging. 'aintain in an upright position to facilitate drainage and to prevent aspiration of gastric secretions. A gastrostomy tube may be placed and is left open so that air entering the stomach through the fistula can escape! minimi ing the danger of regurgitation. Administer broadAspectrum antibiotics as prescribed because of the high ris$ for aspiration pneumonia.

3nterventions postoperatively 1. 'onitor respiratory status. 2. 'aintain 3< fluids! antibiotics! and parenteral nutrition as prescribed. 3. 'onitor inta$e and output and %eight daily. 4. 3nspect surgical site. #. Provide care to the chest tube if in place. 2. Assess for signs of pain. 4. Assess for dehydration and possible fluid overload. 6. 'onitor for anastomotic lea$s as evidenced by purulent chest drainage! increased temperature! and an increased %hite blood cell count. ;. (he doubleAlumen catheter is attached to lo% suction. 1-. 3f a gastrostomy tube is present! it is attached to gravity drainage until the infant can tolerate feedings *usually the fifth to seventh day postoperatively+. 11. &efore oral feedings and removal of the chest tube! a barium s%allo% is performed to verify the integrity of the esophageal anastomosis. 12. &efore feeding! the gastrostomy tube is elevated and secured above the level of the stomach to allo% gastric secretions to pass to the duodenum and s%allo%ed air to escape through the open gastrostomy tube. 13. Feedings through the gastrostomy tube may be prescribed until the anastomosis is healed. 14. >ral feedings are begun %ith sterile %ater! follo%ed by fre0uent small feedings of formula. 1#. (he gastrostomy tube may be removed before discharge or may be maintained for supplemental feedings at home. 12. 3f the infant is a%aiting esophageal replacement! a cervical esophagostomy may be performed. 14. Assess cervical esophagostomy site for redness! brea$do%n! or exudate *continued discharge or saliva can cause s$in brea$do%n+B remove drainage fre0uently and apply a protective ointment! a barrier dressing! andDor a collection device. 16. 3f the infant is a%aiting esophageal replacement! nonnutritive suc$ing is provided by a pacifierB infants %ho remain 8P> for extended periods and have not received oral stimulation fre0uently may have difficulty eating by mouth after surgery and develop oral hypersensitivity and food aversion. 1;. 3nstruct the parents in the techni0ues of suctioning! gastrostomy tube care and feedings! and s$in site care as appropriate. 2-. 3nstruct parents to identify behaviors that indicate the need for suctioning! signs of respiratory distress! and signs of a constricted esophagus *poor feeding! dysphagia! drooling! or regurgitated undigested food+.

HYPERTROPHIC PYLORIC STENOSIS A. .escription 1. /ypertrophy of the circular muscles of the pylorus causes narro%ing of the pyloric canal bet%een the stomach and the duodenum. 2. (he stenosis usually develops in the first fe% %ee$s of life! causing pro:e ti!e ,o'iting! dehydration! metabolic al$alosis! and failure to thrive. &. Assessment 1. <omiting that progresses from mild regurgitation to forceful and pro1ectile and usually occurs after a feeding. 2. <omitus contains gastric contents such as mil$ or formula! may contain mucus! may be blood tinged! and does not usually contain bile. 3. (he child exhibits hunger and irritability. 4. Peristaltic %aves are visible from left to right across the epigastrium during or immediately follo%ing a feeding. #. O!i,e.s(ape& 'ass is in the epigastrium 1ust right of the umbilicus. 2. .ehydration and malnutrition can occur. 4. Electrolyte imbalances can occur. 6. 'etabolic al$alosis can occur. ,. 3nterventions 1. 'onftor vital signs. 2. 'onitor inta$e and output and %eight. 3. 'onitor for signs of dehydration and electrolyte imbalances. 4. Prepare the child and parents for pyloromyotomy if prescribed. .. Pyloromyotomy 1. .escription? An incision through the muscle fibers of the pylorus that may be performed by laparoscopy 2. 3nterventions preoperativelv a. 'onitor hydration status by daily %eights! inta$e and output! and urine for specific gravity b. ,orrect fluid and electrolyte imbalancesB administer fluids intravenously as prescribed for rehydration. c. 'aintain 8P> status. d. 'onitor the number and character of stools. e. 'aintain patency of the nasogastric tube placed for stomach decompression. 3. 3nterventions postoperatively.
1kenpogi

a. b. c. d. e. f. g. h.

'onitor inta$e and output. 'aintain 3< fluids until the infant is ta$ing and retaining ade0uate amounts by mouth. &egin small! fre0uent feedings of glucose! %ater! or electrolyte solution 4 to 2 hours postoperatively as prescribedB advance the diet to formula 24 hours postoperatively as prescribed. 5radually increase amount and interval bet%een feedings until a full feeding schedule is reinstated! usually by 46 hours postoperatively. Feed the infant slo%ly! burping fre0uentlyB handle the infant minimally after feedings. 'onitor for abdominal distention. 'onitor the surgical %ound and for signs of infection. 3nstruct the parents about %ound care and feeding.

LACTOSE INTOLERANCE A. .escription? 3nability to tolerate lactose as a result of an absence or deficiency of lactase! an en yme found in the secretions of the small intestine that is re0uired for the digestion of lactose &. Assessment )ymptoms occurring after the ingestion of mil$ products Abdominal distention ,rampy! abdominal pain .iarrhea Excessive flatus ,. 3nterventions 1. Eliminate the offending dairy product or administer an en yme replacement. 2. Provide information to parents about en yme tablets *7actaid! 7actrase! .airy Ease+ that predigest the lactose in mil$ or supplement the body:s o%n lactase. 3. 3n infants! soyAbased formulas can be substituted for co%:s mil$ formula or human mil$. 4. Provide calcium and vitamin . supplements to prevent deficiency. #. 7imit mil$ consumption to one glass at a time. 2. 3f the child consumes mil$! the child should drin$ it %ith other foods rather than alone. 4. Encourage consumption of hard cheese! cottage cheese! or yogurt *contains inactive lactase en yme+ instead of drin$ing mil$. 6. Encourage consumption of small amounts of dairy foods daily to help colonic bacteria adapt to ingested lactose. ;. 3nstruct parents about the importance of calcium and vitamin . supplements. 1-. 3nstruct parents about the foods that contain lactose! including hidden sources. CELIAC DISEASE A. .escription 1. ,eliac disease also is $no%n as gluten enteropathy or tropical sprue. 2. 3ntolerance to gluten! the protein component of $ar!e"% r"e% oats% an& /(eat )BRO2*! is characteristic. 3. ,eliac disease results in the accumulation of the amino acid glutamine! %hich is toxic to intestinal mucosal cells. 4. 3ntestinal villi atrophy occurs! %hich affects absorption of ingested nutrients. #. )ymptoms of the disorder occur most often bet%een the ages of 1 and # yearsB there is usually an interval of several months bet%een the introduction of gluten in the diet and the onset of symptoms. 2. )trict dietary avoidance of gluten minimi es the ris$ of developing malignant lymphoma of the small intestine and other gastrointestinal malignancies. &. Assessment 1. Acute or insidious diarrheaB stools are %atery and pale %ith an offensive odor 2. Anorexia 3. Abdominal pain and distention 4. 'uscle %asting! particularly in the buttoc$s and extremities #. <omiting 2. Anemia 4. 3rritability ,. ,eliac crisis ,risis is precipitated by infection! fasting! and ingestion of gluten. ,risis can lead to electrolyte imbalance! rapid dehydration! and severe acidosis ,risis causes profuse %atery diarrhea and vomiting. .. 3nterventions 1. 5lutenAfree diet and substituting corn! rice! and millet as grain sources 2. 7ifelong elimination of gluten sources such as %heat! rye! oats! and barley 3. 'ineral and vitamin supplements! including iron! folic acid! and fatAsoluble supplements A! .! E! and " 4. (eaching the parents about a glutenAfree diet and to read food labels carefully for hidden sources of gluten #. 3nstructing the parents in the measures to prevent celiac crisis
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Basi s o6 a G!+ten.#ree Diet #oo&s A!!o/e& 'eat such as beef! por$! and poultry and fish! eggs! mil$ and dairy products! vegetables! fruits! grains! rice! corn! glutenAfree %heat flour! puffed rice! cornfla$es! cornmeal! and precoo$ed glutenAfree cereals #oo&s Pro(i$ite& ,ommercially prepared ice creamB malted mil$B prepared puddingsB grains! including anything made from %heat! rye! oats! or barley! such as breads! rolls! coo$ies! ca$es! crac$ers! cereal! spaghetti! macaroni noodles! beer! and ale HIRSCHSPRUNG0S DISEASE A. .escription 1. /irschsprung:s disease is a congenital anomaly also $no%n as ongenita! agang!ionosis or 'ega o!on. 2. (he disease occurs as the result of an absence of ganglion cells in the rectum and up%ard in the colon. 3. (he disease results in mechanical obstruction from inade0uate motility in an intestinal segment. 4. (he disease may be a familial congenital defect or may be associated %ith other anomalies! such as .o%n syndrome and genital urinary abnormalities. #. A rectal biopsy demonstrates histologic evidence of the absence of ganglionic cells. 2. (he most serious complication is entero o!itisB signs include fever! severe prostration! gastrointestinal bleeding! and explosive %atery diarrhea. 4. (reatment for mild or moderate disease is based on relieving the chronic constipation %ith stool softeners and rectal irrigationsB ho%ever! most children re0uire surgery. 6. (reatment for moderate to severe disease involves a t%oAstep surgical procedure. ;. 3nitially! in the neonatal period! a temporary colostomy is created to relieve obstruction and allo% the normally innervated! dilated bo%el to return to its normal si e. 1-. A complete surgical repair is performed %hen the child %eighs about ; $g *2- pounds+ via a pullAthrough procedure to excise portions of the bo%elB at this time! the colostomy is closed. &. Assessment 1. 8e%born infants a. Failure to pass meconium stool b. 9efusal to suc$ c. Abdominal distention d. &ileAstained vomitus 2. ,hildren a. Failure to gain %eight and delayed gro%th b. Abdominal distention c. <omiting d. ,onstipation alternating %ith diarrhea e. Ri$$on!ike an& 6o+!.s'e!!ing stoo!s ,. 3nterventions? medical management 1. .ietary management 2. )tool softeners 3. .aily rectal irrigations %ith normal saline to promote ade0uate elimination and prevent obstruction .. )urgical management? preoperative interventions 1. Assess bo%el function and administer bo%el preparation as prescribed. 2. 'aintain 8P> status. 3. 'onitor hydration and fluid and electrolyte statusB provide fluids intravenously as prescribed for hydration. 4. Administer antibiotics as prescribed to clear the bo%el of bacteria. #. 'onitor inta$e and output and %eight. 2. 'easure abdominal girth. 4. Avoid ta$ing the temperature rectally. 6. 'onitor for respiratory distress associated %ith abdominal distention! E. 3nterventions postoperatively 1. 'onitor vital signs! avoiding ta$ing the temperature rectally. 2. 'easure abdominal girth. 3. Assess surgical site for redness! s%elling! and drainage. 4. Assess the stoma if present for bleeding or s$in brea$do%n *stoma should be pin$ and moist+. #. Assess anal area for the presence of stool! redness! or discharge. 2. 'aintain 8P> status until bo%el sounds return or flatus is passedB bo%el sounds usually return %ithin 46 to 42 hours. 4. 'aintain the nasogastric tube to allo% intermittent suction until peristalsis returns. 6. 'aintain 3< fluids until the child tolerates appropriate oral inta$eB begin the diet %ith clear li0uids! advancing to regular as tolerated and as prescribed. ;. Assess for dehydration and fluid overload.
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1-. 11. 12. 13.

'onitor inta$e and output and %eight. Assess for pain and provide comfort measures as re0uired. Provide the parents %ith instructions regarding colostomy care and s$in care. (each the parents about the appropriate diet and the need for ade0uate fluid inta$e.

INTUSSUSCEPTION A. .escription 1. 3ntussusception is te!es oping of one portion of the bo%el into another portion. 2. (he condition results in an obstruction to the passage of intestinal contents. &. Assessment 1. ,olic$y abdominal pain that causes the child to scream and dra% the $nees to the abdomen 2. <omiting of gastric contents 3. &ileAstained fecal emesis 4. C+rrant :e!!".!ike stoo!s containing blood and mucus #. /ypoactive or hyperactive bo%el sounds 2. (ender distended abdomen! possibly %ith a palpable sa+sage.s(ape& mass in the upper right 0uadrant ,. 3nterventions 1. 'onitor for signs of perforation and shoc$ as evidenced by fever! increased heart rate! changes in level of consciousness or blood pressure! and respiratory distress! and report immediately. 2. Prepare for hydrostatic reduction if prescribed *not performed if signs of perforation or shoc$ occur+. a. Antibiotics! 3< fluids! and decompression via nasogastric tube may be prescribed. b. 'onitor for the passage of normal! bro%n stool! %hich indicates that the intussusception has reduced itself. 3. After hydrostatic reduction! do the follo%ing? a. 'onitor for the return of normal bo%el sounds! for the passage of barium! and the characteristics of stool. b. Administer clear fluids and advance the diet gradually as prescribed. 4. 3f surgery is re0uired! postoperative care is similar to that follo%ing any abdominal surgery. ABDOMINAL 2ALL DE#ECTS A. >mphalocele 1. >mphalocele is a hemiation of the abdominal contents through the umbilical ring *hernia of the umbilical cord+! usually %ith an intact peritoneal sac. 2. (he protrusion is covered by a translucent sac that may contain bo%el or other abdominal organs. 3. 9upture of the sac results in evisceration of the abdominal contents. 4. 3mmediately after birth! the sac is covered %ith A sterile gau e soa$ed in normal saline to prevent drying of abdominal contentsB a layer of plastic %rap is placed over the gau e to provide additional protection against moisture loss. #. 'onitor vital signs every 2 to 4 hours! particularly temperature because the infant can lose heat through the sac. 2. Preoperatively? 'aintain 8P> status! administer 3< fluids as prescribed to maintain hydration and electrolyte balance! monitor for signs of infection! and handle the infant carefully to prevent rupture of the sac. 4. Postoperatively? ,ontrol pain! prevent infection! maintain fluid and electrolyte balance! and ensure ade0uate nutrition. &. 5astroschisis 1. 5astroschisis occurs %hen the herniation of the intestine is lateral to the umbilical ring. 2. 8o membrane covers the exposed bo%el. 3. (he exposed bo%el is covered loosely in salineAsoa$ed pads! and the abdomen is %rapped in a plastic drapeB %rapping around the exposed bo%el is contraindicated because if the exposed bo%el expands! %rapping could cause pressure and necrosis. 4. Preoperatively? ,are is similar to that for omphaloceleB surgery is performed %ithin several hours after birth because no membrane is covering the sac. #. Postoperatively? 'ost infants have a prolonged ileus and re0uire mechanical ventilation and parenteral nutritionB other%ise! care is similar to that for omphalocele. UMBILICAL HERNIA% INGUINAL HERNIA% OR HYDROCELE A. .escription 1. A hernia is a protrusion of the bo%el through an abnormal opening in the abdominal %all. 2. 3n children! a hernia most commonly occurs at the umbilicus and through the inguinal canal. 3. A hydrocele is the presence of abdominal fluid in the scrotal sac. &. Assessment 1. @mbilical hernia? soft s%elling or protrusion around the umbilicus that is usually reducible %ith the finger 2. 3nguinal hernia a. Painless inguinal s%elling that is reducible b. )%elling that may disappear during periods of rest and is most noticeable %hen the infant cries or coughs 3. 3ncarcerated hernia a. Ehen the descended portion of bo%el becomes tightly caught in the hernial sac! compromising blood supply b. A medical emergency re0uiring surgical repair c. 3rritability d. (enderness at site e. AnorexiaB possible vomiting
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f. Abdominal distention g. .ifficulty defecating h. 'ay lead to complete intestinal obstruction and gangrene 4. 8oncommunicating hydrocele a. 9esidual peritoneal fluid is trapped %ith no communication to the peritoneal cavity. b. (he hydrocele usually disappears by age 1 year. #. ,ommunicating hydrocele a. (he hydrocele is associated %ith a hernia that remains open from the scrotum to the abdominal cavity. b. Assessment ini1udes a bulge in the inguinal area or the scrotum that increases %ith crying or straining and decreases %hen the child is at rest. ,. 3nterventions postoperatively *hernia+ 1. 'onitor vital signs. 2. Assess for %ound infection. 3. 'onitor for redness or drainage. 4. 'onitor inta$e and output and hydration status. #. Advance the diet as tolerated. 2. Administer analgesics as prescribed. .. 3nterventions postoperatively *hydrocele+ 1. Provide ice bags and a scrotal support to relieve pain and s%elling. 2. 3nstruct the child and parents to avoid tub bathing until the incision heals. 3. 3nstruct the child and parents that the child should avoid strenuous physical activities. IRRITABLE BO2EL SYNDROME A. .escription 3rritable bo%el syndrome results from increased motility that can lead to spasm and pain. (he diagnosis is based on the elimination of pathologic conditions. (he syndrome is a selfAlimiting! intermittent problem %ith no definitive treatment. 7actose intolerance! stress and emotional factors may contribute to its occurrence. &. Assessment 1. .iffuse abdominal pain unrelated to meals or activity. 2. Alternating constipation and diarrhea %ith the presence of undigested food and mucus in the stool. ,. 3nterventions 1. 9eassure that the problem is selfAlimiting and intermittent and %ill resolveB medication may be prescribed. 2. Encourage the maintenance of a healthy! %ellA balanced! moderateAfiber diet. 3. Encourage health promotion activities such as exercise and school activities. 4. 3nform the parents of psychosocial resources if re0uired. IMPER#ORATE ANUS A. .escription? 3ncomplete development or absence of the anus in its normal position in the perineum &. Assessment Failure to pass meconium stool Absence or stenosis of the anal rectal canal Presence of an anal membrane External fistula to the perineum or genitourinary system ,. 3nterventions 1. .etermine patency of the anus. 2. 'onitor for the presence of stool in the urine and vagina and report immediately. .. 3nterventions postoperatively 1. 'onitor the s$in for signs of infection. 2. Position sideAlying %ith legs flexed or in a prone position to $eep the hips elevated to reduce edema and pressure on the surgical site. 3. "eep the anal surgical incision clean and dry! and monitor for redness! s%elling! or drainage. 4. 'aintain 8P> status and nasogastric tube if in place. #. 'aintain 3< fluids until gastrointestinal motility returns. 2. Provide colostomy care if present as prescribed. 4. A fresh colostomy stoma %ill be red and edematous! but this should decrease %ith time. 6. 3nstruct the parents to perform anal dilation if prescribed to achieve and maintain bo%el patency. ;. 3nstruct the parents to use only dilators supplied by the physician and a %aterAsoluble lubricant and to insert the dilator no more than 1 to 2 cm into the anus to prevent damage to the mucosa. INGESTION O# POISONS A. Lea& poisoning 1. .escription? Excessive accumulation of lead in the blood 2. ,auses a. (he path%ay for exposure may be food! air! or %ater.
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.ust and soil contaminated %ith lead may be a source of exposure. 7ead enters the child:s body through ingestion or inhalation or through placental transmission to an unborn child %hen the mother is exposedB the most common route is ingestion from handAtoAmouth behavior from contaminated ob1ects or from eating loose paint chips. d. Ehen lead enters the body! it affects the erythrocytes! bones and teeth! and organs and tissues! including the brain and nervous systemB the most serious conse0uences are the effects on the central nervous system. 3. ,helation therapy a. ,helation therapy removes lead from the circulating blood and from some organs and tissues. b. (herapy does not counteract any effects of the lead. c. 'edications include dimercaprol *&A7 in oil+! calcium disodium edetate *,a8a2E.(A+! succimer *,hemet+. d. .imercaprol *&A7+ is contraindicated in children %ith an allergy to peanuts because the medication is prepared in a peanut oil solution. e. Ensure ade0uate urinary output before administering medications. f. Provide ade0uate hydration and monitor $idney function for nephrotoxicity %hen medication is given because the medication is excreted via the $idneys. g. Follo%Aup lead levels to monitor progress are essential. h. Provide instructions to parents about safety from lead ha ards! medication administration! and the need for follo%Aup. i. ,onfirm that the child %ill be discharged to home %ithout lead ha ards. &. Acetaminophen *(ylenol+ 1. .escription a. )eriousness of ingestion is determined by the amount ingested and the length of time before intervention. b. (oxic dose is 1#- mgD$g or greater in children. 2. Assessment a. First 2 to 4 Ahours? malaise! nausea! vomiting! s%eating! pallor! %ea$ness b. 7atent period? 24 to 32 hoursB child improves c. /epatic involvement? may last up to 4 days and may be permanentB right upper 0uadrant pain! 1aundice! confusion! stupor! elevated liver en ymes and bilirubin! prolonged prothrombin time 3. 3nterventions a. Administer antidote? 8Aacetylcysteine b. .ilute antidote in 1uice or soda because of its offensive odor. c. 7oading dose is follo%ed by maintenance doses. ,. Acetylsalicylic acid *aspirin+ 1. .escription a. >verdose may be caused by acute ingestion or chronic ingestion. b. Acute? )evere toxicity occurs %ith 3-- to #-- mgD$g. c. ,hronic? 3ngestion of more than 1-- mgD$g per day for 2 days or more! %hich can be more serious than acute ingestion. 2. Assessment a. 5astrointestinal effects? nausea! vomiting! and thirst from dehydration b. ,entral nervous system effects? hyperpnea! confusion! tinnitus! convulsions! coma! respiratory failure! circulatory collapse c. 9enal effects? oliguria d. /ematopoietic effects? bleeding tendencies e. 'etabolic effects? diaphoresis! fever! hyponatremia! hypo$alemia! dehydration! hypoglycemia 3. 3nterventions a. <omiting may be induced %ith syrup of ipecac or gastric lavage is performed. b. Administer activated charcoal to decrease absorption of salicylate *important in early acetylsalicylic acid toxicity+. c. Administer 3< fluids! sodium bicarbonate! electrolytes! or volume expanders as prescribed. d. Administer vitamin " for bleeding tendencies as prescribed. e. Administer glucose for hypoglycemia as prescribed. f. Prepare the child for dialysis as prescribed if the child is unresponsive to the therapy. ADULT GASTROINTESTINAL TRACT DISORDERS GASTROESOPHAGEAL RE#LU; DISEASE A. .escription 1. 5astroesophageal reflux is the bac$flo% of gastric and duodenal contents into the esophagus. 2. (he reflux is caused by an incompetent lo%er esophageal sphincter! pyloric stenosis! or a motility disorder. 3. )ymptoms may mimic those of a heart attac$. ,auses Food! alcohol! or cigarettes that decreases lo%er esophageal sphincter pressure /iatal hernia 3ncreased abdominal pressure! such as %ith obesity or pregnancy 'edications! such as morphine! dia epam! calcium channel bloc$ers! meperidine! and anticholinergics 8asogastric intubation for more than 4 days Eea$ened esophageal sphincter
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b. c.

&. Assessment 1. Pyrosis 2. .yspepsia 3. 9egurgitation 4. Pain and difficulty %ith s%allo%ing #. /ypersalivation ,. 3nterventions 1. 3nstruct the client to avoid factors that decrease lo%er esophageal sphincter pressure or cause esophageal irritation. 2. 3nstruct the client to eat a lo%Afat! highAfiber dietB avoid caffeine! tobacco! and carbonated beveragesB avoid eating and drin$ing 2 hours before bedtimeB avoid %earing tight clothesB and elevate the head of the bed on 2A to 6A inch bloc$s. 3. Avoid the use of anticholinergics! %hich delay stomach emptying. 4. 3nstruct the client regarding prescribed medications! such as antacids! histamine /2 receptor antagonists! or gastric acid pump inhibitors. #. 3nstruct the client regarding the administration of pro$inetic medications! if prescribed! %hich accelerate gastric emptying. 2. 3f medical management is unsuccessful! surgery may be re0uired and involves a fundoplication *%rapping a portion of the gastric fundus around the sphincter area of the esophagus+B surgery may be performed by laparoscopy. GASTRITIS A. .escription 1. 3nflammation of the stomach or gastric mucosa 2. Acute gastritis is caused by the ingestion of food contaminated %ith diseaseAcausing microorganisms or food that is irritating or too highly seasoned! the overuse of aspirin or other nonsteroidal antiinflammatory drugs *8)A3.s+! excessive alcohol inta$e! bile reflux! or radiation therapy. 3. ,hronic gastritis is caused by benign or malignant ulcers or by the bacteria H. pylori and also may be caused by autoimmune diseases! dietary factors! medications! alcohol! smo$ing! or reflux. &. Assessment Findings in Acute and ,hronic 5astritis ACUTE Abdominal discomfort Anorexia! nausea! and vomiting /eadache /iccupping CHRONIC Anorexia! nausea! and vomiting &elching /eartburn after eating )our taste in the mouth <itamin &12 deficiency ,. 3nterventions 1. Acute gastritis? Food and fluids may be %ithheld until symptoms subsideB after%ard! ice chips! follo%ed by clear li0uids! and then solid food is introduced. 2. 'onitor for signs of hemorrhagic gastritis such as hematemesis! tachycardia! and hypotension! and notify the physician if these signs occur. 3. 3nstruct the client to avoid irritating foods! fluids! and other substances such as spicy and highly seasoned foods! caffeine! alcohol! and nicotine. 4. 3nstruct the client in the use of prescribed medications! such as antibiotics and bismuth salts *Pepto&ismol+. #. Provide the client %ith information about the importance of vitamin &12 in1ections! if a deficiency is present. PEPTIC ULCER DISEASE A. .escription 1. A peptic ulcer is an ulceration in the mucosal %all of the stomach! pylorus! duodenum! or esophagus in portions that are accessible to gastric secretionsB erosion may extend through the muscle. 2. (he ulcer may be referred to as gastric! duodenal! or esophageal depending on its location. 3. (he most common peptic ulcers are gastric ulcers and duodenal ulcers. &. Gastri U! ers 1. .escription a. A gastric ulcer involves ulceration of the mucosal lining that extends to the submucosal layer of the stomach. b. Predisposing factors include stress! smo$ing! the use of corticosteroids! 8)A3.s! alcohol! a history of gastritis! a family history of gastric ulcers! or infection %ith H. pylori. c. ,omplications include hemorrhage! perforation! and pyloric obstruction. 2. Assessment 5na%ing! sharp pain in or left of be midepigastric region 3 to 4 (o+rs a6ter eating /ematemesis 8ausea and vomiting
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3. 3nterventions 1. 'onitor vital signs and for signs of bleeding. 2. Administer small! fre0uent bland feedings during the active phase. 3. Administer histamine /2 receptor antagonists as prescribed to decrease the secretion of gastric acid. 4. Administer antacids as prescribed to neutrali t gastric secretions. #. Administer anticholinergics as prescribed to reduce gastric motility. 2. Administer mucosal barrier protectants as prescribed 1 hour before each meal. 4. Administer prostaglandins as prescribed fur their protective and antisecretory actions. 4. ,lient education a. Avoid consuming alcohol and substances that contain caffeine or chocolate. b. Avoid smo$ing. c. Avoid aspirin or 8)A3.s. d. >btain ade0uate rest and reduce stress. #. 3nterventions during active bleeding a. 'onitor vital signs closely. b. Assess for signs of dehydration! hypovolemic shoc$! sepsis! and respiratory insufficiency. c. 'aintain 8P> status and administer intravenous *3<+ fluid replacement as prescribedB monitor inta$e and output. d. 'onitor hemoglobin and hematocrit. e. Administer blood transfusions as prescribed. f. Assist %ith the insertion of a nasogastric tube for decompression and for lavage access. g. Assist %ith normal saline or tap %ater lavage at room temperature to reduce active bleeding. h. Prepare to assist %ith administering vasopressin *Pitressin+ intravenously as prescribed to induce vasoconstriction and reduce bleeding. 2. )urgical interventions a. Tota! gastre to'"? removal of the stomach %ith attachment of the esophagus to the 1e1unum or duodenumB also called esophago1e1unostomy b. -agoto'"? surgical division of the vagus nerve to eliminate the vagal impulses that stimulate hydrochloric acid secretion in the stomach c. Gastri rese tion? removal of the lo%er half of the stomach and usually including a vagotomyB also called antrectomy. d. Bi!!rot( I? partial gastrectomy! %ith the remaining segment anastomosed to the duodenumB also called gastroduodenostomy. e. Bi!!rot( II? partial gastrectomy! %ith the remaining segment anastomosed to the =e1unumB also called gastro1e1unostomy. f. P"!orop!ast"? enlargement of the pylorus to prevent or decrease pyloric obstruction! thereby enhancing gastric emptying. 4. Postoperative interventions a. 'onitor vital signs. b. Position in Fo%ler:s for comfort and to promote drainage. c. Administer fluids and electrolyte replacements intravenously as prescribedB monitor inta$e and output. d. Assess bo%el sounds. e. 'onitor nasogastric suction as prescribed. f. .o not irrigate or remove the nasogastric tube. g. Assist the physician %ith nasogastric irrigation or removal of the nasogastric tube. h. 'aintain 8P> status as prescribed for 1 to 3 days until peristalsis returns. i. Progress the diet from 8P> to sips of clear %ater to 2 small! bland meals a day as prescribed %hen bo%el sounds return. 1. 'onitor for postoperative complications of hemorrhage! dumping syndrome! diarrhea! $. hypoglycemia! and vitamin &12 deficiency. C. D+o&ena! +! ers 1. .escription a. A duodenal ulcer is a brea$ in the mucosa of the duodenum. b. 9is$ factors and causes include alcohol inta$eB smo$ingB stressB caffeineB the use of aspirin! corticosteroids! and 8)A3.sB and infection %ith H. pylori. c. ,omplications include bleeding! perforation! gastric outlet obstruction! and intractable disease. 2. Assessment &urning pain in the midepigastric area 4 to < (o+rs a6ter eating an& &+ring t(e nig(t 'elena Pain t(at o6ten is re!ie,e& $" eating 3. 3nterventions a. 'onitor vital signs. b. Perform abdominal assessment. c. 3nstruct the client in a bland diet %ith small fre0uent meals. d. Provide for ade0uate rest. e. Encourage the cessation of smo$ing. f. 3nstruct the client to avoid alcohol inta$e! caffeine! the use of aspirin! corticosteroids! and 8)A3.s. g. Administer antacids as prescribed to neutrali e acid secretions. h. Administer histamine /2 receptor antagonists as prescribed to bloc$ the secretion of acid. 4. )urgical interventions? )urgery is performed only if the ulcer is unresponsive to medications or if hemorrhage! obstruction! or perforation occurs. D. D+'ping s"n&ro'e
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1. .escription a. .umping syndrome is rapid emptying of the gastric contents into the small intestine. b. .umping syndrome occurs follo%ing gastric resection. 2. Assessment a. )ymptoms occurring 3- minutes after eating b. 8ausea and vomiting c. Feelings of abdominal fullness and abdominal cramping d. .iarrhea e. Palpitations and tachycardia f. Perspiration g. Eea$ness and di iness h. &orborygmi 3. ,lient education? Preventing .umping )yndrome Eat a highAprotein! highAfat! lo%Acarbohydrate diet. Eat small meals and avoid consuming fluids %ith meals. Avoid sugar and salt. 7ie do%n after meals. (a$e antispasmodic medications as prescribed to delay gastric emptying -ITAMIN B34 DE#ICIENCY A. .escription 1. <itamin &12 deficiency results from an inade0uate inta$e of vitamin &12 or a lac$ of absorption of ingested vitamin &12 from the intestinal tract. 2. Pernicious anemia results from a deficiency of intrinsic factor! %hich is necessary for intestinal absorption of vitamin &12. &. Assessment 1. )evere pallor 2. Fatigue 3. Eeight loss 4. )mooth! beefy red tongue #. )light 1aundice 2. Paresthesias of the hands and feet 4. .isturbances %ith gait and balance ,. 3nterventions 1. 3ncrease dietary inta$e of foods rich in vitamin &12 if the anemia is the result of a dietary deficiency #oo&s Ri ( in -ita'in B34 &re%er:s yeast ,itrus fruits .ried beans 5reen! leafy vegetables 7iver 8uts >rgan meats 2. Administer vitamin &12 in1ections as prescribed %ee$ly initially and then monthly for maintenance *lifelong+ if the anemia is the result of a deficiency of the intrinsic factor.

CIRRHOSIS
A. .escription 1. ,irrhosis is a chronic! progressive disease of the liver characteri ed by diffuse damage to cells %ith fibrosis and nodular regeneration. 2. 9epeated destruction of hepatic cells causes the formation of scar tissue. T"pes o6 Cirr(osis LA=NNEC0S CIRRHOSIS ,irrhosis is alcoholAinduced! nutritional! or portal. ,ellular necrosis causes eventual %idespread scar tissue! %ith fibrotic infiltration of the liver. POSTNECROTIC CIRRHOSIS ,irrhosis occurs after massive liver necrosis. ,irrhosis results as a complication of acute viral hepatitis or exposure to hepatotoxins. )car tissue causes destruction f liver lobules and entire lobes BILIARY CIRRHOSIS
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,irrhosis develops from chronic biliary obstruction! bile stasis and inflammation resulting in severe obstructive 1aundice

CARDIAC CIRRHOSIS ,irrhosis is associated %ith severe! rightAsided congestive heart failure and results in an enlarged! edematous! congested liver. (he liver 3ecornes anoxic! resulting in liver cell necrosis and fibrosis. &. ,omplications 1. Porta! ("pertension? A persistent increase in pressure %ithin the portal vein that develops as a result of obstruction to flo% 4. As ites a. Ascites is the accumulation of fluid %ithin the peritoneal cavity that results in venous congestion of the hepatic capillaries. b. ,apillary congestion leads to plasma lea$ing directly from the liver surface and portal vein. 3. B!ee&ing esop(agea! ,ari es? fragile! thinA%alled! distended esophageal veins that become irritated and rupture <. Coag+!ation &e6e ts a. .ecreased synthesis of bile fats in the liver prevents the absorption of fatAsoluble vitamins. b. Eithout vitamin " and clotting factors 33! <33! 3G! and G! the client is prone to bleeding. #. >a+n&i e? >ccurs because the liver is unable to metaboli e bilirubin and because the edema! fibrosis! and scarring of the hepatic bile ducts interfere %ith normal bile and bilirubin secretion. 2. Porta! s"ste'i en ep(a!opat("? EndAstage hepatic failure and cirrhosis characteri ed by altered level of consciousness! neurological symptoms! impaired thin$ing! and neuromuscular disturbances. ?. Hepatorena! s"n&ro'e a. Progressive renal failure associated %ith hepatic failure b. ,haracteri ed by a sudden decrease in urinary output! elevated blood urea nitrogen and creatinine! decreased urine sodium excretion! and increased urine osmolarity ,. Assessment 1. Anorexia and %eight loss 2. Early morning nausea and vomiting *presence of blood in vomitus+ 3. .yspepsia 4. Flatulence and changes in bo%el habits #. Emaciation 2. Fatigue 4. =aundice 6. Abdominal pain or tenderness ;. Ascites 1-. Peripheral edema 11. .ry s$in and rashes 12. Petechiae or ecchymosis 13. )pider angiomas on the nose! chee$s! upper thorax! and shoulders 14. /epatomegaly 1#. Protruding umbilicus 12. .ilated abdominal veins 14. Fetor hepaticus! the fruity! musty breath odor of chronic liver disease 16. Asterixis *liver flap+? A course tremor characteri ed by rapid! nonrhythmic extension and flexions in the %rist and fingers 1;. .elirium .. 3nterventions 1. Elevate the head of the bed to minimi e shortness of breath. 2. 3f ascites and edema is absent and the client does not exhibit signs of impending coma! a highA protein diet supplemented %ith vitamins is prescribed. 3. Provide supplemental vitamins *& complexB vitamins A! ,! and "B folic acidB and thiamine+ as prescribed. 4. 9estrict sodium inta$e and fluid inta$e as prescribed. #. 3nitiate enteral feedings or total parenteral nutrition as prescribed. 2. Administer diuretics as prescribed. 4. 'onitor inta$e and output and electrolyte balance. 6. Eeigh client and measure abdominal girth daily. ;. 'onitor level of consciousnessB assess for precoma state *tremors! delirium+. 1-. 'onitor for asterixis. 11. 'aintain gastric intubation to assess bleeding or esophagogastric balloon tamponade to control bleeding varices if prescribed. 12. Administer blood products as prescribed. 13. 'onitor coagulation laboratory resultsB administer vitamin " if prescribed. 14. Administer lo% sodium antacids as prescribed. 1#. Administer lactulose *,hronulac+ as prescribed! %hich decreases the p/ of the bo%el! decreases production of ammonia by bacteria in the bo%el! and facilitates the excretion of ammonia. 12. Administer neomycin *'ycifradin+ as prescribed to inhibit protein synthesis in bacteria and decrease the production of ammonia. 14. Avoid medications such as narcotics! sedatives! and barbiturates and any hepatotoxic medications or substances. 16. 3nstruct the client about the restriction of alcohol inta$e. 1;. Prepare the client for paracentesis to remove abdominal fluid. 2-. Prepare the client for surgical shunting procedures if prescribed.
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ESOPHAGEAL -ARICES A. .escription 1. Esophageal varices are dilated and tortuous veins in the submucosa of the esophagus. 2. <arices are caused by porta! ("pertension! often are associated %ith liver cirrhosis! and are at high ris$ for rupture if portal circulation pressure rises. 3. &leeding varices are an emergency. 4. (he goal of treatment is to control bleeding! prevent complications! and prevent the reoccurrence of bleeding. &. Assessment 1. /ematemesis 2. 'elena 3. (arry stools 4. Ascites #. =aundice 2. /epatomegaly and splenomegaly 4. .ilated abdominal veins 6. /emorrhoids ;. )igns of shoc$ ,. 3nterventions 1. 'onitor vital signs. 2. Elevate the head of the bed. 3. 'onitor for orthostatic hypotension. 4. 'onitor lung sounds and for the presence of respiratory distress. #. Administer oxygen as prescribed to prevent tissue hypoxia. 2. 'onitor level of consciousness. 4. 'aintain 8P> status. 6. Administer fluids intravenously as prescribed to restore fluid volume and electrolyte imbalancesB monitor inta$e and output. ;. 'onitor hemoglobin! hematocrit! and coagulation factors. 1-. Administer blood transfusions or clotting factors as prescribed. 11. Assist in inserting a nasogastric tube or a balloon tamponade as prescribed. 12. Assist %ith the administration of iced saline irrigations to achieve vasoconstriction of the varices. 13. Prepare to assist %ith administering vasopressin *Pitressin+ by 3< or intraarterial infusion as prescribed to induce vasoconstriction and reduce bleeding. 14. Prepare to assist %ith administering nitroglycerin *(ridil+ %ith the vasopressin *Pitressin+ if prescribed to prevent vasoconstriction of the coronary arteries. 1#. 3nstruct the client to avoid activities that %ill initiate vasovagal responses. 12. Prepare the client for endoscopic procedures or surgical procedures as prescribed. .. Endoscopic in1ection *sclerotherapy+ 1. )clerotherapy is in1ection of a sclerosing agent into and around bleeding varices. 2. ,omplications include chest pain! pleural effusion! aspiration pneumonia! esophageal stricture! and perforation of the esophagus. E. Endoscopic variceal ligation 1. (he procedure involves ligation of the varices %ith an elastic rubber band. 2. )loughing! follo%ed by superficial ulceration! occurs in the area of ligation %ithin 3 to 4 days. F. )urgical shunt procedures 1. )plenorenal involves splenectomy! %ith anastomosis of the splenic vein to the left renal vein. 2. Portacaval shunting is shunting of the blood from the portal vein to the inferior vena cava. 3. 'esocaval shunting involves a side anastomosis of the superior mesenteric vein to the proximal end of the inferior vena cava. 4. (rans1ugular intrahepatic portalDsystemic a. (he procedure uses the normal vascular anatomy of the liver to create a shunt %ith the use of a metallic stent. b. (he shunt is bet%een the portal and systemic venous system %ithin the liver and is aimed at relieving portal hypertension. CHOLECYSTITIS A. .escription 1. ,holecystitis is an inflammation of the gallbladder that may occur as an acute or chronic process. 2. Acute inflammation is associated %ith gallstones *cholelithiasis+. 3. ,hronic cholecystitis results %hen inefficient bile emptying and gallbladder muscle %all disease cause a fibrotic and contracted gallbladder. 4. A calculus cholecystitis occurs in the absence of gallstones and is due to bacterial invasion via the lymphatic or vascular systems. ,auses Abnormal metabolism of cholesterol and bile salts 5allstones *the most common cause+ Poor or absent blood flo% to the gallbladder

&. Assessment 1. 8ausea and vomiting

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2. 3. 4. #. 2. 4. 6. ;. 1-. 11. 12.

3ndigestion &elching Flatulence Epigastric pain that radiates to the scapula 2 to 4 hours after eating fatty foods and may persist for 4 to 2 hours. Pain locali ed in right upper 0uadrant 5uarding! rigidity! and rebound tenderness 'ass palpated in the right upper 0uadrant M+rp("0s sign *cannot ta$e a deep breath %hen the examiner:s fingers are passed belo% the hepatic margin+ Elevated temperature (achycardia )igns of dehydration

,. &iliary obstruction 1. =aundice 2. .ar$ orange and foamy urine 3. )teatorrhea and clayAcolored feces 4. Pruritus .. 3nterventions 1. 'aintain 8P> status during nausea and vomiting episodes. 2. 'aintain nasogastric decompression as prescribed for severe vomiting. 3. Administer antiemetics as prescribed for nausea and vomiting. 4. Administer analgesics as prescribed to relieve pain and reduce spasm * Note: although morphine sulfate or codeine sulfate may be prescribed, they generally are avoided because they can cause spasm of the sphincter of Oddi and increase pain +. #. Administer antispasmodic *anticholinergics+ as prescribed to relax smooth muscle. 2. 3nstruct the client %ith chronic cholecystitis to eat lo%Afat meals more fre0uently in small amounts. 4. 3nstruct the client to avoid gasAforming foods. 6. Prepare the client for nonsurgical and surgical procedures as prescribed. E. 8onsurgical interventions 1. .issolution therapy a. .issolution therapy is done to remove cholesterol stones. b. 'edications such as chenodeoxycholic acid *,henodiol+ or ursodiol *Actigall+ may be administered orally to decrease the si e of the stones or to dissolve small stones. c. .irect contact %ith repeated in1ections and aspirations of a dissolution agent via percutaneous catheter may be performed. 2. Extracorporeal shoc$ %ave lithotripsy a. )hoc$ %aves are administered that disintegrate stones in the biliary system. b. >ral dissolution follo%s. F. )urgical interventions 1. ,holecystectomy is removal of the gallbladder. 2. ,holedochotomy re0uires incision into the common bile duct to remove the stone. 3. )urgical procedures may be performed by laparoscopy. 5. Postoperative interventions 1. 'onitor for respiratory complications caused by pain at the incisional site. 2. Encourage coughing and deep breathing. 3. Encourage early ambulation. 4. 3nstruct the client about splinting the abdomen to prevent discomfort during coughing. #. Administer antiemetics as prescribed for nausea and vomiting. 2. Administer analgesics as prescribed for pain relief. 4. 'aintain 8P> status and nasogastric tube suction as prescribed. 6. Advance diet from clear li0uids to solids %hen prescribed and as tolerated by the client. ;. 'aintain and monitor drainage from the (Atube! if present Care o6 a T.T+$e PURPOSE AND DESCRIPTION A (Atube is placed alter surgical exploration of the common bile duct. (he tube preserves the patency of the duct and ensure drainage of bile until edema resolves and bile is effectively draining into the duodenum. A gravity drainage bag is attached to the (Atube to collect the drainage. 38(E9<E8(3>8) Position client in semiAFo%ler:s position to facilitate drainage. 'onitor the amount! color! consistency! and odor of drainage. 9eport sudden increases in bile output to the physician 'onitor for inflammation and protect the s$in from irritation. "eep the drainage system belo% the level of the gallbladder.
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'onitor for foul odor and purulent drainage and report to the physician. Avoid irrigation! aspiration or damping of the (Atube %ithout physician:s order. As prescribed clamp the tube before a meal and observe for abdominal discomfort and distention nausea! chills or feverB unclamp the tube if nausea or vomiting occurs.

PANCREATITIS A. .escription 1. Pancreatitis is an acute or chronic inflammation of the pancreas %ith associated escape of pancreatic en ymes into surrounding tissue. 2. Acute pancreatitis occurs suddenly as one attac$ or can be recurrent %ith resolutions. 3. ,hronic pancreatitis is a continual inflammation and destruction of the pancreas! %ith scar tissue replacing pancreatic tissue. 4. Precipitating factors include trauma! the use of alcohol! biliary tract disease! viral or bacterial disease! hyperlipedemia! hypercalcemia! cholelithiasis! hyperparathyroidism! ischemic vascular disease! and peptic ulcer disease. &. Acute pancreatitis 1. Assessment a. Abdominal pain! including a sudden onset at the midepigastric or left upper 0uadrant location %ith radiation to the bac$ b. Pain that is aggravated by a fatty meal! alcohol! or lying in a recumbent position c. Abdominal tenderness and guarding d. 8ausea and vomiting e. Eeight loss f. C+!!en0s sign *discoloration of the abdomen and periumbilical area+ g. T+rner0s sign *bluish discoloration of the flan$s+ h. Absent or decreased bo%el sounds i. Elevated %hite blood cell count! glucose! bilirubin! al$aline phosphatase! urinary amylase 1. Elevated lipase and amylase 2. 3nterventions a. 'aintain 8P> status and maintain hydration %ith 3< fluids as prescribed. b. Administer total parenteral nutrition for severe nutritional depletion. c. Administer supplemental preparations and vitamins and minerals to increase caloric inta$e if prescribed. d. 'aintain nasogastric tube to decrease gastric distention and suppress pancreatic secretion. e. Administer meperidine hydrochloride *De'ero!+ as prescribed for pain because it causes less incidence of smooth muscle spasm of the pancreatic ducts and sphincter of >ddi *note? although morphine sulfate or codeine sulfate may be prescribed! they generally are avoided because they can cause spasm of the sphincter of >ddi and increase pain+. f. Administer antacids as prescribed to neutrali e gastric secretions. g. Administer histamine /2 receptor antagonists as prescribed to decrease hydrochloric acid production and prevent activation of pancreatic en ymes. h. Administer anticholinergics as prescribed to decrease vagal stimulation! decrease gastrointestinal motility and inhibit pancreatic en yme secretion. i. 3nstruct the client in the importance of avoiding alcohol. 1. 3nstruct the client in the importance of follo%Aup visits %ith the physician. $. 3nstruct the client to notify the physician if acute abdominal pain! 1aundice! clayAcolored stools! or dar$ urine develops. ,. ,hronic pancreatitis 1. Assessment a. Abdominal pain and tenderness b. 7eft upper 0uadrant mass c. )teatorrhea and foulAsmelling stools that may increase in volume as pancreatic insufficiency increases d. Eeight loss e. 'uscle %asting f. =aundice g. )igns and symptoms of diabetes mellitus 2. 3nterventions a. 3nstruct the clienf in the prescribed dietary measures *fat and protein inta$e may be limited+. b. 3nstruct the client to avoid heavy meals. c. 3nstruct the client about the importance of avoiding alcohol. d. Provide supplemental preparations and vitamins and minerals to increase caloric inta$e. e. Administer pancreatic en ymes as prescribed to aid in the digestion and absorption of fat and protein. f. Administer insulin or oral hypoglycemic medications as prescribed to control diabetes mellitus! if present. g. 3nstruct the client in the use of pancreatic en yme medications. h. 3nstruct the client in the treatment plan for glucose management. i. 3nstruct the client to notify the physician if increased steatorrhea occurs or if abdominal distention or cramping and s$in brea$do%n develops. 1. 3nstruct the client in the importance of follo%A up visits. ULCERATI-E COLITIS
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A. .escription 1. ,olitis is an ulcerative and inflammatory disease of the bo%el that results in poor absorption of nutrients. 2. ,olitis commonly begins in the rectum and spreads up%ard to%ard the cecum. 3. (he colon becomes edematous and may develop bleeding lesions and ulcersB the ulcers may lead to perforation. 4. )car tissue develops and causes loss of elasticity and loss of ability to absorb nutrients. #. ,olitis is characteri ed by various periods of remissions and exacerbations. 2. )pecific cause is un$no%n but may be related to abnormal immune response in the 53 tract! possibly associated%ith food or bacteria such as the Escherichia coli. 4. Acute ulcerative colitis results in vascular congestion! hemorrhage! edema! and ulceration of the bo%el mucosa. 6. ,hronic ulcerative colitis causes muscular hypertrophy! fat deposits! and fibrous tissue %ith bo%el thic$ening! shortening! and narro%ing. ;. )urgical intervention involves creation of an ostomyB the ostomy can be created %ithin the ileum or at various sites %ithin the large bo%el. 1-. An ileostomy is the surgical creation of an opening into the ileum or small intestine that allo%s for drainage of fecal matter from the ileum to the outside of the body. 11. A colostomy is the surgical creation of an opening into the colon that allo%s for drainage of fecal matter from the colon to the outside of the body. &. Assessment 1. Anorexia 2. Eeight loss 3. 'alaise 4. Abdominal tenderness and cramping #. )evere diarrhea that may contain blood and mucus 2. .ehydration and electrolyte imbalances 4. Anemia 6. <itamin " deficiency 3nterventions 1. Acute phase? 'aintain 8P> status and administer fluids and electrolytes intravenously or total parenteral nutrition as prescribed. 2. 9estrict the client:s activity to reduce intestinal activity. 3. 'onitor bo%el sounds and for abdominal tenderness and cramping. 4. 'onitor stools! noting color! consistency! and the presence or absence of blood. #. 'onitor for perforation! peritonitis! and hemorrhage. 2. Follo%ing the acute phase! the diet progresses from clear li0uids to lo%Aresidue as tolerated. 4. 3nstruct the client to consume a lo%Aresidue! highAprotein dietB vitamins and iron supplements may be prescribed. 6. 3nstruct the client to avoid gasAforming foods and mil$ products! and foods such as %hole %heat grains! nuts! ra% fruits and vegetables! pepper! alcohol! and caffeineAcontaining products. ;. 3nstruct the client to avoid smo$ing. 1-. Administer bul$Aforming agents such as bran! psyllium! or methylcellulose to decrease diarrhea and relieve symptoms. 11. Administer antimicrobial agents! corticosteroids! and immunosuppressants as prescribed to prevent infection and reduce inflammation. .. )urgical interventions 1. (otal proctocolectomy %ith permanent ileostomy a. (he procedure is curative and involves the removal of the entire colon *colon! rectum! and anus %ith anal closure+. b. (he end of the terminal ileum forms the stoma! %hich is located in the right lo%er 0uadrant. 2. "oc$ ileostomy *continent ileostomy+ a. (he "oc$ ileostomy is an intraabdominal pouch that stores the feces and is constructed from the terminal ileum. b. (he pouch is connected to the stoma %ith a nippleli$e valve constructed from a portion of the ileumB the stoma is flush %ith the s$in. c. A catheter is used to empty the pouch! and a small dressing or adhesive bandage is %orn over the stoma bet%een emptyings. 3. 3leoanal reservoir a. ,reation of an ileoanal reservoir is a t%oAstage procedure that involves the excision of the rectal mucosa! an abdominal colectomv! construction of a reservoir to the anal canal! and a temporary loop ileostomy. b. (he ileostomy is closed in 3 to 4 months after the capacity of the reservoir is increased. 4. 3leoanal anastomosis *ileorectostomy+ a. 3leorectostomy does not re0uire an ileostomy. b. A 12A to 1#Acm rectal stump is left after the colon is removed! and the small intestine is inserted into this rectal sleeve and anastomosed. c. 3leorectostomy re0uires a large! compliant rectum. #. Preoperative colostomyDileostomy interventions a. ,onsult %ith enterostomal therapist to assist in identifying optimal placement of the ostomy. b. 3nstruct the client to eat a lo%Aresidue diet for 1 to 2 days before surgery as prescribed. c. Administer intestinal antiseptics and antibiotics as prescribed to cleanse the bo%el and to decrease. the bacterial content of the colon. d. Administer laxatives and enemas as prescribed. 2. Postoperative colostomy interventions a. Place a petrolatum gau e over the stoma as prescribed to $eep it moist! follo%ed by a dry sterile dressing if a pouch *external+ system is not in place. b. Place a pouch system on the stoma as soon as possible. c. 'onitor the stoma for si e! unusual bleeding! or necrotic tissue. d. 'onitor for color changes in the stoma.
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e. f.

8ote that the normal stoma color is pin$ to bright red and shiny! indicating high vascularity. 8ote that a pale pin$ stoma indicates lo% hemoglobin and hematocrit levels and a purpleAblac$ stoma indicates compromised circulation! re0uiring physician notification. g. Assess the functioning of the colostomy. h. Expect that stool is li0uid in the immediate postoperative period but becomes more solid depending on the area of the colostomy? ascending colonFli0uidB transverse colonFloose to semiformedB and descending colonFclose to normal. i. 'onitor the pouch system for proper fit and signs of lea$age. 1. Empty the pouch %hen it is oneAthird full. $. Fecal matter should not be allo%ed to remain on the s$in. l. Administer analgesics and antibiotics as prescribed. m. 3rrigate the perineal %ound *if present+ as prescribed and monitor for signs of infection. n. 3nstruct the client to avoid foods that cause excess gas formation and odor. o. 3nstruct the client about stoma care and irrigations as prescribed *&ox ##A6+. p. 3nstruct the client that normal activities may be resumed %hen approved by the physician. 4. Postoperative ileostomy interventions a. 8ote that normal stool is li0uid. b. 'onitor for dehydration and electrolyte imbalance. c. .o not give suppositories through an ileostomy. COLOSTOMY IRRIGATION P+rpose An enema is given through the stoma to timu1ate bo%el emptying. Des ription 3rrigation is performed by instilling #-- to 1--- m7 lu$e%arm tap %ater thmugh the stoma and allo%ing the %ater and stool to drain into a collection bag. Pro e&+re 3f ambulatory position the client sitting on toilet 3f on bedrest! position the client on the side. /ang the irrigation bag so that the bottom of the bag is at the level of the client:s shoulder or slightly higher 3nsert the irrigation tube carefully %ithout force. &egin the flo% of irrigation. ,lamp tubing if ramping occursB release tubing as cramping subsides. Avoid fre0uent irrigations %ith %ater %hich can lead to loss of fluidt and electrolytes. Perform irrigation around the same time each day. Perform irrigation preferably 1 hour after a meal CROHN0S DISEASE )REGIONAL ENTERITIS* A. .escription 1. ,rohn:s disease is an inflammatory disease that can occur any%here in the gastrointestinal tract but most often affects the terminal ileum and leads to thic$ening and scarring! a narro%ed lumen! fistulas! ulcerations! and abscesses. 2. ,rohn:s disease is characteri ed by remissions and exacerbations. ,auses (he exact cause is un$no%n but conditions that may contribute include? Allergies 5enetic predisposition 3mmune disorders 3nfection 7ymphatic obstruction &. Assessment 1. Fever 2. ,rampli$e and colic$y pain after meals 3. .iarrhea *semisolid+! %hich may contain mucus and pus 4. Abdominal distention #. Anorexia! nausea! and vomiting 2. Eeight loss 4. Anemia 6. .ehydration ;. Electrolyte imbalances

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3nterventions? ,are is similar to the client %ith ulcerative colitisB ho%ever! surgery is avoided as much as possible because recurrence of the disease process in the same region is li$ely to occur. DI-ERTICULOSIS AND DI-ERTICULITIS A. .escription 1. Di,erti +!osis a. .iverticulosis is an outpouching or herniation of the intestinal mucosa. b. (he disorder can occur in any part of the intestine but is most common in the sigmoid colon. ,auses .efects in colon %all strength .iminished colonic motility and increased intraluminal pressure 7o%Afiber diet

2. Di,erti +!itis a. .iverticulitis is inflammation of one or more diverticula that results %hen a diverticulum perforates. b. A perforated diverticulum can progress to intraabdominal perforation %ith generali ed peritonitis. &. Assessment a. 7eft lo%er 0uadrant abdominal pain that increases %ith coughing! straining! or lifting b. Elevated temperature c. 8ausea and vomiting d. Flatulence e. ,rampli$e pain f. Abdominal distention and tenderness g. Palpable! tender rectal mass h. &lood in the stools ,. 3nterventions a. Provide bed rest during the acute phase. b. 'aintain 8P> status or provide clear li0uids during the acute phase as prescribed. c. 3ntroduce a fiberAcontaining diet gradually! %hen the inflammation has resolved. d. Administer antibiotics! analgesics! and anticholinergics to reduce bo%el spasms as prescribed. e. 3nstruct the client to refrain from lifting! straining! coughing! or bending to avoid increased intraabdominal pressure. f. 'onitor for perforation! hemorrhage! fistulas! and abscesses. g. 3nstruct the client to increase fluid inta$e to 2#-- to 3--- m7 daily! unless contraindicated. h. 3nstruct the client to eat soft highAfiber foods such as %hole grains. i. 3nstruct the client to avoid gasAforming foods or foods containing indigestible roughage! seeds! or nuts because these food substances become trapped in diverticula and cause inflammation. 1. 3nstruct the client to consume a small amount of bran daily and to ta$e bul$Aforming laxatives as prescribed to increase stool mass. $. 3nstruct the client to avoid highAfiber foods %hen inflammation occurs because these foods %ill irritate the mucosa further. .. )urgical interventions 1. ,olon resection %ith primary anastomosis is one option. 2. (emporary or permanent colostomy may be re0uired for increased bo%el inflammation. HEMORRHOIDS A. .escription 1. /emorrhoids are dilated varicose veins of the anal canal. 2. /emorrhoids may be internal! external! or prolapsed. 3. 3nternal hemorrhoids lie above the anal sphincter and cannot be seen on inspection of the perianal area. 4. External hemorrhoids lie belo% the anal sphincter and can be seen on inspection. #. Prolapsed hemorrhoids can become thrombosed or inflamed. ,auses ,onstipation! lo%Afiber diet >besity Pregnancy Prolonged sitting )training at defecation

&. Assessment 1. &right red bleeding %ith defecation 2. 9ectal pain 3. 9ectal itching ,. 3nterventions 1. Apply cold pac$s to the analDrectal area follo%ed by sit baths as prescribed.
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2. Apply %itch ha el soa$s and topical anesthetics as prescribed. 3. Encourage a highAfiber diet and fluids to promote bo%el movements %ithout straining. 4. Administer stool softeners as prescribed. .. Endoscopic procedures 1. )clerotherapy 2. Endoscopic ligation E. )urgical procedures 1. ,ryosurgery 2. /emorrhoidectomy F. Postoperative interventions 1. Assist the client to a prone or sideAlying position to prevent bleeding. 2. 'aintain ice pac$s over the dressing as prescribed until the pac$ing is removed by the physician. 3. 'onitor for urinary retention. 4. Administer stool softeners as prescribed. #. 3nstruct the client to increase fluids and highAfiber foods. 2. 3nstruct the client to limit sitting to short periods of time. 4. 3nstruct the client in the use of sit baths 3 to 4 times a day as prescribed. APPENDICITIS A. .escription 1. Appendicitis is inflammation of the appendix. 2. Ehen the appendix becomes inflamed or infected! rupture may occur %ithin a matter of hours! leading to peritonitis and sepsis. ,auses &arium ingestion Fecal mass 'ucosal ulceration )tricture <iral infection

&. Assessment 1. Pain in the periumbilical area that descends to the right lo%er 0uadrant 2. Abdominal pain that is most intense at 'c&urney:s point 3. 9ebound tenderness and abdominal rigidity 4. 7o%grade fever #. Elevated %hite blood cell count 2. Anorexia! nausea! and vomiting 4. ,lient in sideAlying position! %ith abdominal guarding and legs flexed 6. ,onstipation or diarrhea ,. Peritonitis? inflammation of the peritoneum )igns of Peritonitis 3ncreased fever and chills Pallor Progressive abdominal distention and abdominal pain 9estlessness 9ight guarding of the abdomer (achycardia and tachypnea .. Appen&e to'"? surgical removal of the appendix 1. Preoperative interventions a. 'aintain 8P> status. b. Administer fluids intravenously to prevent dehydration. c. 'onitor for changes in level of pain. d. 'onitor for signs of ruptured appendix and peritonitis. e. Position right sideAlying or lo% to semiAFo%ler position to promote comfort. f. 'onitor bo%el sounds. g. Apply ice pac$s to the abdomen for 2- to 3- minutes every hour as prescribed. h. Administer antibiotics as prescribed. i. Avoid the application of heat to the abdomen. 1. Avoid laxatives or enemas. 2. Postoperative interventions a. 'onitor temperature for signs of infection. b. Assess incision for signs of infection such as redness! s%elling! and pain. c. 'aintain 8P> status until bo%el function has returned. d. Advance diet gradually as tolerated and as prescribed! %hen bo%el sounds return. e. 3f rupture of the appendix occurred! expect a Penrose drain to be inserted! or the incision may be left open to heal from the inside out.
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f. g. h. i. 1. $.

Expect that drainage from the Penrose drain may be profuse for the first 12 hours. Position the client in right sideAlying or lo% to semiAFo%ler position! %ith legs flexed! to facilitate drainage ,hange the dressing as prescribed and record the type and amount of drainage. Perform %ound irrigations if prescribed. 'aintain nasogastric suction and patency of tube if present. Administer antibiotics and analgesics as prescribed.

Reference: Silvestri, Linda Anne, Comprehensive Review for the NCLEX-RN, 3rd ed., 200

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