NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: GASTROINTESTINAL SYSTEM

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

GASTRIC SURGERY: peformed when ulcer medical regimen is unsuccessful, ulcer is determined to be precancerous, or complications are present.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Types:

  • Subtotal gastrectomy: removal of a portion of the stomach.
  • Total gastrectomy: removal of the entire stomach.
  • Antrectomy: removal of entire antrum (lower) portion of the stomach.
  • Pyloroplasty: repair of the pyloric opening of the stomach.
  • Vagotomy: interruption of the impulses carried by the vagus nerve, which results in reduction of gastric secretions and decreased physical activity of the stomach (being done less often).
  • Combination of vagotomy and gastrectomy.

B. Analysis/nursing diagnosis:

  • Pain related to surgical incision.
  • Ineffective breathing pattern related to high surgical incision.
  • Risk for trauma related to possible complications postgastrectomy.
  • Knowledge deficit (learning need) regarding medication regimen and factors that aggravate condition.
  • Fear related to possible precancerous lesion.
  • Ineffective individual coping related to adjustments in lifestyle needed to lessen symptoms.

C. Nursing care plan/implementation:

  • Goal: promote comfort in the postoperative period.

a. Analgesics: to relieve pain and allow client to cough, deep breathe to prevent pulmonary complications.

b. Position: semi-Fowler’s to aid in breathing.

  • Goal: promote wound healing.

a. Keep dressings dry.

b. NG tube to low intermittent suction (Levin) or low continuous suction (Salem sump).

(1) Check drainage from NG tube; normally bloody first 2 to 3 hours postsurgery, then brown to dark green.
(2) Excessive bright-red blood drainage: take vital signs; report vital signs, color and volume of drainage to physician immediately.
(3) Irrigate gently with saline in amount ordered; do not irrigate against resistance; may not be done in early postoperative period.
(4) Tape tube securely to face, but prevent obstructed vision.
(5) Frequent mouth and nostril care.3. Goal: promote adequate nutrition and hydration.

a. Administer parenteral fluids as ordered.

b. Accurate I&O.

c. Check bowel sounds, at least q4h; NPO 1 to 3 days; bowel sounds normally return in 21 to 36 hours; oral fluids as ordered when bowel sounds presen—usually 30 mL, then small feedings, then bland liquids to soft diet.

d. Observe for nausea and vomiting due to suture line edema, food intake (too much, too fast).

  • Goal: prevent complications.

a. Check dressing q4h for bleeding.

b. Vitamin B12 and iron replacement as indicated to avoid pernicious anemia and iron-deficiency anemia.

c. Avoid dumping syndrome.

D. Evaluation/outcome criteria:

  • Hemorrhage, dumping syndrome avoided.
  • Healing begins.
  • Adjust lifestyle to prevent recurrence/marginal ulcer.

DUMPING SYNDROME: hypoglycemic-type episode; occurs postoperatively after gastric resection (may also occur after vagotomy, antrectomy, or gastroenterostomy), when food and fluids that are more hyperosmolar than the jejunal secretions pass quickly into jejunum, producing fluid shifts from bloodstream to jejunum. This is a mild problem for about 20% of clients and will disappear in a few months to a year. Symptoms cause serious problem for about 7% of clients. This discomfort may occur during a meal or up to 30 minutes after the meal and last from 20 to 60 minutes. The reaction is greatest after the ingestion of sugar.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Assessment:

  • Subjective data:

a. Feeling of fullness, weakness, faintness.

b. Palpitations.

c. Nausea.

d. Discomfort during or after eating.

  • Objective data:

a. Diaphoresis.

b. Diarrhea.

c. Fainting.

d. Symptoms of hypoglycemia.

B. Analysis/nursing diagnosis:

  • ltered nutrition, more than body requirements, related to body’s inability to properly digest high-carbohydrate, high-sodium foods.
  • Diarrhea related to food passing into jejunum too quickly.
  • Risk for injury related to hypoglycemia.
  • Knowledge deficit (learning need) related to dietary restrictions.

C. Nursing care plan/implementation:

  • Goal: health teaching.

a. Include:

(1) Increased fat, protein to delay emptying.
(2) Rest after meals.
(3) Small, frequent meals.
(4) Fluids between meals.

b. Avoid:

(1) Foods high in salt, carbohydrate.
(2) Large meals.
(3) Stress at mealtime.
(4) Fluids at mealtime.

D. Evaluation/outcome criteria:

  • No complications.
  • Client heals.
  • No further ulcers.
  • Incorporates health teaching into lifestyle and prevents syndrome.

CHOLECYSTITIS/CHOLELITHIASIS: inflammation of gallbladder due to bacterial infection, presence of cholelithiasis (stones, cholesterol, calcium, or bile in the gallbladder), or choledocholithiasis (stone in the common bile duct) and/or obstruction. Acute cholecystitis is abrupt in onset, but the client usually has a history of several attacks of fatty food intolerance. The client with chronic cholecystitis has a history of several attacks of moderate severity and has usually learned to avoid fatty foods to decrease symptoms.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: calculi from increased concentration of bile salts, pigments, or cholesterol due to metabolic or hemolytic disorders, biliary stasis →precipitation of salts into stones, or inflammation causing bile constituents to become altered.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Adult women.
  • Obesity.
  • Pregnancy or previous pregnancies.
  • Use of birth control pills or hormone replacement therapy.
  • High-fat, low-fiber diets.
  • Rapid weight loss.
  • History of Crohn’s disease.
  • Genetics.
  • Age: increased risk over 40.
  • Certain drugs to lower lipids; clofibrate (Atromid-S).
  • Other diseases: cirrhosis of liver.

C. Assessment:

  • Subjective data:

a. Pain:

(1) Type—severe colic, radiating to the back under the scapula and to the right shoulder.
(2) Positive Murphy’s sign—a sign of gallbladder disease consisting of pain on taking a deep breath when pressure is placed over the location of the gallbladder.
(3) Location—right upper quadrant, epigastric area, flank (Abdominal pain by location).
(4) Duration—spasm of duct attempting to dislodge stone lasts until dislodged or relieved by medication, or sometimes by vomiting.

b. GI—anorexia, nausea, feeling of fullness, indigestion, intolerance of fatty foods.

  • Objective data:

a. GI—belching, vomiting, clay-colored stools.

b. Vital signs—increased pulse, fever.

c. Skin—chills, jaundice.

d. Urine—dark amber.

e. Laboratory data—elevated:

(1) WBC count.

(2) Alkaline phosphatase.

(3) Serum amylase, lipase.

(4) AST (SGOT).

(5) Bilirubin.

f. Diagnostic studies:

(1) Ultrasound.
(2) Cholangiography.(3)Computed tomography (CT) scan.
(3) Endoscopic retrograde cholangiopancreatography (ERCP).

D. Analysis/nursing diagnosis:

  • Pain related to obstruction of bile duct due to cholelithiasis.
  • Altered nutrition, more than body requirements, related to ingestion of fatty foods.
  • Altered nutrition, less than body requirements, related to hesitancy to eat due to anorexia and nausea.
  • Risk for fluid volume deficit related to episodes of vomiting.
  • Knowledge deficit (learning need) related to dietary restrictions.

E. Nursing care plan/implementation:

  • Nonsurgical interventions:

a. Goal: promote comfort.

(1) Medications as ordered: meperidine, antibiotics, antispasmodics, electrolytes.
(2) Avoid morphine due to spasmodic effect.
(3) NG tube to low suction.
(4) Diet: fat free when able to tolerate food.
(5) Lithotripsy: gallstones fragmented by shock waves.
(6) Oral dissolution therapy: ursodeoxycholic acid (ursodiol [Actigall]).

b. Goal: health teaching:

(1) Signs, symptoms, and complications of disease.
(2) Fat-free diet.
(3) Desired effects and side effects of prescribed medications.
(4) Prepare for possible removal of gallbladder (cholecystectomy) if conservative treatment unsuccessful.

  • Surgical interventions:

a. Preoperative—Goal: prevent injury

(1) Laparoscopic laser cholecystectomy—tiny incisions/puncture wounds; gallbladder is removed using a video-guided system with a camera; client is discharged that day or next day, able to resume normal diet and work activities in a few days.

(2) Endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy—removes stones from bile duct.

(3) Open-incision cholecystectomy.

(a) Promote tube drainage:

(i) NG tube to low suction.

(ii) T-tube to closed-gravity drainage, to preserve patency of edematous common duct and ensure bile drainage; usual amount 500 to 1,000 mL/24 hr; dark brown drainage.

(iii) Provide enough tubing to allow turning without tension.

(iv) Empty and record bile drainage q8h.

(b) Position: low Fowler’s to semi-Fowler’s to facilitate T-tube drainage.

(c) Dressing: dry to protect skin (because bile excoriates skin).

(d) Clamp T-tube as ordered.

(i) Observe for: abdominal distention, pain, nausea, chills, or fever.

(ii) Unclamp tube and notify physician if symptoms appear.

c. Goal: prevent complications.

(1) IV fluids with vitamins.
(2) Cough, turn, and deep breathe with open incision, particularly with removal of gallbladder (prone to respiratory complication because of high incision).
(3) Early ambulation to prevent vascular complications and aid in expelling flatus.
(4) Monitor for jaundice: skin, sclerae, urine, stools.
(5) Monitor for signs of hemorrhage, infection.

d. Goal: health teaching.

(1) Diet: fat free for 6 weeks.
(2) Signs of complications of food intolerance, pain, infection, hemorrhage.

F. Evaluation/outcome criteria:

  • No complications.
  • Able to tolerate food.
  • Plans follow-up care.
  • Possible weight reduction.

Physiological Integrity: Nursing Care of the Adult Client

OBESITY—more calories consumed than expended leading to fat accumulation. Most common nutritional/metabolic disease in the United States.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Definition: Women—more than 45% above ideal body weight. Men—more than 35% above ideal body weight. Determined by body mass index (BMI) formula: divide weight in kilograms by height in meters squared (or divide weight in pounds by height in inches squared) and multiply by 703: Wt (lb) × 703 or: Wt (kg) × 703
Ht (in2) Ht (m2)

B. Risk factors:

  • Genetics (e.g., ↓ BMI), hormonal.
  • Environmental (e.g., ↓ physical activity).
  • Diet (e.g., ↑ fat, calories).
  • Some medications (e.g., tricyclic antidepressants [TCAs], insulin, sulfonylurea agents).

C. Comorbidity:

  • Cardiovascular disease; hypertension.
  • Type 2 diabetes.
  • Gallbladder disease.
  • Arthritis.
  • Cancer (colorectal, breast, prostate).
  • Stroke.
  • Emotional distress.
  • Surgical risk.

D. Assessment:

  • Overweight—BMI 25.0 to 29.9 kg/m2.
  • Obese—BMI ≥30.0 kg/m2.
  • Morbid obesity—BMI greater than 40 kg/m2.

E. Analysis/nursing diagnosis:

  • Altered nutrition, more than body requirements, related to genetics, environmental, or dietary factors.
  • Chronic low self-esteem/body image disturbance related to view of self in contrast to societal values; control, sex, and love issues.
  • Activity intolerance related to imbalance between oxygen supply and demand, and to sedentary lifestyle.

F. Nursing care plan/implementation—Goal: decrease weight, initially 10% from baseline.

  • Modify eating pattern (quality vs. quantity); ↓ portion size; modify composition: ↓ calories, fat, and cholesterol; ↓ daily kcal by 500 to 1,000.
  • Increase activity—moderate activity 30 minutes daily.
  •  motivation and readiness to lose weight.
  • Weight-loss drugs in combination with lifestyle changes.
  • Surgery—gastric stapling, bariatric (Roux-en-Y).

G. Evaluation/outcome criteria:

  •  Weight loss of 1 to 2 lb/wk for 6 months.
  • Reduction in kcal by 500 to 1,000/day.
  • Increased daily physical activity.
  • Expressed commitment to lose weight.

APPENDICITIS: obstruction of appendiceal lumen and subsequent bacterial invasion of appendiceal wall; acute emergency.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: when obstruction is partial or mild, inflammation begins in mucosa with slight appendiceal swelling, accompanied by periumbilical pain. As the inflammatory process escalates and/or obstruction becomes more complete, the appendix becomes more swollen, the lumen fills with pus, and mucosal ulceration begins. When inflammation extends to the peritoneal surface, pain is referred to the right lower abdominal quadrant. Danger: rigidity over the entire abdomen is usually indicative of ruptured appendix; the client is then prone to peritonitis.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Men more than women.
  • Most frequently seen between ages 10 and 30 years.

C. Assessment:

  • Subjective data:

a. Pain: generalized, then right lower quadrant at McBurney’s point, with rebound tenderness.

b. Anorexia, nausea.

  • Objective data:

a. Vital signs: elevated temperature, shallow respirations.

b. Either diarrhea or constipation.

c. Vomiting, fetid breath odor.

d. Splinting of abdominal muscles, flexion of knees onto abdomen.

e. Laboratory data:

(1) WBC count elevated (>10,000).
(2) Neutrophil count elevated (>75%).

f. Diagnostic studies:

(1) Ultrasound.
(2) CT scan.

D. Analysis/nursing diagnosis:

  • Pain related to inflammation of appendix.
  • Risk for trauma related to ruptured appendix.
  • Knowledge deficit (learning need) related to possible surgery.

E. Nursing care plan/implementation:

  • Goal: promote comfort.

a. Preoperative:

(1) Explain procedures.
(2) Assist with diagnostic work-up.

b. Postoperative:

(1) Relieve pain related to surgical incision.
(2) Prevent infection: wound care, dressing technique.
(3) Prevent dehydration: IVs, I&O, fluids to solids by mouth as tolerated.
(4) Promote ambulation to prevent postoperative complications.

F. Evaluation/outcome criteria:

  • No infection.
  • Tolerates fluid; bowel sounds return.
  • Heals with no complications.

HERNIA: protrusion of the intestine through a weak portion of the abdominal wall.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Types:

  • Reducible: visceral contents return to their normal position, either spontaneously or by manipulation.
  • Irreducible, or incarcerated: contents cannot be returned to normal position.
  • Strangulated: blood supply to the structure within the hernia sac becomes occluded (usually a loop of bowel).
  • Most common hernias: umbilical, femoral, inguinal, incisional, and hiatal.

B. Pathophysiology: weakness in the wall may be either congenital or acquired. Herniation occurs when there is an increase in intra-abdominal pressure from: coughing, lifting, crying, straining, obesity, or pregnancy.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

C. Assessment:

  • Subjective data:

a. Pain, discomfort.

b. History of feeling a lump.

  •  Objective data:

a. Soft lump, especially when straining or coughing.

b. Sometimes alteration in normal bowel pattern.

c. Swelling.

D. Analysis/nursing diagnosis:

  • Activity intolerance related to pain and discomfort.
  • Risk for trauma related to lack of circulation to affected area of bowel.
  • Pain related to protrusion of intestine into hernia sac.

E. Nursing care plan/implementation:

  • Goal: prevent postoperative complications.

a. Monitor bowel sounds.

b. Prevent postoperative scrotal swelling with inguinal hernia by applying ice and support to scrotum.

  • Goal: health teaching.

a. Prevent recurrence with correct body mechanics.

b. Gradual increase in exercise.

F. Evaluation/outcome criteria: healing occurs with no further hernia recurrence.

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DIVERTICULOSIS: A diverticulum is a small pouch or sac composed of mucous membrane that has protruded through the muscular wall of the intestine. The presence of several of these is called diverticulosis. Inflammation of the diverticula is called diverticulitis.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Pathophysiology: weakening in a localized area of muscular wall of the colon (especially the sigmoid colon), accompanied by increased intraluminal pressure.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

  • Diverticulosis:

a. Age: seldom before 35 years; 60% incidence in older adults.

b. History of constipation.

c. Diet history: low in vegetable fiber, high in carbohydrate.

  • Diverticulitis: highest incidence between ages 50 and 60 years.

C. Assessment:

  • Subjective data: pain: cramplike; left lower quadrant of abdomen.
  • Objective data:

a. Constipation or diarrhea, flatulence.

b. Fever.

c. Rectal bleeding.

d. Diagnostic procedures:

(1) Palpation reveals tender colonic mass.
(2) Barium enema (done only in absence of inflammation) reveals presence of diverticula.
(3) Sigmoidoscopy/colonoscopy.

D. Analysis/nursing diagnosis:

  • Constipation related to dietary intake.
  • Pain related to inflammatory process of intestines.
  • Risk for fluid volume deficit related to episodes of diarrhea or bleeding.
  • Risk for injury related to bleeding.
  • Knowledge deficit (learning need) related to prevention of constipation.

E. Nursing care plan/implementation:

  • Goal: bowel rest during acute episodes.

a. Diet: soft, liquid.

b. Fluids, IVs if oral intake not adequate.

c. Medications:

(1) Antibiotics: ciprofloxacin (Cipro), metronidazole (Flagyl), cephalexin (Keflex), doxycycline (Vibramycin).
(2) Antispasmodics: chlordiazepoxide (Librax), dicyclomine (Bentyl), Donnatal, hyoscyamine (Levsin).

d. Monitor stools for signs of bleeding.

  • Goal: promote normal bowel elimination.

a. Diet: bland, high in vegetable fiber if no inflammation.

(1) Include: fruits, vegetables, whole-grain cereal, unprocessed bran.
(2) Avoid: foods difficult to digest (corn, nuts).

b. Bulk-forming agents as ordered: methylcellulose, psyllium.

c. Monitor: abdominal distention, acute bowel symptoms.

  • Goal: health teaching.

a. Methods to avoid constipation.

b. Foods to include/avoid in diet.

c. Relaxation techniques.

d. Signs and symptoms of complications of chronic inflammation: abscess, obstruction, fistulas, perforation, or hemorrhage.

F. Evaluation/outcome criteria:

  • Inflammation decreases.
  • Bowel movements return to normal.
  • Pain decreases.
  • No perforation, fistulas, or abscesses noted.
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