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Chapter 38

Digestive Tract Disorders

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Learning Objectives

• Identify the nursing responsibilities in the care of patientsundergoing diagnostic tests and procedures for disorders of the digestive tract.

• List the data to be included in the nursing assessment ofthe patient with a digestive disorder.

• Describe the nursing care of patients with gastrointestinalintubation and decompression, tube feedings, totalparenteral nutrition, digestive tract surgery, and drugtherapy for digestive disorders.

• Describe the pathophysiology, signs and symptoms,complications, and medical treatment of selected digestivedisorders.

• Assist in developing nursing care plans for patients receivingtreatment for digestive disorders.

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Anatomy and Physiology of the Digestive Tract

• Mouth• Where teeth, tongue, and salivary glands begin food digestion

• Pharynx • Muscular structure shared by the digestive and respiratory

tracts • It joins the mouth and nasal passages to the esophagus

• Esophagus• Long muscular tube that passes through the diaphragm into

the stomach

• Stomach • Churns and mixes food with gastric secretions until a

semiliquid mass called chyme

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Anatomy and Physiology of the Digestive Tract

• Small intestine• Chemical digestion and absorption of nutrients take

place• Approximately 20 feet long and consists of three

sections: the duodenum, the jejunum, and the ileum• Liver and pancreatic secretions enter the digestive

tract in the duodenum

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Anatomy and Physiology of the Digestive Tract

• Large intestine and anus• The first section of the large intestine is the cecum • Ascending colon goes up right side of the abdomen • Transverse colon crosses abdomen just below waist • Descending colon goes down left side of abdomen • The last 6 to 8 inches of the large intestine is the

rectum, which ends at the anus, where wastes leave the body

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Figure 38-1

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Age-Related Changes

• Teeth are mechanically worn down with age • The jaw may be affected by osteoarthritis • A significant loss of taste buds with age • Xerostomia (dry mouth) is common• Walls of esophagus and stomach thin with aging, and

secretions lessen • Production of hydrochloric acid and digestive enzymes

decreases • Gastric motor activity slows• Movement of contents through the colon is slower • Anal sphincter tone and strength decrease

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Health History

• Chief complaint and history of present illness • A detailed description of the present illness • Complaints include weight changes, problems with

food ingestion, symptoms of digestive disturbances, or changes in bowel elimination

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Health History

• Past medical history• Recent surgery, trauma, burns, or infections • Serious illnesses, such as diabetes, hepatitis,

anemia, peptic ulcers, gallbladder disease, and cancer

• Alternative methods of feeding or fecal diversion• Prescription and over-the-counter medications• Food allergy or intolerance

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Health History

• Review of systems • Description of the patient’s general health state • Changes in skin: dryness, bruising, and pruritus• Whether the patient has any mouth problems• Document if the patient has dentures, partial plates,

or natural teeth, and record the last dental examination

• Problems with chewing or swallowing • Changes in appetite, food intake, and weight • Nausea, vomiting, dyspepsia, heartburn, flatus,

abdominal distention, or pain• Assessment of elimination

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Health History

• Functional assessment• Information about general dietary habits should

include the daily pattern of food intake• Attitudes and beliefs about food, and changes in

dietary habits related to health problems • Effects of chief complaint on usual functioning • Note whether the patient is able to obtain and

prepare food, and eat independently

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Physical Examination

• Head and neck • Inspect the mouth

• Abdomen • Inspection • Auscultation • Percussion • Palpation

• Rectum and anus • Palpate for lumps and tenderness in the rectum

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Figure 38-2

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Diagnostic Tests and Procedures

• Radiographic studies• Upper gastrointestinal (UGI or GI) series • Small bowel series• Barium enema examination

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Diagnostic Tests and Procedures

• Endoscopic examinations• Upper GI

• Esophagoscopy, gastroscopy, gastroduodenoscopy, esophagogastroduodenoscopy, endoscopic retrograde cholangiography

• Lower GI• Colonoscopy, proctoscopy, and sigmoidoscopy

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Diagnostic Tests and Procedures

• Laboratory studies • Gastric analysis • Occult blood test • Stool examination

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Figure 38-3

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Figure 38-4

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Therapeutic Measures

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Gastrointestinal Intubation

• Tube feedings • Delivered by gravity flow or by infusion pump

• Gastrointestinal decompression • For the relief or prevention of distention• Levin and gastric sump tubes

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Total Parenteral Nutrition

• Bypasses digestive tract by delivering nutrients directly to the bloodstream

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Figure 38-5

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Figure 38-6

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Figure 38-7

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Figure 38-9

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Gastrointestinal Surgery

• Preoperative nursing care• The digestive tract is usually cleansed

• Magnesium citrate or large-volume cathartic (laxative) solutions; enemas

• Diet limited to liquids 24 hours before surgery• Intravenous fluids• Oral antibiotics• Nasogastric tube inserted and attached to suction

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Gastrointestinal Surgery

• Postoperative nursing care• Be sure gastrointestinal suction is draining • Inspect, describe, and measure the drainage • Abdomen for distention and bowel sounds• Administer intravenous fluids • Keep strict intake and output records • Drug therapy

• Emetics, antiemetics, laxatives, cathartics, antidiarrheals, antacids, anticholinergics, mucosal barriers, histamine-2 (H2)-receptor blockers, prostaglandins, and antibiotics

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Disorders of the Digestive Tract

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Anorexia

• Causes• Nausea, decreased sense of taste or smell, mouth

disorders, and medications • Emotional problems such as anxiety, depression, or

disturbing thoughts

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Anorexia

• Medical diagnosis • Physician assesses for malnutrition • Weight may be monitored over several weeks • Complete history and physical examination• Serum hemoglobin, iron, total iron-binding capacity,

transferrin, calcium, folate, B12, zinc

• Thyroid function tests

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Anorexia

• Medical treatment • Correctable causes of anorexia are treated, but

sometimes no physical cause is found • Nutritional supplements

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Anorexia

• Assessment• Record chronic and recent illnesses,

hospitalizations, medications, and allergies • Female patient’s obstetric history• Symptoms: pain, nausea, dyspnea, extreme fatigue • The functional assessment reveals patterns of

activity and rest, usual dietary patterns, current stressors, and coping strategies—all can affect appetite

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Anorexia

• Interventions• Assist with oral hygiene before and after meals• Teach proper oral hygiene; refer for dental care • Relieve nausea before presenting a meal tray • Before serving meal tray, remove bedpans/emesis

basins from sight, conceal drains and drainage collection devices, deodorize room if necessary

• Socialization during mealtime• Respect food likes and dislikes• Position patient comfortably with easy access to

food

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Feeding Problems

• Patients with paralysis, arthritis, neuromuscular disorders, confusion, weakness, or visual impairment are likely to need assistance

• Medical diagnosis and treatment • Identifying problems, prescribing treatment• Patients often referred to physical therapy and

occupational therapy

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Feeding Problems

• Assessment• Assess each patient’s ability to feed self • Determine nature of patient’s difficulty and identify

remaining abilities • Assess visual acuity, range of motion and muscle

strength in both arms, and range of motion and grip strength in both hands; ability to follow instructions

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Feeding Problems

• Interventions• Proper positioning and arrangement of the meal tray• Provide assistive devices• Open milk cartons, cut meat, butter bread, and

season food

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Stomatitis

• A general term for inflammation of the oral mucosa

• Medical treatment is directed toward determining the cause and eliminating it; a soft, bland diet may be ordered

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Vincent’s Infection

• Bacterial infection that causes a metallic taste and bleeding ulcers in the mouth, foul breath, and increased salivation

• Topical antibiotics and mouthwashes to treat infection; rest, a nutritious diet, and good oral hygiene

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Herpes Simplex

• Caused by the herpes simplex virus, type 1 • Ulcers and vesicles in mouth and on lips • Occur with upper respiratory tract infections,

excessive sun exposure, or stress • Spirits of camphor, topical steroids, and

antiviral agents as treatment

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Aphthous Stomatitis (“Canker Sore”)

• May be caused by a virus • Characterized by ulcers of the lips and mouth

that recur at intervals • Topical or systemic steroids may be used

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Candida albicans

• Yeastlike fungus causes the oral condition known as thrush or candidiasis

• Bluish white lesions on the mucous membranes

• Patients at high risk include those on steroid or long-term antibiotic therapy

• Treated with oral or topical antifungal agents; vaginal nystatin tablets can be used like lozenges and allowed to dissolve in the mouth

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Nursing Care

• Assessment• Pain location, onset, and precipitating factors • Record any known illnesses and treatments,

including drugs and radiation therapy • Describe habits, including diet, oral care practices,

alcohol intake, and use of tobacco • Assess patient’s stress level • Inspect lips and oral cavity for redness, swelling,

and lesions

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Nursing Care

• Interventions• Gentle oral hygiene, prescribed mouthwashes• The teeth and tongue can be cleansed with a soft-

bristle toothbrush, sponge, or cotton-tipped applicator

• Medications must be given as ordered

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Dental Caries

• A destructive process of tooth decay• The only treatment for dental caries is removal

of the decayed part of the tooth, followed by filling the cavity with a restorative material

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Periodontal Disease

• Begins with gingivitis; progresses to involve the other structures that support the teeth

• Gums red, swollen, painful, and bleed easily• Primarily from inadequate oral hygiene• Treatment in early stage: dental care for teeth

cleaning and correction of contributing problems

• Untreated, abscesses develop around the roots, the teeth loosen, and extraction is necessary

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Figure 38-10

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Nursing Care

• Assessment• Observe condition of teeth and gums • Document missing or broken teeth, caries, redness

or lesions of the gums, and gum recession

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Nursing Care

• Interventions• Most patients are treated for dental and gum

conditions in dentists’ offices • Interventions directed at minimizing pain until the

problem can be corrected by a dentist • Provide oral care for patients who cannot do it

themselves

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Oral Cancer

• Squamous cell carcinoma and basal cell carcinoma

• Risk factors • Cancer of the lip related to prolonged exposure to

irritants, including sun, wind, and pipe smoking • Factors that increase the risk of cancers inside the

mouth include tobacco and alcohol use, poor nutritional status, and chronic irritation

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Oral Cancer

• Signs and symptoms • Tongue irritation, loose teeth, and pain in the tongue

or ear • Malignant lesions may appear as ulcerations,

thickened or rough areas, or sore spots • Leukoplakia: hard, white patches in the mouth;

premalignant

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Oral Cancer

• Medical diagnosis and treatment • A biopsy of suspicious lesions• Treatment includes surgery, radiation, or

chemotherapy, or a combination of these

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Oral Cancer

• Assessment• History of prolonged sun exposure, tobacco use, or

alcohol consumption • Assess for difficulty swallowing or chewing,

decreased appetite, weight loss, change in fit of dentures, and hemoptysis

• The physical examination should focus on examination of the mouth for lesions

• Assess the neck for limitation of movement and enlarged lymph nodes

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Figure 38-11

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Oral Cancer

• Interventions• Impaired Oral Mucous Membrane • Ineffective Breathing Pattern • Pain• Imbalanced Nutrition: Less Than Body

Requirements• Impaired Verbal Communication • Disturbed Body Image • Risk for Infection • Ineffective Tissue Perfusion

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Parotitis

• Inflammation of the parotid glands• Causes painful swelling of the salivary glands

below the ear next to the lower jaw; pain increases during eating

• Treated with antibiotics, mouthwashes, and warm compresses; surgical drainage or removal may be necessary

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Achalasia

• Progressively worsening dysphagia • Failure of the lower esophageal muscles and

sphincter to relax during swallowing • Thought to be a neuromuscular defect affecting

the esophageal muscles• Treatment includes drug therapy, dilation, and

surgical measures

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Esophageal Cancer

• Pathophysiology• No known cause, but predisposing factors are

cigarette smoking, excessive alcohol intake, chronic trauma, poor oral hygiene, and eating spicy foods

• Signs and symptoms • Progressive dysphagia

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Esophageal Cancer

• Medical diagnosis • Barium swallow, computed tomography,

esophagoscopy, and endoscopic ultrasonography

• Medical and surgical treatment • Surgery, radiation, chemotherapy, or various

combinations

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Figure 38-12

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Esophageal Cancer

• Assessment• Dysphagia, pain, and choking • Hoarseness, cough, anorexia, weight loss, and

regurgitation • The functional assessment documents the use of

alcohol and tobacco and dietary practices

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Esophageal Cancer

• Interventions• Pain • Imbalanced Nutrition: Less Than Body

Requirements • Anxiety• Risk for Injury • Impaired Gas Exchange • Deficient Knowledge

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Nausea and Vomiting

• Nausea: sometimes referred to as queasiness• Vomiting: forceful expulsion of stomach

contents through the mouth • Complications

• Significant losses of fluids and electrolytes• Aspiration

• Medical treatment• Antiemetics • Intravenous fluids • Oral fluids may be limited to clear liquids or withheld• Nasogastric tube

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Nausea and Vomiting

• Assessment• Onset, frequency, and duration of present illness • Conditions under which nausea and vomiting occur • Amount, color, odor, and contents of the vomitus • Surgeries, chronic illnesses, allergies, and

medications • General appearance; record vital signs,

height/weight • Assess pulse and blood pressure, tissue turgor,

mental status, and muscle tone • Inspect, auscultate, and palpate the abdomen for

distention, bowel sounds, and tenderness

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Nausea and Vomiting

• Interventions• Imbalanced Nutrition and Deficient Fluid Volume • Risk for Aspiration

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Hiatal Hernia

• Pathophysiology • Protrusion of lower esophagus and stomach up

through the diaphragm and into the chest

• Causes

• Weakness of diaphragm muscles where esophagus and stomach join, but exact cause is not known

• Factors are excessive intra-abdominal pressure, trauma, and long-term bed rest in a reclining position

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Hiatal Hernia

• Signs and symptoms • Many people have no symptoms at all; others report

feelings of fullness, dysphagia, eructation, regurgitation, and heartburn

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Figure 38-13

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Hiatal Hernia

• Medical diagnosis • Barium swallow examination with fluoroscopy• Esophagoscopy• Esophageal manometry

• Medical treatment • Drug therapy, diet, and measures to avoid

increased intra-abdominal pressure• Surgery: fundoplication and placement of the

synthetic Angelchik prosthesis

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Figure 38-14

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Figure 38-15

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Hiatal Hernia

• Assessment• Document symptoms• Record factors that trigger symptoms as well as

measures that aggravate or relieve them • Patient’s dietary habits, use of alcohol and tobacco,

and medication history

• Interventions• Chronic Pain • Risk for Aspiration • Imbalanced Nutrition: Less Than Body

Requirements

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Hiatal Hernia

• Postoperative care• Turning, coughing, and deep breathing • Patient might have nasogastric tube in place and

connected to suction for a day or two• Until bowel function returns, the patient is given only

intravenous fluids • Tell the patient to expect mild dysphagia for several

weeks

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GERD

• Backward flow of gastric contents from the stomach into the esophagus• Pathophysiology

• Abnormalities around the LES, gastric or duodenal ulcer, gastric or esophageal surgery, prolonged vomiting, and prolonged gastric intubation

• Eventually causes esophagitis

• Signs and symptoms • Painful burning sensation that moves up and down,

commonly occurs after meals, and is relieved by antacids

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GERD

• Medical diagnosis • Suggested by the signs and symptoms• Endoscopy, biopsy, gastric analysis, esophageal

manometry, 24-hour monitoring of esophageal pH, and acid perfusion tests

• Medical treatment and nursing care • Like those described earlier for hiatal hernia

• Drug therapy may include H2-receptor blockers,

prokinetic agents, and proton pump inhibitors• If medical care unsuccessful, surgical fundoplication

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Gastritis

• Pathophysiology • Inflammation of the lining of the stomach • Mucosal barrier that normally protects the stomach

from autodigestion breaks down • Hydrochloric acid, histamine, and pepsin cause

tissue edema, increased capillary permeability, possible hemorrhage

• Helicobacter pylori thought to be prime culprit

• Signs and symptoms • Nausea, vomiting, anorexia, a feeling of fullness,

and pain in the stomach area

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Gastritis

• Medical diagnosis • Gastroscopy• Laboratory studies to detect occult blood in the

feces, low blood hemoglobin and hematocrit, and low serum gastrin levels; H. pylori can be confirmed by breath, urine, stool, or serum tests, or by gastric tissue biopsy

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Gastritis

• Medical treatment • Oral fluids and foods withheld until the acute

symptoms subside; IV fluids administered• Medications to reduce gastric acidity and relieve

nausea• Analgesics for pain relief and antibiotics for H. pylori • Surgical intervention may be needed

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Gastritis

• Assessment• Patient’s present illness• Pain, indigestion, nausea, and vomiting • Determine the onset, duration, and location of pain • Note factors that trigger or relieve the symptoms • Diet, use of alcohol and tobacco, activity/rest patterns • Patient’s general appearance for signs of distress • Compare vital signs, height, weight to previous readings • Note the skin color and check turgor • Inspect abdomen for distention; palpate for tenderness • Auscultate abdomen for increased bowel sounds

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Gastritis

• Interventions• Pain• Imbalanced Nutrition: Less Than Body

Requirements• Deficient Fluid Volume • Ineffective Coping

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Peptic Ulcer

• Pathophysiology • Loss of tissue from lining of the digestive tract • Classified as gastric or duodenal

• Causes • Contributing factors: drugs, infection, stress • Most ulcers are caused by the microorganism H.

pylori

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Peptic Ulcer

• Signs and symptoms • Burning pain • Nausea, anorexia, weight loss

• Complications • Hemorrhage, perforation, or pyloric obstruction

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Peptic Ulcer

• Medical diagnosis • Barium swallow examination, gastroscopy, and

esophagogastroduodenoscopy • H. pylori can be detected by antibodies in the blood

or stool, and by a breath test

• Medical treatment • Drug therapy • Diet therapy • Managing complications

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Peptic Ulcer

• Care of the patient managed medically • Assessment

• Pain, including location, aggravating factors, and measures that bring relief; relationship between pain and food intake

• Recent serious illnesses, previous peptic ulcer disease, and a medication history

• Functional assessment: patient’s usual diet, use of alcohol and tobacco, activities, sleep patterns, and stressors

• Vital signs; height and weight; skin and mucous membranes for turgor and moisture

• Inspect abdomen for distention and palpate for tenderness • Auscultate for bowel sounds

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Peptic Ulcer

• Care of the patient managed medically• Interventions

• Pain• Imbalanced Nutrition: Less Than Body Requirements • Risk for Injury • Ineffective Coping

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Peptic Ulcer

• Care of the patient managed surgically• Assessment

• Pain, nausea, and vomiting

• Measure vital signs at frequent intervals

• Note the amount and type of IV fluids, and check the infusion site for swelling or redness

• Document patency of the nasogastric tube as well as the color and amount of drainage

• Breath sounds; inspect the wound dressing for bleeding

• Inspect abdomen for distention and auscultate for bowel sounds

• Monitor urine output and palpate for bladder distention

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Peptic Ulcer

• Care of the patient managed surgically• Interventions

• Risk for Injury • Imbalanced Nutrition: Less Than Body Requirements • Decreased Cardiac Output

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Stomach Cancer

• Pathophysiology• Begins in the mucous membranes, invades the

gastric wall, and spreads to the regional lymphatics, liver, pancreas, and colon

• No specific signs or symptoms in the early stages• Late signs and symptoms are vomiting, ascites, liver

enlargement, and an abdominal mass

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Stomach Cancer

• Risk factors • H. pylori infection, pernicious anemia, chronic

atrophic gastritis, and achlorhydria, type A blood, and a family history

• Cigarette smoking, alcohol abuse, and a diet high in starch, salt, pickled foods, salted meats, and nitrates

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Stomach Cancer

• Medical diagnosis • Gastroscopy, endoscopic ultrasound, upper GI

series, CT, PET scan, MRI, laparoscopy • Laboratory studies include hemoglobin and

hematocrit, serum albumin, liver function tests, and carcinoembryonic antigen

• Medical treatment • Surgery, chemotherapy, and radiation therapy

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Figure 38-16

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Stomach Cancer

• Preoperative care of the patient with stomach cancer • Inform about the nasogastric tube and IV fluids;

teach coughing, deep breathing, and leg exercises • Identify/support patient’s coping methods • Include sources of support, such as family members

or a spiritual counselor, in the preoperative care

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Stomach Cancer

• Postoperative care of the patient with stomach cancer • Assessment

• Comfort, appetite, and nausea and vomiting • Monitor weight changes and determine dietary preferences • Identify the patient’s support system and coping strategies

• Interventions• Pain • Imbalanced Nutrition: Less Than Body Requirements • Ineffective Coping

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Obesity

• Increased weight caused by excessive body fat • Causes

• Heredity, body build/metabolism, psychosocial factors

• Basic problem: caloric intake exceeds metabolic demands

• Complications • Cardiovascular and respiratory problems,

polycythemia, diabetes mellitus, cholelithiasis (gallstones), infertility, endometrial cancer, and fatty liver infiltration

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Obesity

• Medical diagnosis • Standard weight tables • Measuring skinfold thickness • Endocrine function tests

• Medical and surgical treatment • Weight reduction diet accompanied by a planned

exercise program • Drug therapy• Bariatric surgery

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Obesity

• Assessment• Identify factors that contribute to obesity • Ask about usual dietary practices • Identify factors that trigger overeating and reactions

to overeating • Collect data about previous efforts to lose weight

and current interest in losing weight

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Obesity

• Interventions for the obese patient managed nonsurgically • Imbalanced Nutrition: More Than Body

Requirements • Ineffective Tissue Perfusion • Ineffective Breathing Pattern • Disturbed Body Image

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Obesity

• Interventions after bariatric surgery• Impaired Gas Exchange • Impaired Tissue Perfusion • Impaired Skin Integrity • Imbalanced Nutrition: Less Than Body

Requirements

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Malabsorption

• One or more nutrients are not digested or absorbed

• Many causes: bacteria, deficiencies of bile salts or digestive enzymes, alterations in the intestinal mucosa, and absence of all or part of the stomach or intestines

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Malabsorption

• Signs and symptoms • Steatorrhea • Weight loss, fatigue, decreased libido, easy

bruising, edema, anemia, and bone pain• Bloating, cramping, abdominal cramps, and diarrhea

are symptoms of lactase deficiency

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Malabsorption

• Medical diagnosis • Sprue: based on laboratory studies, endoscopy with

biopsy, and radiologic imaging studies • Lactase deficiency: based on the health history, the

lactose tolerance test, a breath test for abnormal hydrogen levels, and if necessary, biopsy of the intestinal

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Malabsorption

• Medical treatment • Sprue: diet and drug therapy; foods that aggravate

symptoms eliminated from the diet • Celiac disease: avoid products that contain gluten• Tropical sprue: antibiotics, oral folate, and vitamin

B12 injections

• Lactase deficiency: eliminate milk and milk products

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Malabsorption

• Nursing care• Document the patient’s symptoms • Note stool characteristics • In the case of celiac sprue, teach the patient how to

eliminate gluten from the diet • Give antibiotics as ordered for tropical sprue • If folic acid therapy continued, instruct patient in

self-medication • The effect of therapy is evaluated by the return of

normal stool consistency • Advise the patient with lactase deficiency of dietary

restrictions and alternative products

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Diarrhea

• The passage of loose, liquid stools with increased frequency

• May have cramps, abdominal pain, and a feeling of urgency before bowel movements

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Diarrhea

• Causes • Spoiled foods, allergies, infections, diverticulosis,

malabsorption, cancer, stress, fecal impactions, and tube feedings

• Adverse effect of some medications

• Complications • Dehydration, electrolyte imbalances, and metabolic

acidosis • Malnutrition and anemia

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Diarrhea

• Medical treatment • Acute diarrhea usually treated by resting the

digestive tract and giving antidiarrheal drugs • Severe, persistent diarrhea may require TPN

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Diarrhea

• Assessment• Diarrhea and onset, severity, precipitating factors,

and measures that bring relief • Ask about stool characteristics, including amount,

color, odor, and unusual contents, such as blood, mucus, or undigested food

• Functional assessment focuses on usual diet, dietary changes, recent and current medications, recent travel to a foreign country

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Diarrhea

• Interventions• Deficient Fluid Volume and Imbalanced Nutrition:

Less Than Body Requirements • Impaired Skin Integrity • Pain • Self-Care Deficit

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Constipation

• Hard, dry, infrequent stools that are passed with difficulty

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Constipation

• Causes• Frequently ignoring the urge to defecate• Frequent use of laxatives or enemas• Inactivity• Inadequate water intake • Diet low in fiber and high in cheese, lean meat,

pasta• Drugs that slow intestinal motility/increase urine

output• Diseases of the colon or rectum, as well as brain or

spinal cord injury; abdominal surgery

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Constipation

• Complications• Valsalva maneuver

• The rapid changes in blood flow can be fatal to a patient with heart disease

• Hemorrhoids• Fecal impaction

• Medical treatment • Laxatives, suppositories, enemas, or combination

for prompt results • Stool softeners

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Constipation

• Assessment• Usual pattern of bowel elimination, including

frequency, amount, color, unusual contents, and pain associated with defecation

• Information about diet, exercise, and drug therapy• Any aids to elimination; type and frequency of use• Examine abdomen for distention or visible

peristalsis • Auscultate for bowel sounds in all four quadrants of

the abdomen

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Constipation

• Interventions• Maintained with diet, fluids, exercise, and regular

toilet habits • Megacolon

• Regular enemas for bowel cleansing

• Fecal impaction • Assess for impaction by inserting a gloved, lubricated

finger into the rectum • Remove impaction following agency protocol or specific

physician’s orders

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Intestinal Obstruction

• Causes• Strangulated hernia, tumor, paralytic ileus, stricture,

volvulus (twisting of the bowel), intussusception (telescoping of the bowel into itself), and postoperative adhesions

• Signs and symptoms • Vomiting (possibly projectile), abdominal pain, and

constipation • Blood or purulent drainage passed rectally • Abdominal distention, especially with colon

obstruction

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Intestinal Obstruction

• Complications • Fluid and electrolyte imbalances and metabolic

alkalosis• Gangrene and perforation of the bowel

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Figure 38-17

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Intestinal Obstruction

• Medical diagnosis • History, physical examination, and laboratory

studies; confirmed by radiologic studies

• Medical treatment • Gastrointestinal decompression; intravenous fluids;

and surgical intervention

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Intestinal Obstruction

• Assessment • Symptoms, including pain and nausea • Onset and progression of symptoms • Hernia, cancer of the digestive tract, and abdominal

surgeries • Ask when the patient’s last bowel movement was

and if the characteristics were normal

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Intestinal Obstruction

• Interventions • Acute Pain • Deficient Fluid Volume • Risk for Infection • Ineffective Breathing Pattern • Anxiety

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Appendicitis

• Pathophysiology• Inflammation of the appendix• A ruptured appendix allows digestive contents to

enter the abdominal cavity, causing peritonitis

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Appendicitis

• Signs and symptoms • Pain at McBurney’s point, midway between the

umbilicus and the iliac crest • Temperature elevation, nausea, and vomiting • Elevated WBC count (10,000-15,000/mm3 )• Peritonitis: absence of bowel sounds, severe

abdominal distention, increased pulse and temperature, nausea/vomiting; rigid abdomen

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Figure 38-18

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Appendicitis

• Medical treatment• Nothing by mouth• A cold pack to the abdomen may be ordered • Laxatives and heat applications should never be

used for undiagnosed abdominal pain • Immediate surgical treatment indicated• Ruptured appendix: surgery may be delayed 6-8

hours while antibiotics and IV fluids given

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Appendicitis

• Assessment• Location, severity, onset, duration, precipitating

factors, and alleviating measures in relation to the pain

• Previous abdominal distress, chronic illnesses, surgeries; record allergies and medications

• Temperature; abdominal pain, distention, and tenderness; presence and characteristics of bowel sounds

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Appendicitis

• Preoperative interventions• Semi-Fowler or side-lying position with the hips

flexed • Until physician determines the diagnosis, analgesics

may be withheld • If rupture suspected, elevate patient’s head to

localize the infection

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Appendicitis

• Postoperative interventions• Administer antibiotics, intravenous fluids, and

possibly gastrointestinal decompression • Assist the patient in turning, coughing, and deep

breathing; incentive spirometry• Splint the incision during deep breathing • Early ambulation• Assess abdominal wound for redness, swelling, and

foul drainage • Wound care as ordered or according to agency

policy

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Peritonitis

• Pathophysiology • Inflammation of peritoneum caused by chemical or

bacterial contamination of the peritoneal cavity

• Signs and symptoms • Pain over affected area, rebound tenderness,

abdominal rigidity and distention, fever, tachycardia, tachypnea, nausea, and vomiting

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Peritonitis

• Medical diagnosis • History and physical • Complete blood cell count, serum electrolyte

measurements, abdominal radiography, computed tomography, and ultrasound

• Paracentesis

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Peritonitis

• Medical treatment • Gastrointestinal decompression, intravenous fluids,

antibiotics, and analgesics• Surgery to close a ruptured structure and remove

foreign material and fluid from the peritoneal cavity

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Peritonitis

• Assessment• Onset, location, and severity of the pain and any

related symptoms • Record a history of abdominal trauma, including

surgery • Take and record vital signs • Inspect abdomen for distention and auscultate for

the presence of bowel sounds

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Peritonitis

• Interventions• Acute Pain• Decreased Cardiac Output • Imbalanced Nutrition: Less Than Body

Requirements • Anxiety

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Abdominal Hernia

• Pathophysiology • Weakness in the abdominal wall that allows a

portion of the large intestine to push through• Weak locations include the umbilicus and the lower

inguinal areas of the abdomen; may also develop at the site of a surgical incision

• Classified as reducible or irreducible

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Abdominal Hernia

• Signs and symptoms • A smooth lump on the abdomen• With incarceration, the patient has severe

abdominal pain and distention, vomiting, and cramps

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Figure 38-19

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Abdominal Hernia

• Medical diagnosis• Health history and physical examination

• Medical treatment• Surgical repair

• Herniorrhaphy • Hernioplasty

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Abdominal Hernia

• Assessment• Chief complaint • Ask about pain and vomiting• Inspect for abnormalities, and listen for bowel

sounds in all four abdominal quadrants

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Abdominal Hernia

• Preoperative interventions • Risk for Injury• Impaired Skin Integrity

• Postoperative interventions • Impaired Urinary Elimination • Constipation • Acute Pain • Risk for Injury

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Inflammatory Bowel Disease

• Pathophysiology • Ulcerative colitis and Crohn’s disease• Inflammation and ulceration of intestinal tract lining

• Exact cause is unknown • Possible causes: infectious agents, autoimmune

reactions, allergies, heredity, and foreign substances

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Inflammatory Bowel Disease

• Signs and symptoms • Ulcerative colitis

• Diarrhea with frequent bloody stools, abdominal cramping

• Crohn’s disease

• If the stomach and duodenum are involved, symptoms include nausea, vomiting, and epigastric pain

• Involvement of the small intestine produces pain and abdominal tenderness and cramping

• An inflamed colon typically causes abdominal pain, cramping, rectal bleeding, and diarrhea

• Systemic signs and symptoms include fever, night sweats, malaise, and joint pain

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Inflammatory Bowel Disease

• Complications • Hemorrhage, obstruction, perforation (rupture),

abscesses in the anus or rectum, fistulas, and megacolon

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Inflammatory Bowel Disease

• Medical diagnosis • History and physical examination • Abdominal radiography • Barium enema examination with air contrast;

colonoscopy with biopsy, ultrasonography, CT, and cell studies

• Video capsule • Medical treatment

• Drug therapy, diet, and rest

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Inflammatory Bowel Disease

• Assessment• Onset, location, severity, and duration of pain • Note factors that contribute to the onset of pain• Onset and duration of diarrhea; presence of blood • Vital signs, height and weight, measures of

hydration• Inspect perianal area for irritation or ulceration• Maintain accurate intake and output records • Measure diarrhea stools if possible and count as

output

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Inflammatory Bowel Disease

• Interventions• Acute Pain • Diarrhea • Deficient Fluid Volume • Imbalanced Nutrition: Less Than Body

Requirements • Ineffective Coping• Risk for Injury

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Diverticulosis

• Pathophysiology• Small saclike pouches in intestinal wall: diverticula • Weak areas of the intestinal wall allow segments of

the mucous membrane to herniate outward

• Risk factors • Lack of dietary residue• Age, constipation, obesity, emotional tension

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Diverticulosis

• Signs and symptoms • Often asymptomatic, but many people report

constipation, diarrhea, or periodic bouts of each• Rectal bleeding, pain in left lower abdomen, nausea

and vomiting, and urinary problems

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Figure 38-20

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Diverticulosis

• Complications• Diverticulitis

• Bleeding, obstruction, perforation (rupture), peritonitis, and fistula formation

• Medical diagnosis • Symptoms• Abdominal CT and barium enema examination

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Diverticulosis

• Medical treatment • High-residue diet without spicy foods• Stool softeners or bulk-forming laxatives;

antidiarrheals; broad-spectrum antibiotics; anticholinergics

• Surgical intervention may be necessary

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Diverticulosis

• Assessment• Assess patient’s comfort and stool characteristics;

note nausea and vomiting • Monitor patient’s temperature • Assess abdomen for distention and tenderness

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Diverticulosis

• Interventions• Fluids as permitted; monitor intake and output • Antiemetics, analgesics, anticholinergics as ordered• Be alert for signs of perforation• Teach patient about diverticulosis, including the

pathophysiology, treatment, and symptoms of inflammation

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Colorectal Cancer

• Pathophysiology• Cancer of the large intestine• People at greater risk for colorectal cancer are

those with histories of inflammatory bowel disease, or family histories of colorectal cancer or multiple intestinal polyps

• High-fat, low-fiber diet and inadequate intake of fruits and vegetables also contribute to development

• Can develop anywhere in the large intestine • Three fourths of all colorectal cancers are located in the

rectum or lower sigmoid colon

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Figure 38-21

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Colorectal Cancer

• Signs and symptoms • Right side of the abdomen

• Vague cramping until the disease is advanced • Unexplained anemia, weakness, and fatigue related to

blood loss may be the only early symptoms

• Left side or in the rectum • Diarrhea or constipation and may notice blood in the stool • Stools may become very narrow, causing them to be

described as pencil-like • Feeling of fullness or pressure in the abdomen or rectum

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Colorectal Cancer

• Medical and surgical treatment • Usually treated surgically• Combination chemotherapy postoperatively if tumor

extends through the bowel wall or if lymph nodes involved

• Early stage rectal cancer sometimes treated with radiation and surgery

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Colorectal Cancer

• Assessment• Vital signs, intake and output, breath sounds, bowel

sounds, and pain • Appearance of wounds and wound drainage • If there is a colostomy, measure and describe the

fecal drainage

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Colorectal Cancer

• Interventions• Risk for Injury • Ineffective Tissue Perfusion • Acute Pain • Sexual Dysfunction • Ineffective Coping

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Polyps

• Small growths in the intestine • Most benign but can become malignant• Inherited syndromes: familial polyposis and

Gardner’s syndrome• Usually asymptomatic; found on routine testing • Complications are bleeding and obstruction • Diagnosed by barium enema or endoscopic

exam • Colectomy for familial polyposis or Gardner’s

syndrome because of the high risk of malignancy

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Hemorrhoids

• Internal or external dilated veins in the rectum • Thrombosed

• Blood clots form in external hemorrhoids; become inflamed and very painful

• Risk factors • Constipation, pregnancy, prolonged sitting or

standing

• Signs and symptoms • Rectal pain and itching • Bleeding with defecation• External hemorrhoids easy to see; appear red/bluish

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Figure 38-22

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Hemorrhoids

• Medical diagnosis and treatment • Diagnosed by visual inspection• Nonsurgical treatment

• Topical creams, lotions, or suppositories soothe and shrink inflamed tissue

• Sitz baths often comforting • The physician may order heat or cold applications

• Outpatient procedures: ligation, sclerotherapy. Thermocoagulation/electrocoagulation, laser surgery

• Hemorrhoidectomy • The surgical excision (removal) of hemorrhoids

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Hemorrhoids

• Assessment• After hemorrhoidectomy, monitor vital signs, intake

and output, and breath sounds. Assess the perianal area for bleeding and drainage

• Interventions• Acute Pain• Impaired Skin Integrity • Constipation

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Anorectal Abscess

• An infection in the tissue around the rectum • Signs and symptoms are rectal pain, swelling, redness,

and tenderness • Treated with antibiotics followed by incision and

drainage • Preoperatively, pain is treated with ice packs, sitz

baths, and topical agents as ordered

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Anorectal Abscess

• Postoperatively, pain treated with opioid analgesics • Patient teaching emphasizes importance of

thorough cleansing after each bowel movement• Advise patient to consume adequate fluids and a

high-fiber diet to promote soft stools

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Anal Fissure

• Laceration between the anal canal and the perianal skin

• May be related to constipation, diarrhea, Crohn’s disease, tuberculosis, leukemia, trauma, or childbirth

• Signs and symptoms include pain before and after defecation and bleeding on the stool or tissue

• If fissure chronic, the patient may experience pruritus, urinary frequency or retention, and dysuria

• Usually heal spontaneously, but can become chronic • Conservative treatment: sitz baths, stool softeners, and

analgesics • Surgical excision may be necessary

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Anal Fistula

• Abnormal opening between anal canal and perianal skin

• Develops from anorectal abscesses or related to inflammatory bowel disease or tuberculosis

• Patient typically complains of pruritus and discharge• Sitz baths provide some comfort• Surgical treatment is excision of fistula and surrounding

tissue • Sometimes a temporary colostomy to allow the surgical

site to heal • Postoperative care: analgesics and sitz baths for pain

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Pilonidal Cyst

• Located in the sacrococcygeal area • Results from an infolding of skin, causing a

sinus that is easily infected because of its closeness to the anus

• Once infected, it is painful and swollen and may form an abscess

• Surgical excision usually recommended • Care is similar to that for the patient having a

hemorrhoidectomy

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Patient Education to Promote Normal Bowel Function

• Good hand washing and proper food handling • People who recognize that stress affects their

gastrointestinal function may benefit from relaxation techniques and stress management training

• Signs and symptoms of digestive problems should be reported for prompt diagnosis and treatment if indicated

• Teaching patients what is normal, how to promote normal function, and how to detect problems can help to avoid serious gastrointestinal dysfunction