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GASTRO-INTESTINAL SYSTEM

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					GASTRO-INTESTINAL SYSTEM                                           Inform client that the stool is white for 24 –
                                                                    72 hours
DIAGNOSTIC TESTS                                                 Observe for Ba impaction : distended
Laboratory Tests                                                    abdomen, constipation
    1. CEA ( Carcinoembryonic Antigen)                    3. LGIS (Ba Enema)
             (+) colorectal Ca                               To visualize the colon
             X heparin for 2 days                            Low residue / clear liquid diet for 2 days
             Specimen by venipuncture                        Laxative for cleansing the bowel
                                                              Suppository / cleansing enema in A.M.
    2.   Exfoliative Cytology                                 BaSO4 per rectum
              Detect malignant cells                         Care after the procedure – same as UGIS
              Written consent                            ENDOSCOPY
              Liquid diet
              UGI : NGT insertion                        1. UGI Endoscopy
              LGI : laxative; enema                           Direct visualization of esophagus, stomach, and
              Cells are obtained from saline                     duodenum
              Lavage – NGT / Proctoscope                      Obtain written consent
                                                               NPO for 6 – 8 hours
    3.   Stool for Occult Blood (Guaiac Stool Exam)            Anticholinergic (AtSO4) as ordered
               Detect G.I. Bleeding                           Sedatives, narcotics, tranquilizers
               High fiber diet 48 – 72 hours                  E.g. Diazepam, Meperidine HCl
               X red meats, poultry, fish, turnips,           Remove dentures, bridges
                   horseradish                                 Local spray anesthetic on posterior pharynx –
               Withold for 48 hrs: Iron, Steroids,               instruct : X swallow saliva
                   Indomethacine, Colchicine                   After the procedure
               3 stool specimen ( 3 successive days)          Side – lying position
    4.   Fecal Analysis                                        NPO until gag reflex returns (2 – 4 hrs)
        Stool for Ova and Parasites                           NSS gargle; throat lozenges
        Send fresh, warm stool specimen                       Monitor VS
        Stool Culture                                         Assess : bleeding, crepitus (neck), fever, neck /
        Sterile test tube / cotton – tipped applicator           throat pain, dyspnea, dysphagia, back / shoulder
        Stool for Lipids                                         pain
        Assess steatorrhea                                    Advise to avoid driving for 12 hours if sedative
         fat diet, No alcohol ( 3 days )                        was used.
        72 hour stool specimen ( store on ice )
        X mineral oil, neomycin SO4                      2. LGI Endoscopy
                                                          Proctosigmoidoscopy (sigmoid, rectum)
    5.   Gastric Analysis                                           Clear liquid diet 24 hours before
              Measures secretion of HCI and pepsin                 Administer cathartic / laxative as ordered
              NPO for 12 hours                                     Cleansing enema
              NGT is inserted , connected to suction               Knee – chest / lateral position
              Gastric contents collected every 15                  After the procedure
                  minutes to 1 hour                                 Supine position for few minutes
                                                                    Assess for signs of perforation
RADIOGRAPHIC TESTS                                                  Bleeding
                                                                    Pain
1. Scout Film / Flat Plate of the Abdomen                           Fever
              Plain X – ray of the abdomen                         Hot sitz bath for discomfort
              X belts / jewelries                        3. Colonoscopy
2. UGIS ( Barium Swallow)                                      Sedation
          To visualize the esophagus, stomach,                Position : left side, knees flexed
             duodenum and jejunum                              After the procedure:
          NPO for 6 – 8 hours                                 Monitor VS (note for vasovagal response)
          Barium Sulfate (BaSO4) per orem                     Assess for s and sx of perforation.
          X – rays taken on standing, lying position
          After the procedure:                           4.   Ultrasonography
          Laxative                                             NPO for 8 – 12 HOURS
          Increase fluid intake                                Laxative as ordered ( bowel gas)
ADMINISTERING GASTROSTOMY OR                             GASTROINTESTINAL DISORDERS
JEJUNOSTOMY FEEDING
     Verify doctor’s order.                             Hiatal Hernia (Diaphragmatic Hernia)
     Assist client to a Fowler’s position.
     Insert feeding tube into the ostomy opening 10     1. Sliding Hiatal Hernia
      – 15 cm. (4 to 6 in.) if one is not sutured in           Protrusion of the esophagogastric junction into
      place. (Lubricate tube before insertion)                    the thoracic cavity and back into the abdominal
     Check the patency of the tube sutured in place –            cavity in relation to position changes
      pour 15 to 30 ml. of water into the asepto         Causes:
      syringe.                                                 Muscle weakness in the esophageal hiatus:
     Administer feeding slowly. Hold syringe 7 to             Aging process
      15 cm. (3 to 6 inches) above the ostomy                  Congenital muscle weakness
      opening.                                                 Obesity
     Flush the tube with 30 ml. of water after                Trauma
      feeding.                                                 Surgery
     Keep the client in Fowler’s position or slightly         Prolonged increases in intraabdominal pressure
      elevated right lateral position for at least 30    2.Paraesophageal / Rolling Hernia
      mins.                                                        The gastric junction remains below the
     Assess status of peristomal skin.                                diaphragm, but the fundus of the stomach
     Make relevant documentation.                                     and the greater curvature rolls into the
                                                                       thorax next to the esophagus
Indications                                              Cause : anatomic defect
          Major GI diseases, fistulas or inflammatory   Assessment
            diseases                                               Heartburn due to gastroesophageal reflux
          Severe trauma or burns                                  Dysphagia
          Severe GI side effects from radiation or                Dyspnea
            chemotherapy                                           Abdominal pain
          Severe malnutrition                                     Nausea and vomiting
          Need for extensive support over an                      Gastric distention, belching, flatulence
            extended period.                             COLLABORATIVE MANAGEMENT
          Usual site of TPN catheter insertion is
            subclavian vein.                             1. Medications
          Place the client in Trendelenburg position              Antacids
            during insertion of TPN catheter                       Antiemetics
          The primary purpose of TPN is to                        Histamine Receptor Antagonists
            administer glucose ( 25 – 35% dextrose)                Gastric Acid Secretion Inhibitors
          Administer TPN solution at room               AVOID:
            temperature                                            Anticholinergics
          Consume prepared formulas within 24                     Xanthine derivatives
            hours to prevent contamination.                        Ca – channel blockers
          Maintain a steady infusion rate                         Diazepam
          Use infusion pump e.g. IVAC                   These drugs lower the LES pressure (low esophageal
          Do not attempt to “catch up” if infusion is   sphincter)
            delayed.
          Monitor urine and blood glucose levels.       2. Relieve pain
          Care of catheter insertion site.                       Antacids
          Practice strict aseptic technique             3. Modify diet
          Cleanse site with antiseptic solution ;           High CHON diet to enhance LES pressure
            change sterile dressings daily.                  Small frequent feedings ( 4 to 6 )
          Monitor for signs and symptoms of                 Eat slowly and chew food properly
            infection                                    Avoid :
          Provide good oral hygiene                              Fatty foods
                                                                  Cola beverages
                                                                  Coffee
                                                                  Tea
                                                                  Chocolate
                                                                  Alcohol
These foods and beverages decrease LES pressure             Chronic achlorhydria
     Assume upright position before and after eating       Pernicious anemia
        (1-2 hrs.)                                          Villous adenoma
     X eat at least 3 hrs. before bedtime to prevent       + family history
        nighttime reflex                                    Excess intake of raw foods
     X evening snacks                                      Drinking large, volume of hot tea
     Reduce BW if obese                                    Atrophic gastritis
     Promote lifestyle changes                            ASSESSMENT
     Elevate HOB 6 to 12 in. for sleep                        Progressive loss of appetite
     X factors that increase intraabdominal pressure          Gastric fullness (early satiety)
     Use of constrictive clothing                             Dyspepsia (4 weeks or more)
     Straining                                                + guaiac stool exam
     Heavy lifting                                            Nausea and vomiting
     Bending, stooping                                        Hematemesis / melena
     Coughing                                                 Pain induced by eating, relieved by vomiting
     X smoking (causes rapid and significant drop in            (late symptom)
        LES pressure)                                          Weight loss, loss of strength, anemia,
                                                                 obstruction
SURGERY                                                        Palpable abdominal mass
Nissen Fundoplication (gastric wrap – around)
Preop Care                                                 COLLABORATIVE MANAGEMENT
           Teach on DBCT exercises, incentive             Medical Management
               spirometry to prevent postop respiratory         Surgery (Subtotal/ Total Gastrectomy)
               complications                               Nursing Management
           Inform on possible postop contraptions:             Care of the client undergoing gastric surgery
               Chest tube
               NGT                                         PEPTIC ULCER DISEASE
SURGERY – POSTOP CARE                                           Impairment of the mucosa and deeper structures
1. Facilitate AW clearance                                          of the esophagus, stomach, duodenum or
               a. Semi – Fowler’s position                          jejunum
               b. Reinforce DBCT exercises, incentive           With remissions and exacerbations
                    spirometry, chest physiotherapy        Cause : Unknown

2. Facilitate swallowing                                                     Theory
               a. A large NGT is inserted to prevent the
                   fundoplication from being made too      HCl + Pepsin               Mucous Secretion
                   tightly                                                              (Protector)
               b. Drainage from NG tube turns to           (Aggressor)
                   yellowish green within first 8 hrs,          ↓
                   postop                                  ↑secretion:                 secretion:
               c. Oral fluids after peristalsis returns;                              blood flow
                   near normal diet within 6 weeks                                   Irritants
               d. Small, frequent meals                    stress
               e. Maintain upright position                stimulants                 Damage of mucous
               f. Avoid gas- forming foods                                            membrane
               g. Frequent position changes and early
                   ambulation to clear air from the GI           PEPTIC ULCER DISEASE
                   tract
               h. Report for persistent dysphagia and      PREDISPOSING FACTORS
                   gas pain                                   1.Stress
                                                                   PNS   gastric motility,  HCl
GASTRIC CANCER                                                2. Cigarette smoking
 in middle – aged males                                           Stimulant ; Vasoconstrictor
                                                              3. Alcohol
Predisposing Factors                                               Irritant; vasoconstrictor; beer  gastric acid
 Excess intake of nitrite – cured, salt – cured and               secretion
    smoke – cured foods                                       4. Caffeine
 Cigarette smoking                                                Stimulant ; vasoconstrictor
    5.    Drugs                                            DUODENAL ULCER
          ASA, NSAIDs Steroids
      6. Gastritis                                          executive ulcer
          HCl; mucous ulceration
      7. Infection
          Campylobacter/ H. Pylori
      8. Zollinger – Ellison Syndrome                       80% incidence
          Pancreatic tumor
          (gastrinoma)                                      25 – 50 years
                    
          ↑Gastrin secretion                                well – nourished
                    
          ↓HCL secretion                                    oversecretion of HCI
                    
      Multiple areas of ulcerations                        radiates to right
9. Irregular, hurried meals (stressful)
                                                           3 to 4 hrs. p.c.
10. Fatty, spicy, highly acidic foods,
     (stimulants, irritants)                               relieved by food
11. Type A personality                                     commonly experienced 12MN to 3Am
                “stress personality”
12. Type O blood
                                                           melena, more common
                 pepsinogen levels  PEPSIN
13. Genetics
                 in parietal cell mass   acid          complications
                    secretion                              obstruction
                                                           hemorrhage
    GASTRIC ULCER                                          perforation
                                                           peritonitis
        “poor man’s” ulcer
                                                    HEMORRHAGE : most life threatening
        “laborer’s ulcer
                                                    complication of PUD  hypovolemic shock

        20 % incidence                             COLLABORATIVE MANAGEMENT
                                                    Medications
        50 years and above                            1. Antacids
                                                    Neutralize HCl
        Malnourished                               Taken 1 to 2 hrs. p.c.
                                                    Amphogel (AL – OH)
        Normal HCl secretion                       Basaljel (AL – Carbonate)
        normal gastric emptying rate               Maalox (AL – Mg – OH)
         back – diffusion of HCl                  Gaviscon (AL – Mg – Trisilicate)
        radiates to left                           Milk of Magnesia (Mg – OH)
                                                    Riopan (Magaldrate)
        ½ to 2 hrs. p.c.
        X relieved by food
                                                    Alka – 2 (Calcium carbonate)
                                                    Tums (Calcium carbonate)
                                                    Rolaids (Calcium carbonate)
         nausea and vomiting, hematemesis
                                                    Mylanta (AL – Mg – OH with Simethicone)
         common
                                                    Maalox plus Gelusil (AL – Mg – OH with
        complications                              Simethicone)
        hemorrhage                                 Magnesium based  diarrhea
        perforation                                Aluminum – based  constipation
        peritonitis                                2. Histamine (H2) receptor antagonists
                                                             Reduces HCl secretion
                                                             Taken with meals
                                                             Tagamet (Cimetidine)
          Zantac (Ranitidine)                                     3.  Small, frequent feedings during
          Pepcid (Famotidine)                                         exacerbation
          Axid (Nizatidine)                                      4. Avoid the following:
Side effects:                                                     5. Fatty foods
     Diarrhea                                                    6. Coffee, tea, cola drinks, chocolate
     Abdominal cramps                                            7. Spices, red /black pepper
     Confusion                                                   8. Alcohol
     Dizziness                                                   9. Bedtime snacks
     Weakness                                                    10. Binge eating
     Cimetidine – antiandrogenic (gynecomastia,                 11. Large quantities of milk (400 mls/day
         libido, impotence)                                            is allowed)
3.Cytoprotective                                       Quit smoking
          Coats ulcer                                 Coping
           prostaglandin synthesis                  Stress Therapy
          Taken on an empty stomach (30 – 60 mins.   Recreation and hobbies
              before meals)                           Regular pattern of exercise
          Carafate (Sucralfate)                      Stress reduction at home and at work
4. Prostaglandin analogue
          Replaces gastric prostaglandin             NURSING MANAGEMENT OF THE PATIENT WITH
          Cytotec (Misoprostol)                      GASTRIC SURGERY
5. Proton pump inhibitor                                  Preop Care
          Gastric acid secretion inhibitor                    o Provide psychosocial support
          Losec (Omeprazole)                                  o Teach DBCT exercises (high
6. H. Pylori Drug treatment                                        abdominal incision  respiratory
          Pepto – Bismul (bismuth compound)                       complications)
          Amoxicillin / Tetracycline                          o Provide nutritional support – TPN
          Flagyl (Metronidazole)                              o Inform about postop measures
SURGERY                                                                 Nasogastric tube
1.Vagotomy                                                              TPN until peristalsis returns
     Resection of the vagus nerve
     Decrease cholinergic stimulation                POSTOP CARE
                                                     1.Promote patent airway and ventilation
                    HCl secretion                             Semi – Fowler’s position
                   gastric motility                           Reinforce DBCT exercises , incentive
                                                                  spirometry
2.Pyloroplasty                                                 Administer analgesic before activities
 Surgical dilatation of the pyloric sphincter                 Splint incision before patient coughs
 Improves gastric emptying of acidic chyme                    Encourage early ambulation

3.Antrectomies                                        2.Promote adequate nutrition
     Removal of 50% of the lower part of the              NPO until peristalsis returns
         stomach                                           Measure NG drainage accurately (reddish for
Types                                                         the first 12 hrs)
     Billroth I (Gastroduodenostomy)                      Monitor for signs of leakage of anastomosis,
     Billroth II (Gastrojejunostomy)                         e.g. dyspnea, pain, fever, when oral fluids are
     The duodenum is bypassed to permit the flow             initiated
         of the bile                                       Small, frequent feedings
4.Subtotal Gastrectomy                                     Monitor for early satiety and regurgitation
     Removal of 75% of the distal stomach with            Eat less food at a slower pace
         Billroth I or II repair                           Monitor weight regularly
                                                      3.Prevent potential complications
NURSING MANAGEMENT                                    a.Bleeding – first 24 hours; 4th to 7th day postop due to
    Relieve pain                                     nonhealing
    Take prescribed medications as ordered           b.Monitor NG drainage for blood
    Promote a healthy lifestyle                           Avoid unnecessary irrigation or repositioning of
    Diet                                                     the NGT
          1. Liberal bland diet during exacerbation        Monitor for signs of peritonitis:
          2. Eat slowly and chew food properly             Severe abdominal pain, rigidity fever
                                                              •Thrombosis
                                                              •Bacterial Invasion
c.Dumping Syndrome
                                                                       
A group of unpleasant vasomotor and G.I. symptoms
                                                                    Abscess
caused by rapid emptying of gastric content into the
jejunum                                                                
      Early signs and symptoms (5 to 30 minutes p.c.)
                                                                   Gangrene
 Weakness                                                             
 Tachycardia                                                 Perforation (24 to 36 hours)
 Dizziness                                                            
 Diaphoresis                                                      Peritonitis
 Pallor                                                      ASSESSMENT
 Feeling of fullness or discomfort                                Acute abdominal pain that usually starts in the
 Nausea                                                               epigastric or umbilical region.
 diarrhea                                                         Pain gradually becomes localized in RLQ / Mc
      Late signs and symptoms (2 to 3 hrs. p.c.)                      Burney’s point (halfway between the umbilicus
Hyperglycemia                                                          and the anterior spine of the ilium)
                                                                  Pain is initially intermittent then becomes
insulin secretion                                                     steady and serves over a short period.
                                                                   Anorexia, nausea and vomiting
         
                                                                   Rigid abdomen, guarding
HYPOGLYCEMIA
                                                                   Rebound tenderness (Blumberg sign)
                                                                   Fever (temperature = 38 – 38.5ºC)
MANAGEMENT OF DUMPING SYNDROME
                                                                   Elevated wbc (above 10,000 / cu. mm.)
   Eat in a recumbent or semi – recumbent
                                                                   Psoas sign (lateral position with right hip
     position
                                                                       flexion)
   Lie down after meal (left side)
                                                                   Decreased or absent bowel sounds
   Small, frequent feedings
                                                              COLLABORATIVE MANAGEMENT
   Moderate fat, high protein diet
                                                                   Bed rest
   Limit carbohydrates, no simple sugars
                                                                   NPO
   Give fluids after meals
                                                                   Relieve pain (cold application over the abdomen)
   Avoid very hot and cold foods and beverages
                                                                   Avoid factors that increase peristalsis, thereby
   Anticholinergic or antispasmodic
                                                              rupture:
                                                                   Heat application over the abdomen
d.Marginal Ulcers
                                                                   Laxative
      Occur where gastric acids contact the operative
                                                                   Enema
         site (site of anastomosis or jejunum)
                                                                   IVF therapy to maintain fluid – electrolyte
e.Alkaline Reflux Gastritis
                                                                       balance
      Caused by reflux of duodenal contents
                                                                   Antibiotic therapy
f.Vitamin B12 Deficiency
                                                                   Surgery : Appendectomy
      Due to partial or total loss of the intrinsic factor
         secreted by the parietal cells of the stomach
                                                              APPENDECTOMY
                                                                   Spinal anesthesia
APPENDICITIS
                                                                   Flat on bed for 6 – 8 hours
 Inflammation of the vermiform appendix
                                                                   Monitor for return of sensation in the lower
 More common in males, 10 to 30 years of age
                                                                     extremities
 Causes
                                                                   NPO until peristalsis returns
         o Obstruction by fecalith or foreign bodies,
                                                                   Ambulation after 24 hours
             infection
                                                                   If appendicitis ruptured (peritonitis): with
         o Low fiber diet
                                                                     penrose drains; Semi – Fowler’s position to
         o High intake of refined carbohydrates
                                                                     localize inflammation within the pelvic area
PATHOPHYSIOLOGY
                                                                   Resume all normal
Inflammation
                                                                   activities within
                                                                  2 to 4 weeks
 Intraluminal Pressure                                       PERITONITIS
                                                             Inflammation of the peritoneum
•Lymphoid Swelling
•Decreased Venous Drainage
Causes                                                   Entrapment of fecal material
   Ruptured appendix                                             and bacteria
   Perforated peptic ulcer                                             ↓
   Diverticulitis                                        Inflammation and infection
   Pelvic inflammatory disease                           ↓                       ↓
   Urinary tract infection or trauma                     Scarring
   Bowel obstruction                                                             Abscess
   Bacterial invasion                                                         • Bleeding
                                                                               • Perforation
ASSESSMENT                                                                     • Peritonitis
 Abdominal pain and tenderness
 Abdominal guarding and rigidity                         ASSESSMENT
 Abdominal distention                                     Crampy lower left quadrant abdominal pain worsens
 Paralytic ileus                                             with movement, coughing or straining
 Fever                                                    Low - grade fever
 Elevated wbc (20,000/cu. mm. or higher)                  Chronic constipation with episodes of diarrhea
 Nausea and vomiting                                      Nausea and vomiting
 Signs of early shock:                                    Abdominal distention and tenderness
 Tachycardia                                              Occult bleeding
 Tachypnea                                                Signs and symptoms of peritonitis due to
 Oliguria                                                    development of abscess or perforation
 Restlessness                                            COLLABORATIVE MANAGEMENT
 Weakness                                                         High fiber diet
 Pallor                                                           Liberal fluid intake of 2,500 to 3,000
 Diaphoresis                                                          mls./day
                                                                   Avoid nuts and seeds which can become
COLLABORATIVE MANAGEMENT                                               trapped in the diverticula
    Monitor VS, I and O                                           Bulk – forming laxatives
    NGT is inserted to relieve abdominal distention               During an acute episode:
    Bed rest in Semi – Fowler’s position                          Bed rest
    Encourage deep breathing exercises                            NPO, then clear liquids to rest the bowel
    Peritoneal lavage with warm saline                            X other foods to prevent further irritation
    Insertion of drainage tubes                                       of the mucosa
    Fluid, electrolyte and colloid replacement                    IVF’s, antibiotics, analgesics,
    Antibiotics                                                       anticholinergics (Pro – Banthine)
    TPN solutions                                                 NGT insertion to relieve distention
                                                                   Weight loss to reduce intraabdominal
DIVERTICULITIS                                                         pressure
     Diverticulum is outpouching of the mucosal          CHRONIC INFLAMMATORY BOWEL
        lining of the G.I. Tract, commonly in the colon   DISORDERS (CIBD’s)
     Diverticula / diverticulosis are multiple           A. Regional Enteritis (Crohn’s Disease)
        outpouchings                                           Transmural
     Diverticulitis is acute inflammation and                 Ileum / Ascending colon
        infection caused by trapped fecal material and         Cause
        bacteria                                               Unknown
Cause                                                          Jewish
low fiber diet                                                Environmental
                                                               Age 20 – 30 40 – 60
PATHOPHYSIOLOGY                                                Bleeding ↓
Low fecal volume in the colon                                  Perianal Involvment ↑
             ↓                                                 Fistulas ↑
Increased intraluminal pressure                                Rectal Involvement 20%
             ↓                                                 Diarrhea 5 – 6 soft stool / day
Decreased muscle strength in                                   Abdominal Pain 
        the colon wall                                         Weight Loss           
             ↓                                                 Interventions-Diet, TPN, Steroids, Azulfidine,
Herniation / Outpouching                                          Ileostomy / Colectomy
   of mucuous membrane
B. Ulcerative Colitis                                    Characterized by compromised blood flow to the
     Mucuous Ulceration                                 trapped segment of bowel. Intestinal obstruction occurs,
     Rectum / Lower colon                               and gangrene of the viscera can develop rapidly
     Cause
                 Unknown                                 ASSESSMENT
                 Familial                                     Lump: groin, around umbilicus, from an old
             o Jewish                                             surgical incision
                 Emotional stress                             Disappears when lying down, reappears with
     Age 15 – 40                                                 standing , coughing, straining or lifting.
     Bleeding                                                Sensation of heaviness
     Severe                                                  Vague discomfort
     Perianal Involvment -Mild                               Nausea, vomiting, distention, pain (strangulated
     Fistulas - Rare                                             hernia)
     Rectal Involvement - 100%                          COLLABORATIVE MANAGEMENT
     Diarrhea - 20 – 30 watery stool / day              Surgery : Herniorrhaphy / Hernioplasty
     Abdominal Pain - 
     Weight Loss -                                     Preop Care
     Interventions - Diet                                    Assess for presence of URTI. Sneezing or
                 TPN                                             coughing could weaken the repair.
                 Steroids                                Postop Care
                 Azulfidine                                   Encourage to deep breathe, but no coughing
                 Ileostomy /                                     exercises
                 Proctocolectomy                              Increase fluid intake to prevent constipation.
                                                              Monitor for bladder distention.
ABDOMINAL HERNIAS                                             Ice bags are applied after inguinal hernia repair
 A protrusion of an organ or structure through a                to minimize discomfort during ambulation
   weakened abdominal muscle; a congenital or            Discharge Teachings:
   acquired defect.                                           X heavy lifting, pushing, pulling for about 6
 Causes                                                         weeks
        Congenital / acquired muscle weakness                X driving, climbing stairs for few weeks.
        Increased intraabdominal pressure                    Monitor incision for signs of infection.
        Heavy lifting                                        Stool softeners or bulk laxatives as prescribed
        Obesity                                                 to prevent straining at defecation.
        Pregnancy                                            Sexual activity may be resumed once healing is
                                                                 complete and comfort assured.
TYPES OF HERNIA
1. Reducible – can be returned by manipulation           COLORECTAL CANCER
2. Irreducible – requires surgery                             Cause: Unknown
3. Inguinal Hernia – common among males                       Predisposing Factors:
Indirect Inguinal Hernia                                      Age above 40 years
Protrusion of bowel is through inguinal ring, follows        Predisposing Factors
the course of spermatic cord and moves down into the           low in fiber
scrotum                                                        high in fat, protein and refined carbohydrates
Direct Inguinal Hernia                                        Obesity
Protrusion is through inguinal wall at the point of          History of chronic constipation
muscle weakness                                               History of IBD, familial polyposis or colon
Umbilical Hernia – common among infants                          polyps
Protrusion is through congenital defect in muscle            Family history of colon cancer
Femoral Hernia – common among females                         Most Common Site: Rectosigmoid area (70%)
Protrusion is through femoral ring and down the         ASSESSMENT
femoral canal                                            Ascending (Right) Colon Cancer
Incisional Hernia – common after surgery                  Occult blood in stool
Protrusion is through inadequately healed surgical       Anemia
repair                                                    Anorexia and weight loss
Incarcerated Hernia                                       Abdominal pain above umbilicus
Characterized by bowel obstruction                       Palpable mass
Strangulated Hernia
Distal Colon / Rectal Cancer                              TYPES OF COLOSTOMIES
     Rectal bleeding                                     Ascending Colostomy
     Changed bowel habits                                 Stoma is on the right abdomen
     Constipation or Diarrhea                             Fecal drainage is watery
     Pencil or ribbon – shaped stool                     Transverse (Double – Barreled) Colostomy
     Tenesmus                                             The right stoma is called proximal stoma; drains
     Sensation of incomplete bowel emptying                  semi – formed feces
                                                           The left stoma is called distal stoma; drains mucus
Duke’s Classification of Colorectal Cancer                Transverse Loop Colostomy
    Stage A: confined to bowel mucosa, 80 – 90%           Has 2 openings in the transverse colon, but one
        5- year survival rate                                 stoma
    Stage B: invading muscle wall                         Indicated in IBD’s
    Stage C: lymph node involvement                      Descending and Sigmoid Colostomy
    Stage D: metastases or locally unresectable           Stoma on the left abdomen
        tumor, less than 5% 5 – year survival rate         Fecal drainage is well - formed

Guidelines for Early Detection of Colorectal Cancer       COLONIC SURGERY
     Digital rectal examination yearly after age 40      Postop Care
     Occult blood test yearly after age 50                    Managing the perineal wound (APR)
     Proctosigmoidoscopy every 5 years after age              May require up to 6 months to completely heal
         50, following 2 negative results of yearly            Wound irrigations with normal saline and
         examination                                              absorbent dressings until wound closes.
COLLABORATIVE MANAGEMENT                                       Drainage is initially copius and serosanguinous,
Surgery                                                           to be drained at regular basis to prevent
A. Hemicolectomy for ascending and transverse colon               infection and abscess formation.
    cancer                                                     T – binder is used to secure perineal dressing.
B. Abdomino – Perineal Resection (APR) for                     Sitz baths once more the patient is ambulatory
    rectosigmoid cancer                                        Foam pads or soft pillows to promote comfort
     There are 2 incisions: lower abdomen incision               when sitting.
         to remove to sigmoid; perineal incision to            Side – lying position during sleep.
         remove the rectum                                     Stoma Monitoring
     T – binder is used to secure perineal dressing           The stoma is red and with slight edema for 5 –
     Necessitates permanent colostomy                            7 days
Chemotherapy                                                   Dark, dusky, or brown – black stoma indicates
Fluorouracil is the most effective drug for colorectal           ischemia and necrosis
cancer                                                         The stoma should protrude by ½ to ¾ inches
Radiotherapy                                                      over abdomen
Adjuvant treatment for rectal cancer                          Flatus and fecal drainage usually begin in 4 to 7
                                                                  days, as peristalsis returns
COLONIC SURGERY                                                Empty the pouch when it is 1/3 to ½ full of
Preop Care                                                        stool
     Provide psychosocial support                             Loop colostomy is opened 48 – 72 hours
     Thorough bowel cleansing:                                   postop, with cautery at bedside
     Diet modification                                        Teaching for Self – Care
     Low residue diet 3 to 5 days preop, to reduce       Stoma Care
        the bulk of stool in the colon                         Gently encourage the client to look at the stoma
     Clear liquid diet 24 hours preop                         Inform that stoma has no touch or pain
     Mechanical cleansing                                        sensation
     Laxatives as ordered                                     Instruct to report immediately any purple or
     Cleansing enema as ordered                                  black discoloration of the stoma
     Pharmacologic suppression of colon bacteria              Cleanse the stoma initially with antiseptic
     Neomycin sulfate tablets to reduce bacterial             Skin care
        flora. (it is poorly absorbed in the colon,            Wash the skin with warm water, pat dry
        thereby enhance excretion of colonic bacteria)         Assess skin for signs of irritation or infection.
     Vitamin C and K supplement because these are             When pouch seal leaks, change pouch
        lost during repeated enema administration                 immediately
                                                               Use skin barrier to protect the peristomal skin
                                                                  from liquid stool
         E.g. karaya preparation                               Use smaller – sized pouch or pouch cover during
         Skin infection caused by Candida Albicans is           sexual activity
          treated with nystatin (Mycostatin) powder             Use of a binder or special underwear to hold the
COLOSTOMY IRRIGATION                                             pouch secure
 Initial colostomy irrigation is done to stimulate
     peristalsis; subsequent irrigations are done to         HEMORRHOIDS
     promote evacuation of feces at a regular and                 Dilated blood vessels beneath the lining of the
     convenient time                                                 skin in the anal canal
 Recommended with sigmoid colostomy                         Two Types of Hemorrhoids
 Initiated 5 to 7 days postop                                External hemorrhoids – occur below the anal
 Done in semi – Fowler’s position; then sitting on a            sphincter
     toilet bowl once ambulatory.                             Internal hemorrhoids – occur above the anal
 Use warm normal saline solution                                sphincter
 Initially, introduce 200 mls. of NSS then 500 to           Causes
     1,000 mls. Subsequently                                      Chronic constipation
 Dilate stoma with lubricated gloved finger before               Pregnancy
     insertion of catheter                                        Obesity
 Lubricate catheter before insertion.                            Prolonged sitting or standing
 Insert 2 to 4 inches of the catheter into the stoma             Wearing constricting clothings
 Height of solution 18 inches above the stoma                    Disease conditions like liver cirrhosis, RSCHF
 If abdominal cramps occur during introduction of           ASSESSMENT
     solution, temporarily stop the flow of solution until        Constipation( in an effort to prevent pain or
     peristalsis relaxes.                                            bleeding associated with defecation.)
 Allow the catheter to remain in place for 5 to 10               Anal pain
     minutes for better cleansing effect; then remove             Rectal bleeding
     catheter to drain for 15 to 20 minutes.                      Anal itchiness
 Clean the stoma, apply new pouch                                Mucous secretion from the anus
MANAGING ODOR                                                     Sensation of incomplete evacuation of the
      Avoid gas – forming and foul odor foods, e.g.                 rectum
          dairy products , highly seasoned foods, fish,           Internal hemorrhoids may prolapse
          cabbage, celery, cauliflower, eggs, carbonated     COLLABORATIVE MANAGEMENT
          beverages, nuts                                         High fiber diet, liberal fluid intake
      Rinse pouch with tepid water or weak vinegar               Bulk laxatives
          solution.                                               Hot Sitz bath, warm compress
      Place deodorant tablet or small amount of                  Local anesthetic application – Nupercaine
          mouthwash or a piece of charcoal into the               Surgery
          pouch.                                                          o Hemorrhoidectomy
      X use pulverized ASA – it causes irritation of                     o Sclerotherapy (5% phenol in oil)
          the stoma and damages the colostomy appliance                   o Cryosurgery
Postop Care                                                               o Rubber – band ligation
Supporting a Positive Self – Concept                        Preop Care
      Encourage to view the stoma                            Low residue diet to reduce the bulk of stool
      Encourage to verbalize feelings, fears and             Stool softeners
          concern about stoma                                POSTOP CARE
      Encourage to participate in colostomy care                 Promotion of comfort
Encourage to gradually resume all usual activities                   Analgesics as prescribed
Avoid tight belts or waistbands over the stoma                       Side – lying position
Advise to always carry colostomy supplies when                       Hot Sitz bath 12 to 24 hrs. postop
travelling                                                        Promotion of elimination
Resolving Grief                                                           Stool softener as prescribed
 Encourage client to express feelings of loss                             Encourage the client to defecate as
 Explore client’s usual coping strategies for handling                        soon as the urge occurs
     grief                                                                 Analgesic before initial defecation
Preventing Sexual Dysfunction                                             Enema as prescribed, using a small –
 Explore positions that minimize stress and pressure                          bore rectal tube
     on the pouch                                                 Patient Teaching
 Empty and clean the pouch before sexual activity                         Clean rectal area thoroughly after each
                                                                               defecation
       Sitz bath at home especially after defecation
       Avoid constipation:
         High – fiber diet
         High fluid intake
         Regular exercise
         Regular time for defecation
         Use stool softener until healing is complete
Notify physician for the following:
     Rectal bleeding
     Suppurative drainage
     Continued pain on defecation
     Continued constipation

				
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