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Chapter_021.pptx

Chapter 21

Gastrointestinal Function

Some changes in the gastrointestinal (GI) tract are due to normal aging; factors such as polypharmacy, stress, poor nutrition, multiple comorbidities, and poor hygiene may also contribute to alteration in GI function.

Many systemic changes in functions of digestion and absorption of nutrients result from changes in older patients’ cardiovascular and neurologic systems rather than GI systems.

Age-Related Changes in Structure and Function

One fourth of those 65 or older are edentulous.

Taste buds may atrophy with age.

Changes in smooth muscle lining lower in the esophagus may contribute to a decrease in the strength of esophageal contractions and sphincter weakness.

Neurogenic, hormonal, and vascular changes may also contribute to decrease in esophageal motility.

Age-Related Changes in Oral Cavity, Pharynx, and Esophagus

Decreased production of gastric acid, pepsin, bicarbonate, prostaglandins, and mucous

Gastric emptying time is increased secondary to decreased elasticity of the stomach wall.

Decreased stomach capacity

Age-Related Changes in Stomach

Atrophy and broadening of the villi leading to a decrease in absorptive surface

Decrease in the production of lactase

Overpopulation of certain intestinal bacteria

Atrophy of the muscle layers and mucosa in colon

Decrease in contraction of the muscle wall when the rectum is filled with stool

Diverticuli are prevalent.

Age-Related Changes in Small and Large Intestine

Gallbladder and bile ducts are unaffected by aging.

Incidence of gallstones does increase with age.

Fibrosis, fatty acid deposits, and atrophy of pancreas

Volume of pancreatic secretions declines.

Decrease in enzyme activity which affects fat digestion

Increased incidence of pancreatic cancer and pancreatitis

Age-Related Changes in Gallbladder and Pancreas

Liver size decreases after age 50, but function remains WNL.

Decrease in hepatic blood flow affects drug metabolism.

Decreased ability to compensate for infectious, immunologic, and metabolic disorders

Age-Related Changes in Liver

No clear-cut GI diseases can be attributed directly to aging process.

Older adults may complain of symptoms related to GI tract that have not been related to a specific diagnosis.

Any symptom reported by an older patient needs thorough assessment by the nurse.

Common Gastrointestinal Symptoms

Nausea without vomiting originates in the brain, rather than GI track, and is usually a response to a metabolic disorder.

Obtain information about the amount and characteristics of the emesis (food particles, bile, or blood) and other symptoms.

Interventions: drink clear liquids, progressing from eating bland foods to solid foods, and small frequent feedings

Fluid replacement should be a priority for vomiting.

Pharmacologic therapy can cause sedation, confusion, and delirium in older adults.

Nausea and Vomiting

Determine whether decreased food intake is due to loss of appetite.

Assess other symptoms: weight loss, nausea, vomiting, abdominal pain, diarrhea, and constipation

Interventions: monitoring of intake, output, and weight

Small, frequent feedings may be helpful.

Anorexia

Difficult to fully assess

Assess in terms of the three pathways for pain impulses: visceral pain pathways—often diffuse, is poorly localized, and has a gnawing, burning, or cramping quality; somatic or parietal pathways—is usually sharp, more intense, constant, and better localized than visceral pain; referral pathways—usually sharp and well localized; it may resemble somatic pain

Abdominal Pain

Elicit information about duration, location, mode of onset, intensity, quality, rhythm, relationship to food, alleviating and aggravating factors, and radiation, as well as ability to pass stool and gas.

Older adults are also less likely to exhibit leukocytosis, fevers, rebound tenderness, or local rigidity.

Interventions include measures to increase comfort and pain relief, and may include IV fluids, NGT, monitoring of VS, I&O, and for vomiting and diarrhea.

Abdominal Pain Symptoms and Interventions

Belching primarily comes from the unconscious swallowing of air, assess for other symptoms suggestive of gastritis or peptic ulcer disease

Complaints of bloating and fullness are related to a motility disorder or malabsorption.

Flatus is normal, excessive flatus may comes with swallowing more air, the nature of the foods consumed or lactose intolerance

Interventions: patient education about the cause and nature of intestinal gas, changing dietary factors

Gas

Increase in frequency of stools, or a change in consistency

Due to increased bowel motility or interference in normal absorption of water and nutrients in bowel

Inquire about normal bowel habits, precipitating events and characteristics of the diarrhea

Interventions: adequate fluid and electrolyte balance, assessing for complications, and providing emotional support as necessary

Diarrhea

Patients with chronic diarrhea should avoid gas-forming foods, vegetables, spices, and milk products.

Patients with acute diarrhea should consume bland foods, such as the BRAT diet and clear liquids.

Chronic and Acute Diarrhea

Often a complication of polypharmacy

Often defined according to patient’s perception of abnormal bowel function

Common causes include diet, mechanical obstruction, drug side effects, multiple comorbidities, and mobility and functional issues.

Interventions: increasing fluid intake and fiber, combined with light exercise and development of a regular toileting routine that includes responding to the urge to defecate and OTC laxatives

Constipation

Involuntary passing of stool, may be acute or chronic

May significantly alter quality of life

Causes: colorectal lesions, neurologic problems, laxative abuse, unrecognized lactose intolerance, diabetic neuropathy, poor dietary habits, or immobility

Interventions: education concerning prevention and treatment of incontinence bowel control program

Fecal Incontinence

Inflammation of gums surrounding teeth, may result in pain and bleeding; can lead to periodontitis, a spreading of inflammation to underlying tissues, bones, or roots of the teeth

Most common reason for tooth loss with advancing age

Candida albicans, or thrush, is an infection causing white lesions on the oral mucosa, in persons with compromised immune systems or taking immunosuppressant drugs and antibiotics.

Gingivitis and Periodontitis

Obtain history of dental care and hygiene practices

Complete health history focusing on other illnesses and concomitant medications, and physical assessment of the mouth

Can you name four nursing diagnoses for gingivitis and periodontitis?

Gingivitis and Periodontitis: Assessment and Diagnosis

Inadequate oral mucous membrane

Inadequate dentition

Inadequate health maintenance

Inadequate nutrition, resulting from pain

The patient with gingivitis or periodontitis will do the following:

Maintain a comfortable and functional oral cavity

Establish and maintain a mouth care routine, including regular professional dental care

Maintain normal body weight and nutritional status

Gingivitis and Periodontitis: Planning and Expected Outcomes

Promote regular oral hygiene, regular preventive dental care, and maintenance of nutritional status.

Assess knowledge of importance of oral hygiene.

Teach that professional dental care should be sought routinely every 6 months or more often as needed.

Gingivitis and Periodontitis: Intervention

Documentation of achievement of expected outcomes, establishment and maintenance of regular dental care and oral hygiene practices, and prevention of infection

Evaluation focuses on the older adult’s ability to carry out recommendations and whether any changes in self-care have occurred as a result.

Gingivitis and Periodontitis: Evaluation

Weakened esophageal smooth muscle and incompetent sphincter function

Causes include stroke, neurologic disease, local trauma or tissue damage, and tumors that may obstruct flow of food and liquids in esophagus.

Compromise nutritional status, increase risk of aspiration pneumonia, and lead to decreased quality of life

Dietary modification may be recommended following speech–language pathologist evaluation and modified barium swallow.

Dysphagia

Accurate and precise history focusing on whether dysphagia occurs with liquids, solids, or both.

Physical exam including neuro assessment, oral cavity and salivary glands, observation of swallowing capability, and examination of neck and thyroid glands

Can you name four nursing diagnoses for dysphagia?

Dysphagia: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Maintain weight within 10% of ideal body weight

Remain free from aspiration

Learn techniques to swallow that minimize pain

Be free of epigastric discomfort

Be able to verbalize fears related to the diagnosis and prognosis

Dysphagia: Planning and Expected Outcomes

Maintain hydration and nutritional status, prevent aspiration, and provide emotional support and information regarding diagnosis and prognosis

Instruction regarding eating habits and maintaining weight and nutrition are important.

Educate to sleep with head of bed elevated

Dysphagia: Intervention

Documentation of achievement of expected outcomes, prevention of aspiration, and maintenance of nutrition

Evaluate how patient is coping with diagnosis and their ability to adhere to the dietary recommendations and modify behaviors and lifestyle to reduce symptoms.

Dysphagia: Evaluation

Causes of gastroesophageal reflux disease (GERD): lower esophageal sphincter dysfunction, delayed gastric emptying, hiatal hernia, and increased intraabdominal pressure

Medications can decrease esophageal sphincter pressures.

Esophagitis simply an inflammation of esophagus caused by reflux from prolonged vomiting or an incompetent lower esophageal sphincter

Gastroesophageal Reflux and Esophagitis (GERD)

Mucosal damage depends on contact time between esophageal mucosa and gastric contents, and acidity and quantity of gastric secretions.

Heartburn, retrosternal discomfort, and regurgitation of sour, bitter material usually after eating a lot of fatty or spicy foods or alcohol

Strictures may develop making food passage difficult.

Pulmonary aspiration

GERD Symptoms

Is a major cause of reflux and esophagitis and occurs when part of stomach protrudes through an opening of diaphragm

May be intermittent or continuous

Most hiatal hernias are asymptomatic and require no treatment.

Symptoms, when they arise, include heartburn, gastric regurgitation, dysphagia, and indigestion.

Hiatal Hernia

Begins with history of symptoms and possible aggravating factors

Older adults may have atypical symptoms including hoarseness, chest pain, postprandial fullness, respiratory symptoms, and belching.

Drug and diet histories are important components of assessment.

Can you name three nursing diagnoses for hiatal hernia?

Hiatal Hernia: Assessment and Diagnosis

Potential for aspiration, resulting from regurgitation

Inadequate nutrition, resulting from pain or dysphagia

Need for health teaching, resulting from lack of exposure to disease process and treatment modalities

The patient will do the following:

Remain free from aspiration

Maintain weight within 10% of ideal body weight

Verbalize an understanding of the disease process and treatment approaches

Hiatal Hernia: Planning and Expected Outcomes

Maintain adequate nutrition, prevent aspiration, and instruct patients and families about disease process and treatment approaches.

Instruct on avoiding foods that increase symptoms, maintenance of health, and smoking cessation.

Document achievement of expected outcomes, prevention of complications, and appropriate dietary and lifestyle changes.

Refer to medical management if symptoms have not subsided.

Hiatal Hernia: Intervention and Evaluation

Malabsorption causes the majority of cases.

Causes of malabsorption include gastritis, alcoholism, gastric surgery, inflammatory bowel disease, autoimmune disorders, and long-term use of proton-pump inhibitors or histamine-2 blockers.

Decrease in production of the intrinsic factor results in reduced absorption of vitamin B12.

Treatment—injection of vitamin B12

Vitamin B12 Deficiency

Causes transient inflammation, hemorrhages, and erosion into gastric mucosal lining

Associated with alcoholism, aspirin or nonsteroidal antiinflammatory drug (NSAID) ingestion, smoking, and severely stressful conditions such as burns, trauma, central nervous system damage, chemotherapy, and radiotherapy

Acute Gastritis

Inflammation of stomach lining that may occur repeatedly or continue over period of time

Possible causes: ulcers, hiatal hernias, vitamin deficiencies, chronic alcohol use, gastric mucosal atrophy, achlorhydria, and peptic ulceration

Major symptom of gastritis is abdominal pain.

Other symptoms: indigestion, distention, decreased appetite, nausea, and vomiting

Chronic Gastritis

Occurs in critically ill patients, such as those with burns, sepsis, multiorgan failure, major surgery, or head injury

Stress ulcers are produced by mucosal ischemia from lack of blood supply to gastric mucosa during the poststress period and increased sensitivity of gastric mucosa to hydrochloric acid and pepsin

Major clinical manifestation of stress ulcers is painless, gastric bleeding.

Preventive measures: antacids and histamine blockers or sucralfate

Stress-Induced Gastritis

History and review of systems

Assess for complaints of indigestion, abdominal or epigastric discomfort, nausea, vomiting, or anorexia and possible GI blood loss

Can you name three nursing diagnoses for gastritis?

Gastritis: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Experience relief of epigastric symptoms

Maintain adequate fluid and electrolyte balance

Verbalize understanding of the disease and factors that contribute to the disease

Gastritis: Planning and Expected Outcomes

Provide acid-suppressing drugs as ordered; small, frequent, easily digested meals; maintain a calm environment; monitor fluid and electrolyte status; and teach about precipitating and contributory factors.

Teach patient necessity of limiting or eliminating alcohol and tobacco use, avoiding aspirin and other NSAIDs, and seeking prompt medical attention for symptoms of indigestion and epigastric pain.

Gastritis: Intervention

Documentation of achieved expected outcomes, a decrease in symptoms, and lack of evidence of GI hemorrhaging or other complications

Evaluate older patient’s adherence to necessary lifestyle changes.

Gastritis: Evaluation

Ulcerative condition caused by erosion of GI mucosa from digestive action of hydrochloric acid and pepsin

Peptic ulcer—Helicobacter pylori infection

Gastric ulcers and duodenal ulcers—NSAID use

Genetic and environmental factors play a role in development.

Peptic Ulcer Disease (PUD)

Hydrochloric acid secretion usually normal or reduced with increased rate of diffusion of gastric acid back into tissue

Risk factors include H. pylori infection, NSAID use, cigarette smoking, and alcohol abuse

Symptoms: gnawing or burning pain in the epigastric region that comes and goes; eating may lead to pain relief, pain may be worse on an empty stomach, nausea, vomiting, and weight loss are common

Gastric Ulcers

Increased rate of gastric acid secretion and increased emptying rate of acid from stomach to duodenum

H. pylori migrates from stomach to duodenum in the presence of dysplastic changes in the duodenal mucosa.

Symptoms: periods of exacerbation and remission and follow a pain–food–relief pattern, pain begins 2–4 hours after meals, burning or cramp-like pain located mid-epigastrium

Duodenal Ulcers

Assess patient’s complaint of abdominal or epigastric pain including location, character, and especially alleviating and precipitating factors

Signs of complications: melena or hematemesis

Older adults typically have a blunted presentation.

Can you name three nursing diagnoses for PUD?

PUD: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Report a decrease in abdominal or epigastric pain

Adhere to the prescribed dietary, activity, and medication regimen

Acknowledge aggravating factors, such as smoking, alcohol use, stress, or frequent use of aspirin, or NSAIDs

PUD: Planning and Expected Outcomes

Educate on lifestyle changes, dietary modifications, and drugs that may be used in treatment plan.

If surgery performed, instruct on dietary modifications and dumping syndrome.

Instruct patient to maintain adequate nutrition and fluid and electrolyte balance.

PUD: Intervention

Document achievement of expected outcomes, prevention of complications, elimination of symptoms, and increased knowledge base.

Evaluate for complications of medical treatments.

PUD: Evaluation

The nurse caring for the older adult should be aware that aspiration pneumonia can develop from which of the following GI conditions? (Select all that apply.)

Dysphagia

Peptic ulcer

GERD

Hiatal hernia

Stress ulcer

Quick Quiz!

ANS: A, C

Answer to Quick Quiz

Inflammatory process of stomach or small intestine

Caused by bacteria, viruses, medications, radiation, ingestion of irritating foods, or allergic reactions, or parasitic infection

Varying manifestations: abdominal cramping, profuse diarrhea, and vomiting

Profuse diarrhea may cause dehydration and electrolyte imbalances.

Enteritis

History of recent food intake, nausea, vomiting, and diarrhea, including amount, duration, frequency, and stool characteristics

Physical examination includes inspection of mucous membranes and assessment of orthostatic blood pressure, temperature, and abdominal tenderness.

Can you name two nursing diagnoses for enteritis?

Enteritis: Assessment and Diagnosis

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The patient will do the following:

Maintain adequate fluid volume and electrolyte balance

Have a continual decline in the number of liquid, nonformed stools until baseline is achieved

Enteritis: Planning and Expected Outcomes

Maintain hydration and monitor fluid and electrolyte status

Determine patient has available assistance if condition worsens

Educate on signs and symptoms of dehydration and prevention of bacterial and parasitic enteritis

Documentation of achievement of expected outcomes, prevention of complications, and return to baseline status

Enteritis: Intervention and Evaluation

Partial or complete blockage of GI contents in either small or large intestine

Mechanical obstructions caused by tumors, adhesions, or hernias

Paralytic ileus involves decreased or absent peristalsis resulting from neurologic or vascular disorders.

Vascular disorders may cause intestinal or mesenteric ischemia resulting in obstruction.

Intestinal Obstruction

Abdominal distention

Percussion will elicit tympanic sounds.

Hyperactive bowel sounds above site of a mechanical obstruction; bowel sounds below site will be absent.

Vomiting is almost always present.

Diarrhea—if obstruction is not complete

Complications: perforation of bowel, chemical or bacterial peritonitis, hypovolemic shock, and septic shock

Intestinal Obstruction Presentation

History of precipitating event; focus on type and frequency of vomiting and diarrhea and the location and character of pain

Physical examination: focus on presence and character of bowel sounds, presence of abdominal distention, vital signs, and urinary output

Sudden elevation of temperature—classic sign of peritonitis

Can you name four nursing diagnoses for intestinal obstruction?

Intestinal Obstruction: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Maintain adequate fluid volume and electrolyte balance

Verbalize a tolerable level of discomfort

Regain and maintain adequate nutrition, as evidenced by achievement of pre-illness body weight

Will state relief from nausea

Maintain passage of soft formed stool

Intestinal Obstruction: Planning and Expected Outcomes

Management of patient with ileus or intestinal obstruction includes maintenance of hydration and promotion of comfort.

Nasogastric or nasointestinal tubes usually required for decompression

Provide comfort measures: Repositioning, mouth care, skin care, and music or meditation

If surgery required, prepare patient and family about expectations.

Intestinal Obstruction: Intervention

Document achievement of expected outcomes and prevention of complications

Vital signs, intake and output, bowel sounds, and bowel elimination patterns should be recorded.

Evaluate incision site and wound healing status following surgery.

Intestinal Obstruction: Evaluation

Saclike protrusions of mucosa as a result of increased intraluminal pressure

Related to the blood supply or nutrition of the bowel, lack of dietary fiber or roughage and decreased fecal bulk

Atrophy of musculature of bowel wall may weaken intestine and cause diverticula

Diverticulosis usually symptom free—diagnosed as incidental finding on x-ray or sigmoidoscopy

If symptoms: vague abdominal discomfort, constipation, or diarrhea

Diverticula

Diverticulitis is an inflammation of or around a diverticular sac.

May result in obstruction of the large intestine, fistulae, and abscesses

Symptoms: constipation or diarrhea, left-sided lower abdominal pain, fever, flatulence, nausea, and vomiting; older adults may not have fever.

Complications: perforation and peritonitis, ureteral obstruction, and significant lower GI bleeding

Diverticulitis

History of elimination patterns and changes in frequency and stool characteristics

Exercise patterns, pain, bloating, nausea, vomiting, medical, surgical, and family history related to bowel

Physical examination may reveal left lower quadrant tenderness or guaiac-positive stool, or fever and chills for diverticulitis

Can you name three nursing diagnoses for diverticular disease?

Diverticular Disease: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Experience fewer episodes of constipation

Verbalize pain relief and remain free from abdominal pain

Verbalize self-care practices to minimize symptoms of diverticulosis and prevent complications of diverticulitis

Diverticular Disease: Planning and Expected Outcomes

Instruct on prevention and elimination of constipation and initiate dietary changes

Teach about development of diverticula and escalation to diverticulitis

For diverticulitis: manage pain, initiate bowel rest, intravenous fluids if NPO status, and hospitalization if acutely ill

Diverticular Disease: Intervention

Documentation of achievement of expected outcomes, prevention of complications, and maintenance of regular bowel patterns and habits

Evaluate the understanding of the disease and measures to prevent complications

Diverticular Disease: Evaluation

Any growth that protrudes from a mucous membrane in GI tract

Adenomatous polyps or adenomas—may become cancerous

Usually asymptomatic; occasionally may bleed, causing bright red blood in feces

Growths often discovered incidentally by sigmoidoscopy, colonoscopy, or barium enema

Colon Polyps

History of changes in routine pattern of elimination, symptoms such as blood in stool

Detailed family history

Physical examination may be unremarkable; guaiac-positive stool during rectal examination

Can you name two nursing diagnoses for colon polyps?

Colon Polyps: Assessment and Nursing Diagnosis

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The patient will do the following:

Verbalize knowledge of the disease process and potential outcomes

Obtain medical follow-up as suggested by the American Cancer Society or a health care provider

Colon Polyps: Planning and Expected Outcomes

Educate and reinforce American Cancer Society’s suggested guidelines for prevention and early detection of colorectal cancer.

Evaluate and document achievement of expected outcomes and prevention of complications.

Colon Polyps: Intervention and Evaluation

Dilations of veins in mucous membrane inside or outside rectum from an increase in pressure in pelvic and rectal areas.

Result of constipation, obesity, pregnancy, liver disease, prolonged sitting, pelvic tumors, and anal intercourse

Internal hemorrhoids—minor bleeding with defecation

External hemorrhoids—pain, pressure, itching, irritation, and palpable mass

Hemorrhoids

History of constipation and symptoms of anal and rectal pain or blood in stool

Physical examination may be unremarkable except for a painful anus and rectum which may make a thorough examination difficult.

Can you name three nursing diagnoses for hemorrhoids?

Hemorrhoids: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Experience fewer episodes of constipation

Establish a regular pattern of bowel elimination

Report a decrease in anal and rectal pain

Verbalize knowledge of self-care practices to minimize the occurrence of hemorrhoids

Hemorrhoids: Planning and Expected Outcomes

Teach prevention and elimination of constipation

Review high fiber diet, adequate fluids and exercise

Encourage over-the-counter anesthetic ointments and creams and sitz baths for pain relief

Encouraged not to strain when defecating

Emphasize importance of reporting any rectal bleeding

Hemorrhoids: Intervention

Documentation of achievement of expected outcomes, prevention of complications, and maintenance of regular bowel patterns and habits

Hemorrhoids: Evaluation

Cholelithiasis is the presence or formation of gallstones in the gallbladder.

Risk factors: obesity, female gender, multiparity, sedentary lifestyle, and advancing age

Symptom: right upper quadrant pain that may radiate to the right scapular area, sharp, crampy, or dull pain that begins suddenly, often directly after a meal, nausea and vomiting

Cholecystitis may be acute or chronic.

Cholelithiasis and Cholecystitis

Gall stones may lodge along the biliary tract, obstructing the flow of bile.

Causing biliary pain, jaundice, pancreatitis, or cholangitis (inflammation of the bile ducts)

Cholecystitis results in a thickening of the gallbladder wall which can lead to ischemia, necrosis, gangrene, and possible perforation of the gallbladder itself, leading to peritonitis.

Complications

History of episodes of pain, nausea, and vomiting

Identify precipitating factors.

Physical examination may reveal tender right upper quadrant and possibly jaundice.

Can you name three nursing diagnoses for gallbladder disease?

Gallbladder Disease: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Experience pain relief

Verbalize knowledge of the disease process, prevention of complications, and treatment options available

Verbalize a feeling of being rested after nighttime sleeping

Gallbladder Disease: Planning and Expected Outcomes

Provide pain relief and instruct patient and family about disease process, treatment options, and potential complications.

Review signs and symptoms of complications.

Documentation of achievement of expected outcomes, prevention of complications, prevention of infection, and assessment of patient’s knowledge of disease process

Gallbladder Disease: Intervention and Evaluation

Inflammation of pancreas, often has no known cause

Acute pancreatitis: organ returns to normal after treatment

Chronic pancreatitis: permanent and progressive destruction of pancreas occurs

Symptoms: severe abdominal pain in epigastric to right upper quadrant area, occasionally radiating through to back, nausea, vomiting, abdominal distention, and fever

Pancreatitis

History of precipitating factors, such as alcohol abuse or presence of gallstones

Assess symptoms of abdominal pain, anorexia, nausea, and vomiting

Physical examination may be difficult depending on patient’s pain.

Can you name three nursing diagnoses for pancreatitis?

Pancreatitis: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Maintain adequate fluid volume and electrolyte balance

Obtain pain relief

Stabilize and maintain weight

Not experience complications

Pancreatitis: Planning and Expected Outcomes

Maintain fluid and electrolyte balance.

Provide pain relief measures and prevent complications.

Teach to avoid alcohol consumption, referral if need.

Teach about low-fat diet for pancreatitis resulting from biliary tract disease.

Provide information and emotional support for patients who may need surgery.

Pancreatitis: Intervention

Documentation of achievement of expected outcomes, prevention of complications, prevention of recurrence, and maintenance of adequate nutrition

Pancreatitis: Evaluation

Inflammation of liver, caused by variety of factors such as chemicals and alcohol, but most common cause is viral infection

Five major viruses can act as the causative agent for hepatitis: A, B, and C viruses are most common in the United States.

Hepatitis

Clinical picture of hepatitis is essentially the same for disease caused by all the viruses

Prodromal phase: malaise, fatigue, possible right upper quadrant pain, nausea and vomiting, anorexia, and low-grade fever

Icteric phase: jaundice and dark urine; patients may start to feel better

Convalescent phase: jaundice and other symptoms disappear, and patients feel fully recovered; will take 3–6 months for liver to return to normal functioning status

Hepatitis Presentation

Review any possible exposure to hepatitis virus.

Assess for right-upper quadrant tenderness, fatigue, malaise, and jaundice.

Ask about changes in functional status; has activity level decreased from baseline.

Review nutritional intake and assess for anorexia.

Palpate for an enlarged liver.

Can you name four nursing diagnoses for hepatitis?

Hepatitis: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Verbalize the causes of hepatitis, the treatment plan, and mechanisms to prevent spreading to others

Participate in activities of daily living (ADLs) without experiencing fatigue

Consume a well-balanced, high-calorie diet, as evidenced by a food diary

Demonstrate self-care activities as much as possible within limitations

Hepatitis: Planning and Expected Outcomes

Teach about spread of hepatitis and mechanisms of prevention.

Explain that rest is an important treatment.

Provide several small feedings throughout day will help alleviate effect of anorexia.

Increase fluids to 2,000–3,000 mL/day unless contraindicated.

Discuss use of non-alcohol lotions, soft clothes and linens, and tepid baths using as little mild soap as possible for pruritis.

Hepatitis: Intervention

Documentation of achievement of expected outcomes, coupled with patient’s successful self-management of the disease

Evaluate food intake, weight trends, and activity tolerance.

Hepatitis: Evaluation

The nurse is obtaining a history and physical assessment on the older adult patient. The patient complains of left lower-quadrant pain that is very tender. Pain is 7/10 on the pain scale. Patient has the following vital signs: 150/89, 92, 20, 38.0. The nurse suspects the patient has which of the following conditions?

Colon cancer

Hepatitis

Acute cholelithiasis

Diverticulitis

Quick Quiz!

ANS: D

Answer to Quick Quiz

Chronic disorder of liver in which there is permanent, irreversible destruction of hepatocytes

Early symptoms: fatigue, malaise, anorexia, a change in bowel habits, nausea and vomiting, and dull, heavy pain in right upper quadrant

Later symptoms: jaundice and edema in peripheral sites

Ultimately, bleeding, portal hypertension, ascites, and encephalopathy develop.

Alcoholic Cirrhosis

Bleeding tendencies result from declining clotting and coagulation factors.

Ascites—accumulation of serous fluid in the abdominal cavity, results from poor liver function and decreased production of albumin by the liver.

Portal hypertension—an increase in pressure in the portal vein and its feeders because of liver congestion or obstruction.

Encephalopathy—late stage in long-term liver disease caused liver’s inability to detoxify ammonia

Alcoholic Cirrhosis Presentation

History of onset and duration of symptoms

Question patient about changes in color of stool, rectal bleeding, and bloody emesis

Thorough physical assessment of all body systems, especially skin and abdomen, and respiratory and mental status

Assess nutritional status

Can you name six nursing diagnoses for alcoholic cirrhosis?

Alcoholic Cirrhosis: Assessment and Diagnosis

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Be free from skin breakdown

Demonstrate the ability to pace activity and ADLs within current ventilatory function

Remain free from injuries and bleeding

Demonstrate resolution of cerebral dysfunction

Maintain or gain weight to an appropriate level

Identify positive aspects about self and express an optimistic outlook regarding relationships

Alcoholic Cirrhosis: Planning and Expected Outcomes

Major focus is preventing common complications

Inspect skin for signs of breakdown or redness

Elevate head of bed and maintain oxygen supplementation as indicated

Prevent bleeding

Assess orientation and psychomotor function

Provide nutritional support

Encourage discussion of feelings about self-esteem

Alcoholic Cirrhosis: Intervention

Documentation of achievement of expected outcomes and prevention or early detection of complications

Alcoholic Cirrhosis: Evaluation

Older adults have increase in incidence of polypharmacy and alterations in pharmacodynamics and pharmacokinetics.

May result from direct toxicity, conversion of a drug to an toxic metabolites, or immune mechanisms responding to the presence of a “foreign” invader

Clinical manifestations are similar to viral hepatitis, may be immediate or delayed.

Liver failure onset may be abrupt, lasting only a few days, with outcomes ranging from resolution, to organ transplantation, to death.

Drug-Induced Hepatitis

100

Information obtained regarding exact name of ingested substance, dosage and amount taken, and length of time since ingestion occurred

History of emesis after ingestion also pertinent

Can you name three nursing diagnoses for drug-induced hepatitis?

Drug-Induced Hepatitis: Assessment and Diagnosis

101

203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Verbalize an understanding of the disease process and interventions

Not experience life-threatening complications of liver failure

Verbalize understanding of current medications and their interactions

Drug-Induced Hepatitis: Planning and Expected Outcomes

102

Discuss adverse effect of certain medications with patient and provide written material as reminders to avoid these drugs

Must monitor patient carefully for signs and symptoms of liver failure, percuss liver size, assess skin and sclera of eyes, and monitor level of consciousness

Drug-Induced Hepatitis: Intervention

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Documentation of achievement of expected outcomes and prevention of complications

Drug-Induced Hepatitis: Evaluation

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Usually remain asymptomatic

Most seek evaluation when dysphagia, choking when eating, hoarseness, heartburn unintentional weight loss, and fatigue develop

Risk factors: obesity, reflux, history of Barrett’s esophagus, heavy alcohol intake, cigarette smoking, diet low in fiber, and HPV

Those with Barrett’s esophagus are urged to seek screening for esophageal cancer

Esophageal Cancer Presentation (1 of 2)

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Many people attribute these signs and symptoms to some of the more common disorders that affect older adults and fail to seek treatment

Proximity of the tumor to the aorta and the trachea, in addition to the potential for metastasis, results in a generally poor prognosis.

Progression of the disease includes esophageal obstruction, coughing, hiccups, bleeding, malnutrition, cachexia, pneumonia, and eventual death.

Esophageal Cancer Presentation (2 of 2)

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History focusing on risk factors for esophageal cancer

Review of systems reveals symptoms of dysphagia, eating difficulties, and aspiration.

Physical examination note: Palpable lymph nodes, organ enlargement from metastasis, significant and recent weight loss and substernal epigastric pain radiating to the neck, jaws, ears, and shoulder

Can you name three nursing diagnoses for esophageal cancer?

Esophageal Cancer: Assessment and Diagnosis

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Inadequate nutrition, resulting from inadequate intake of nutrients in the diet because of dysphagia

Potential for aspiration

Fear, resulting from uncertain

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The patient will do the following:

Initially stabilize weight and then achieve an individually determined weight gain

Remain free from aspiration

Verbalize fears related to the diagnosis and prognosis

Esophageal Cancer: Planning and Expected Outcomes

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Maintain hydration and nutritional status, prevent of aspiration, maintain comfort, and provide emotional support.

Persons with risk factors for esophageal cancer should be instructed to reduce or eliminate factors.

Documentation of achievement of expected outcomes, prevention of aspiration, and maintenance of adequate nutrition

Esophageal Cancer: Intervention and Evaluation

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Symptoms may be vague until cancer has infiltrated and spread throughout body.

Mimics other diseases, so misdiagnosis and self-medication for chronic “stomach problems” are common and may delay diagnosis and treatment.

Cause is unknown; incidence is higher when gastric acid is low.

Associated with environmental and genetic factors, including diet, smoking, heavy alcohol consumption and infection with H. pylori

Gastric Cancer

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Usually well-advanced when symptoms begin to appear

Initially: vague, uneasy sense of fullness, indigestion, and distention after meals

Progression: anorexia, nausea, and vomiting, and weight loss; dysphagia, back pain, weakness, fatigue, hematemesis, and a change in bowel habits

Advanced: weight loss, pain, vomiting, anorexia, dysphagia, and palpable mass

Gastric Cancer Presentation

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History and review of symptoms pertaining to GI system, including indigestion, discomfort after eating, nausea, anorexia, vomiting, or any chronic “stomach problem”

Question regarding changes in dietary or bowel patterns and habits, use of prescription and OTC medications, and home remedies

Physical examination may reveal no obvious abnormalities except when advanced.

Can you name three nursing diagnosis for gastric cancer?

Gastric Cancer: Assessment and Diagnosis

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203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient will do the following:

Discuss thoughts and feelings related to the diagnosis with appropriate people

Use appropriate resources for support counseling

Maintain adequate nutrition

Effectively manage pain

Gastric Cancer: Planning and Expected Outcomes

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Maintain hydration, nutrition, and fluid and electrolyte balance and provide emotional support to individual and family.

Dispelling misconceptions and offering realistic sense of hope

Documentation of achievement of expected outcomes, prevention of malnutrition, maintenance of comfort, and continued family support

Gastric Cancer: Intervention and Evaluation

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Age is significant risk factor.

Causes: diet, environment, smoking, alcohol, obesity, sedentary lifestyle, and genetics

The carcinoembryonic antigen (CEA) is used to gauge effectiveness of therapy and may be useful at time of diagnosis for prognostic value.

Colorectal Carcinoma

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Tumors tend to grow slowly, may remain asymptomatic for a long time.

Cancer of the rectum: bright red bleeding and changes in the characteristics of the stool

Cancer in the sigmoid and descending colon tend to grow around the bowel leading to an obstruction, change in fecal elimination pattern is a common symptom

Clinical manifestations of colorectal cancer depend on the location and extent of the tumor.

Colorectal Carcinoma Presentation

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History of symptoms: diarrhea, constipation, abdominal pain, blood in the stool, or melena, malaise, weight loss, weakness, and fatigue

Family history of colorectal cancer, polyps, and any previous bowel surgeries is important.

Physical examination may reveal mass in abdomen or guaiac-positive stool, or it may be unremarkable.

Can you name three nursing diagnoses for colorectal carcinoma?

Colorectal Carcinoma: Assessment and Diagnosis

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203656 (BB) - Please note that in other chapters, for question "Can you name ... nursing diagnose ...", the answer has been listed in the notes part. Please provide the same in this slide.

The patient do the following:

Maintain weight and adequate nutrition

Verbalize comfort after taking an analgesic

Verbalize acceptance of permanent or temporary body changes resulting from a colostomy

Colorectal Carcinoma: Planning and Expected Outcomes

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Depend on stage of disease and treatment modalities necessary

Encourage eating small, frequent, high-calorie, high-protein meals.

Manage pain with both pharmacologic and nonpharmacologic relief measures.

If patient requires colostomy, patient should be encouraged to verbalize and express feelings.

Encourage patient to have follow-up examinations and procedures to check for recurrence.

Colorectal Carcinoma: Intervention

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Documentation of achievement of expected outcomes and prevention of complications

Documentation of patient’s methods of coping with lifestyle changes imposed by various treatment modalities

Colorectal Carcinoma: Evaluation

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Pancreatic cancer is lethal; the disease usually affects older adults.

Risk factors: smoking, obesity, diabetes, cirrhosis, and a family history

Arises in the head of the organ in most cases

Pancreatic Cancer

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Grows rapidly and has invaded locally or metastasized at time of diagnosis

Symptoms occur late in the course of the disease and are vague and insidious in onset.

Manifestations differ according to the location of the tumor within the pancreas: pain and weight loss (tail of the pancreas), steatorrhea, weight loss, and jaundice (head of the pancreas).

Nonspecific findings: Anorexia, fatigue, digestive problems, blood clots, and diarrhea

Pancreatic Cancer Presentation

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History of symptoms and review of possible factors

Assessment for pain pattern, nausea, vomiting, weight loss, weakness, and stool changes

Physical examination may be unremarkable.

Can you name three nursing diagnoses for pancreatic cancer?

Pancreatic Cancer: Assessment and Diagnosis

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Acute pain, resulting from abdominal discomfort

Decreased ability to cope, resulting from diagnosis of terminal stage

Decreased family’s ability to cope, resulting from diagnosis of terminal stage

123

The patient will do the following:

Verbalize adequate relief of pain or ability to cope with incompletely relieved pain

Verbalize concerns and feelings related to the diagnosis and prognosis

Demonstrate improved coping strategies, as evidenced by incorporation of alternative coping behaviors and techniques in their interactions

Pancreatic Cancer: Planning and Expected Outcomes

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Provide pain relief and encourage to verbalize feelings.

Encourage families to spend time with the patient.

May also be necessary to assist patient and family in dealing with imminent death.

Documentation of achievement of expected outcomes, prevention of complications, and provision of a comfortable environment

Pancreatic Cancer: Intervention and Evaluation

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Gastrointestinal cancer in the older adult often does not have a good prognosis, either because it is caught too late or it is invasive. When caring for a patient with any of the GI cancers, what are some of the important nursing interventions to help the patient maintain quality of life?

Quick Quiz!

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Answers will vary but should include nutrition, pain management, psychosocial support.

Answer to Quick Quiz

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More common where hepatitis is endemic

Risk factors: Alcoholic cirrhosis, hemochromatosis, fatty liver disease, obesity, diabetes, anabolic steroid use, and exposure to aflatoxins

Primary Liver Cancer

128

Indicator that the primary cancer is incurable

Weight loss is a common early finding.

Signs and symptoms of liver involvement are the late signs of organ failure (e.g., ascites and portal hypertension).

The overall prognosis is poor.

Cause of death is most often pneumonia, malnutrition, emboli, hepatic failure, or hemorrhage.

Nursing management is similar to that for patients with alcoholic cirrhosis.

Metastatic Liver Cancer

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