NCLEX: Gastrointestinal disorders

Gastrointestinal disorders: Nursing diagnoses

Focus topic: Gastrointestinal disorders

The following nursing diagnoses are commonly used in patients with GI disorders. For each diagnosis, you’ll also find nursing interventions with rationales.

Gastrointestinal disorders: Constipation

Focus topic: Gastrointestinal disorders

Related to inadequate intake of fluid and bulk, Constipation may pertain to all patients undergoing periods of restricted food or fluid intake.

Expected outcomes
• Patient expresses decreased feelings of constipation.
• Patient reports a more regular bowel elimination pattern.
• Patient identifies proper methods used to help promote a regular bowel pattern.

Nursing interventions and rationales
• Record intake and output accurately to ensure correct fluid replacement therapy.
• Note the color and consistency of stool and frequency of bowel movements to form the basis of an effective treatment plan.

• Promote ample fluid intake, if appropriate, to minimize constipation with increased intestinal fluid content.
• Encourage the patient to increase dietary intake of fiber to improve intestinal muscle tone and promote comfortable elimination.
• Discourage routine use of laxatives and enemas to avoid trauma to intestinal mucosa, dehydration, and eventual failure of defecation stimulus. (Bulk-adding laxatives aren’t irritating and are usually permitted.)
• Encourage the patient to walk and exercise as much as possible to stimulate intestinal activity.
• Encourage the patient to take the time necessary each day to have a bowel movement to help promote a regular bowel pattern.

Gastrointestinal disorders: Diarrhea

Focus topic: Gastrointestinal disorders

Related to malabsorption, inflammation, or irritation of the bowel, Diarrhea may be associated with irritable bowel syndrome, colitis, Crohn’s disease, and other conditions.

Expected outcomes
• Patient reports cessation of diarrhea as evidenced by formed stool.
• Patient identifies proper methods for treating diarrhea.

Nursing interventions and rationales
• Assess the patient’s level of dehydration and electrolyte status. Fluid loss secondary to diarrhea can be life-threatening.
• Monitor the patient’s weight daily to detect fluid loss or retention.
• Note the color and consistency of stool and frequency of bowel movements to monitor treatment effectiveness.
• Test stool for occult blood, and obtain stool for culture to help evaluate factors contributing to diarrhea.
• Assess for fecal impaction. Liquid stool may seep around an impaction.

Fluids are fine, but forget fiber

Focus topic: Gastrointestinal disorders

For acute diarrhea, provide the following dietary regimen:

  • Give clear fluids, including glucose, electrolyte-containing beverages, and commercial rehydration preparations, orally. Clear fluids provide rapidly absorbed calories and electrolytes with minimal stimulation. After diarrhea has stopped for 24 to 48 hours, progress to a full fluid diet, then to a regular diet.
  • Avoid milk, caffeine, and high-fiber foods for 1 week to avoid irritating the intestinal mucosa.
  • In chronic diarrhea, encourage the patient to avoid foods and activities that may cause diarrhea. His awareness and self-regulation of contributing factors help manage chronic diarrhea.

Ineffective tissue perfusion: GI

Focus topic: Gastrointestinal disorders

Related to reduced blood flow, Ineffective tissue perfusion: GI may be associated with cirrhosis, hepatic failure, and other conditions.

Expected outcomes
• Patient maintains adequate blood flow to the intestinal mucosa.
• Patient identifies reportable symptoms such as pain after eating.

Nursing interventions and rationales
• Assess the patient for bowel sounds, increasing abdominal girth, pain, nausea and vomiting, and electrolyte imbalance. Acute changes may indicate a surgical emergency due to ischemia.
• If the patient has a chronic circulatory problem, provide small, frequent feedings of light, bland foods to promote digestion. Also, encourage rest after feedings to maximize blood flow available for digestion.

Gastrointestinal disorders: Bowel incontinence

Focus topic: Gastrointestinal disorders

Related to neuromuscular involvement, Bowel incontinence may be seen in patients who have had a hemorrhoidectomy, radical prostatectomy, or abdominal perineal resection.

Expected outcomes
• Patient remains continent of stool.
• Patient identifies measures to help maintain bowel schedule.

Nursing interventions and rationales
• Establish a schedule for defecation — 1/2 hour after a meal works well for active peristalsis. A regular pattern encourages adaptation and routine physiologic function.
• Instruct the patient to use the bathroom or commode if possible to allow easy defecation without anxiety.

• If bedpan use is necessary, assist the patient to the most normal position possible for defecation to increase comfort and reduce anxiety.
• Instruct the patient to bear down or help him lean his trunk forward to increase intra-abdominal pressure.
• If necessary, use a glycerine suppository or gentle manual stimulation with a lubricated finger in the anal sphincter to encourage regular physiologic function, stimulate peristalsis, minimize infection, and promote comfort with elimination.
• Provide skin care to prevent infection and promote comfort.
• Refrain from commenting about “accidents” to avoid embarrassing the patient and help promote his self-image.

Gastrointestinal disorders: Common GI disorders

Focus topic: Gastrointestinal disorders

Below are several common GI disorders, along with their causes, pathophysiology, signs and symptoms, diagnostic test findings, treatments, and nursing interventions.

Gastrointestinal disorders: Appendicitis

Focus topic: Gastrointestinal disorders

Appendicitis occurs when the appendix becomes inflamed. It’s the most common major surgical emergency. More precisely, this disorder is an inflammation of the vermiform appendix, a small, finger-like projection attached to the cecum just below the ileocecal valve. The appendix may harbor good bacteria that protect the gut and play a role in the immune system.

What causes it
Causes of appendicitis include:
• mucosal ulceration
• fecal mass (fecalith)
• stricture
• barium ingestion
• viral infection.

Mucosal ulceration triggers inflammation, which temporarily obstructs the appendix. The obstruction blocks mucus outflow. Pressure in the now-distended appendix increases, and the appendix contracts. Bacteria multiply, and inflammation and pressure continue to increase, restricting blood flow to the organ and causing severe abdominal pain.

Inflammation can lead to infection, clotting, tissue decay, and perforation of the appendix. If the appendix ruptures or perforates, the infected contents spill into the abdominal cavity, causing peritonitis, the most common and dangerous complication.

What to look for
Initially, the patient may manifest these signs and symptoms:
• abdominal pain, generalized or localized in the right upper abdomen, eventually localizing in the right lower abdomen (McBurney’s point)
• anorexia
• nausea and vomiting
• board-like abdominal rigidity
• retractive respirations
• increasingly severe abdominal spasms and rebound spasms. (Rebound tenderness on the opposite side of the abdomen suggests peritoneal inflammation.)
Later symptoms include:
• constipation (although diarrhea is also possible)
• fever of 99º to 102º F (37.2º to 38.9º C)
• tachycardia

• sudden cessation of abdominal pain (indicates perforation or infarction of the appendix).

Gastrointestinal disorders

What tests tell you
• White blood cell (WBC) count is moderately elevated, with increased immature cells.
• Ultrasound of the abdomen and pelvis can help diagnose a nonperforated appendix. CT scan can help to identify abscess.

How it’s treated
An appendectomy is the only effective treatment for appendicitis. If peritonitis develops, treatment involves GI intubation, parenteral replacement of fluids and electrolytes, and administration of antibiotics.

What to do
For suspected appendicitis or to prepare for appendectomy
• Administer I.V. fluids to prevent dehydration. Never administer cathartics or enemas because they may rupture the appendix.
• Give the patient nothing by mouth, and administer analgesics judiciously because they may mask symptoms of rupture.
• Place the patient in Fowler’s position to reduce pain. (This is also helpful postoperatively.) Never apply heat to the lower right abdomen or perform palpation; these actions may cause the appendix to rupture.

After an appendectomy
• Monitor the patient’s vital signs and intake and output.
• Give analgesics, as ordered.
• Document bowel sounds, passing of flatus, or bowel movements — signs of peristalsis return. If these signs appear in a patient whose nausea and abdominal rigidity have subsided, he’s ready to resume oral fluids.
• Watch closely for possible surgical complications. Continuing pain and fever may signal an abscess. The complaint that “something gave way” may mean wound dehiscence. If an abscess or peritonitis develops, incision and drainage may be necessary. Frequently assess the dressing for wound drainage.
• If peritonitis complicates appendicitis, the patient may need an NG tube to decompress the stomach and reduce nausea and vomiting. If so, record drainage, and provide good mouth and nose care.

• Evaluate the patient. He should demonstrate appropriate activity restrictions, be able to resume a normal diet and bowel elimination pattern, and understand the importance of follow-up care.

Gastrointestinal disorders: Gallbladder and biliary tract disorders

Focus topic: Gastrointestinal disorders

Gallbladder and biliary tract disorders, such as cholecystitis, cholelithiasis, choledocholithiasis, and cholangitis, are common, painful conditions that usually require surgery and may be life-threatening. They typically accompany calculus deposition and inflammation.

What causes it
The exact cause of cholecystitis is unknown; risk factors include:
• a high-calorie, high-cholesterol diet, associated with obesity
• elevated estrogen levels from hormonal contraceptives, postmenopausal therapy, pregnancy, or multiparity
• diabetes mellitus, ileal disease, hemolytic disorders, liver disease, or pancreatitis
• genetic factors
• weight-reduction diets with severe calorie restriction and rapid weight loss.

Certain conditions (such as age, obesity, and estrogen imbalance) cause the liver to secrete bile that’s abnormally high in cholesterol or that lacks the proper concentration of bile salts. Excessive water and bile salts are reabsorbed, making the bile less soluble. Cholesterol, calcium, and bilirubin then precipitate into gallstones.

What to look for
In acute cholecystitis, acute cholelithiasis, and choledocholithiasis, look for:
• the classic attack with severe midepigastric or right upper quadrant pain radiating to the back or referred to the right scapula, commonly after meals rich in fats
• recurring fat intolerance
• belching that leaves a sour taste in the mouth
• flatulence
• indigestion
• diaphoresis

• nausea
• chills and low-grade fever
• possible jaundice and clay-colored stools with common duct obstruction.

Gastrointestinal disorders

The gist of cholangitis

Focus topic: Gastrointestinal disorders

In cholangitis, look for:
• abdominal pain
• high fever and chills
• possible jaundice and related itching
• weakness and fatigue.

Ileus ailments

Focus topic: Gastrointestinal disorders

In gallstone ileus, look for:
• nausea and vomiting
• abdominal distention
• absent bowel sounds (in complete bowel obstruction)
• intermittent colicky pain over several days.

Gastrointestinal disorders

What tests tell you
• Ultrasonography reveals calculi in the gallbladder with 96% accuracy. PTHC distinguishes between gallbladder disease and cancer of the pancreatic head in patients with jaundice.

• CT scan may identify ductal stones.
• ERCP visualizes the biliary tree after endoscopic examination of the duodenum, cannulation of the common bile and pancreatic ducts, and injection of a contrast medium.
• Cholescintigraphy detects obstruction of the cystic duct.
• If stones are identified in the common bile duct by radiologic examination, a therapeutic ERCP may be performed before cholecystectomy to remove the stones.
• Oral cholecystography shows calculi in the gallbladder and biliary duct obstruction.
• Laboratory tests showing an elevated icteric index and elevated total bilirubin, urine bilirubin, and alkaline phosphatase levels support the diagnosis.
• WBC count is slightly elevated during a cholecystitis attack.
• Serum amylase levels distinguish gallbladder disease from pancreatitis.
• Serial enzyme tests and an electrocardiogram (ECG) should precede other diagnostic tests if heart disease is suspected.

How it’s treated
Several treatments exist for gallbladder and biliary tract disorders:
• Surgery, usually elective, is the treatment of choice for gallbladder and duct disease. Procedures may include cholecystectomy, cholecystectomy with operative cholangiography and, possibly, exploration of the common bile duct.
• A low-fat diet is prescribed to prevent attacks as well as vitamin K for itching, jaundice, and bleeding tendencies caused by vitamin K deficiency.
• During an acute attack, treatment may include insertion of an NG tube and I.V. line as well as antibiotic administration.
• A nonsurgical treatment for choledocholithiasis involves insertion of a flexible catheter, formed around a T tube, through the sinus tract into the common bile duct. Guided by fluoroscopy, the doctor directs the catheter toward the stone. A Dormia basket is threaded through the catheter to entrap the calculi.

That’s really trippy — I mean, tripsy

  • Lithotripsy, the ultrasonic breakup of gallstones, is usually unsuccessful and has a significant recurrence rate. The relative ease, short length of stay, and cost-effectiveness of laparoscopic cholecystectomy have made dissolution and lithotripsy less viable options.

What to do
• For information on preoperative and postoperative care of surgical patients.
• Evaluate the patient. He should return to normal nutrition and hydration status, be free from complications, and be able to tolerate normal activity and follow diet restrictions.

Gastrointestinal disorders: Cirrhosis

Focus topic: Gastrointestinal disorders

Cirrhosis, a chronic liver disease, is characterized by widespread destruction of hepatic cells, which are replaced by fibrous cells. This process is called fibrotic regeneration. Cirrhosis is a common cause of death in the United States and, among people ages 35 to 55, the fourth leading cause of death. It can occur at any age.

What causes it
There are many types of cirrhosis, and causes differ with each type:
• Laënnec’s cirrhosis (also known as portal, nutritional, or alcoholic cirrhosis), the most common type of cirrhosis, results from malnutrition (especially of dietary protein) and chronic alcohol ingestion.
• Biliary cirrhosis results from bile duct diseases.
• Pigment cirrhosis may stem from disorders such as hemochromatosis.
• Other causes of cirrhosis include drug- or toxin-induced hepatic failure and chronic right-sided heart failure.
• In about 10% of patients, cirrhosis has no known cause.

Cirrhosis is characterized by irreversible chronic injury of the liver, extensive fibrosis, and nodular tissue growth. These changes result from:
• liver cell death (hepatocyte necrosis)
• collapse of the liver’s supporting structure (the reticulin network)
• distortion of the vascular bed (blood vessels throughout the liver)
• nodular regeneration of the remaining liver tissue.

First one thing, then another

Focus topic: Gastrointestinal disorders

When the liver begins to malfunction, blood clotting disorders (coagulopathies), jaundice, edema, and many metabolic problems develop. Fibrosis and the distortion of blood vessels may impede
blood flow in the capillary branches of the portal vein and hepatic artery, leading to portal hypertension (elevated pressure in the portal vein). Increased pressure may lead to the development of esophageal varices — enlarged, tortuous veins in the lower part of the esophagus where it meets the stomach. Esophageal varices may easily rupture and leak large amounts of blood into the upper GI tract.

Gastrointestinal disorders


What to look for
Cirrhosis affects many body systems. Assess the patient for these signs and symptoms:
• GI (usually early and vague) — anorexia, indigestion, nausea and vomiting, constipation or diarrhea, dull abdominal ache
• respiratory — pleural effusion, limited thoracic expansion
• central nervous system — progressive signs and symptoms of hepatic encephalopathy, including lethargy, mental changes, slurred speech, asterixis (flapping tremor), peripheral neuritis, paranoia, hallucinations, extreme obtundation, coma
• hematologic — bleeding tendencies (nosebleeds, easy bruising, bleeding gums), anemia
• endocrine — testicular atrophy, menstrual irregularities, gynecomastia, loss of chest and axillary hair
• skin — severe pruritus, extreme dryness, poor tissue turgor, abnormal pigmentation, spider angiomas, palmar erythema, possibly j aundice
• hepatic — jaundice, hepatomegaly, ascites, edema of the legs
• miscellaneous — musty breath, enlarged superficial abdominal veins, muscle atrophy, pain in the right upper abdominal quadrant that worsens when the patient sits up or leans forward, palpable liver or spleen, temperature of 101º to 103º F (38.3º to 39.4º C), bleeding from esophageal varices.

What tests tell you
• Liver biopsy, the definitive test for cirrhosis, reveals destruction and fibrosis of hepatic tissue.
• A liver scan shows abnormal thickening and a liver mass.
• Cholecystography and cholangiography allow visualization of the gallbladder and the biliary duct system, respectively.
• Splenoportal venography allows visualization of the portal venous s ystem.
• PTHC helps differentiate extrahepatic from intrahepatic obstructive jaundice and helps reveal hepatic disorders and gallstones.
• CT scan can show lobe enlargement, vascular changes, and nodules.

• WBC count, hematocrit, and hemoglobin, albumin, serum electrolyte, and cholinesterase levels are decreased.
• Globulin, serum ammonia, total bilirubin, alkaline phosphatase, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and lactate dehydrogenase levels are increased.
• Anemia, neutropenia, and thrombocytopenia are present. PT and PTT are prolonged.

Vanishing vitamins

Focus topic: Gastrointestinal disorders

• Folic acid, iron levels, and vitamins A, B12, C, and K are decreased.
• Glucose tolerance tests may be abnormal.
• Galactose tolerance and urine bilirubin tests are positive.
• Fecal and urine urobilinogen levels are elevated.

How it’s treated
Therapy aims to remove or alleviate the underlying cause of cirrhosis, prevent further liver damage, and prevent or treat complications. In cases of active variceal bleeding, treatment aims to actively control blood loss through medication, surgery, or balloon tamponade. The patient may benefit from a high-protein diet, but this may be restricted by developing hepatic encephalopathy. Sodium is usually restricted to 200 to 500 mg/day and fluids to 1 to 11/2 qt (1 to 1.5 L)/day.
If the patient’s condition continues to deteriorate, he may need tube feedings or TPN. Other supportive measures include:
• supplemental vitamins — A, B complex, C, and K — to compensate for the liver’s inability to store them
• vitamin B12, folic acid, and thiamine for anemia
• rest and moderate exercise and avoiding exposure to infections and toxic agents
• antiemetics, such as trimethobenzamide (Tigan) for nausea (when absolutely necessary)
• vasopressin for esophageal varices
• diuretics, such as furosemide (Lasix) and spironolactone (Aldactone), for edema with careful monitoring because fluid and electrolyte imbalance may precipitate hepatic encephalopathy
• paracentesis and infusions of salt-poor albumin to alleviate ascites
• insertion of a TIPS
• surgical procedures, including endoscopic sclerotherapy (or banding of varices), splenectomy, esophagogastric resection, and surgical shunts to relieve portal hypertension
• liver transplantation for the patient with advanced disease
• programs for preventing cirrhosis, which usually emphasize avoiding alcohol.

What to do
• Check skin, gums, stool, and vomitus regularly for bleeding. Apply pressure to injection sites to prevent bleeding.
• Observe closely for signs of behavioral or personality changes. Report increasing stupor, lethargy, hallucinations, or neuromuscular dysfunction. Watch for asterixis, a sign of developing hepatic encephalopathy.
• To assess fluid retention, weigh the patient and measure abdominal girth daily, inspect his ankles and sacrum for dependent edema, and accurately record intake and output.

Handle with care

Focus topic: Gastrointestinal disorders

• To prevent skin breakdown associated with edema and pruritus, avoid using soap when you bathe the patient. Instead, use lubricating lotion or moisturizing agents. Handle him gently, and turn and reposition him frequently to keep skin intact.
• Evaluate the patient’s response to therapy. Look for him to maintain normal nutrition and skin integrity. Note whether he has adapted his lifestyle and diet to his disorder and whether he understands the need for appropriate follow-up care.

Gastrointestinal disorders




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