Review of Anatomy and Physiology • It may occur with or without

inflammation.
The main function of the GI system is to
supply nutrients to body cells. This is • Malnutrition affects body
accomplished through the processes of (1) composition and functional status.
ingestion (taking in food), (2) digestion Other terms used to describe
(breaking down food), and (3) absorption malnutrition include undernutrition
(transferring food products into and overnutrition.
circulation).

Elimination is the process of excreting the

Assessment
waste products of digestion.
Subjective Data

• Important Health Information

Nutrition
• Past Health History
• Patient’s Bowel Habits
• History or Presence of Dse.
• Weight History
• Medications

Functional Health Patterns

• Health Perception – Health

Management
• Nutritional - Metabolic Pattern
• Elimination Pattern
CHO – main source of energy. 4cal/g
• Activity – Exercise Pattern
CHON – needed for tissue growth, • Sleep – Rest Pattern
• Cognitive – Perceptual Pattern
repair and maintenance, body regulatory • Role – Relationship Pattern
functions, energy production. 4cal/g • Sexual – Reproductive Pattern
Fats – another major source of energy for • Value – Belief Pattern
the body. Carriers of Objective Data
essential fatty acids and fat – soluble • Mouth (Inspection and Palpation
vitamins. 9cal/g • Abdomen (Inspection,
Vitamins Minerals Auscultation, Percussion,
Palpation)
• Rectum and Anus

Malnutrition

Diagnostic

• For most diagnostic studies, make

sure a signed consent form for the
procedure has been completed
and is in the medical record.

• The HCP doing the procedure is

responsible for explaining the
procedure and obtaining written
consent.
• Malnutrition is a deficit, excess, or
imbalance of essential nutrients.
 • You have a key role in teaching Virtual Colonoscopy:
patients about the procedures.

• When preparing the patient, it is

important to ask about any known
allergies to drugs, iodine, shellfish,
Many GI system diagnostic
procedures require (1) measures to
cleanse the GI tract and (2)
ingestion or injection of a contrast
medium or a radiopaque tracer.

Barium Swallow: A barium swallow is a

special type of X-ray test that helps your Virtual colonoscopy combines CT scanning
doctor take a close look at the back of or MRI to produce images of the colon and
your mouth and throat, known as the rectum less invasively. It requires radiation
pharynx, and the tube that extends from and prior cleansing of the colon but no
the back of the tongue down to the sedation. Compared to conventional
stomach, known as the esophagus. To do colonoscopy, virtual colonoscopy provides
a barium swallow, you swallow a chalky a better view inside the colon that is narrow
white substance known as barium. It’s from inflammation or a growth. If a polyp is
often mixed with water to make a thick found, it will have to be removed by
drink that looks like a milkshake. When it’s conventional colonoscopy. Virtual
swallowed, this liquid coats the inside of colonoscopy may be less sensitive in
your upper GI. obtaining information on the details and
color of the mucosa and in detecting small
Radiologic Studies | Upper Gastrointestinal (less than 10 mm) or flat polyps.
Series: An upper GI series with small
bowel follow-through provides visualization Endoscopy:
of the oropharyngeal area, esophagus,
stomach, and small intestine. The
procedure consists of the patient
swallowing contrast medium (a thick
barium solution or gastrograffin) and then
assuming different positions on the x-ray
table. The movement of the contrast
medium is observed with fluoroscopy, and
a series of x-rays are taken. An upper GI
series is useful in identifying esophageal
strictures, polyps, tumors, hiatal hernias, Endoscopy refers to the direct visualization
foreign bodies, and ulcers. of a body structure through an endoscope. An
endoscope is a fiberoptic instrument with a light
Radiologic Studies | Lower Gastrointestinal and camera attached, allowing the ability to
Series: The purpose of a lower GI series, or a take video and still pictures (Figure 8.0). Some
barium enema, is to observe (using endoscopes have a channel through which to
fluoroscopy) the colon filling with contrast pass instruments, such as biopsy forceps and
medium and to observe (by x-ray) the filled cytology brushes. Endoscopy can examine the
colon. The patient receives an enema of esophagus, stomach, duodenum, and colon.
Endoscopic retrograde
contrast medium. This procedure identifies
cholangiopancreatography (ERCP) visualizes
polyps, tumors, and other lesions in the
the pancreatic, hepatic, and common bile
colon. ducts. Endoscopy is often combined with
diagnostic procedures, including biopsy,
cytologic
 DIAGNOSTIC NURSING RESPONSIBILITIES:

Colonoscopy: Directly visualizes entire colon up to ileocecal valve with Before: Bowel preparation prior varies depending on HCP. Patient
flexible fiberoptic scope. Patient's position is changed frequently should avoid fiber for up to 72 hr prior, then either a clear or full liquid
during procedure to assist with advancement of scope to cecum. diet 24 hr before. Bowel cleansing should follow a split-dose regimen.
Used to diagnose or detect inflammatory bowel disease, polyps, The evening before the procedure, the patient should drink a
tumors, and diverticulosis and dilate strictures. Procedure allows for cleansing solution. The second dose should begin 4-6 hr before the
biopsy and removal of polyps without laparotomy. procedure. A split-dose regimen started early morning the day of a
procedure provides better cleansing for patients scheduled in the
afternoon. Encourage the patient to drink all the solution. Stools will be
clear or clear yellow liquid when the colon is clean. Bisacodyl tablets
or suppositories may be given before the cleansing solution to remove
the bulk of the stool. Explain to patient that a flexible scope will be
inserted while patient in side-lying position and sedation will be given.
After: Patient may have abdominal cramps caused by stimulation of
peristalsis because the bowel is constantly inflated with air during
procedure. Teach patients about pain post-colonoscopy and the
characteristics of this pain. Tell patients if pain lasts longer than 24 hr to
notify HCP. Check vital signs. Observe for rectal bleeding and
manifestations of perforation (e.g., malaise, abdominal distention,
tenesmus).

Endoscopic retrograde cholangiopancreatography (ERCP): Before Explain procedure. Keep patient NPO & fur before. Ensure
Fiberoptic endoscope (using fluoroscopy) is orally inserted into consent signed. Give sedation immediately before and during
descending duodenum. Then common bile and pancreatic ducts are procedure. Give antibiotics if ordered.
cannulated. Contrast medium is injected into ducts to allow for direct
visualization of structures. Can be used to retrieve a gallstone from After: Check vital signs. Assem for perforation or Infection. Pancreatitis
distal common bile duct, dilate strictures, biopsy, and diagnose is most common complication. Check for return of gag reflex.
pseudocysts.

Esophagogastroduodenoscopy Test may use video imaging to Before: Keep patient NPO for 8 hr. Ensure comment form is signed. Give
visualize stomach motility. Detects inflammation, ulcerations, tumors, preoperative medication if ordered. Explain to patient that local
varices, or Mallory. Weiss tears. Biopsies may be taken. Varices can be anesthesia may be sprayed on throat before insertion of scope and
treated with band ligation or sclerotherapy. that patient will be sedated during procedure.
 After: Keep patient NPO until gag reflex returns Gently tickle back of
throat to determine reflex. Use warm saline gargles for relief of sore
throat. Check temperature 415-30min for 1-2 hr (sudden temperature
spike is sign of perforation).

Laparoscopy Visualize peritoneal cavity and contents with Before: Ensure consent form is signed. Keep patient NPO 8 hr. Give
laparoscope. Double-puncture peritoneoscopy permits better preoperative sedative medication. Ensure bladder and bowels are
visualization of abdominal cavity, especially liver. Done in operating emptied.
room. Can obtain biopsy specimen.
After: Observe for complications of bleeding and bowel perforation
after the procedure.

Sigmoidoscopy Directly visualizes rectum and sigmoid colon with Before: Bowel preparation similar to colonoscopy. Explain to patient
lighted flexible endoscope. Sometimes a special table is used to tilt knee-chest position, need to take deep breaths during insertion of
patient into knee-chest position. Used to detect tumors, polyps, scope, and possible urge to defecate as scope is passed. Encourage
inflammatory and infectious diseases, fissures, hemorrhoids patient to relax and let abdomen go limp.

After: Observe for rectal bleeding after polypectomy or biopsy.

Video Capsule Endoscopy Patient swallows a vitamin-sized capsule Before: Keep patient NPO for 8 hr. May have bowel preparation similar
with camera, which provides endoscopic visualization of GI tract (Fig. to colonoscopy.
38.11). Camera takes >50,000 images during test, relaying them to
monitoring device that patient wears After swallowing capsule, clear liquids resumed in 2 hr
Liver Function Studies: Liver function tests motility disorders such as achalasia,
(LFTs) are laboratory (blood) studies that scleroderma, or esophageal spasm.
reflect hepatic disease.
• Complications include stricture;
ulceration and possible fistula;
aspiration pneumonia; Barrett’s
esophagus, which increases the
risk of adenocarcinoma

ASSESSMENT

1. Signs and Symptoms of GERD

• Heartburn
• Complaints of spontaneous
Liver Biopsy: The purpose of a liver biopsy is
regurgitation of sour or bitter
to obtain hepatic tissue to use to establish
gastric contents into the mouth
a diagnosis of cancer or assess and stage
• Generalized dysphagia may
fibrosis. It may be done to follow the
occur
progress of liver disease, such as chronic
• May present with substernal
hepatitis.
types of
chest pain, hoarseness, sore
liver biopsy throat, or chronic cough

The open method involves

making an incision and
removing a wedge of tissue.
It is done in the operating
DIAGNOSTIC EVALUATION
room with the patient under close method
general anesthesia, often
with another surgical
procedure.

Alterations / Problems in GI and Nutrition, 1. Endoscopy

Acute and Chronic
2. Barium Swallow
Gastroesophageal Reflux Dse.
3. Esophageal Manometry

4. Acid Perfusion Test

5. Ambulatory 24 hour pH Monitoring

POSSIBLE NURSING DIAGNOSIS

• Gastric contents flow back into the

esophagus due to incompetent
lower esophageal sphincter.
• May result from impaired gastric
emptying from gastroparesis or 1. Acute Pain 2. Deficient Knowledge
partial gastric outlet obstruction; or
THERAPEUTIC INTERVENTIONS 1. Nissen fundoplication; upper portion of
the stomach is wrapped around the distal
esophagus and sutured, creating a tight
LES

2. There are several endoscopic

procedures that reduces reflux symptoms
by tightening the LES

3. For strictures, mechanical dilatation may

be necessary several times.

Hiatal Hernia: A protrusion of part of the

stomach thru the hiatus of the diaphragm
• Have patient follow a bland and into the thoracic cavity. Results from
antireflux diet muscle weakening caused by aging or
• Raise head of bed 6 to 8 inches (15 other conditions such as esophageal
to 20cm) carcinoma, trauma, or as complication
• Remain upright for 3 hours after after certain surgical procedures.
eating
• Avoid overeating types of
hiatal hernias
• Cease smoking to help increase LES
pressure.
• Reduce or eliminate alcohol intake sliding hernia paraesophageal hernia

• Avoid tight - fitting clothes, which

increase intra abdominal pressure.

PHARMACOLOGIC INTERVENTIONS

• Antacids as needed to treat

heartburn; provides symptomatic
relief but does not heal esophageal
lesions
• Histamine 2 receptor antagonists, ASSESSMENT
such as ranitidine and famotidine to
decrease gastric acid secretions 1. May be asymptomatic
• Proton pump inhibitor (PPI) such as 2. Patient may report feeling of
omeprazole or lansoprazole to fullness or chest pain
suppress gastric acids resembling angina

3. Sliding hernia may cause

dysphagia, heartburn (with or
SURGICAL INTERVENTIONS without episodes of
regurgitation of gastric
contents into the mouth), or
retrosternal or substernal chest
pain from gastric reflux.

4. Severe pain or shock may

result from incarceration of
stomach in thoracic cavity
with paraesophageal hernia.

Surgery is indicated for patients who do not

respond to other approaches. Consists of
DIAGNOSTIC EVALUATION SURGICAL INTERVENTION

• Upper GI series with

barium contrast shows
outline of hernia in the
esophagus • Gastropexy to fix the stomach in
position is indicated if symptoms are
• Endoscopy visualizes severe.
defect and rules out • Nissen Fundoplication
other disorders, such as
tumors or esophagitis Achalasia

CAUSES
Anything that greatly increases the Intra-
abdominal pressure or a lifestyle that
weakens the connective tissue of the body
can potentially cause a hiatal hernia

• primary esophageal motility

disorder characterized by the
absence of esophageal peristalsis
THINGS THAT INCREASE ABDOMINAL
PRESSURE and impaired relaxation of the
Obesity THINGS THAT WEAKEN CONNECTIVE lower esophageal sphincter (LES) in
TISSUE
Smoking and Alcoholism response to swallowing.
Pregnancy

Trauma
Poor Diet
• occurs when nerves in the
Heavy Lifting
Sedentary Lifestyle
esophagus become damaged. As
Constipation (Straining to Go)
Chronic Stress a result, the esophagus becomes
paralyzed and dilated over time
Excessive Coughing
and eventually loses the ability to
THERAPEUTIC INTERVENTION squeeze food down into the
stomach
Elevate head of the bed 6 to 8 inches (15
to 20cm) to reduce nightime reflux ASSESSMENT

PHARMACOLOGIC INTERVENTION

1. Antacids to neutralize gastric acid and

reduce pain

2. If patient has esophagitis, give histamine

2 receptor antagonist (cimetidine or
ranitidine) or PPIs (omeprazole) to
decrease gastric secretions • Inability to swallow (dysphagia),
which may feel like food or drink is
stuck in your throat
• Regurgitating food or saliva
 • Heartburn small bites, and avoiding
• Belching swallowing large volumes of food
• Chest pain that comes and goes or liquid. Patient education centers
• Coughing at night on adaptations the patient may
• Pneumonia (from aspiration of food make to avoid esophageal pain,
into the lungs) regurgitation, and weight loss.
• Weight loss
PHARMACOLOGIC INTERVENTIONS
• Vomiting
• Botox (botulinum toxin type A). This
muscle relaxant can be injected
DIAGNOSTICS directly into the esophageal
sphincter with an endoscopic
needle. The injections may need to
be repeated, and repeat injections
may make it more difficult to
perform surgery later if needed.
• Your doctor might suggest muscle
relaxants such as nitroglycerin
(Nitrostat) or nifedipine (Procardia)
• Esophageal Manometry before eating. These medications
• Upper GI Series have limited treatment effect and
• Upper Endoscopy severe side effects.

SURGICAL INTERVENTIONS

POSSIBLE NURSING DIAGNOSES • Heller myotomy. The surgeon cuts

the muscle at the lower end of the
• Imbalanced Nutrition: Less Than esophageal sphincter to allow food
Body Requirements to pass more easily into the
• Acute Pain stomach. The procedure can be
• Risk for Aspiration done noninvasively (laparoscopic
• Deficient Knowledge Heller myotomy). Some people
who have a Heller myotomy may
later develop gastroesophageal
reflux disease (GERD).

• Peroral endoscopic myotomy

(POEM). In the POEM procedure,
the surgeon uses an endoscope
THERAPEUTIC INTERVENTIONS inserted through your mouth and
down your throat to create an
incision in the inside lining of your
esophagus. Then, as in a Heller
myotomy, the surgeon cuts the
muscle at the lower end of the
esophageal sphincter.

• Pneumatic dilation
• Some patients with achalasia
benefit from eating slowly, taking
 • Nausea related to effects of drug
therapy

THERAPEUTIC INTERVENTIONS:

For Nausea

• When trying to control nausea:

Nausea : Nausea is an uneasiness of the
• Drink clear or ice-cold drinks.
stomach that often accompanies the urge
• Eat light, bland foods (such as
to vomit, but doesn't always lead to
saltine crackers or plain bread).
vomiting.
• Avoid fried, greasy, or sweet foods.
Vomiting: Vomiting is the forcible voluntary • Eat slowly and eat smaller, more
or involuntary emptying ("throwing up") of frequent meals.
stomach contents through the mouth. • Do not mix hot and cold foods.
• Drink beverages slowly.
NAUSEA AND VOMITING POSSIBLE CAUSES: • Avoid activity after eating.
• Avoid brushing your teeth after
eating.
• Seasickness
• Choose foods from all the food
and other motion
groups as you can tolerate them
sicknesses
to get adequate nutrition.
• Early
pregnancy
• Intense pain
• Exposure to For Vomiting
chemical toxins
• Drinking gradually larger amounts
• Emotional
of clear liquids
stress (fear)
• Avoiding solid food until the
• Gallbladder
vomiting episode has passed
disease
• Resting
• Food poisoning
• Temporarily discontinuing all oral
• Indigestion
medications, which can irritate the
• Various VIRUSES
stomach and make vomiting
• Certain smells or odors
worse
Another concern with vomiting is
DEHYDRATION. Adults have a lower risk of
becoming dehydrated because they can
usually detect the symptoms of
Gastrointestinal Bleeding
dehydration (such as increased thirst and
dry lips or mouth). Children have a greater • Symptom of
risk of becoming dehydrated, especially if many upper or
the vomiting occurs with diarrhea, lower GI
because young children may often be disorders
unable to tell an adult about symptoms of
dehydration. • May be
obvious (in
NURSING DIAGNOSES: emesis or stool)
or occult
• Risk for deficient fluid volume
(hidden)
related to vomiting
• Acute Pain related to vomiting • May result
secondary to vascular dilatation from trauma anywhere along
and hyperperistalsis
the GI tract; erosions or ulcers; esophageal Characteristics of blood to help
or gastric varices; etc. determine the site of origin

ASSESSMENT:
Bright red Bright red flow Shades of black Tarry stool
hematemesis or coating stool (“coffee – ground”) (melena) –
– from rectum emesis – vomited occurs when
– vomited or distal colon from esophagus, excessive blood
from high in and small stomach and accumulates in
esophagus intestine duodenum the stomach

DIAGNOSTIC EVALUATION

• Complete Blood Count –decreased

Hct and Hgb; coagulation
studies evaluate prothrombin time.

• Endoscopy visualizes the GI mucosa

and source of bleeding and also
determines the risk of rebleeding

• Changes in bowel patterns or in • Imaging studies may be necessary

stool color (dark black, red, or to detect source of bleeding
streaked with blood)
• Stool test for occult blood.
• Hematemesis
• Nausea, abdominal pain or
tenderness, or rectal pain
POSSIBLE NURSING DIAGNOSES
• Intermittent melena or “coffee -
ground” emesis to large amount of • Bowel Incontinence
melena with clots or bright red
hematemesis • Deficient fluid volume
• Rapid pulse, drop in BP, and signs of
• Imbalanced nutrition: less than
shock may occur in significant
body requirements
blood loss

THERAPEUTIC INTERVENTIONS:

Same interventions for Shock

• Oxygen therapy
• Intubation and assisted ventilation if
necessary
• Fluid resuscitation for hypovolemic
shock, preferably thru two large-
bore or central lines, initially with LR
solution
• Blood product replacement as
indicated
• Pallor, weakness, dizziness, and
• Hemodynamic monitoring with
shortness of breath may occur as
Swan-Ganz catheter, especially for
anemia develops
cardiogenic shock
• Stool or emesis will test positive for
• Hypothermia blanket in septic
occult blood
shock to cool patient (ppt
additional info pic)
 along with lifestyle change and
dietary modifications
• Discontinue any medications such
as NSAIDs that may be causing
bleeding.

Gastritis:

Monitoring:

• general term for a group of

conditions with one thing in
common: inflammation of the
lining of the stomach.
• most often the result of infection
with the same bacterium that
• Monitor intake and output, VS, and
causes most stomach ulcers.
CVP to evaluate fluid status
• Gastritis may occur suddenly
• Observe for changes indicating
(acute
shock, such as tachycardia,
• gastritis), or appear slowly over time
hypotension, tachypnea,
(chronic gastritis).
• decreased urine output and
changes in mental status
• Monitor stools and NG drainage for
COMMON CAUSES:
blood.
• Maintain patient on NG tube and • Helicobacter pylori
NPO status to rest GI tract and • Long term use of NSAIDs
evaluate bleeding. • Aspirin
• Alcohol
• Excessive amounts of caffeine
PHARMACOLOGIC INTERVENTIONS: • High stress levels
• Smoking
• For upper GI bleeding,
• Intolerance to spicy/citric food
histamine-2 blockers may used to
block the acid- secreting action of
histamine.
• Antacids or cytoprotective agents ASSESSMENT
such as sucralfate may be also • Gnawing or burning ache or pain
used. (indigestion) in your upper
• If peptic ulcer disease is the cause, abdomen that may become either
an antiulcer drug is prescribed, worse or better with eating
 • Nausea • Administer I.V. fluids as ordered to
• Vomiting maintain fluid and
• A feeling of fullness in your electrolyte imbalance.
upper abdomen after eating • When the patient can
tolerate oral feedings,
provide a bland diet
that takes into account
his food preference.
Restart feedings slowly.
• Offer smaller, more
frequent servings to
reduce the amount of
irritating gastric
DIAGNOSTIC EVALUATION secretions.
• H. pylori Test - H.
pylori may be detected in
a blood test, in a stool THERAPEUTIC INTERVENTIONS
test or by a breath test.
• Help patient identify specific foods
• Endoscopy - If a that cause gastric upset and
suspicious area is found, eliminate them from his diet.
your doctor may remove • Administer antacids and other
small tissue samples prescribed medications as ordered.
(biopsy) for laboratory • If pain or nausea interferes with the
examination. A biopsy patient’s appetite, administer pain
can also identify the medications or antiemetics about 1
presence of H. pylori in hour before meals.
your stomach lining. • Monitor the patient’s fluid intake
and output and electrolyte levels
• Upper GI series
• Assess the patient for presence of
bowel sounds.
• Monitor the patient’s response to
SYMPTOMS antacids and
• other prescribed medications.
• Monitor the patient’s compliance
to treatment
• and elimination of risk factors in his
lifestyle.
• Teach the patient about the
disorder.
POSSIBLE NURSING DIAGNOSES • Urge the patient to seek immediate
attention for
• Imbalanced Nutrition: Less Than
• recurring signs and symptoms, such
Body Requirements
as hematemesis, nausea, or
• Acute Pain
vomiting.
• Risk for Deficient Fluid Volume
• Knowledge Deficit

PHARMACOLOGIC INTERVENTIONS
THERAPEUTIC INTERVENTIONS • Antibiotics to kill H. pylori
(clarithromycin, amoxicillin,
• If the patient is vomiting, give
metronidazole)
antiemetics.
 • Proton pump inhibitors to reduce b. Decreased Hgb and Hct, indicating
acid secretions. anemia
• Histamine – 2 blockers to reduce the c. Orthostatic blood pressure and
amount of acid released into the pulse changes
digestive tract
• Antacids to neutralize stomach
acid DIAGNOSTIC EVALUATION

• Upper GI Series – outlines ulcer or

area of inflammation.
Peptic Ulcer Disease: A lesion in the mucosa
of the lower esophagus, stomach, pylorus, • Endoscopy –
or deudenum esophagogastroduodenoscopy) –
visualizes duodenal mucosa and
CAUSATIVE FACTORS:
helps identify inflamm. changes,
lesions, bleeding sites, and
malignancy

• Gastric Secretory Studies – elevated

in Zollinger – Ellison syndrome

• H. pylori antibody titer – may be

positive, esp. in recurrent ulcers;
however, there is a high rate of
false – positive results; C – urea
breath test or biopsy testing is more
a. H. pylori definitive than H. pylori
b. NSAIDs use
c. Zollinger – Ellison Syndrome
d. Genetic factors POSSIBLE NURSING DIAGNOSES
e. Cigarette smoking, stress,
socioeconomic factors • Acute Pain
• Deficient Fluid Volume
• Deficient Knowledge
ASSESSMENT • Diarrhea
• Imbalanced nutrition: Less than
Abdominal pain body requirements

a. Occurs in the epigastric area

radiating to the back; described as
THERAPEUTIC INTERVENTIONS
dull, aching, and gnawing
b. Pain may increase when the
stomach is empty, at night, or
approx. 1 to 3 hours after eating.
Pain is relieved by taking antacids
(common in duodenal ulcers

Nausea, anorexia, early satiety (common

with gastric ulcers), belching • Diet therapy includes well –
balanced meals at regular
Dizziness, syncope, hematemesis, melena
intervals; avoid dietary irritants
with GI hemorrhage
• Eliminate cigarette smoking, which
a. Positive fecal occult blood decreases rate of healing and
increases rate of recurrence
 • Eliminate NSAIDs from diet and
reduce alcohol intake. Types of IBD
• Monitor the patient for signs of
bleeding through fecal occult
blood, vomiting, persistent diarrhea,
Crohn’s disease
and change in VS causes pain and Ulcerative colitis Microscopic
swelling in the causes swelling colitis causes
digestive tract. It can and sores
affect any part from intestinal
the mouth to the (ulcers) in the inflammation
PHARMACOLOGIC INTERVENTIONS anus. It
commonly affects the
most large intestine that’s only
small intestine and (colon and detectable with a
• Histamine - 2 (H2) receptor upper part of the rectum). microscope.
large intestine.
antagonists to reduce gastric acid
secretion
• Proton-pump inhibitor to help ulcer CAUSES OF IBD
heal quickly in 4 to 8 weeks
• Cytoprotective drug sucralfate, • Genetics: As many as 1 in 4 people
which protects ulcer surface with IBD have a family history of the
against acid, bile, pepsin disease.
• Antacids to reduce acid • Immune system response: The
concentration and help reduce immune system typically fights off
symptoms infections. In people with IBD, the
• Antibiotics immune system mistakes foods as
foreign substances. It releases
antibodies (proteins) to fight off this
SURGICAL INTERVENTIONS threat, causing IBD symptoms.

• Environmental triggers: People with

a family history of IBD may develop
the disease after exposure to an
environmental trigger. These
triggers include smoking, stress,
medication use and depression.

Crohn’s Disease
• Gastroduodenostomy (Bilroth I)
• Gastrojejunostomy (Bilroth II)
• Antrectomy
• Total gastrectomy
• Pyloroplasty
• Vagotomy

INFLAMMATORY BOWEL DISEASE:

Inflammatory bowel disease (IBD) is a A chronic transmural inflammation of the
group of disorders that cause chronic GI tract that usually affects the small and
inflammation (pain and swelling) in the large intestines, they can occur in any part
intestines. of the alimentary canal

IBD includes Crohn’s disease and

ulcerative colitis.
ASSESSMENT:
• Stool Analysis – (+) leukocytes but
1.Signs and symptoms are characterized by
no pathogen
exacerbations and remissions; onset may
• Barium Enema
be abrupt or insidious
• Upper GI Barium – shows classic
2. Crammpy intermittent pain “string sign”
• Colonoscopy
a.
b. Inflammatory pattern results in
milder abdominal pain, but with
SIGNS AND SYMPTOMS
malnutrition due to malabsorption
and weight loss, and possible
anemia (hypochromic or
macrocytic)
c. Fibrostenotic pattern may present
with partial small bowel obstruction:
diffuse abdominal pain, nausea, POSSIBLE NURSING DIAGNOSES
vomiting, and bloating
• Acute pain
d. Perforating pattern is characterized
• Anxiety
by sudden profuse diarrhea, fever,
• Diarrhea
localized tenderness, (due to
• Imbalanced nutrition: less than
abscess), and symptoms of fistulae,
requirements
such as pneumaturia and recurrent
• Risk for fluid volume deficit
urinary tract infections
THERAPEUTIC INTERVENTIONS
3. Abdominal tenderness occurs, especially
in the right lower quadrant; right lower • Diet low in residue fiber, and fat,
quadrant fullness or mass is palpable and high in calories, protein, and
carbohydrates, with vitamin
4. Chronic diarrhea caused by irritating
supplements (esp. vitamin K)
discharge; usual consistency is soft or
semiliquid. Bloody stools or steatorrhea • During exacerbation,
may occur. Fecal urgency and tenesmus hyperalimentation to maintain
occur. nutrition while allowing the bowel to
rest
5. Low – grade fever occurs if abscesses are
present • During remission, regular balanced
diet to maintain ideal body weight.
6. Arthralgia may also occur.
• Monitor frequency and consistency
of stools to evaluate volume losses
and effectiveness of therapy

• Monitor electrolytes, esp. K. monitor

I&O, acid-base balance

• Monitor for distention, increased

temp., hypotension, and rectal
bleeding; all signs of obstruction
DIAGNOSTIC EVALUATION
caused by inflammation.
• Increased WBC count and
sedimentation rate; decreased
Hgb; decreased albumin; and
possibly decreased K, Mg, and Ca
due to diarrhea
PHARMACOLOGIC INTERVENTIONS • Subtotal colectomy with ileorectal
anastomosis (spares the rectum)
• Total proctocolectomy with end
ileostomy for severe disease in the
colon and rectum

Ulcerative Colitis

A chronic
inflammatory
disease of the
mucosa, and
• 5 – aminosalicylic acid PO or by
less frequently,
enema or suppository
the submucosa
• Sulfasalazine PO to inhibit
of the colon
inflammatory processes (effective
and the
only for colonic disease)
rectum
• Corticosteriods to reduce
inflammation Usually begins
• Antibiotics such as metronidazole to in the rectum and sigmoid and spreads
treat infection and try to induce upward, eventually involving the entire
remission colon
• Immunomodulators
Multiple crypt abscesses develop in the
• Infliximab (a new monoclonal
mucosa, which may become necrotic and
antibody) blocks action of tumor
lead to ulceration.
necrosis factor
• Antispasmodics (dicyclomine) and Complications may include perforation,
bulking agents (psyllium) to help hemorrhage, toxic megacolon, abscess
reduce abdominal pain formation, stricture and obstruction, anal
• Antidiarrheal agents to control fistula, malnutrition, anemia, and
diarrhea related to malabsorption secondary colon cancer.
of bile salts

ASSESSMENT
SURGICAL INTERVENTIONS
1. Diarrhea is the prominent symptom; it
Indicated only for complications. Roughly may be bloody or contain pus or mucus.
70% of Crohn’s disease patients eventually Tenesmus (painful straining), urgency, and
require one or more operations for cramping may be associated with bowel
obstruction, fistulae, fissures, abscesses, movements
toxic megacolon or perforation
2. Crampy abdominal pain may be
Surgical options include: prominent and brought on by certain
foods or diary products

3. May be increased bowel sounds, and left

lower abdomen may be tender on
palpation

4. As the disease progresses, there may be

anorexia, nausea and vomiting, weight
• Segmental bowel resection with
loss, fever, dehydration, hypokalemia, and
anastomosis
cachexia
6. There may be associated systemic • Imbalanced nutrition: less than
manifestations such as arthritis, iritis, and body requirements
skin lesions. • Ineffective coping
• Risk for infection

DIAGNOSTIC EVALUATION
THERAPEUTIC INTERVENTIONS
1. Stool evaluation for
culture and ova and
parasite rules out other
causes of diarrhea.
Test for blood are
positive during active
disease

2. Blood tests may

show low hemoglobin
and hematocrit • During acute exacerbations, bed
caused by bleeding; rest, IV fluids containing potassium
increased WBC, and vitamins, and clear liquid diet
are indicated
erythrocyte sedimentation rate; decreased
K, Mg, and albumin levels • For severe dehydration and
excessive diarrhea, total parenteral
3. Proctosigmoidoscopy or colonoscopy
nutrition may be necessary to rest
with biopsy is necessary to confirm
the intestinal tract and restore
diagnosis
nitrogen balance.
4. Barium enema determines the extent of
• Monitor I&O, including liquid stools
disease and detects pseudopolyps,
carcinoma, and strictures • Monitor serum or fingerstick glucose
of the patient on corticosteroids or
hyperalimentation, and report
elevations.

SIGNS AND SYMPTOMS • Weigh patient daily; rapid increase

or decrease may relate to fluid
imbalance, slower change related
to nutritional status.

PHARMACOLOGIC INTERVENTIONS

• Iron supplements to treat anemia

from chronic bleeding; blood
replacement for massive bleeding
• Sulfasalazine is the mainstay drug
for acute and maintenance
therapy\
• If sulfasalazine is not tolerated, oral
POSSIBLE NURSING DIAGNOSES
salicylates such as mesalamine
• Acute pain appear to be as effective as
• Chronic pain sulfasalazine
• Deficient fluid volume
 • Mesalamine enema is available Malabsorption Syndrome
for proctosigmoiditis; suppository for
• A group of
proctitis
symptoms and
• Corticosteroids may be used IV
physical signs
orally or by enema to manage
resulting from poor
inflammatory disease and induce
nutrient absorption
remission.
in the small
• Antidiarrheal medications may
intestine,
be prescribed to control diarrhea,
especially of fats
rectal urgency and cramping, and
and fat soluble
abdominal pain; however, their use
vitamins A, D, E,
is not routine
and K.

• Poor absorption of other nutrients,

SURGICAL INTERVENTIONS including CHO, CHON, Minerals
may also occur.

• Multiple causes including

gallbladder or pancreatic disease,
lymphatic obstruction, vascular
impairment, or bowel resection

• Also known/associated with Celiac

Disease

Celiac Disease

ASSESSMENT
Surgery is recommended when patient fails Ages 3 to 9 months
to respond to medical therapy, if clinical
status is worsening, for severe hemorrhage, • Acutely ill; severe diarrhea and
or for signs of toxic megacolon. vomiting
Noncurative procedures (possible curative • Irritability
procedure and reconstruction later • Possible failure to thrive
include: Ages 9 to 18 months
a. Temporary loop colostomy for • Slackening of weigh followed by
decompression of toxic megacolon weight loss
b. Colectomy with ileorectal • Abnormal stools
anastomosis o Pale, soft, bulky
Curative surgery aims to remove entire o Offensive color
colon and rectum to cure patient of o Greasy (steatorrhea)
ulcerative colitis. Procedures include: o May increase in number
• Abdominal distention
a. Total proctocolectomy with end- • Anorexia, discoloration of teeth
ileostomy • Muscle wasting: most obvious in
b. Total proctocolectomy with buttocks and proximal parts of
continent ileostomy extremities
c. Total colectomy with ileal reservoir – • Hypotonia, seizure
anal anastomosis • Mood changes: ill humor, irritability,
temper tantrums, shyness
• Mild clubbing of fingers
• Vomiting: usually occurs in evening
 • Aphthous ulcers, dermatitis
Lymphatic Lymphangiectasia,
Older Child and Adult Obstruction Whipple Disease,
Signs and symptoms are commonly related Lymphoma,
Chylous ascites
to nutritional or secondary deficiencies
resulting from disease
Others
• Anemia, vitamin deficiency (A, D, E,
Drugs Antibiotics,
K)
antimetabolites,
• Hypoproteinemia with edema
neomycin,
• Hypocalcemia, hypokalemia, laxatives
hypomagnesemia Collagen Vascular Scleroderma
• Hypoprothrombinemia from vitamin Infestations Hookworms,
K deficiency tapeworm,
• Disaccharide (sugar intolerance) giardiasis, immune
• Osteoporosis due to calcium defects
deficiency

Anorexia, fatigue, weight loss DIAGNOSTIC EVALUATION

May have colicky abdominal pain, 1. Small – bowel biopsy, which

distention, flatulence, constipation, and demonstrates characteristic abnormal
steatorrhea (bulky, greasy, pale stools) mucosa

Reduced Digestion • Severely damaged or flat, villous

Pancreatic Cystic fibrosis, lesions
Exocrine pancreatitis, • Histologic recovery after gluten
Deficiency Schwachman elimination
syndrome • Histologic recurrence of villous injury
Bile salt deficiency Cholestasis, biliary within 2 years of gluten
atresia, hepatitis, reintroduction
cirrhosis, bacterial
deconjugation 2. Hemoglobin, folic acid, and vit K levels
Enzyme Defects Lactase, sucrase, may be reduced
enterokinase,
lipase deficiencies 3. Prothrombin time may be prolonged

4. Elevated IgA endomysium antibodies

Reduced Absorption and IgA anti-tissue transglutaminase
Primary Glucose – galactose antibodies
absorption malabsorption,
defects abetalipoproteinemia, 5. Total protein and albumin may be
cystinuria, Hartnup decreased
disease
6. 72 hour stool collection for fecal fat is
Decreased Crohn’s disease,
increased
mucosal malnutrition, short
surface area bowel syndrome, 7. D-xylose absorption test – decreased
antimetabolite blood and urine levels
chemotherapy,
familial villous atrophy 8. Sweat test and pancreatic function
Small intestinal Celiac disease, studies may be done to rule out cystic
disease tropical sprue, fibrosis
giardiasis, immune or
allergic enteritis,
Crohn’s disease,
Lymphoma, AIDS
POSSIBLE NURSING DIAGNOSES 2. Pancreatic enzymes are
given for pancreatic insufficiency (cystic
• Acute pain
fibrosis, pancreatitis)
• Deficient fluid volume
• Imbalanced nutrition: less
than body requirements
Intestinal Obstruction
• Readiness for enhanced
knowledge Mechanical Obstruction
• Risk for impaired skin integrity
• Risk for infection

THERAPEUTIC INTERVENTIONS

A physical blockage to the passage of

intestinal contents.

May result from postsurgical adhesions,

hernia, volvulus, hematoma, tumor,
intussusception, stricture, stenosis, foreign
body, fecal or barium impaction, or polyp
1. Dietary modifications include a lifelong
gluten – free diet, avoiding all foods
containing wheat, rye, barley, and possibly Functional Obstruction:
oats
• Also
• Biopsy reverts to normal when with known as
appropriate diet Paralytic
• Clinical signs of improvement ileus
should be seen 1 to 4 weeks after
proper diet is initiated Involves no
physical
2. In some cases, fats may be reduced obstruction
3. Lactose and sucrose may be eliminated Peristalsis is
from diet for 6 to 8 weeks, based on ineffective,
reduced disaccharidase activity blood
supply is
not interrupted, and the condition usually
PHARMACOLOGIC INTERVENTIONS disappears spontaneously after 2 to 3 days

1. Supplemental vitamins and minerals

• Folic acid for 1 to 2 months CAUSES

• Vitamins A and D because of
spinal cord injuries, vertebral fractures,
decreased absorption
peritonitis, pneumonia, GI or abdominal
• Iron as needed for anemia
surgeries, wound dehiscence
• Vitamin K if there is evidence of
hypoprothrombinemia and
bleeding
• Calcium if milk is restricted
ASSESSMENT 1. Abdominal Xrays show intestinal gas or
fluid
• Crampy abdominal pain that may
occur in waves (colic) 2. Barium enema shows a distended, air
• No bowel movements; however, filled colon or a closed sigmoid loop
blood or mucus may be passed
3. Decreased serum sodium, potassium,
• Vomiting, first of stomach contents,
and chloride levels because of vomiting;
then bilious, finally containing fecal
elevated white blood cell counts with
matter (if obstruction of ileum or
necrosis, strangulation, or peritonitis; and
distal)
increased serum amylase levels from
• Abdominal distention
irritation of the pancreas by the bowel
Signs of dehydration – malaise, thirst, dry loop.
mucus membrane
4. Arterial blood gas analysis may indicate
Signs and symptoms of large bowel metabolic acidosis or alkalosis
obstruction develop more slowly with
5. Flexible sigmoidoscopy or colonoscopy
constipation being prominent
may be done to identify cause.
Signs of shock – pallor, hypertension,
tachycardia, reduced level of
consciousness POSSIBLE NURSING DIAGNOSES
Pediatic Alert: Episodes of severe • Acute pain
abdominal pain combined with vomiting in • Anxiety
the infant suggest intussusception. • Constipation
• Deficient fluid volume
Gerontological Alert: Watch for air – fluid
• Ineffective breathing pattern
lock syndrome in elderly patients, who
• Risk for infection
often remain in the recumbent position for
• Risk for injury
extended periods. In this syndrome, fluid
collects in dependent bowel loops, and
peristalsis is too weak to push fluid “uphill”.
The obstruction primarily occurs in the large THERAPEUTIC INTERVENTIONS
bowel. Turn the patient every 10 minutes 1. Correct fluid and electrolyte imbalances:
until enough flatus is passed to decompress
the abdomen. A rectal tube may help. • Na, K, blood component therapy
• Normal saline or Ringer’s lactose to
correct interstitial fluid deficit
DIAGNOSTIC EVALUATION 2. Nasogastric decompression of GI tract to
reduce gastric secretions; nasointestinal
tubes such as Cantor or Miller Abbott may
also be used

3. Treatment for shoch and peritonitis with

IV fluids, vasopressors, or antibiotics

4. Hyperalimentation to correct protein

deficiency from chronic obstruction,
paralytic ileus, or infection

5. Ambulation to try to induce peristalsis in

a patient with paralytic ileus.
SURGICAL INTERVENTIONS

1. Bowel resection with end to end

anastomosis

2. Closed bowel procedure such as lysis of

adhesions or reduction of volvulus

3. Double – barrel ostomy if end to end

anastomosis too risky

4. Loop colostomy to divert fecal stream

and decompress bowel, with bowel
resection to be done as second
procedure.