Gastrointestinal System: Chapter Eighteen

CHAPTER EIGHTEEN
Gastrointestinal System
PHYSIOLOGY OF THE 4. Previous problems associated with GI tract, including

GASTROINTESTINAL SYSTEM gastritis, hepatitis, colitis, gallbladder disease, peptic
or duodenal ulcer, hernia, and hemorrhoids.
Digestion, Absorption, and Elimination 5. Unexplained or unplanned weight gain or loss.
Process 6. Medication history, including over-the-counter
A. Digestion: physical and chemical breakdown of food. (OTC) and prescription drugs.
1. Length of time food remains in stomach depends on 7. Previous surgeries related to GI system.
type of food, gastric motility, and psychologic factors; B. Assess vital signs for client’s overall status.
average time is 3 to 4 hours. C. Assess for presence and characteristics of abdominal
2. The pH of the stomach is acidic, which promotes pain.
production of pepsin to begin the initial breakdown D. Assess client’s mouth.
of proteins. 1. Presence of adequate saliva, condition of teeth and
3. Chyme (food mixed with gastric secretions) moves tongue.
through the pylorus into the small intestine. 2. Presence of the gag reflex.
4. Intestinal digestive enzymes are released from the villi 3. Presence of oral lesions.
in the small intestine. E. Evaluate the abdomen (client should be lying flat).
B. Absorption: transfer of food products into circula- 1. Inspect: divide the abdomen into four quadrants and
tion. perform visual inspection for contour, scars, masses,
1. Occurs in small intestine, where villi provide absorp- and movement (aortic pulsation may be visible).
tive surface area; minimal amount of nutrients are Figure 18-1 shows anatomic divisions of the abdomen.
absorbed in the stomach. 2. Auscultate: each quadrant should be auscultated for
2. Carbohydrates are broken down into monosaccha- bowel sounds.
rides, fats to glycerol and fatty acids, and proteins to a. Bowel sounds are considered absent if no sound is
amino acids; all are absorbed through the villi of the heard for 5 minutes in any one quadrant.
small intestine. b. Normally, soft gurgles should be heard every 5 to
3. Intrinsic factor is secreted in the stomach and pro- 20 seconds.
motes absorption of vitamin B12 (cobalamin) in the c. Borborygmi: loud, gurgling bowel sounds; may
small intestine. precede diarrhea.
4. Presence of chyme in small intestine stimulates
contraction of the gallbladder and relaxation of the ALERT To determine characteristics of bowel sounds, note
sphincter of Oddi; this process releases bile for diges- presence in each quadrant, as well as frequency and pitch.
tion of fats.
C. Elimination: excretion of waste products. 3. Percussion: purpose is to determine presence of fluid,
1. Large intestine absorbs water and electrolytes and distention and/or masses.
forms feces. a. Tympany is a high-pitched hollow sound com-
2. Serves as a reservoir for fecal mass until defecation monly heard over areas distended with air.
occurs. b. Dullness is a short high-pitched sound with little
resonance; heard over fluid or solid masses.
System Assessment 4. Palpation: purpose is to determine areas of tender-
A. Evaluate client’s history. ness, resistance, and swelling; deep palpation is used
1. Dietary and bowel habits. to identify organs and possible masses.
2. Nausea, vomiting, diarrhea, indigestion, constipation, a. Begin with light palpation of each quadrant;
flatulence: precipitating and alleviating factors. observe facial expression for any area of discomfort
3. Pain related to gastrointestinal (GI) tract. and/or guarding.
355
356 CHAPTER 18 Gastrointestinal System
RUQ LUQ
4 1 7
5 2 8
RLQ LLQ 6 3 9
FIGURE 18-1 Anatomic Divisions of the Abdomen. Left, Abdomen divided into four quadrants. Right, Abdomen divided into nine topographic regions:
1, epigastrium; 2, umbilical; 3, suprapubic; 4, right hypochondrium; 5, right lumbar or flank; 6, right inguinal or iliac; 7, left hypochondrium; 8, left
lumbar or flank; 9, left inguinal or mac. (From Monahan FD et al: Phipps’ medical-surgical nursing: health and illness perspectives, ed 8, St. Louis,
2007, Mosby.)
b. Begin in area of least discomfort; if there is a

Box 18-1 OLDER ADULT CARE FOCUS
problem area, palpate it last.
c. Check for rebound tenderness by pressing two Changes in Gastrointestinal System Related
fingers firmly over painful site and withdraw them to Aging
rapidly; pain occurs on release of pressure.
• Decreased hydrochloric acid and decreased absorption of
F. Assess rectal area for lesions, hemorrhoids, or
vitamins; encourage frequent small feedings that are high in
ulcerations. vitamins.
G. Evaluate elimination patterns and effects of aging on GI • Decreased peristalsis and decreased sensation to defecate;
tract (Box 18-1). encourage diet high in fiber and minimum of 2000 mL of
H. Evaluate dietary pattern and fluid intake. fluid daily; encourage physical activity.
I. Assess stool specimen. • Decreased lipase from pancreas to aid in fat digestion;
1. Color, consistency, odor. encourage smaller meals because diarrhea may be caused by
2. Presence of blood or mucus. increased fat intake.
• Decreased liver activity with decreased production of
DISORDERS OF THE GASTROINTESTINAL enzymes for drug metabolism, tendency toward accumula-
(GI) SYSTEM tion of medications; instruct clients not to double up on their
medications, especially cardiac medications.
Nausea and Vomiting
Nausea is an unpleasant feeling that vomiting is
imminent. Vomiting is an involuntary act in which 2. Iatrogenic: resulting from a disease treatment.
the stomach contracts and forcefully expels gastric a. Chemotherapy/radiation.
contents. b. Medications.
A. Loss of fluid and electrolytes is the primary consequence c. Surgery (postoperative complication).
of repeated vomiting; the very young and the older 3. Pregnancy: vomiting most often occurs in the
adult are more susceptible to complications of fluid morning.
imbalances. 4. Vomiting in children is common.
B. Prolonged vomiting will precipitate a metabolic problem. 5. Further investigation and intervention is needed for
1. Metabolic alkalosis is associated with prolonged vom- progressively severe vomiting, persistent vomiting
iting and loss of hydrochloric acid. over 24 hours, and/or symptoms of dehydration.
2. Metabolic acidosis occurs with severe prolonged vom-
iting of contents of the small intestine, resulting in ALERT Monitor client’s hydration status; modify client’s care
loss of bicarbonate. based on results of diagnostic tests.
Assessment B. Assessment.
A. Precipitating causes. 1. Identify precipitating cause.
1. Pathogenic: related to a disease process (GI obstruc- 2. Assess frequency of vomiting, amount of vomiting,
tion, toxic substances, etc.). and contents of vomitus.
CHAPTER 18 Gastrointestinal System 357
3. Hematemesis: presence of blood in vomitus.

a. Bright red blood is indicative of bleeding. Constipation
b. Coffee-ground material is indicative of blood Constipation exists when there is a decrease in frequency
retained in the stomach; the digestive process has of bowel movements; stool is hard and difficult to pass,
broken down the hemoglobin. and there is less than one bowel movement every 3 days.
4. Projectile vomiting: vomiting not preceded by nausea
in which vomitus is expelled with excessive force. Assessment
5. Presence of fecal odor and bile in vomitus indicates a A. Precipitating causes.
backflow of intestinal contents into stomach. 1. Decreased fiber and fluid intake.
6. Vomiting in children is usually self-limiting; assess for 2. Immobility, inadequate exercise.
fever, diarrhea, and abdominal pain accompanying 3. Medications: narcotics, antidepressants, iron supple-
nausea and vomiting. ments, anticonvulsants.
C. Diagnostics: clinical manifestations. 4. Older adult client.
5. Overuse of laxatives.
Treatment 6. Ignoring the urge to defecate.
A. Eliminate the precipitating cause. 7. Diverticulosis, tumors, intestinal obstructions.
B. Antiemetics (see Appendix 18-2).
C. Parenteral replacement of fluid if loss is excessive
(Chapter 6). ALERT Evaluate client’s use of home remedies and OTC drugs.
Assess what the client is using to treat constipation; frequently,
the older adult client is using harsh laxatives.
Nursing Interventions
Goal: To prevent recurrence of nausea and vomiting and
ensuing complications. B. Clinical manifestations.
A. Prophylactic antiemetics for the client with a tendency 1. Abdominal distention.
to vomit. 2. Decrease in the amount of stool.
B. Prompt removal of unpleasant odors, used emesis con- 3. Dry, hard stool; straining to pass stool.
tainer, and soiled linens. 4. Impaction.
C. Good oral hygiene. a. Constipation, rectal discomfort.
D. Place conscious client on side or in semi-Fowler’s b. Anorexia, nausea, vomiting.
position; place unconscious client on side with head c. Diarrhea around impacted stool.
of bed slightly elevated to promote drainage of oral C. Diagnostics: clinical manifestations.
cavity.
E. Withhold food and beverages initially after vomiting; Treatment
begin oral intake slowly—for adults, begin with tea, A. Change dietary intake: increase intake of high-fiber
water, or oral rehydrating solutions at room temperature; foods and fluids.
for infants and children, begin with oral rehydrating B. Bulk laxatives, stool softeners, or enemas for occasional
solutions. constipation problem (see Appendix 18-3).
F. Assess surgical client for presence of bowel sounds and C. Instruct client to maintain normal bowel schedule and
distention; do not begin oral administration of fluids if not to ignore urge to defecate.
abdomen is tender or distended or no bowel sounds are D. Discourage long-term use of laxatives and enemas.
present. E. Encourage regular exercise.
G. Support abdominal and thoracic incisions during
vomiting. Nursing Interventions
ALERT Identify client potential for aspiration; intervene to ALERT Assess and intervene when client has a problem with
prevent aspiration. elimination.
Goal: To relieve nausea and vomiting. Goal: To identify client at risk for developing constipation
A. Administer antiemetics. and institute preventive measures (Box 18-2).
B. Evaluate precipitating causes; relieve if possible. Goal: To implement treatment measures for fecal impac-
C. Gastric decompression with a nasogastric tube may be tion removal.
used for prolonged vomiting. A. An impaction may be present if client has had no bowel
Goal: To assess client’s response to prolonged vomiting. movement for 3 days or has passed only small amounts
A. Monitor fluid and electrolyte status (Chapter 6). of semisoft or liquid stool.
B. Assess for continued presence of gastric distention. B. Steps in removing impaction:
C. Assess for adequate hydration. 1. Manually check for presence of impaction with non-
D. Assess for presence of other symptoms. sterile, lubricated gloved finger.
3. Medications (antibiotics and antacids).

Box 18-2 OLDER ADULT CARE FOCUS
4. Food intolerance (lactose intolerance) or allergies to
Preventing Fecal Impaction certain foods.
5. Malabsorption problems: celiac disease and cystic
• Increase intake of high-fiber foods: raw vegetables, whole- fibrosis.
grain breads and cereals, fresh fruits.
B. Clinical manifestations.
• Increase fluid intake.
• Maintain regular activity: daily walking, swimming,
1. Frequent, loose, watery bowel movements; sense of
or biking. If confined to wheelchair, change position urgency.
frequently, perform leg raises and abdominal muscle 2. Stools may contain undigested food, mucus, pus, or
contractions. blood; frequently are foul smelling.
• Discourage use of laxatives and enemas: client may become 3. Abdominal bloating, cramping, distention, and vom-
dependent on them. If absolutely necessary, warm mineral iting frequently occur with diarrhea.
oil enemas may soften and lubricate stool. 4. Hyperactive bowel sounds.
• Encourage use of bulk-forming products to provide increased 5. May precipitate dehydration, hypokalemia, and
fiber (methylcellulose, psyllium). hypovolemia, progressing to shock.
• Encourage bowel movement at same time each day. C. Diagnostics: stool examination; enzyme immunoassay
• Try to position client on bedside commode rather than on
(EIA) for rotavirus.
a bedpan.
• If client is experiencing diarrhea, check to see if stool is
Treatment
oozing around an impaction.
A. Identify and treat the underlying problem.
B. Decrease activity and irritation of the GI tract by
decreasing intake.
2. Gently attempt to break up impaction using a scissor C. Parenteral replacement of fluids and electrolytes, if diar-
motion with the fingers. rhea is severe.
3. Emphasis is on prevention of impaction (see Box D. Do not administer antidiarrheal medications if causative
18-2). agent is bacterial or parasitic. Antidiarrheals prevent
client from purging the bacteria or parasite and traps the
causative organism(s) in the intestines and prolongs the
NURSING PRIORITY Monitor client’s heart rate during and problem (Appendix 18-4).
after digital removal of feces; vagal stimulation can precipitate E. Viral infections are either treated with medication or left
bradycardia. to run their course, depending on the severity and type
of virus.
F. Rotavirus vaccine (RotaTeq) should not be given to
Diarrhea severely immunocompromised infants.
Diarrhea is the rapid movement of intestinal contents
through the small bowel. Nursing Interventions
A. Significant increase in number of stools, along with an Goal: To decrease diarrhea and prevent complications.
increase in looseness of stool. A. Identify precipitating causes and eliminate, if possible.
B. Infants and older adults are most susceptible to compli- B. Offer soft, easily digestible food; does not have to be
cations of dehydration and hypovolemia. clear liquids.
C. Acute diarrhea is most often caused by an infection and C. Fluid and electrolyte replacement.
is self-limiting when all causative agents or irritants have 1. Administer oral rehydrating solutions (ORSs); prog-
been evacuated. ress fluids and diet as tolerated.
D. Rotavirus is the most common pathogen in young chil- 2. Frequently offer ORSs in small amounts at room
dren hospitalized for treatment of diarrhea. temperature; do not offer high-carbohydrate fluids
1. Affects all age groups and is most common in cool (juices), carbonated fluids, broth, or sports drinks.
weather. 3. Nausea and vomiting are not contraindications to
2. Incubation period is 48 hours. offering ORSs.
3. Important source of nosocomial infections in D. Maintain good hygiene in the rectal area to prevent skin
hospital. excoriation.
4. Children 6 to 24 months old are at increased risk for Goal: To evaluate client’s response to diarrhea.
complications. A. Evaluate changes in vital signs correlating with fluid loss
and hydration status (Chapter 6).
Assessment B. Evaluate electrolyte changes and urine specific gravity.
A. Precipitating causes. C. Record intake and output and daily weight if diarrhea is
1. Bacteria (Escherichia coli, Salmonella), viruses (rotavi- progressive.
rus), and parasites (Giardia lamblia). D. Inspect abdomen for distention, auscultate for bowel
2. Food poisoning (frequently, infection by bacteria). sounds, and palpate for areas of tenderness.
Goal: To prevent spread of diarrhea. Assessment

A. Good hand hygiene. A. Risk factors.
B. Initiate contact precautions (Appendix 6-8). 1. Lifestyle factors: obesity; smoking; excess alcohol
1. Proper disposal of diapers and soiled linens close to intake; consumption of high-fat or acidic foods;
bedside. eating large meals; consumption of caffeine and car-
2. Instruct family regarding hand hygiene techniques. bonated beverages; stress.
3. Maintain separate clean and dirty areas in the room; 2. Pathologic predisposing factors: PUD, asthma, cystic
keep bedpans, soiled linens, and soiled diapers away fibrosis, cancer.
from clean areas. 3. Medications decreasing LES pressure: calcium
C. Instruct parents regarding importance of hand hygiene channel blockers, nitrates, anticholinergics.
and how to care for infant or child at home. 4. Anatomic factors: eating heavy meal before lying
down, strenuous exercise after eating, scoliosis, poor
esophageal sphincter tone, consuming an excessive
NURSING PRIORITY Consider acute onset diarrhea as amount of food and beverage.
infectious until the cause is determined. 5. Clients with prolonged chronic GERD are at
increased risk for cancer.
B. Clinical manifestations.
1. Reflux esophagitis (heartburn, dyspepsia).
Gastroesophageal Reflux Disease 2. Increased pain after meals; may be relieved by
Gastroesophageal reflux disease (GERD) is caused by antacids.
the backward flow or reflux of gastric contents into the 3. Activities that increase intraabdominal pressure
esophagus (esophageal reflux). Amount of damage increase esophageal discomfort.
depends on the amount and composition of gastric con- 4. Pain may radiate to back and neck.
tents, as well as the ability of the esophagus to remove the 5. Regurgitation not associated with belching or
acidic fluids. nausea.
A. Gastric contents are able to move from area of increased C. Complications.
pressure (stomach) to area of lower pressure (esophagus) 1. Aspiration of gastric contents: pneumonia, chronic
through the malfunctioning lower esophageal sphincter bronchitis.
(LES), reflux occurs, and the esophagus is exposed to 2. Dental erosion.
acid (Figure 18-2). D. Diagnostics: 24-hour pH monitoring, esophageal
B. The acid breaks down the esophageal mucosa, and an manometry, esophagoscopy (Appendix 18-1).
inflammatory response is initiated.
C. Hiatal hernia: a herniation of a portion of the stomach Treatment
into the esophagus; frequently presents with same symp- A. Medical.
toms as GERD; clinical course and management are 1. Diet therapy: avoid intake of fatty foods; eat small,
the same. frequent meals; try chewing gum after and between
meals.
2. Avoid wine and other alcoholic beverages, caffeinated
drinks, chocolate.
3. Medications: histamine-2 receptor antagonists (H2R
blockers), proton pump inhibitors (PPIs) (Appendix
18-5), and GI stimulants or promotility drugs
(Appendix 18-2).
B. Surgical: fundoplication or antireflux surgery.
Impaired C. Endoscopic intervention at lower esophagus and gastro-
esophageal Defective
motility mucosal
esophageal sphincter (fundoplication, radiofrequency,
defense sclerosing agents).
Delayed LES Nursing Interventions

gastric dysfunction
emptying Goal: To decrease esophageal reflux.
A. Avoid drinking beverages during meals, including
alcohol and carbonated beverages.
Reflux of B. Avoid temperature extremes in foods.
gastric
contents C. Avoid drinking fluids 3 hours before bedtime.
FIGURE 18-2 Factors involved in the pathogenesis of gastroesopha- D. Elevate the head of the bed on 6- to 8-inch blocks.
geal reflux disease (GERD) (From Lewis SL et al: Medical-surgical E. If overweight, lose weight to decrease abdominal pres-
nursing: assessment and management of clinical problems, ed 7, St. sure gradient.
Louis, 2007, Mosby.) F. Avoid tobacco, NSAIDs, and salicylates.
G. Decrease intake of highly seasoned foods and tomato

products.
H. Eat small, frequent meals (up to 5 per day at 3-hour Esophageal Esophageal
intervals) to prevent gastric dilation. cancer varices
I. Avoid any food that precipitates discomfort (fats,
caffeine, chocolate, nicotine will decrease esophageal
sphincter tone).
J. Do not lie down for 2 to 3 hours after eating.
Gastritis
Gastritis is an inflammation and breakdown of the normal
gastric mucosa barrier.
A. Acute gastritis is generally self-limiting with no residual
damage. Duodenal Gastritis
B. May be chronic or acute, diffuse or localized. ulcer Gastric
ulcer
Assessment Gastric
cancer
A. Risk factors/etiology.
1. Often caused by dietary indiscretion (gastric irritants:
FIGURE 18-3 Common causes of gastrointestinal bleeding. (From
coffee, aspirin, alcohol). Ignatavicius DD, Workman ML: Medical-surgical nursing: patient-
2. Smoking or exposure to radiation, psychologic centered collaborative care, ed 6, Philadelphia, 2010, Saunders.)
stress.
3. Microorganisms: Helicobacter pylori, contaminated
foods (Staphylococcus or Salmonella organisms).
4. Medications causing gastric irritation (aspirin, corti- Treatment
costeroids, chemotherapy). A. Eliminate cause.
5. Prolonged alcohol abuse, binge drinking. B. Medical management.
6. Acute gastritis is a common problem in intensive care 1. Antiemetics, antacids, PPIs and H2R blockers
units because of stress. Clients with burns, uremia, (Appendix 18-5).
sepsis, shock, mechanical ventilation, or multiorgan 2. Treatment for H. pylori with antibiotics and PPIs.
dysfunction who are not receiving enteral feeding are C. Surgical intervention, if medical treatment fails or hem-
at significantly increased risk. orrhage occurs.
Goal: To decrease gastric irritation.
NURSING PRIORITY Best practice for the prevention A. Nothing by mouth (NPO status) initially, with IV fluid
of gastritis in clients who are ventilator dependent is and electrolyte replacement.
the routine administration of antiulcerative medication
B. Plan of care for nausea and vomiting.
(Appendix 18-5).
C. Begin ORSs as client tolerates them.
Goal: To monitor fluid status and prevent dehydration
(Chapter 6).
B. Clinical manifestations (may be asymptomatic). Goal: To assist client to identify and avoid precipitating
1. Epigastric tenderness. causes.
2. Anorexia, nausea, vomiting.
3. Chronic gastritis: frequently caused by the Helico-
bacter pylori. Gastroenteritis
a. May precipitate pernicious anemia. Gastroenteritis is the irritation and inflammation of the
b. Associated with peptic ulcer disease. mucosa of the stomach and small bowel.
C. Diagnostics (Appendix 18-1).
1. Endoscopy with biopsy to rule out gastric Assessment
carcinoma. A. Risk factors/etiology.
2. Stool examination for occult blood. 1. Equal incidence in men and women but more severe
3. Gastric analysis for decreased acid production in infants and older adults.
(achlorhydria). 2. Salmonella: fecal oral transmission by direct contact
4. Serum, stool, and gastric biopsy for H. pylori. or via contaminated food.
D. Complications. 3. Staphylococcal: transmission via foods that were
1. Ulceration and hemorrhaging (Figure 18-3). handled by contaminated carrier.
2. Cancer of the stomach. 4. Dysentery: E. coli and Shigella.
B. Clinical manifestations. 3. Combination of restrictive and malabsorptive surgery:

1. Abdominal cramping, distention, and pain. the stomach is decreased in size with formation of a
2. Nausea, vomiting, and diarrhea. gastric pouch that empties directly into the jejunum;
3. Anorexia, fever and chills. greatest loss of weight is usually achieved over the first
C. Diagnostics: stool culture. year.
Treatment Nursing Interventions

A. Nothing by mouth until nausea subsides. Goal: To prepare client for surgery (Chapter 3).
B. Rehydrate with water and ORSs. A. Discuss the importance of early ambulation to reduce
C. Client resumes eating with bland, easily digestible foods. complications.
D. Appropriate medication for causative agents. B. Length of time in hospital depends on procedure.
C. Dietary changes.
Nursing Interventions Goal: To maintain homeostasis postoperatively (Chapter 3).
See Nursing Interventions section under Nausea and A. Immediately postoperative airway may be a problem;
Vomiting. maintain good pulmonary hygiene; positive end expira-
tory pressure (PEEP) and or ventilator support may be
necessary.
Obesity B. Increased risks for thromboembolic problems: sequential
An imbalance between energy expenditure and caloric compression stockings, encourage early ambulation and
intake that results in an abnormal increase in fat cells. administer thromboprophylaxis with low-molecular-
A. According to the CDC, 65% of people in the United weight heparin.
States over age 20 are obese. C. Do not adjust an NG tube, and do not insert NG tube
B. Children are considered overweight if their weight is in even if there is protocol to do so for nausea and vomiting;
the 95th percentile or higher for their age, gender, and notify surgeon.
height on the growth chart. D. Observe client for development of anastomotic leaks:
C. Classified according to the body mass index (BMI); see increasing back, shoulder and or abdominal pain, unex-
Chapter 2. plained tachycardia or decrease urine output; notify
surgeon of these findings.
Assessment E. May use abdominal binder to protect incision.
A. Risk factors. F. In client with diabetes, assess for fluctuations in serum
1. Genetic predisposition. blood glucose; may require less antihypoglycemics.
2. Sedentary lifestyle: energy intake (food) exceeds G. Client with malabsorption surgery may experience
energy expenditure. dumping syndrome (Box 18-3).
3. Sociocultural: environment conducive to excessive
caloric intake. Home Care
4. Obesity puts client at increased risk for cardiovascu- A. Diet.
lar, respiratory, and musculoskeletal problems, as well 1. Eat at least 3 meals a day; chew food completely.
as increased risk for development of diabetes. 2. Drink fluids throughout the day, but do not drink
B. Clinical manifestations. fluids with meals.
1. A BMI of 25 to 29.9 kg/m2 is considered overweight. 3. Avoid high-calorie, high-sugar, and high-fat foods.
2. A BMI of over 30 kg/m2 is considered obese. 4. Stop eating when you feel full.
3. Android obesity: fat is distributed over the abdomen 5. Try to get 50 to 60 g of protein daily; may need to
and upper body (apple-shaped). take a protein supplement.
4. Gynecoid obesity: fat is distributed over the upper 6. Learn how to avoid dumping syndrome (see Box
legs (pear-shaped). 18-3).
5. Android obesity is considered to be a higher risk for B. Take a chewable or liquid multivitamin with iron.
obesity-related problems, especially elevated triglyc- C. Can expect to lose 50% to 70% of excess body weight
eride and lipid levels as well as the development of over 5 years.
type 2 diabetes. D. For women, do not try to get pregnant for about 18
months after surgery.
Treatment E. Join a support group for long-term psychosocial
A. Lifestyle changes and modification of dietary intake. implications.
B. Bariatric surgery.
1. Laproscopic adjustable-banded gastroplasty (LABG)
involves placing a band around the fundus of the Peptic Ulcer Disease
stomach; band may or may not be inflatable. Peptic ulcer disease (PUD) is an erosion of the GI mucosa
2. Malabsorptive: Roux-en-Y bypass (REG) or gastric by hydrochloric acid and pepsin. Any location in the GI
bypass involves bypassing segments of small intestine tract that comes in contact with gastric secretions is sus-
so less food is absorbed. ceptible to ulcer development.
Box 18-3 DUMPING SYNDROME
Cardia
Condition occurs when a large bolus of gastric chyme and
hypertonic fluid enter the intestine.
Goal: To assess for symptoms of condition.
• Weakness, dizziness, tachycardia. Fundus
• Epigastric fullness, abdominal cramping, hyperactive bowel
sounds.
• Diaphoresis. Gastric
Lesser ulcer Greater
• Generally occurs within 15 to 30 minutes after eating. curvature
curvature
• Usually self-limiting and resolves in about 6 to 12 months.
Goal: To prevent dumping syndrome. Pyloric Body
• Decrease amount of food eaten at one meal; eat small meals sphincter
at 3-hour intervals.
• Decrease simple carbohydrates; increase proteins and high-
fiber foods as tolerated.
• No added fluid with meal; fluids can be taken 30 to 45
minutes before meals or 1 hour after meals. Antrum
Duodenal
• Decrease concentrated sweets; add fruits high in pectin to ulcer
diet (peaches, plums, apples) to slow carbohydrate absorp- FIGURE 18-4 The most common sites for peptic ulcers. (From Ignata-
tion in small intestine. vicius DD, Workman ML: Medical-surgical nursing: patient-centered col-
• Position client in semi-recumbent position during meals; laborative care, ed 6, Philadelphia, 2010, Saunders.)
client may lie down on the left side for 20 to 30 minutes
after meals to delay stomach emptying.
• Hypoglycemia may occur 2 to 3 hours after eating, caused symptoms may overlap from one type of ulcer to
by rapid entry of carbohydrates into jejunum. another.
(1) Gastric ulcers: pain is high in epigastric area;
ALERT Implement measures to improve client’s nutritional occurs 1 to 2 hours after eating.
intake. Prevent dumping syndrome and/or care for client (2) Duodenal ulcers: pain is in midepigastric area,
experiencing dumping syndrome.
just below the xiphoid process, or in the back;
occurs 2 to 4 hours after eating and is relieved
by antacids or eating.
A. Types of peptic ulcers (Figure 18-4).
1. Duodenal (most common).
2. Gastric. NURSING PRIORITY Be careful to avoid confusing ulcer
3. Physiologic stress ulcers. pain and indigestion with angina; do not administer antacids
B. Histamine release occurs with the erosion of the gastric to cardiac clients complaining of midepigastric distress or
mucosa in both duodenal and gastric ulcers. This results “heartburn.”
in vasodilation and increased capillary permeability,
which further stimulates the secretion of gastric acid and
pepsin. The continued erosion will eventually damage Diagnostics
the blood vessels, leading to hemorrhage or erosion A. Helicobacter pylori: breath test; serum and stool analysis;
through gastric mucosa. differentiation is made between colonization and
C. Characteristics. infection.
1. Risk factors. B. Gastric analysis with possible biopsy.
a. Helicobacter pylori: most common factor in both
types of ulcers. Treatment
b. Medications: aspirin, NSAIDs, corticosteroids, A. Medications (see Appendix 18-5).
reserpine. 1. Medications to eliminate H. pylori bacteria.
c. Alcohol abuse, smoking. a. Metronidazole (Flagyl).
d. Chronic gastritis. b. Omeprazole (Prilosec).
e. Hot, rough, or spicy foods are not a factor. c. Clarithromycin (Biaxin), amoxicillin, tetracycline.
f. Duodenal ulcers are associated with high secretion 2. Antacids.
of HCL acid. 3. Histamine-2 receptor (H2R) antagonists.
g. Physiologic stress ulcers are associated with physi- 4. Prostaglandin analogs and proton pump inhibitors
cal stress: burns, sepsis, and trauma. (PPIs).
2. Clinical manifestations. B. Lifestyle modifications.
a. Burning pain lasting minutes to hours; the pain 1. Eat a nonirritating or bland diet; avoid foods that
associated with ulcers may be confusing, and cause discomfort.
2. Decrease or stop smoking. b. Fluid volume replacement.

3. Minimize use of NSAIDs and antiinflammatory c. Antiulcer medications.
medications. d. Pyloroplasty to enlarge opening of pyloric valve.
4. Decrease or eliminate alcohol consumption. E. Surgical interventions for intractable ulcers and/or
complications.
Complications 1. Partial gastrectomy: removal of majority of stomach
A. Frequently result in an emergency situation—initially (antrum and pylorus) with anastomosis to either the
treated conservatively; however, surgery may be duodenum or the jejunum.
necessary. 2. Vagotomy: severing of the vagus nerve to decrease
B. Hemorrhage: bleeding when ulcer erodes through a acid-secreting stimulus to gastric cells.
vessel (see Figure 18-3). 3. Pyloroplasty (pyloric stenosis repair): enlargement of
1. Clinical manifestations. pyloric valve to facilitate passage of gastric contents
a. Pain, nausea, vomiting. into the small intestine; may be done in combination
b. Hematemesis, melena, or both. with vagotomy.
c. More common in duodenal ulcers. F. Postoperative complications.
d. Vital signs may reveal symptoms of shock 1. Dumping syndrome: affects up to half of clients who
(Chapter 16). have undergone gastrectomy (see Box 18-3).
2. Treatment. 2. Postprandial hypoglycemia: results from dumping
a. Fluid volume replacement: blood, normal saline, syndrome; concentrated carbohydrates cause hyper-
Ringer’s lactate. glycemia, and excessive insulin is released, causing
b. Medications to decrease acid production (Appen- hypoglycemia about 2 hours after meals.
dix 18-5).
c. NPO, nasogastric tube; saline lavage may be done. ALERT Teach client methods to prevent and/or manage
d. Surgery if unresponsive to conservative therapy. complications associated with diagnosis.
NURSING PRIORITY Recognize and implement measures
to manage potential circulatory complications (e.g., occurrence Goal: To promote health and prevent reoccurrence of
of a hemorrhage); carefully evaluate the client’s blood pressure. PUD.
Orthostatic hypotension (a blood pressure decrease of 10 mm Hg A. Identify factors in lifestyle contributing to development
or more) may be indicative of hypovolemia. of ulcer.
B. Identify factors that precipitate pain and discomfort.
C. Avoid aspirin compounds and NSAIDs.
C. Perforation. D. Identify presence of H. pylori and follow therapy; ulcers
1. Clinical manifestations. tend to reoccur, so discontinuation or interruption of
a. Sudden, severe, unrelenting abdominal pain. therapy can be detrimental.
b. Rigid, “board-like” abdomen. E. Client should not take any other medications or OTC
c. Hyperactive to absent bowel sounds. drugs that are not prescribed.
d. Severity of peritonitis is proportional to size of
perforation and amount of gastric spillage (see
Figure 18-6). ALERT Evaluate use of home remedies and OTC drugs. The
client with PUD may have been using antacids for a prolonged
2. Treatment.
time.
a. Antibiotics.
b. Perforation may seal, if not, laparoscopic or surgi-
cal closure. Goal: To relieve acute pain and promote healing.
c. Fluid volume replacement. A. Dietary modifications.
D. Gastric outlet obstruction: more common in duodenal 1. May be NPO with NG suctioning for acute episode
ulcers in the area of the pyloric valve. of gastric pain with nausea and vomiting (Appendix
1. Clinical manifestations. 18-8).
a. Gradual onset of symptoms. 2. Nonirritating, bland foods are generally tolerated
b. History of PUD. better during healing of acute episodes.
c. Swelling, dilation of stomach. 3. Encourage small, frequent meals.
d. Vomiting: foul-smelling and frequently projectile. 4. Help client identify specific dietary habits that exac-
e. Relief may be obtained by vomiting. erbate or precipitate pain.
2. Treatment. B. Identify characteristics of pain and activities that increase
a. Decompress the stomach with NG suctioning; or decrease pain.
maintain continuous decompression to allow for Goal: To promote homeostasis for client with gastric
healing. obstruction.
A. Nasogastric suctioning and careful assessment of hydra- F. Based on client’s condition, total parenteral nutrition
tion status; IV fluid replacement. may be necessary to maintain adequate nutrition
B. Reposition client from side to side to maintain good (Appendix 18-7).
gastric suctioning. G. Encourage ambulation to promote peristalsis.
C. After several days of decompression, NG tube may be Goal: To identify dumping syndrome (see Box 18-3).
clamped for short periods and gastric residual measured; Goal: To prevent the development of pernicious anemia
less than 200 mL residual is within normal range. after total gastric resection (see discussion of vitamin B12
D. When gastric residual is within normal amount, oral deficiency, Chapter 14).
feedings may begin at 30 mL per hour and gradually
increased; closely monitor for signs of obstruction. Appendicitis
Goal: To promote homeostasis when client is Appendicitis is the inflammation and obstruction of the
hemorrhaging. appendix, leading to bacterial infection. If appendicitis is
A. Assess client response to hemorrhage. not treated, the appendix can become gangrenous and
1. Evaluate hemoglobin and hematocrit levels. burst, causing peritonitis and septicemia, which could
2. Assess for distention, increase in pain, and progress to death. It is the most common reason for emer-
tenderness. gency abdominal surgery in children.
3. Correlate vital signs with changes in client’s overall A. Obstruction of the blind sac of the appendix precipitates
condition. inflammation, ulceration, and necrosis.
4. Assess stools and nasogastric drainage for presence of B. If the necrotic area ruptures, intestinal contents spill into
blood. the peritoneal cavity, causing peritonitis.
B. Maintain nasogastric decompression and suctioning
(Appendix 18-8). Assessment
1. Insert nasogastric tube for removal of gastric contents A. Risk factors/etiology.
and maintain gastric suction. 1. Age: peak at 10 to 12 years of age; uncommon in
2. May implement saline solution lavage. children younger than 2 years.
C. Monitor for hypovolemia and maintain hydration status 2. Diet: risk associated with a diet low in fiber and high
(Chapter 6). in refined sugars and carbohydrates.
1. Establish peripheral infusion line, preferably with 3. Obstruction to opening of appendix: hardened fecal
large-gauge needle for blood infusion. matter, foreign bodies, or microorganisms.
2. Insert indwelling urinary catheter to monitor urinary B. Clinical manifestations (Figure 18-5).
output; evaluate urine specific gravity. 1. Abdominal cramping and pain, beginning near the
3. Prepare to administer whole blood transfusion (see navel and then migrating toward McBurney’s point
Appendix 14-3) and IV fluids. (right lower quadrant); pain worsens with time.
D. Hemodynamic monitoring (Appendix 17-9). 2. Rovsing sign: pain in right lower quadrant when pal-
E. Maintain NPO status, begin oxygen administration, pating or percussing other quadrants.
maintain bed rest, and position client supine with legs 3. Anorexia, nausea, vomiting, diarrhea.
slightly elevated. 4. Low-grade fever.
Goal: To assess for complications of perforation and peri-
tonitis (see Acute Abdomen section).
Goal: To assist client to return to homeostasis after gastric
resection.
A. Provide general postoperative care as indicated (see
Chapter 3).
B. Maintain nasogastric suction until peristalsis returns (see
Appendix 18-8).
ALERT Monitor and maintain GI drainage. Distention and

obstruction of the nasogastric tube is a common problem for this
client.
C. Assess continuously for:

1. Increasing abdominal distention.
2. Nausea, vomiting.
3. Changes in bowel sounds.
D. No oral fluids until client tolerates clamping and/or
removal of nasogastric tube. FIGURE 18-5 Appendicitis. (From Zerwekh J, Claborn J: Memory note-
E. Begin oral fluids slowly: clear liquids first; then progress book of nursing, vol 2, ed 3, Ingram, Texas, 2007, Nursing Education
to bland, soft diet. Consultants)
5. Side-lying position with knees flexed. E. Do not administer enemas.

6. Client complains of pain when asked to cough; asking F. Avoid unnecessary palpation of abdomen.
client to cough is better assessment method than pal-
pating for rebound tenderness.
7. Sudden relief from pain may indicate rupture of ALERT Determine whether client is prepared for surgery or
procedures. Appendicitis is a very common problem; know how
appendix.
to care for client during diagnostic phase.
C. Diagnostics: no specific diagnostic tool; diagnosis made
from compilation of findings.
1. Clinical manifestations. Goal: To maintain homeostasis and healing after appen-
2. Urinalysis to rule out urinary tract infection. dectomy (see Chapter 3).
3. Abdominal ultrasonography and CT to differentiate Goal: To prevent abdominal distention and to assess bowel
from other abdominal problems. function after abdominal laparotomy.
4. CBC reveals elevated white blood cell count. A. Maintain NPO status; then begin clear liquid diet, pro-
5. Pregnancy test for adolescent females to rule out gressing to soft diet as tolerated.
ectopic pregnancy. B. Gastric decompression by nasogastric tube; maintain
D. Complications: rupture and peritonitis. patency and suction (Appendix 18-8).
C. Monitor abdomen for distention and increased pain.
Treatment D. Assess peristaltic activity.
A. Presurgery: fluid resuscitation, prophylactic antibiotic E. Evaluate and record character of bowel movements.
therapy; after diagnosis of appendicitis has been estab- Goal: To decrease infection and promote healing after
lished, pain management with analgesics. abdominal laparotomy.
B. Open appendectomy or laparoscopic appendectomy. A. Place client in semi-Fowler’s position to localize and
C. Abdominal laparotomy and peritoneal lavage if appendix prevent spread of infection and reduce abdominal
has ruptured. tension.
B. Antibiotics are usually administered via IV infusion;
Nursing Interventions monitor response to antibiotics and status of IV infusion
Goal: To assess clinical manifestations and to prepare for site.
surgery. C. Monitor vital signs frequently (every 2 to 4 hours) and
A. Careful nursing assessment for clinical manifestations evaluate for escalation of infectious process.
(Box 18-4). D. Provide appropriate wound care; evaluate drainage from
B. Maintain NPO status until otherwise indicated. abdominal Penrose drains and incisional area.
C. Maintain bed rest in position of comfort. Goal: To maintain adequate hydration and nutrition and
to promote comfort after abdominal laparotomy.
A. Maintain adequate hydration via IV infusion.
ALERT Determine need for administration of pain medications.
B. Evaluate tolerance of oral liquids when nasogastric tube
Do not give narcotics for pain control before a diagnosis of
appendicitis is confirmed, because this could mask signs if the is removed.
appendix ruptures. C. Begin oral administration of clear liquids when peristal-
sis returns.
D. Progress diet as tolerated.
D. Do not apply heat to the abdomen; cold applications E. Administer analgesics as indicated.
may provide some relief or comfort.
ALERT Identify infection; peritonitis is common after surgery for
a ruptured appendix.
Box 18-4 UNDIAGNOSED ABDOMINAL PAIN
DO NOT
Give anything by mouth.
Acute Abdomen
Put any heat on the abdomen. Acute abdomen encompasses a broad spectrum of urgent
Give an enema. pathologies frequently requiring emergent surgical
Give strong narcotics. intervention. Also called peritonitis, this condition is char-
Give a laxative. acterized by a generalized inflammation of the peritoneal
DO cavity, resulting in an intraabdominal infection.
Maintain bed rest. A. Intestinal motility is decreased, and fluid accumulates
Place in a position of comfort. as a result of the inability of the intestine to reabsorb
Assess hydration. fluid.
Assess abdominal status: distention, bowel sounds, passage of B. Fluid leaks into the peritoneal cavity, precipitating
stool or flatus, generalized or local pain.
fluid, electrolyte, and protein losses, as well as fluid
Keep client NPO until notified otherwise.
depletion.
Assessment 2. Abdominal CT and ultrasonography.

A. Risk factors/etiology. 3. Peritoneal lavage (aspiration) to evaluate abdominal
1. Chemical peritonitis may result from an infection, fluid.
the perforation of peptic ulcer, or a ruptured ectopic
pregnancy. Treatment
2. Bacterial peritonitis results from traumatic injury A. Identify and treat precipitating cause; frequently requires
(abdominal trauma, ruptured appendix). surgical intervention.
3. Chemical peritonitis is rapidly followed by bacterial B. Narcotic analgesic may be administered during diagnos-
peritonitis. tic phase to ensure client cooperation.
4. Pancreatic necrosis, pyelonephritis, ectopic preg- C. Antibiotics.
nancy, malignancy, bile duct obstruction, and duode- D. IV fluids and electrolyte replacement.
nal ulcer may cause acute abdomen. E. Decrease abdominal distention: NPO, NG tube.
ALERT Monitor status of client who has undergone surgery; Nursing Interventions
identify infection. Peritonitis is a potential complication any time
Goal: To provide pain control, wound care, prevent com-
the abdomen is entered, either through trauma or for surgery.
plications of immobility, and monitor postoperative
B. Clinical manifestations (Figure 18-6). progress (Chapter 3).
1. Presence of precipitating cause. Goal: To maintain fluid and electrolyte balances and reduce
2. Sharp or knife-like pain and/or dull and deep-seated gastric distention.
pain over involved area; rebound tenderness; pain A. Maintain nasogastric suction (Appendix 18-8).
may radiate to back, shoulder, or scapula. B. Maintain IV fluid replacement: normal saline or
3. Sudden, excruciating pain suggests the possibility of lactated Ringer’s solution to maintain hydration
rupture. and urine output of 30 mL/hr; assess urine specific
4. Abdominal mass or distention: note color and gravity.
contour of abdomen. C. Administer potassium supplements with caution because
5. Abdominal muscle rigidity (“board-like” abdomen), of possible renal complications.
guarding. D. Assess level of distention and return of peristalsis and
6. Unexplained persistent or labile fever. bowel function.
7. Anorexia, nausea, vomiting. E. Maintain intake and output records.
8. Tachycardia, hypotension, shallow respirations: F. Assess for problems of dehydration and hypovolemia
signs of impending or actual shock. (Chapter 6).
9. Decreased or absent bowel sounds. G. Encourage activities to facilitate return of bowel
10. Hypovolemia, dehydration. function.
11. Shallow respirations in attempt to avoid pain. 1. Encourage ambulation.
C. Diagnostics. 2. Attempt to decrease analgesics and maintain ade-
1. CBC for elevated white blood cell count and hemo- quate pain control.
concentration of fluid shifts (Chapter 6). 3. Maintain adequate hydration.
PERITONITIS “HOT BELLY”

I.D. Cause
• Antibiotics
NS. IV Fluids
K’ Abd
Rx Distention
100° F
Plus
• Fever
• Rebound
•N&V Tenderness
• Anorexia
• “Board-like” Abdomen
• Pulse • Abd Distention & Rigidity
• BP
• Dehydration • WBC
DX
• Pain
• Bowel Sounds
Risk Factors H...

SHHwels
Nursing Care
• Abdominal Surgery Bo ing • IV’s & Electrolyte Balance
• Ectopic Pregnancy Sleep & GI Distention
• Perforation: • Decrease Pain:
Position w/ Knees Flexed
Trauma Analgesics
Ulcer Quiet Environment
• Prevent Complications:
Appendix Rupture Immobility
Diverticulum Pulmonary
Fluid Balance
FIGURE 18-6 Peritonitis. (From Zerwekh J, Claborn J: Memory notebook of nursing, vol 2, ed 3, Ingram, Texas, 2007, Nursing Education Consultants.)
Goal: To reduce infectious process. C. Severe diverticulitis.

A. Administer antibiotics via IV infusion; assess client’s 1. Broad-spectrum antibiotics.
tolerance of antibiotics and status of infusion site. 2. Bowel rest: NPO; may have an NG tube; hydration
B. Evaluate vital signs and correlate with progress of infec- with IV fluids.
tious process. 3. Pain management with opioids; avoid morphine
C. Maintain in semi-Fowler’s position to enhance respira- (decreases peristalsis).
tions, as well as to localize drainage and prevent forma- 4. Surgery for obstruction, abscess, hemorrhage, or
tion of subdiaphragmatic abscess. perforation.
Goal: To help client understand dietary implications and
maintain prescribed therapy to prevent exacerbations.
Diverticular Disease A. Teach client about eating a high-fiber diet when
When a diverticulum (a pouch-like herniation of superfi- asymptomatic.
cial layers of the colon through weakened muscle of the B. Maintain high fluid intake.
bowel wall) becomes inflamed, it is known as diverticuli-
tis. Multiple diverticula are known as diverticulosis.
Meckel’s diverticulum is diverticular disease of the ileum ALERT Adapt the diet to the special needs of the client;
in children. It is the most common congenital anomaly of determine client’s ability to perform self-care.
the GI tract in children.
Assessment C. Weight reduction, if indicated.

A. Risk factors/etiology. D. Avoid activities that increase intraabdominal pressure
1. Diet. (e.g., straining at stool, bending, lifting); avoid wearing
a. Low-fiber diet; high intake of processed foods. tight restrictive clothing.
b. Constipation. E. Use bulk laxatives, avoid enemas and harsh laxatives.
c. Indigestible fibers (corn, seeds, etc.) may precipi- Goal: To decrease colon activity in client with
tate diverticulitis, but they do not contribute to the diverticulitis.
development of diverticula. A. Maintain clear liquids or NPO status.
2. Age: 50% of adults are affected by age 80 years. B. Bed rest.
3. As diverticula form, the colon wall becomes thick- C. Adequate hydration via parenteral fluids.
ened; diverticulitis results from retention of stool and D. As attack subsides, gradually introduce food and
bacteria in the diverticulum. fluids.
4. Inactivity and constipation.
B. Clinical manifestations. Home Care
1. Diverticular disease is frequently asymptomatic; A. High-fiber diet to prevent diverticulitis.
symptoms vary with degree of inflammation. B. If client has any abdominal distress, all fiber should be
2. Diverticulitis occurs when undigested food and bac- avoided until tenderness resolves.
teria are trapped in the diverticula. C. Report fevers, constant abdominal pain, and dark, tarry
a. Fever. stools.
b. Left lower quadrant pain; may be accompanied by
nausea and vomiting.
c. Abdominal distention and increased pain on Inflammatory Bowel Disease (IBD)
palpation. IBD is characterized by chronic inflammation of the
d. May progress to abscess, intestinal obstruction, intestine with periods of remission and exacerbation. It is
and/or perforation. considered an autoimmune disease; tissue damage is due
C. Diagnostics (Appendix 18-1). to overactive sustained inflammatory response.
1. Computed tomography and/or ultrasound. A. Crohn’s disease (ileitis or enteritis) is inflammation
2. Barium enema or colonoscopy are contraindicated in occurring anywhere along the GI tract; patches of
acute diverticulitis. inflammation occur next to healthy bowel tissue; most
frequent site is the terminal ileum.
Treatment B. Ulcerative colitis is an inflammation and ulceration that
A. Management of uncomplicated diverticulum. most commonly occurs in the sigmoid colon and rectum;
1. High-fiber diet. inflammation frequently begins in the rectum and
2. Decreased intake of fat and red meat. spreads in a continuous manner up the colon; seldom is
3. Stool softeners, bulk laxatives. the small intestine involved.
4. Increased activity: walking, exercise. C. Clients frequently experience periods of complete remis-
B. Diverticulitis. sion that alternate with exacerbations.
1. Oral antibiotics when symptoms are mild. D. Even though the two conditions have different criteria
2. Antispasmodic medications. for diagnosis, a clear differentiation cannot be made
3. Liquid or low-fiber diet. between them in about one-third of the cases.
Assessment 2. Total removal of colon, rectum, and anus with forma-

A. Risk factors/etiology. tion of continent ileostomy (Kock’s pouch).
1. Familial tendency. 3. Minimally invasive surgery (MIS) involves a laparos-
2. Commonly occur in the teenage years, with a copy to remove small areas of diseased tissue in the
second peak in occurrence in clients 60 years old ileum and ileocecal areas.
and older.
3. Altered inflammatory response. Nursing Interventions
B. Clinical manifestations—Crohn’s disease. Goal: To promote hemodynamic stability and hydra-
1. Steatorrhea, multiple diarrhea stools per day. tion.
2. Weight loss; nutritional deficiencies; impaired A. Evaluate and maintain adequate hydration status.
absorption of vitamin B12 (cobalamin). B. Encourage good fluid intake (3000 mL/day).
3. Intermittent fever. C. Evaluate electrolyte status; monitor potassium level if on
4. Entire thickness of bowel wall is involved; fistulas are corticosteroids.
not uncommon. D. Assess characteristics in patterns of stool.
5. Nausea, cramping, flatulence. Goal: To promote nutrition.
C. Clinical manifestations—ulcerative colitis. A. Balanced diet with increased protein and calories.
1. Rectal bleeding. B. Assess for iron deficiency anemia due to blood loss and
2. Diarrhea, one to two diarrhea stools per day; may reduced intake of iron.
contain small amounts of blood. C. Assess for anemia due to lack of absorption of vitamin
3. Number of stools increases with exacerbation of con- B12 (cobalamin); monthly injections or daily oral or nasal
dition; 10-20 stools per day in acute exacerbation. spray may be necessary.
4. Increased in systemic symptoms (fever, malaise, D. Help client identify and avoid foods that precipitate
anorexia) with exacerbation. diarrhea.
5. Tenesmus (uncontrollable straining). E. Parenteral nutrition or enteral feeding may be necessary
6. Minimal small bowel involvement. because of malabsorption (Appendix 18-7, Appendix
D. Diagnostics (see Appendix 18-1). 18-9).
F. Supplemental folic acid for clients on long-term sul-
Complications fasalazine treatment.
A. Crohn’s disease. G. Supplemental liquid nutrition.
1. Perirectal and intraabdominal fistulas; fissures and Goal: To promote emotional and psychosocial stability.
rectal abscesses. A. Frequent bowel movements, rectal discomfort, and
2. Perforation and peritonitis. uncontrollable disease result in anxiety, frustration, and
3. Nutritional deficiencies, especially of fat-soluble depression—promote comfort by keeping anal area clean
vitamins. and keeping room clear of offensive odors.
B. Ulcerative colitis. B. Establish trust, encourage self-care strategies, explain all
1. Perforation and peritonitis with toxic megacolon. procedures and treatments.
2. Increased risk for cancer after 10 years. C. Encourage rest to prevent fatigue.
D. Symptoms of reoccurrence of the problem—call the
Treatment physician if these occur.
A. Dietary modifications: increased calories, protein, and 1. Continued diarrhea and weight loss.
fluids. Encourage client to eat small servings several 2. Chills, fever, malaise.
times a day.
B. Medications for Crohn’s disease. Home Care
1. Antiinflammatory: aminosalicylates (sulfasalazine; A. Dietary modifications, avoidance of foods that cause
see Appendix 6-9) and corticosteroids (see Appendix diarrhea.
6-7). B. Medication regimen: precautions regarding steroids or
2. Antimicrobials: prevent or treat infection. immunosuppressive medications.
3. Immunosuppressants to decrease or suppress the C. Dressings and wound care if fistula is present.
immune response (see Appendix 23-3). D. Identify appropriate measures to decrease stress in
4. Antidiarrheals. lifestyle.
C. Medications for ulcerative colitis: aminosalicylates and E. Acute symptoms may be exacerbated or, as disease pro-
corticosteroids to decrease inflammation. gresses, may become chronic.
D. Surgical intervention may be necessary if client fails to
respond to medical management and if fistulas, perfora-
tion, bleeding, or intestinal obstruction occur. Intestinal Obstruction
1. Total removal of colon, rectum, and anus with Interference with normal peristalsis and impairment to
formation of permanent ileostomy (Appendix forward flow of intestinal contents is known as intestinal
18-12). obstruction.
FIGURE 18-7 Bowel obstructions. (From Lewis SL et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis,
2007, Mosby.)
A. Types of obstruction (Figure 18-7). F. Increased pressure causes an increase in capillary perme-
1. Mechanical obstruction. ability and leakage of fluids and electrolytes into perito-
a. Strangulated hernia. neal fluid; this leads to a severe reduction in circulating
b. Intussusception: the telescoping of one portion of volume.
the intestine into another (occurs most often in G. Intussusception is the most common cause of intestinal
infants and small children). obstruction in children from ages 3 months to 6 years.
c. Volvulus: twisting of the bowel. H. The location of the obstruction determines the
d. Tumors: cancer (most frequent cause of obstruc- extent of fluid and electrolyte imbalance and acid-base
tion in older adults). imbalance.
e. Adhesions. 1. Dehydration and electrolyte imbalance do not occur
2. Neurogenic: interference with nerve supply in the rapidly if obstruction is in the large intestine.
intestine. 2. If the obstruction is located high in the intestine,
a. Paralytic ileus or adynamic ileus occurring as a dehydration occurs rapidly because of the inability of
result of abdominal surgery or inflammatory the intestine to reabsorb fluids; metabolic alkalosis
process. develops from loss of gastric acid due to vomiting or
b. Potential sequelae from spinal cord injury. NG suctioning.
3. Vascular obstruction: interference with the blood
supply to the bowel. Assessment
a. Infarction of superior mesenteric artery. A. Risk factors/etiology: identify type of obstruction and
b. Bowel obstructions related to intestinal ischemia precipitating cause.
may occur very rapidly and may be life- B. Clinical manifestations.
threatening. 1. Vomiting.
B. Regardless of the precipitating cause, the ensuing prob- a. Occurs early and is more severe if the obstruction
lems are a result of the obstructive process. is high.
C. The higher the obstruction in the intestine, the more b. Higher obstruction may contain bile, and vomit-
rapidly symptoms will occur. ing may be projectile.
D. Fluid, gas, and intestinal contents accumulate proximal c. Vomiting caused by lower obstructions occurs
to the obstruction. This causes distention proximal to more slowly and may be foul smelling due to the
the obstruction and bowel collapse distal to the presence of bacteria and fecal material.
obstruction. 2. Abdominal distention.
E. As fluid accumulation increases, so does pressure against 3. Bowel sounds initially may be hyperactive proximal
the bowel. This precipitates extravasation of fluids and to the obstruction and decreased or absent distal to
electrolytes into the peritoneal cavity. Increased pressure the obstruction; eventually, all bowel sounds will be
may cause the bowel to rupture. absent.
4. Colicky-type abdominal pain. H. Measure abdominal girth to determine whether disten-

5. Fluid and electrolyte imbalances, dehydration. tion is increasing.
6. Intussusception. I. Encourage activities to facilitate return of bowel
a. Child is healthy with sudden occurrence of acute function.
abdominal pain. 1. Encourage physical activity, as tolerated.
b. Child may pass one normal stool; then as condition 2. Attempt to decrease amount of medication required
deteriorates, the child may pass a stool described for effective pain control.
as “currant jelly” (a mixture of blood and mucus). 3. Maintain hydration.
c. A “sausage-shaped” mass may be palpated in the J. Frequently, the position of comfort is side-lying with
abdomen. knees flexed.
Goal: To provide appropriate preoperative preparation
ALERT Determine characteristics of bowel sounds. This is when surgery is indicated (see Chapter 3).
particularly important for the client with intestinal problems. Goal: To maintain homeostasis and promote healing after
abdominal laparotomy (see Chapter 3).
C. Diagnostics (Appendix 18-1). Goal: To decrease infection and promote healing after
a. Abdominal x-ray to differentiate obstruction from surgery.
perforation. A. Monitor client’s response to antibiotics.
b. Barium enema to identify area of obstruction; only B. Monitor vital signs frequently and evaluate for presence
done after a bowel perforation has been ruled out. or escalation of infectious process.
C. Provide wound care. Evaluate drainage and healing from
Complications abdominal Penrose or Jackson-Pratt drains, as well as
A. Infection/septicemia. from abdominal incisional area.
B. Gangrene of the bowel.
C. Perforation of the bowel.
D. Severe dehydration and electrolyte imbalances. ALERT Empty and reestablish negative pressure of portable
wound suction devices (Hemovac and Jackson-Pratt drains).
Treatment
A. Mechanical and vascular intestinal obstructions are gen- Goal: To reestablish normal nutrition and promote comfort
erally treated surgically; ileostomy or colostomy may be after abdominal laparotomy.
necessary. A. Evaluate tolerance of liquids when nasogastric tube is
B. Conservative treatment includes nasogastric suctioning removed.
and decompression (Appendix 18-8). B. Begin administration of clear liquids initially and con-
C. Fluid and electrolyte replacement. tinue to evaluate for peristalsis and/or distention, nausea,
D. Intussusception: hydrostatic reduction by water-soluble and vomiting.
contrast, air, or barium enema. C. Progress diet as tolerated.
D. Administer analgesics as indicated.
Nursing Interventions E. Promote psychologic comfort.
Goal: To prepare client for diagnostic evaluation and to 1. Respond promptly to requests.
maintain ongoing nursing assessment for pertinent data 2. Carefully explain procedures.
(see Appendix 18-1). 3. Encourage questions and ventilation of feelings
A. Monitor all stools; passage of normal stool may indi- regarding status of illness.
cate reduction of the obstruction, especially an 4. Encourage parents to ask questions and to room-in
intussusception. with infant or child; rapidity of the onset of child’s
B. Classic signs and symptoms of intussusception may not condition challenges parents’ ability to cope.
be present; observe child for diarrhea, anorexia, vomit-
ing, and episodic abdominal pain.
Goal: To decrease gastric distention and to maintain hydra- Hernia
tion and electrolyte balance. A hernia is a protrusion of the intestine through an abnor-
A. Maintain NPO status. mal opening or weakened area of the abdominal wall.
B. Maintain nasogastric suction (Appendix 18-8). A. Types.
C. Monitor IV fluid replacement: most often normal saline 1. Inguinal: a weakness in which the spermatic cord in
or lactated Ringer’s solution. men and the round ligament in women passes through
D. Administer potassium supplements with caution because the abdominal wall in the groin area; more common
of complications of decreased renal function. in men; most common type of hernia in children.
E. Evaluate peristalsis, presence of any bowel function. 2. Femoral: protrusion of the intestine through the
F. Maintain accurate intake and output records. femoral ring; more common in women.
G. Assess for dehydration, hypovolemia, and electrolyte 3. Umbilical: occurs most often in children when the
imbalance (Chapter 6). umbilical opening fails to close adequately; most
common hernia in infants; may occur in adults when Assessment

the rectus muscle is weak from surgical incision. A. Risk factors/etiology.
4. Incisional or ventral: weakness in the abdominal wall 1. Occurs most often in first-born, full-term male
caused by a previous incision. infants (infantile hypertrophic pyloric stenosis).
5. Classification. 2. Seen more frequently in Caucasian infants.
a. Reducible: hernia may be replaced into the 3. First-born male infant of a mother who was affected
abdominal cavity by manual manipulation. is at increased risk.
b. Incarcerated or irreducible: hernia cannot be B. Clinical manifestations.
pushed back into place. 1. Onset of vomiting may be gradual, usually occurs at
c. Strangulated: blood supply and intestinal flow in 3 weeks or as late as 5 months; is progressive and may
the herniated area are obstructed; strangulated be projectile.
hernia leads to intestinal obstruction. 2. Emesis is not bile stained but may be curdled from
B. Risk factors. length of time in stomach.
1. Chronic cough, such as smoker’s cough or cough 3. Vomiting occurs shortly after feeding.
associated with cystic fibrosis. 4. Infant is hungry and irritable.
2. Obesity or weakened abdominal musculature. 5. Infant does not appear to be in pain or acute
3. Straining during bowel movement or lifting heavy distress.
objects. 6. Weight loss occurs, if untreated.
4. Pregnancy. 7. Stools decrease in number and in size.
8. Dehydration occurs as condition progresses; hypo-
Assessment chloremia and hypokalemia occur as vomiting
A. Clinical manifestations. continues.
1. Hernia protrudes over the involved area when the 9. Upper abdomen is distended, and an “olive-shaped”
client stands or strains, or when the infant cries. mass may be palpated in the right epigastric area.
2. Severe pain occurs if hernia becomes strangulated. C. Diagnostics (Appendix 18-1).
3. Strangulated hernia produces symptoms of intestinal D. Treatment: surgical release of the pyloric muscle
obstruction. (pyloromyotomy).
B. Diagnostics (Appendix 18-1).
Treatment Goal: To maintain hydration and gastric decompression;
A. Preferably elective surgery through abdominal incision. to initiate appropriate preoperative nursing activities
B. Laparoscopic hernia repair. (Appendix 18-8).
C. Emergency surgery for strangulated hernias producing A. Maintain nasogastric decompression if NG tube is in
intestinal obstruction. place and record type and amount of drainage.
B. Assess hydration status and electrolyte balance—espe-
Nursing Interventions cially serum calcium, sodium, and potassium levels.
Goal: To prepare client for surgery, if indicated (see C. NPO status with continuous IV infusion (most often
Chapter 3). saline solutions) may be required.
Goal: To maintain homeostasis and promote healing after D. Accurate intake and output records: complete descrip-
herniorrhaphy. tion of all vomitus and stools.
A. General postoperative nursing care (see Chapter 3). E. Monitor vital signs and check for signs of peritonitis.
B. Repair of an indirect inguinal hernia: assess male clients F. Preoperative teaching for parents.
for development of scrotal edema. Goal: To maintain adequate hydration and promote healing
C. Encourage deep breathing and activity. after pyloromyotomy.
D. If coughing occurs, teach client how to splint the A. Postoperative vomiting in the first 24 to 48 hours is not
incision. uncommon; maintain IV fluids until infant tolerates
E. Refrain from heavy lifting for approximately 6 to 8 adequate oral intake.
weeks after surgery. B. Continue to monitor infant in the same manner as in
F. Wound care. the preoperative period.
a. Keep wound clean and dry: use occlusive dressing or C. Feedings are initiated early; bottle-fed infant may begin
leave open to air. with clear liquids containing glucose and electrolytes,
b. Change diapers frequently and/or prevent irritation small amounts offered frequently.
and contamination in incisional area. D. Breastfed infants: mother can express breast milk and offer
small amounts in a bottle or initially limit nursing time.
Pyloric Stenosis Goal: To help parents provide appropriate home care after
Pyloric stenosis is the obstruction of the pyloric sphincter pyloromyotomy.
by hypertrophy and hyperplasia of the circular muscle of A. No residual problems are anticipated after surgery.
the pylorus. B. Instruct parents regarding care of the incisional area.
C. Most common areas of metastasis include regional

Cancer of the Stomach lymph nodes, liver, lungs, and peritoneum.
Tumors in the cardia and fundus of the stomach are asso-
ciated with a poor prognosis. Assessment
A. Cancer (adenocarcinoma) occurs in the wall of the A. Risk factors/etiology.
stomach. 1. Family history (first-degree relative) of colorectal
B. Metastasis generally occurs by direct extension of the cancer.
malignant growth into adjacent organs and structures 2. Incidence increases significantly after the age
(esophagus, spleen, pancreas, etc.). of 50.
C. Because of the ability of the stomach to accommodate 3. History of inflammatory bowel disease.
the growing tumor, symptoms may not be evident until 4. High-fat, high-calorie, low-residue diet with high
metastasis has occurred. intake of red meat increases anaerobic bacteria in
bowel, which convert bile acids into carcinogens.
Assessment 5. Alcohol, tobacco use, and obesity are also associated
A. Risk factors/etiology. with increased risk.
1. Increased incidence in men. B. Clinical manifestations.
2. Peak incidence in seventh decade. 1. Symptoms are vague early in disease state and may
3. Presence of H. pylori is considered an increased risk take years to present.
factor 2. Bloody stools, melena (dark tarry) stools.
4. Increased incidence in presence of other chronic 3. Change in bowel habits: constipation and diarrhea.
gastric problems. 4. Change in shape of stool (pencil- or ribbon-shaped
B. Clinical manifestations. in sigmoid or rectal cancer).
1. Early symptoms. 5. Weakness and fatigue from iron deficiency anemia
a. Loss of appetite, persistent indigestion. and chronic blood loss.
b. Early satiety, dyspepsia. 6. Pain, anorexia, and unexpected weight loss are late
c. Nausea, vomiting. symptoms.
d. Blood in stool. 7. Bowel obstruction may lead to perforation and
2. Later symptoms. peritonitis.
a. Pain often exacerbated by eating. C. Diagnostics (Appendix 18-1).
b. Weight loss, anemia. 1. Sigmoidoscopy and colonoscopy with biopsies.
c. Nausea and vomiting due to impending GI 2. Carcinoembryonic antigen (CEA) tumor marker
obstruction. detected in blood.
d. Presence of a palpable mass in the stomach; ascites
from involvement of peritoneal cavity. Treatment
C. Diagnostics (Appendix 18-1). A. Colon resection: may have resection with or without a
1. Gastroscopy and biopsy. colostomy or may have an abdominal-perineal resection
2. Full-body imaging for metastasis. that includes resection of the sigmoid colon, rectum, and
anus.
Treatment B. Laser photocoagulation: destroys small tumors and pal-
Gastrectomy is the preferred method of treatment. liative for large tumors obstructing bowel.
C. Endoscopic excision or electrocoagulation for small,
Nursing Interventions localized tumors or for clients who are poor surgical
See Nursing Interventions for gastric resection under Peptic candidates.
Ulcer Disease. D. Radiation therapy: external, intracavity, or implanted;
may be used preoperatively to shrink tumor size.
E. Chemotherapy: reduces recurrence and prolongs survival
Cancer of the Colon and Rectum in stage II and III rectal tumors.
(Colorectal Cancer)
Colorectal cancer (cancer of the colon and/or the Nursing Interventions
rectum) is the third most common cancer in the United Goal: To provide information to high-risk clients.
States and the second leading cause of cancer-related A. Diet: high-fiber, low-fat diet with a decreased intake of
deaths. red meat.
A. 85% of colorectal cancers arise from adenomatous polyps B. Digital rectal exams yearly after age 40.
that can be detected and removed by sigmoidoscopy or C. Annual fecal occult blood testing after age 50.
colonoscopy. D. Flexible sigmoidoscopy or colonoscopy every 3 or 5 years
B. Symptoms frequently do not appear until condition is after age 50 for high risk; otherwise every 10 years for
advanced with metastatic sites. average risk.
Goal: To provide preoperative care. C. Keep room clean and free of offensive smells; client may
A. Determine extent of surgery anticipated; colostomy is be very self-conscious regarding open wound and/or
not always done. stoma; provide opportunity for questions and discussion.
B. Bowel preparation: low-residue diet, cathartics 24 hours
before surgery; enemas may or may not be used the Home Care
evening before surgery. A. Recovery period is long; help client and family identify
C. Oral neomycin to decrease bacteria in the bowel. community resources.
D. If colostomy is to be done, discuss implications and B. Help client and family identify resources and obtain
identify appropriate area for stoma on abdomen (see equipment for colostomy care (see Appendix 18-12).
Appendix 18-12). C. Instruct client in care of perineal wound if it is not
E. Prepare client for change in body image if colostomy is healed.
indicated. 1. Sitz baths: always check temperature of water; wound
Goal: To provide appropriate wound care after abdominal- tissue can be easily damaged.
perineal resection. 2. Presence of continuous drainage may indicate a
A. Client will have three incisional areas. fistula.
1. Abdominal incision. D. Identify community resources for client: home health
2. Incisional area for colostomy. visits, social services, etc.
3. Perineal incision. E. Assess client’s ability to care for stoma; help client begin
self-care before discharge (Appendix 18-12).
ALERT Identify factors interfering with wound healing and/or
symptoms of infection.
Celiac Disease (Malabsorption Syndrome)
Celiac disease is also known as sprue, gluten enteropathy,
B. Perineal wound. and malabsorption syndrome. This disease is an immune
1. Wound may be left open to heal by secondary inten- reaction to rye, wheat, barley, and oat grains that leads to
tion: provide warm sitz baths (100.4° to 100.6° F) for an inflammatory response, causing damage to the villi of
10 to 20 minutes to promote debridement, increase the small intestines and resulting in the inability to absorb
circulation to the area, and promote comfort. nutrients (malabsorption).
2. Wound may be partially closed with drains ( Jackson- A. Previously considered a disease of childhood with symp-
Pratt and/or Hemovac) in place: assess the wound for toms beginning between the ages of 1 year and 5 years;
integrity of suture line and presence of infection; celiac disease is now commonly seen at all ages with
drainage should be serosanguineous; drains remain in mean age of diagnosis being 40 years.
place until drainage is less than 50 mL/24 hour B. Symptoms frequently begin in early childhood, but
(Chapter 3). condition may not be diagnosed until client is an
3. Wound may be open and packed: drainage is profuse adult.
first several hours after surgery; may require frequent C. Development of celiac disease is dependent on genetic
reinforcement and dressing change; drainage is predisposition, ingestion of gluten, and immune-medi-
serosanguineous. ated response.
C. Position client with a perineal wound on his or her side;
do not allow client to sit for prolonged period until Assessment
wound is healed. A. Cause: congenital defect or an autoimmune response in
D. Assess status of stoma and healing of abdominal incision gluten metabolism.
(see Appendix 18-12). B. Clinical manifestations.
Goal: To maintain homeostasis and promote healing after 1. Symptoms may begin when child has increased intake
abdominal-perineal resection or colon resection (see of foods containing gluten: cereals, crackers, breads,
Chapter 3). cookies, pastas, etc.
A. Infections, hemorrhage, wound disruption, thrombo- 2. Foul-smelling diarrhea with abdominal distention
phlebitis, and stoma problems are the most common and anorexia in infants and toddlers.
complications. 3. Poor weight gain in children, failure to thrive.
B. Help client begin to become independent with colos- 4. Constipation, vomiting, and abdominal pain may be
tomy care early in recovery period (see Appendix 18-12). the initial presenting symptoms in adults.
Goal: To provide psychosocial support. 5. Vitamin deficiency leads to central nervous system
A. Emotional support is essential with cancer diagnosis; impairment and bone malformation.
recovery is long and frequently painful. 6. May be associated with other autoimmune conditions
B. Sexual dysfunction may occur; determine from physician (rheumatoid arthritis, type 1 diabetes, thyroid
if nerve paths for erection and ejaculation were in area disease).
of resection; provide opportunity for questions. C. Diagnostics: biopsy of duodenum and small intestine.
Treatment B. The final repair closes the colostomy, and the bowel is
Primarily dietary management: gluten-free diet. reanastomosed.
Nursing Interventions Nursing Interventions

Goal: To help client and family understand diet therapy Goal: To promote normal attachment and prepare infant
and promote optimal nutrition intake. and parents for surgery.
A. Written information regarding a gluten-free diet; corn, A. Allow parents to ventilate feelings regarding congenital
rice, potato, and soy products may be substituted for defect of infant.
wheat in diet. B. Foster infant-parent attachment.
B. Diet should be well balanced and high in protein. C. General preoperative preparation of the infant; neonate
C. Teach client and/or family how to read food labels for does not require any bowel preparation.
gluten content; thickenings, soups, instant foods may D. Careful explanation of colostomy to parents.
contain hidden sources of gluten. Goal: See Nursing Interventions for client who has under-
D. Important to discuss the necessity of maintaining a life- gone abdominal surgery in the Intestinal Obstruction
long gluten-restricted diet; problems may occur in clients section of this chapter.
who relax their diet and experience an exacerbation of Goal: To help parents understand and provide appropriate
the disease state. home care for their infant/child after colostomy (see
E. Lack of adherence to dietary restrictions may precipitate Appendix 18-12).
growth retardation, anemia, and bone deformities. A. Colostomy is most often temporary.
B. Parents should be actively involved in colostomy care
before discharge.
ALERT Adapt the diet to meet client’s specific needs.
Hemorrhoids
Dilated hemorrhoidal veins of the anus and rectum; may
Hirschsprung’s Disease be internal ( above the internal sphincter) or external
Hirschsprung’s disease (congenital aganglionic megaco- (outside of the external sphincter).
lon) is characterized by a congenital absence of ganglionic
cells that innervate a segment of the colon wall. Assessment
A. Clinical symptoms vary depending on the age when A. Risk factors/etiology: conditions that increase anorectal
symptoms are recognized, the length of the affected pressure.
bowel, and presence of inflammation. 1. Pregnancy, obesity, prolonged constipation.
B. Most common site is the rectosigmoid colon; colon 2. Prolonged standing or sitting.
proximal to the area dilates (i.e., megacolon). 3. Portal hypertension.
4. Straining at bowel movement.
Assessment B. Clinical manifestations.
A. Risk factors/etiology: congenital anomaly. 1. External hemorrhoids appear as protrusions at the
B. Clinical manifestations. anus.
1. May be acute and life-threatening or may be a chronic 2. Prolapsed hemorrhoids may bleed or become
presentation. thrombosed.
2. Internal sphincter loses ability to relax for defecation. 3. Thrombosed hemorrhoid: a blood clot in a hemor-
3. Newborn. rhoid that causes inflammation and pain.
a. Failure to pass meconium within 48 hours after 4. Rectal bleeding during defecation.
birth. C. Diagnostics: rectal examination.
b. Vomiting, abdominal distention.
c. Reluctance to take fluids. Treatment
4. Older infant and child. A. Conservative treatment.
a. Chronic constipation, impactions. 1. Sitz baths, stool softeners, ointments, topical
b. Passage of ribbon-like, foul-smelling stools and anesthetics.
diarrhea. 2. Prevent constipation: diet high in fiber (bran) and
c. Failure to thrive. roughage with increased water intake.
d. Lack of appetite. 3. Avoid straining with bowel movement; keep anal area
C. Diagnostics: rectal biopsy to confirm. clean.
B. Aggressive treatment.
Treatment 1. Ligation of prolapsed, thrombosed hemorrhoids with
A. Surgical correction usually involves resection of agangli- small rubber band.
onic bowel with creation of a temporary colostomy to 2. Infrared coagulation for bleeding hemorrhoids.
relieve the obstruction. 3. Surgery for painful, large, bleeding hemorrhoids.
Goal: To provide appropriate information to help client Home Care
manage problem at home. A. Encourage bulk laxatives and increased fluid intake to
A. Avoid prolonged standing or sitting. promote soft stool for first bowel movement.
B. Take sitz baths to decrease discomfort. B. Rectal pain may be severe; analgesics and local applica-
C. Use OTC ointments to decrease discomfort. tion of moist heat may be used.
D. Apply ice pack, followed by a warm sitz bath, if severe C. Review preventive techniques; weight loss and avoidance
discomfort occurs. of constipation.
E. Avoid constipation and straining at stool.
Appendix 18-1 GASTROINTESTINAL SYSTEM DIAGNOSTICS
X-Ray 3. Client should avoid aspirin, NSAIDs, iron supplements, and

Upper Gastrointestinal Series or Barium Swallow gelatin containing red coloring for a week before procedure.
X-ray examination in which barium is used as a contrast material; 4. May give preoperative medication for relaxation and to decrease
used to diagnose structural abnormalities and problems of the secretions.
esophagus and stomach. As the client swallows the barium, x-ray 5. For upper GI studies, a topical anesthesia will be used to anes-
films are obtained to show the structures, function, position, and thetize the throat before insertion of the scope.
abnormalities of organs from mouth through jejunum. 6. Upper GI studies: assess client’s mouth for dentures and remov-
Nursing Implications able bridges.
1. Explain procedure to client (usually not done on client with acute 7. Lower GI studies: help client into the left side-lying, knee-chest
abdomen until possibility of perforation has been ruled out). position; explain the need to take a deep breath during the
2. Maintain client’s nothing by mouth (NPO) status 8 hours insertion of the scope; client may feel urge to defecate as scope
before procedure. is passed.
3. Client will swallow barium to coat the GI tract for visualization 8. Conscious sedation frequently used for lower GI studies or
of various landmarks and structures. colonoscopy.
4. After examination, promote normal excretion of barium to Nursing Implications During Procedure
prevent impaction. Barium can cause constipation, so encourage 1. Verify informed consent and client identification.
extra fluid. It may be necessary to use a stool softener or laxative 2. For upper GI studies, confirm NPO status for past 8 hours; for
to promote evacuation of barium. lower GI studies, confirm bowel preparation.
5. Stool should return to normal color within 72 hours. 3. Assess for presence of GI bleeding; notify physician if any
bleeding is present.
Lower Gastrointestinal Series or Barium Enema 4. Maintain safety: airway precautions during sedation; position-
X-ray examination of the colon in which barium is used as a con- ing, monitor level of sedation (Chapter 3).
trast medium; barium is administered rectally. Nursing Implications After Procedure
Nursing Implications 1. Upper GI: maintain client’s NPO status until the gag reflex returns;
1. Maintain client’s NPO status for 8 hours before test. Client may position client on his or her side to prevent aspiration until gag
have clear liquids the evening before the test. or cough reflex returns; use throat lozenges or warm saline solu-
2. Colon must be free of stool; laxatives and enemas are adminis- tion gargles for relief of sore throat.
tered the evening before the test. 2. Monitor vital signs and O2 saturation during recovery.
3. Explain to client that he or she may experience cramping and 3. Observe for signs of perforation: upper GI bleeding—dyspha-
the urge to defecate during the procedure. gia, substernal or epigastric pain; lower GI bleeding—rectal
4. After the procedure, increase fluids and administer a laxative to bleeding, increasing abdominal distention.
assist in expelling the barium. 4. Assist client to upright position: observe for orthostatic
Endoscopy hypotension.
Gastroscopy, Esophagogastroduodenoscopy (EGD), 5. Warm sitz bath for any anal discomfort.
Colonoscopy, Sigmoidoscopy Analysis of Specimens
Endoscopy is the direct visualization of the gastrointestinal tract Paracentesis; Diagnostic Peritoneal Lavage
(GI) via a flexible, fiberoptic, lighted scope. Procedure: A catheter is inserted into the peritoneal cavity, most
Upper GI: inflammation, ulcerations, tumors; evaluation and often just below the umbilicus.
treatment of esophageal varices. Purposes
Lower GI: evaluation of diverticular disease or irritable bowel 1. To determine effect of blunt abdominal trauma.
syndrome; treatment of active bleeding or ulceration; identifica- 2. To assess for presence of ascites.
tion of polyps, tumors, inflammation, fissures, or hemorrhoids. 3. To identify cause of acute abdominal problems (e.g., perfora-
The endoscope is capable of obtaining biopsy specimens and clip- tion, hemorrhage).
ping benign polyps. • To assess for intraabdominal bleeding after a blunt trauma
Nursing Implications Before Procedure to the abdomen. If no blood is aspirated, normal saline is
1. Upper GI: NPO for up to 12 hours before procedure. infused into the peritoneal cavity. The fluid is aspirated or
2. Lower GI: bowel prep—cathartics and/or enemas, clear liquid allowed to drain by gravity. Fluid should return clear with a
diet for 24 hours before test. slight yellow cast if there is no injury. Bloody fluids, presence
Continued
Appendix 18-1 GASTROINTESTINAL SYSTEM DIAGNOSTICS—cont’d
of bacterial or fecal material, high white or red blood cell 3. Contraindicated in pregnancy and in clients with coagulation
count occur with a positive test result; immediate surgery may defects or possible bowel obstruction.
be required.
• If client has abdominal fluid from ascites or other abdominal Stool Examination
pathologic conditions, a specimen of the fluid is obtained Stool is examined for form and consistency and to determine
without instilling fluid. whether it contains mucus, blood, pus, parasites, or fat. Stool will
Nursing Implications be examined for presence of occult blood.
1. A nasogastric tube may be used to maintain gastric decompres- Nursing Implications
sion during procedure. 1. Collect stool in sterile container if examining for pathologic
2. Have the client void before the procedure, if client has a full organisms.
bladder at the time of insertion of the catheter, risk for bladder 2. A fresh, warm stool is required for evaluation of parasites or
perforation and peritonitis is increased. pathogenic organisms.
3. In clients with chronic liver problems, assess coagulation lab 3. Collect the sample from various areas of the stool.
values before procedure. 4. The result of the guaiac test for occult blood is positive when
4. Place client in semi-Fowler’s position. the paper turns blue.
5. Maintain sterile field for puncture. 5. Document medications and over-the-counter drugs client is
6. In clients with ascites, usually do not drain more than 1 L. taking when sample is obtained.
Complications 6. Sample should be approximately the size of a walnut or 30 mL,
1. Perforation of bowel: peritonitis. if soft.
2. Introduction of air into abdominal cavity; client may com-
plain of right referred shoulder pain (caused by air under the
diaphragm).
Appendix 18-2 ANTIEMETICS
MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONS

Dopamine Antagonists Depress or blocks dopamine receptors chemoreceptor trigger zone
of the brain.
Phenothiazines—suppress emesis Central nervous system 1. Subcutaneous injection or intravenous administration

Chlorpromazine hydrochloride depression, drowsiness, may cause tissue irritation and necrosis.
(Thorazine): PO, suppository, IM dizziness, blurred vision, 2. Use with caution in children; do not administer
Promethazine (Phenergan): PO, hypotension, photosensitivity Thorazine to infants less than 6 months old,
IM, suppository Compazine to children weighing less than 20 lb or
High-Alert Medication for IV route less than 2 years old, or Torecan to children less than
Prochlorperazine (Compazine): PO, 12 years old.
suppository, IM 3. Thorazine should be used only in situations of severe
Thiethylperazine maleate (Torecan): nausea or vomiting. Can also be used for intractable
PO, suppository, IM hiccups.
4. Torecan: cautious use in clients with liver and kidney
diseases.
Prokinetics—stimulate motility Restlessness, drowsiness, fatigue, 1. Used to decrease problems with esophageal reflux and
Metoclopramide (Reglan): PO, IM, anxiety, headache nausea and vomiting associated with chemotherapy.
IV 2. Use with caution in clients when increase in peristalsis
may be detrimental (perforation, obstruction).
Antihistamines Depress the chemoreceptor trigger zone, block histamine receptors.
Hydroxyzine (Atarax, Vistaril): PO, Sedation; anticholinergic 1. Caution client regarding sedation: should avoid
IM effects—blurred vision, dry activities that require mental alertness.
Dimenhydrinate (Dramamine, mouth, difficulty in urination 2. Administer early to prevent vomiting.
Marmine): PO, suppository, IM and constipation; paradoxical 3. Use with caution in clients with glaucoma and asthma.
excitation may occur in 4. Subcutaneous injection may cause tissue irritation and
children necrosis; use Z-track injection technique.
GI, Gastrointestinal; IM, intramuscular; IV, intravenous; PO, by mouth (oral).

Appendix 18-3 LAXATIVES
General Nursing Implications

— Laxatives should be avoided in clients who have nausea, vomiting, undiagnosed abdominal pain and
cramping, and/or any indications of appendicitis.
— Dietary fiber should be taken for prevention of, and as first-line treatment for, constipation.
— Daily intake of fluids should be increased.
— Constipation is determined by stool firmness and frequency.
— Increasing activity will increase peristalsis and decrease constipation.
— Narcotic analgesics and anticholinergics will cause constipation.
— A laxative should be used only briefly and in the smallest amount necessary.
— Use laxatives with caution during pregnancy.

Bulk laxatives—stimulate peristalsis and Esophageal irritation, 1. Not immediately effective; 12 to 24 hours before
passage of soft stool impaction, abdominal effects are apparent.
Methylcellulose (CITRUCEL) fullness, flatulence 2. Use with caution in clients with difficulty swallowing.
Psyllium (Metamucil, Perdiem) 3. Administer with full glass of fluid to prevent problems
Fibercon with irritation and impaction.
Bran
Surfactants—decrease surface tension, Occasional mild 1. Do not use concurrently with mineral oil.
allowing water to penetrate feces abdominal cramping 2. Not recommended for children less than 6 years old.
Docusate (Colace, Surfak)
Stimulants—stimulate and irritate the Diarrhea, abdominal 1. Use for short period of time.
large intestine to promote peristalsis cramping 2. Do not use in presence of undiagnosed abdominal
and defecation pain or GI bleeding.
Bisacodyl (Dulcolax): suppository, PO
Senna concentrate (Senokot, Ex-Lax):
PO, suppository
Bowel evacuants—nonabsorbable Nausea, bloating, 1. Primary use is in preparing the bowel for examination.
osmotic agents that pull fluid into abdominal fullness. 2. Clear liquids only (no gelatin with red coloring) after
the bowel administration.
Polyethylene glycol (GoLYTELY, 3. GoLYTELY requires the client to drink a large
Colyte): PO, NG amount of fluid (4 L); provide 8 to 10 oz chilled at a
Magnesium citrate: PO time to increase client consumption and enhance
taste.
4. Best if consumed over 3 to 4 hours.
5. Evacuants cause frequent bowel movements; advise
client to plan accordingly.
Appendix 18-4 ANTIDIARRHEAL AGENTS

Anhydrous morphine (Paregoric): Lightheadedness, dizziness, 1. Opioid derivatives, suppress peristalsis.
PO sedation, nausea, vomiting, 2. Not recommended during pregnancy or
paralytic ileus, abdominal breastfeeding.
cramping 3. Can produce drug dependence and mild
withdrawal symptoms.
4. Encourage increased fluids.
5. Avoid activities that require mental alertness.
Diphenoxylate HCl May precipitate constipation 1. Absorbent, has soothing effect, and absorbs toxic
Atropine (Lomotil): PO and an impaction substances.
Loperamide HCl (Imodium, 2. May interfere with absorption of oral medications.
Kaopectate II caplets): PO 3. Should not be given to clients with fever >101°.
Bismuth subsalicylate (Kaopectate, 4. Do not give in presence of bloody diarrhea.
Pepto-Bismol): PO
PO, by mouth (orally).
Appendix 18-5 ANTIULCER AGENTS

Antacid An alkaline substance that will neutralize gastric acid secretions; nonsystemic. Some
combination antacids also relieve gas, and some work as laxatives. Several antacids form a protective
coating on the stomach and upper GI tract.
Aluminum hydroxide (Amphojel) Constipation, phosphorus 1. Avoid administration within 1 to 2 hours of other
Aluminum hydroxide and depletion oral medications; should be taken frequently—before
magnesium salt combinations with long-term use and after meals and at bedtime.
(Gelusil, Maalox, Gaviscon) Constipation or diarrhea, 2. Instruct clients to take medication even if they do
hypercalcemia, renal calculi not experience discomfort.
3. Clients on low-sodium diets should evaluate sodium
content of various antacids.
4. Administer with caution to the client with cardiac
disease, because GI symptoms may be indicative of
cardiac problems.
Sodium preparations Rebound acid production, 1. Discourage use of sodium bicarbonate because of
Sodium bicarbonate (Rolaids, alkalosis occurrence of metabolic alkalosis and rebound acid
Tums): PO production.
Histamine H2 Receptor Antagonists Reduce volume and concentration of gastric

acid secretion.
Cimetidine (Tagamet): PO, IV, IM Rash, confusion, lethargy, 1. Take 30 minutes before or after meals.
diarrhea, dysrhythmias 2. May be used prophylactically or for treatment of
PUD.
3. Do not take with oral antacids.
Ranitidine (Zantac): PO, IM, IV Headache, GI discomfort, 1. Use with caution in clients with liver and renal
jaundice, hepatitis disorders.
2. Do not take with aspirin products.
3. Wait 1 hour after administration of antacids.
Nizatidine (Axid): PO Anemia, dizziness 1. Use with caution in clients with renal or hepatic
Famotidine (Pepcid): PO, IV Headache, dizziness, problems.
constipation, diarrhea 2. Dosing may be done with without regard to food or
to meal time.
3. Caution clients to avoid aspirin and other NSAIDs.
Appendix 18-5 ANTIULCER AGENTS—cont’d

Proton Pump Inhibitors Inhibit the enzyme that produces gastric acid.
Omeprazole (Prilosec): PO Headache, diarrhea, dizziness 1. Administer before meals.

Lansoprazole (Prevacid): PO 2. Do not crush or chew; do not open capsules.
3. Sprinkle granules of Prevacid over food; do
not chew granules.
4. The combination of omeprazole (Prilosec)
with clarithromycin (Biaxin) effectively treats
clients with Helicobacter pylori infection in
duodenal ulcer.
Cytoprotective Agents Bind to diseased tissue provides a protective barrier to acid.
Sucralfate (Carafate): PO Constipation, GI discomfort 1. Avoid antacids.

2. Used for prevention and treatment of stress ulcers,
gastric ulceration, and PUD.
3. May impede the absorption of medications that
require an acid medium.
Prostaglandin Analogues Suppresses gastric acid secretion; increases protective mucus and
mucosal blood flow.
Misoprostol (Cytotec) GI problems, headache 1. Contraindicated in pregnancy.

2. Indicated for prevention of NSAID-induced ulcers.
GI, Gastrointestinal; IM, intramuscular; IV, intravenous; NSAID, nonsteroidal antiinflammatory drug; PO, by mouth (orally); PUD, peptic ulcer disease.
Appendix 18-6 INTESTINAL MEDICATIONS
Intestinal Antibiotics Decrease bacteria in the GI tract; used to sterilize bowel before surgery.
Kanamycin sulfate (Kantrex): PO Suprainfection of the bowel 1. Do not have side effects of parenterally
Neomycin sulfate (Mycifradin administered aminoglycosides.
sulfate): PO
Paromomycin (Humatin): PO Vomiting and diarrhea 1. Administer with meals.

2. Administer with caution in clients with ulcerative
bowel disease.
5 Aminosalicylates (5 ASA) Antiinflammatory effect in small bowel and colon; used to treat
ulcerative colitis and Crohn’s disease.
Sulfasalazine (Azulfidine): PO Nausea, fever rash, arthalgia 1. Assess client for allergy to sulfur.
2. Should not be used with thiazide diuretics.
3. Monitor CBC; maintain adequate hydration.
4. May continue on medication to maintain remission.
Mesalamine (Asacol): PO, GI symptoms, headache 1. Suppository or enema has minimal systemic effects.
(Pentasa): PO enteric coated 2. Rectal administration is usually at night.
tablet
(Rowasa) Suppository or enema
Balsalazide (Colazal): PO Abdominal pain, headache
PO, By mouth (orally).

Appendix 18-7 PARENTERAL NUTRITION
▲ Parenteral Nutrition (PN) An intravenous (IV) delivery of is temporarily unavailable, give D10W or D20W until PN solu-
highly concentrated nutrients and vitamins. tion is available.
1. Goal is to provide adequate nutrition and to facilitate healing 7. Monitor intake and output and compare daily trends. Body
and growth of new body tissue. weight is an indication of the adequacy of hydration. Tissue
2. Conditions that interfere with the process of nutrition: inges- healing is an indication of adequacy of protein and positive
tion, digestion, absorption. nitrogen balance.
Goal: To maintain client in positive nitrogen balance and 8. Check label on bag of solution against orders; check solution
promote healing. for leaks, clarity, or color changes.
Routes of Administration Maintenance

1. Peripheral: Partial parenteral nutrition (PPN) is administered 1. A sterile occlusive dressing should be used at the catheter site;
via a large peripheral vein or peripherally inserted central cath- change site dressing every 48 to 72 hours or per facility
eter (PICC) when nutritional support is indicated for a short protocol.
period; may use IV fat (lipid) emulsions. 2. Change IV tubing every 24 hours or per facility protocol.
2. Central: Total parenteral nutrition (TPN) is administered via 3. Do not draw blood or measure central venous pressure (CVP)
a parenteral line (PICC, Hickman, Broviac, central line) from the PN line.
inserted in the antecubital, jugular, or subclavian vein and 4. Maintain record of daily weight; desired weight gain is approxi-
threaded into the vena cava; used for nutritional support in the mately 2 pounds per week.
client who requires in excess of 2500 calories per day for an
extended period. Solutions used are hypertonic with high ALERT Evaluate client’s nutritional status: monitor client’s
glucose content and require rapid dilution. response to TPN.
Nursing Implications
1. PN may be commercially prepared and then customized in the Complications
hospital pharmacy specifically for the client’s most recent blood 1. Hyperglycemia may be caused by too rapid infusion of solution.
analysis findings; nothing should be added to solution after it has Blood glucose is monitored every 4 to 6 hours during initial
been prepared in the pharmacy. infusion, and sliding scale insulin may be ordered.
2. Orders are written daily, based on the current electrolyte and 2. Fat emulsion syndrome may occur in clients receiving IV fat
protein status; always check the doctor’s order for correct fluid (lipid) emulsion. Monitor for fever, increased triglycerides, and
for the day. clotting problems.
3. Solution may be refrigerated for up to 24 hours, but solution 3. Refeeding syndrome is characterized by fluid retention, electro-
should be taken out of refrigeration 30 minutes prior to infu- lyte imbalances, and hyperglycemia; occurs in clients with
sion. If solution has been hanging for 24 hours, it should be chronic malnutrition states. Hypophosphatemia occurs and is
discarded and a new bag of solution hung. associated with dysrhythmias and respiratory complications.
4. Begin PN at a slow rate (40 to 60 mL per hour) and then gradu- 4. Site infection: Monitor site and change dressing according to
ally increase rate to prescribed infusion rate. Maintain constant policy; clients may be immunosuppressed and signs of infection
flow rate; if infusion of solution is behind, determine how much, may be masked. If infection is suspected (erythema, tenderness,
divide that amount over about 24 hours, and gradually increase exudates), a culture should be done and health care provider
rate to level of previous infusion order. Do not randomly accel- notified immediately.
erate the infusion to “catch up” over an hour; PN must be admin- Septicemia: Strong glucose solutions provide good media for
istered via an infusion pump. bacteria; strict aseptic techniques in dressing changes.
5. Monitor serum blood glucose levels on a regular basis; some 5. Air embolus or risk for pneumothorax (central line): Increased
institutions require glucose testing every 4 to 6 hours. May be tendency to occur during insertion of central catheter line and
less frequent after first week of administration. during dressing changes; place client in Trendelenburg position
6. Infusion is initiated and discontinued on a gradual basis to allow during insertion and during dressing changes (see Appendix
the pancreas to compensate for increased glucose intake. If TPN 6-10 for care of central line).
Appendix 18-8 NURSING PROCEDURE: NASOGASTRIC TUBES
1. Levin tube: Single lumen. d. Always validate placement of a nasogastric tube prior to
a. Suctioning gastric contents. instilling anything into tube.
b. Administering tube feedings. • Characteristics of nasogastric drainage.
c. Connect to intermittent suction. a. Normally is greenish yellow, with strands of mucus.
2. Salem sump tube: Double lumen (smaller blue lumen vents the b. Coffee-ground drainage: old blood that has been broken
tube and prevents suction on the gastric mucosa, maintains down in the stomach.
intermittent suction, regardless of suction source). c. Bright red blood: indicates bleeding in the esophagus, the
a. Suctioning gastric contents and maintaining gastric stomach, or the lungs.
decompression. d. Foul-smelling (fecal odor): occurs with reverse peristalsis in
b. Do not clamp, irrigate, or apply suction to air vent tube. bowel obstruction; increase in amount of drainage with
c. Connect to continuous low suction. obstruction.
• If duodenal placement is required, have client lay in right lateral
✓ KEY POINTS position for several hours. Provide enough excess in the tube to
allow the tube to migrate down into duodenum.
ALERT Insert feeding/nasogastric tubes and determine whether Clinical Tips for Problem Solving
characteristics of nasogastric drainage are with in normal limits. • Abdominal distention: Check for patency and adequacy of
drainage, determine position of tube, assess presence of bowel
• Before insertion, position the client in high-Fowler’s position, sounds, and assess for respiratory compromise from distention.
if possible. (If client cannot tolerate high-Fowler’s, place in left • Nausea and vomiting around tube: Place client in semi-Fowl-
lateral position.) er’s position or turn to side to prevent aspiration; suction oral
• Use a water-soluble lubricant to facilitate insertion. pharyngeal area. Attempt to aspirate gastric contents and vali-
• Measure the tube from the tip of the client’s nose to the earlobe date placement of tube. Tube may not be far enough into
and from the nose to the xiphoid process to determine the stomach for adequate decompression and suction; try reposi-
approximate amount of tube to insert to reach the stomach. tioning. If tube patency cannot be established, tube may need
• Insert the tube through the nose into the nasopharyngeal area; to be replaced.
flex the client’s head slightly forward. • Inadequate or minimal drainage: Validate placement and
• Secure the tube to the nose; do not allow the tube to exert pres- patency; tube may be in too far and be past pyloric valve or not
sure on the upper inner portion of the nares. in far enough and in the upper portion of the stomach. Reassess
• Validating placement of tube. length of tube insertion and characteristics of drainage, request
a. Aspirate gastric contents. x-ray for validation.
b. Measure pH of aspirated fluid (pH of gastric secretions is
ALERT ALWAYS check the placement of a gastric tube before
usually less than 4).
injecting or irrigating it; placement should be checked each shift;
c. It is no longer recommended to determine placement by inject-
do not adjust or irrigate the nasogastric tube on a client after a
ing air and listening with a stethoscope for sound of air in
gastric resection.
the stomach.
Appendix 18-9 NURSING PROCEDURE: ENTERAL FEEDING
Short-Term • Aspirate gastric contents to determine residual. If residual is

1. Nasogastric: Provides alternative means of ingesting nutrients more than 200 mL, and there are signs of intolerance (nausea,
for clients. vomiting, distention), hold next feeding for 1 hour and recheck
2. Nasointestinal: A weighted tube of soft material is placed in residual or, if residual is greater than half of last feeding, delay
the small intestine to decrease chance of regurgitation. A stylet next feeding for 1 to 2 hours.
or guide wire is used to progress the tube into the intestine. Do • Return aspirated contents to stomach to prevent electrolyte
not remove stylet until tube placement has been verified via imbalance.
x-ray. Do not attempt to reinsert stylet while tube is in place; • Flush the tube with 30 to 50 mL of water:
this could result in perforation of the tube. a. After each intermittent feeding.
b. Every 4 to 6 hours for continuous feeding.
Long-Term c. Before and after each medication administration.
1. Percutaneous endoscopic gastrostomy (PEG): A tube is • When a PEG or PEJ tube is placed, immediately after insertion
inserted percutaneously into the stomach; local anesthesia and measure the length of the tube from the insertion site to the
sedation are used for tube placement. distal end and mark the tube at the skin insertion site. This tube
2. Percutaneous endoscopic jejunostomy (PEJ): A tube is should be routinely checked to determine whether the tube is
inserted percutaneously into the jejunum. migrating from the original insertion point.
3. Gastrostomy: A surgical opening is made into the stomach, and • Prevent diarrhea:
a gastrostomy tube is positioned with sutures. a. Slow, constant rate of infusion.
b. Keep equipment clean to prevent bacterial contamination.
Methods of Administering Enteral Feedings c. Check for fecal impaction; diarrhea may be flowing around
• Continuous: Controlled with a feeding pump. Decreases nausea impaction.
and diarrhea. d. Identify medical conditions that would precipitate diarrhea.
• Intermittent: Prescribed amount of fluid infuses via a gravity • For continuous feeding, change feeding reservoir every 24
drip or feeding pump over specific time. For example, 350 mL hours.
is given over 30 minutes.
• Cyclic: Involves feeding solution infused via a pump for a part
of a day, usually 12 to 16 hours. This method may be used for NURSING PRIORITY If in doubt of a tube’s placement or
weaning from feedings. position, stop or hold the feeding and obtain x-ray confirmation of
Nursing Implications location.
• The client should be sitting or lying with the head elevated 30
to 45°. Head of bed should remain elevated for 30 to 60 minutes
after feeding if intermittent or cyclic feeding is used.
• If feedings are intermittent, tube should be irrigated with water ALERT Change rate and amount of tube feeding based on
before and after feedings. client’s response.
Appendix 18-10 NURSING PROCEDURE: ENEMAS
Types of Enemas to stimulate peristalsis. Repeated multiple times by raising and

Soap suds enema: Castile soap is added to tap water or normal lowering container until flatus is expelled and abdominal disten-
saline. Dilute 5 mL of castile soap in 1 liter of water. tion is relieved.
Tap water enema: Request order for specific quantity when
administered to infants or children; should not be repeated ✓ KEY POINTS: Administering an Enema
because of risk for water toxicity. Use caution when administer- • Fill enema container with warmed solution.
ing to adults with altered cardiac and renal reserve. • Allow solution to run through the tubing before inserting into
Saline enemas: Are the safest enemas to administer; safe for rectum so that air is removed.
infants and children. • Place client on left lateral Sims’ position.
Retention enema: An oil-based solution that will soften the stool. • Generously lubricate the tip of the tubing with water-soluble
Should be retained by client 30 to 60 minutes. Typically 150 to lubricant.
200 mL. May be mineral oil or similar oil; or may include anti- • Gently insert tubing into client’s rectum (3 to 4 inches for adults,
biotics or nutritive solution. 1 inch for infants, 2 to 3 inches for children), past the external
Hyptertonic enema: Used when only a small amount of fluid is and internal sphincters.
tolerated (120-180 mL). Commercially prepared Fleets enema. • Raise the solution container no more than 12 to 18 inches above
Carminative enema: An agent used to expel gas from the GI tract. the client.
Example is magnesium sulfate/glycerin/water (MGW). • Allow solution to flow slowly. If the flow is slow, the client will
Harris flush or return flow enema: Mild colonic irrigation of 100 experience fewer cramps. The client will also be able to tolerate
to 200 mL of fluid into and out of the rectum and sigmoid colon and retain a greater volume of solution.
Appendix 18-10 NURSING PROCEDURE: ENEMAS—cont’d
Clinical Tips for Problem Solving If client complains of abdominal cramping during instillation of
If client expels solution prematurely: fluid:
• Place client in supine position with knees flexed. • Slow the infusion rate by lowering the fluid bag.
• Slow the water flow and continue with the enema.
If the enema returns contain fecal material before surgery or diag-
nostic testing, repeat enema. If, after three enemas, returns still ALERT Assist and intervene with client who has an alteration in
contain fecal material, notify physician. elimination.
Appendix 18-11 NURSING PROCEDURE: STOOL SPECIMEN
Types of Stool • Collect stool specimen in a clean, dry container. If stool is to be

• Normal → semisoft to semisolid, brown color evaluated for organisms, use a sterile container. Use a tongue
• Narrow, ribbon-like stool → spastic or irritable bowel, or blade to obtain specimens from several areas of the stool and
obstruction place in the stool collection container.
• Diarrhea → spastic bowel, viral infection • The client collecting a stool specimen for an occult blood test
• Blood and mucus, soft stool → bacterial infection needs to follow directions regarding diet restrictions (no red
• Mixed blood or pus → colitis meat, beets, or foods that may cause the stool to turn red or lead
• Yellow or green stool → severe, prolonged diarrhea; rapid transit to a false-positive result).
through bowel • Stool specimen should be approximately size of a walnut. If stool
• Black stool → gastrointestinal bleeding or intake of iron is liquid, approximately 30 mL is needed.
supplements • Take the specimen to the laboratory. Do not allow it to remain
• Tan, clay-colored, or white stool → liver or gallbladder in unit.
problems
• Red stool → colon or rectal bleeding; some medications and
foods may also cause a red coloration ALERT Obtain specimen from client for laboratory tests.
• Fatty stool, pasty or greasy → intestinal malabsorption, pancre-
atic disease
✓ KEY POINTS: Collecting the Specimen

• Always wear gloves during procedure.
• Use clean bedpan or bedside commode to collect stool; do not
use stool that has been in contact with toilet bowl water or urine.
Appendix 18-12 NURSING PROCEDURE: CARE OF THE CLIENT WITH AN OSTOMY
Types of Ostomies (Figure 18-8) Preoperative Care

Colostomy: Opening of the colon through the abdominal wall; 1. Preoperative education: Actively involve family and client;
stool is generally semisoft and bowel control may be achieved. encourage questions concerning the procedure.
Ileostomy: Opening of the ileum through the abdominal 2. Placement of stoma is evaluated, and site is selected with client
wall; stool drainage is liquid and excoriating; drainage is fre- standing. Select a site that is easily seen and accessible to client;
quently continuous; therefore it is difficult to establish bowel select a flat area of the abdomen, avoiding skin creases and folds;
control. Fluid and electrolyte imbalances are common select site that does not interfere with clothing.
complications.
Kock’s ileostomy: May be referred to as a “continent” ileos- ✓ KEY POINTS: Postoperative Nursing Implications—
tomy; an internal reservoir for stool is surgically formed. Initial Care
Decreases problem of skin care caused by frequent irritation of • Evaluate stoma every 8 hours after surgery. It should remain
stoma by drainage. Primary complications are leakage at the pink and moist; dark blue stoma indicates ischemia.
stoma site and peritonitis. • Measure the stoma and select an appropriately sized appliance.
Mild to moderate swelling is common for the first 2 to 3 weeks
Goals after surgery, which necessitates changes in size of the
1. Maintain physiologic and psychologic equilibrium. appliance.
2. Assist client to maintain total care of colostomy or ileostomy • Appliance should fit easily around the stoma and cover all
before discharge. healthy skin.
Continued
Appendix 18-12 NURSING PROCEDURE: CARE OF THE CLIENT WITH AN OSTOMY—cont’d
The ascending colostomy The transverse (double- The transverse loop

is done for right-sided tumors. barreled) colostomy is colostomy has two openings
often used in such emergen- in the transverse colon, but one
cies as intestinal obstruction stoma. Usually temporary.
or perforation because it
can be created quickly.
There are two stomas. The
proximal one, closest to the
small intestine, drains feces.
The distal stoma drains
mucus. Usually temporary.
Descending colostomy Sigmoid colostomy
FIGURE 18-8 Types of colostomies. (From Monahan FD et al: Phipps’ medical-surgical nursing: health and illness perspectives, ed 8, St. Louis,
2007, Mosby.)
• Keep the skin around the stoma clean, dry, and free of stool and • Assist the client to control odors: diet and odor-control tablets.
intestinal secretions. Prevent contamination of the abdominal • Kock’s ileostomy is drained when client experiences fullness. A
incision. nipple valve is created in surgery and drained by insertion of a
• Change the skin appliance only when it begins to leak or catheter.
becomes dislodged.
• Ostomy bags should be changed when about one-third full to Clinical Tips for Problem Solving
avoid weight of bag dislodging skin barrier. If water does not flow easily into colostomy stoma:
• Check for kinks in tubing from container.
✓ KEY POINTS: Irrigation • Check height of irrigating container.
• Do not irrigate an ileostomy or maintain regular irrigations in • Encourage client to change positions, relax, and take a few deep
child with colostomy. breaths.
• Irrigate colostomy at same time each day to assist in establishing If client experiences cramping, nausea, or dizziness during
a normal pattern of elimination. irrigation:
• Involve client in care as early as possible. • Stop flow of water, leaving irrigation cone in place.
• In adults, irrigate with 500 to 1000 mL of warm tap water. • Do not resume until cramping has passed.
• Check water temperature and height of water bag; if water is
NURSING PRIORITY Use a cone tipped ostomy irrigator; do too hot or flows too rapidly, it can cause dizziness.
not use an enema tube/catheter. If client has no return of stool or water from irrigation:
Do not irrigate more than once a day. • Be sure to apply drainable pouch; solution may drain as client
Do not irrigate in the presence of diarrhea. moves around.
• Have client increase fluid intake; he or she may be
• Place the client in a sitting position for irrigation, preferably in dehydrated.
the bathroom with the irrigation sleeve in the toilet. • Repeat irrigation next day.
• Elevate the solution container approximately 12 to 20 inches If diarrhea occurs:
and allow solution to flow in gently. If cramping occurs, lower • Do not irrigate colostomy.
fluid or clamp the tubing. • Check client’s medications; sometimes they may cause
• Allow 25 to 45 minutes for return flow. Client may want to walk diarrhea.
around before the return starts. • If diarrhea is excessive and/or prolonged, notify physician.
• Encourage client to participate in care of his or her own colos-
tomy. Have client perform return demonstration of colostomy
irrigation before leaving the hospital. ALERT Provide ostomy care.
Study Questions Gastrointestinal System More questions on

companion CD!
1. On the second day after gastric resection, the client’s 6. An obese client has had a combination restrictive
nasogastric tube is draining bile-colored liquid contain- malabsorptive bariatric surgery. What will be important
ing coffee-ground material. What is the best nursing for the nurse to include in discharge teaching for this
action? client?
1 Continue to monitor the amount of drainage and 1 Increase intake of foods high in iron, calcium, and
correlate it with any change in vital signs. vitamin B12 to prevent deficiencies.
2 Reposition the nasogastric tube and irrigate the tube 2 Do not take any added fluids with meals or imme-
with normal saline solution. diately after meals.
3 Call the physician and discuss the possibility that 3 Elevate bed to prevent development of gastroesoph-
the client is bleeding. ageal reflux during sleep.
4 Irrigate the nasogastric tube with iced saline solu- 4 Plan intake of three balanced meals a day with
tion and attach the tube to gravity drainage. increased fluids between meals.
2. The nurse is providing preoperative care for a client who 7. In planning discharge teaching for the client who has
will have a gastric resection. What will the preoperative undergone a gastrectomy, the nurse includes what infor-
teaching include? mation regarding dumping syndrome?
1 A nasogastric tube will be in place several days after 1 The syndrome will be a permanent problem, and the
surgery. client should eat 5 to 6 small meals per day.
2 The client will be started on a low-residue, bland 2 The client should decrease the amount of fluid con-
diet about 2 days after the surgery. sumed with each meal and for 1 hour after each
3 Explain the anticipated prognosis and implications meal.
that the client may have a malignancy. 3 The client should increase the amount of complex
4 A urinary retention catheter will be in place for 1 carbohydrates and fiber in the diet.
week after surgery. 4 Activity will decrease the problem; it should be
3. The nurse is planning care for a client scheduled for scheduled about 1 hour after meals.
gastroduodenoscopy and a barium swallow. What will 8. The nurse is assessing a child with a tentative diagnosis
the nursing care plan include? of appendicitis. The nursing assessment is most likely
1 Anticipating the client will receive a low-residue to reveal what characteristics concerning the pain?
diet in the evening and then receive nothing by 1 Rebound tenderness in the right lower quadrant,
mouth (NPO status) 6 to 12 hours before the test. associated with decreased bowel sounds and
2 Discussing with the client the nasogastric tube and vomiting
the importance of gastric drainage for 24 hours after 2 Gnawing pain, radiating through to the lower back,
the test. with severe abdominal distention
3 Explaining to the client that he will receive nothing 3 Sharp pain with severe gastric distention, frequently
by mouth (NPO status) for 24 hours after the test associated with hemoptysis
to make sure his stomach can tolerate food. 4 Pain on light palpation in midepigastric area,
4 Discussing the general anesthesia and explaining to chronic low-grade fever, and diarrhea
the client that he will wake up in the recovery room 9. The nurse is caring for a client who has been diagnosed
4. In preparing a pediatric client for an appendectomy, the with a bleeding duodenal ulcer. What data identified on
nurse would question which doctor’s orders? a nursing assessment would indicate an intestinal per-
1 Penicillin 600,000 units IVPB, now foration and require immediate nursing action?
2 Obtain signed consent form from parents. 1 Increasing abdominal distention, with increased
3 Administer enemas until clear. pain and vomiting
4 500 mL Ringer’s lactate solution at 50 mL/hr 2 Decreasing hemoglobin and hematocrit with bloody
5. What are the best nursing actions in caring for a client stools
with appendicitis before surgery? 3 Diarrhea with increased bowel sounds and
Select all that apply: hypovolemia
______ 1 Maintain bed rest. 4 Decreasing blood pressure with tachycardia and
______ 2 Offer full liquids to maintain hydration. disorientation
______ 3 Position client on side, legs flexed to the 10. The nurse is caring for a client who is scheduled for a
abdomen with the head slightly elevated. gastric endoscopy. Which of the following actions must
______ 4 Position client on left side; apply a warm the nurse perform before the client is able to eat or drink
K-Pad to the abdomen. after the endoscopy?
______ 5 Administer narcotic for pain and allow client 1 Check oxygen saturation.
to assume position of comfort. 2 Give small sips of water.
______ 6 Maintain NPO and begin a peripheral IV for 3 Check all vital signs.
fluid replacement. 4 Assess the client’s gag reflex.
11. A client is admitted with duodenal ulcers. What will 15. The nurse is assisting a client immediately before a
the nurse anticipate the client’s history to include? colonoscopy. The nurse will direct the client and help
1 Recent weight loss him move into what position?
2 Increasing indigestion after meals 1 Prone
3 Awakening with pain at night 2 Sims’ lateral
4 Episodes of vomiting 3 Slight Trendelenburg
12. The nurse is preparing discharge teaching for a client 4 Flat with lithotomy stirrups
with a diagnosis of gastroesophageal reflux disease 16. What will be important for the nurse to do when col-
(GERD). What would be important for the nurse to lecting a stool specimen for an occult blood (Hemoc-
include in this teaching plan? Select all that apply: cult) test?
______ 1 Elevate the head of the bed. 1 Samples should be taken from two areas of the stool.
______ 2 Decrease intake of caffeine products. 2 Three separate stool samples will be required for
______ 3 Take an antacid before bedtime. accuracy of test.
______ 4 Increase fluid intake with meals. 3 The nurse should collect about 20 mL of stool
______ 5 Take ranitidine (Zantac) at bedtime. sample.
______ 6 Eat a bedtime snack of milk and protein. 4 Any red color on or near the specimen is considered
13. The nurse is conducting discharge dietary teaching for positive.
a client with diverticulosis who is recovering from an 17. A school-age child with a diagnosis of celiac disease asks
acute episode of diverticulitis. Which statement by the the nurse, “Which foods will make me sick?” Which of
client would indicate to the nurse that the client under- the following food items would the nurse teach the child
stood his dietary teaching? to avoid?
1 “I will need to increase my intake of protein and 1 Rice cereals, milk, and tapioca
complex carbohydrates to increase healing.” 2 Corn cereals, milk, and fruit
2 “I need to eat foods that contain a lot of fiber to 3 Corn or potato bread and peanut butter
prevent problems with constipation.” 4 Malted milk, white bread, and spaghetti
3 “I will not put any added salt on my food, and I will 18. The nurse practitioner orders half-strength enteral
decrease intake of foods that are high in saturated formula at a rate of 55 mL/hr. A can holds 250 mL.
fat.” How many cans would the nurse need for the next 24
4 “Milk and milk products can cause a lactose intoler- hours?
ance. If this occurs, I need to decrease my intake of Answer: ______ cans
these products.”
14. What is the priority nursing action for the client who Answers and rationales to these questions are in the section at
is complaining of nausea in the recovery room after the end of the book titled Chapter Study Questions: Answers
gastric resection? and Rationales.
1 Evaluate the nasogastric tube for patency.
2 Call the physician for an antiemetic order.
3 Place client in semi-Fowler’s position so that he will
not aspirate.
4 Medicate the client with a narcotic analgesic.

Gastrointestinal System: Chapter Eighteen

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Gastrointestinal System: Chapter Eighteen

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CHAPTER EIGHTEEN

PHYSIOLOGY OF THE 4. Previous problems associated with GI tract, including

b. Begin in area of least discomfort; if there is a

3. Hematemesis: presence of blood in vomitus.

3. Medications (antibiotics and antacids).

Goal: To prevent spread of diarrhea. Assessment

Delayed LES Nursing Interventions

G. Decrease intake of highly seasoned foods and tomato

B. Clinical manifestations. 3. Combination of restrictive and malabsorptive surgery:

Treatment Nursing Interventions

Box 18-3 DUMPING SYNDROME

2. Decrease or stop smoking. b. Fluid volume replacement.

ALERT Monitor and maintain GI drainage. Distention and

C. Assess continuously for:

5. Side-lying position with knees flexed. E. Do not administer enemas.

Assessment 2. Abdominal CT and ultrasonography.

PERITONITIS “HOT BELLY”

Risk Factors H...

Goal: To reduce infectious process. C. Severe diverticulitis.

Assessment C. Weight reduction, if indicated.

Assessment 2. Total removal of colon, rectum, and anus with forma-

4. Colicky-type abdominal pain. H. Measure abdominal girth to determine whether disten-

common hernia in infants; may occur in adults when Assessment

C. Most common areas of metastasis include regional

Nursing Interventions Nursing Interventions

Appendix 18-1 GASTROINTESTINAL SYSTEM DIAGNOSTICS

X-Ray 3. Client should avoid aspirin, NSAIDs, iron supplements, and

Appendix 18-1 GASTROINTESTINAL SYSTEM DIAGNOSTICS—cont’d

Appendix 18-2 ANTIEMETICS

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONS

Phenothiazines—suppress emesis Central nervous system 1. Subcutaneous injection or intravenous administration

Antihistamines Depress the chemoreceptor trigger zone, block histamine receptors.

GI, Gastrointestinal; IM, intramuscular; IV, intravenous; PO, by mouth (oral).

Appendix 18-3 LAXATIVES

General Nursing Implications

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONS

Appendix 18-4 ANTIDIARRHEAL AGENTS

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONS

PO, by mouth (orally).

Appendix 18-5 ANTIULCER AGENTS

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONS

Histamine H2 Receptor Antagonists Reduce volume and concentration of gastric

Appendix 18-5 ANTIULCER AGENTS—cont’d

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONS

Omeprazole (Prilosec): PO Headache, diarrhea, dizziness 1. Administer before meals.

Cytoprotective Agents Bind to diseased tissue provides a protective barrier to acid.

Sucralfate (Carafate): PO Constipation, GI discomfort 1. Avoid antacids.

Misoprostol (Cytotec) GI problems, headache 1. Contraindicated in pregnancy.

Appendix 18-6 INTESTINAL MEDICATIONS

Paromomycin (Humatin): PO Vomiting and diarrhea 1. Administer with meals.

PO, By mouth (orally).

Appendix 18-7 PARENTERAL NUTRITION

Routes of Administration Maintenance

Appendix 18-8 NURSING PROCEDURE: NASOGASTRIC TUBES

Appendix 18-9 NURSING PROCEDURE: ENTERAL FEEDING

Short-Term • Aspirate gastric contents to determine residual. If residual is

Appendix 18-10 NURSING PROCEDURE: ENEMAS

Types of Enemas to stimulate peristalsis. Repeated multiple times by raising and