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GIT
Fall Semester
Nur 221
Anatomy overview of the GIT
Function of the GIT:
- Breakdown of food for digestion
- Absorption of nutrients produced by digestion
into the bloodstream
- Elimination of undigested foodstuffs and
other waste products
Assessment of the GIT
 Health Hx and clinical manifestation:
- Pain (Abdominal)
- Dyspepsia (indigestion)
- Intestinal gas (belching , flatulence)
- N&V
- Changing in bowel habit and stool ch.ch
(diarrhea, constipation
- jaundice, history of GI surgery or problems,
appetite and eating patterns, teeth, and nutritional
assessment including weight patterns
 PE & Diagnostic procedure
 Psychosocial, spiritual, and cultural factors
Common Sites of Referred Abdominal
Pain
Diagnostic test:
-
CBC, PT,PTT, LFT, S.amylase, billirubin,
stool analysis
Breath test (hydrogen breath test, urea breath test)
Abd U\S
Imaging studies: CT, MRI
Upper Gastrointestinal Tract Study (barium meal)
Lower Gastrointestinal Tract Study (Barium enema)
Endoscopic procedures (gastroscopy)
Colonoscopy
Quadrants of the Abdomen
Gastritis
 Inflammation of gastric and stomach mucosa
 Acute: rapid onset of symptoms
- usually caused by dietary indiscretion.
FOOD irritating … highly seasoned or contaminated by
microorganism.
- Other causes include overuse of medications (aspirin &
NSAID), alcohol, bile reflux, and radiation therapy.
- Ingestion of strong acid or alkali.
 Chronic- prolonged inflammation: due to benign or
malignant ulcers, or by helicobacter pylori (H. pylori),
 Can be due to autoimmune disease as pernicious anemia,
dietary factors (caffeine), medications NSAID, alcohol,
smoking, chronic reflux of pancreatic secretions or bile
 Pathophysiology:
gastric mucus membrane is edematous and hyperemic
(congested with fluid &blood) & may perforated. Very
little acid and a much mucus is secreted. superficial
ulceration may occur & cause hemorrhage
 Symptoms:
- For acute gastritis:
Abd discomfort, headache, lassitude, nausea, vomiting,
anorexia, hiccupping, feeling of fullness.
- In chronic gastritis:
Anorexia, heartburn after eating, belching, sour taste in
the mouth, nausea and vomiting, intolerance of some
foods, May have vit. B12 deficiency due to malabsorption
 Assessment & Dx finding:
- hypochlorhydria (↓HCl) or hyperchloridria (↑HCl), or
achlorhydria
- diagnosis made by: UGI x-ray series, endoscopy &
biopsy, histological examination of tissue specimen,
CBC, stool for occult blood
 Medical management:
- In acute gastritis: may heal by it self in 1 day, with
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anaroxia for 2-3 days, it also treated by
refrain pt from alcohol & food until symptoms subside
nonirritating diet is recommended
Supportive therapy (NGI; IV fluid; antiacid; Sedative
If hemorrhage present (blood transfusion with fluid
replacement)
Neutralize and dilute the agent if the cause is acid or alkali
ingestion, avoid emetics and lavage due to danger of
perforation and damage to esophagus
*In sever cases surgery is performed
(gastrojejunostomy)
- For chronic gastritis:
modifying the patient's diet
promoting rest,
 reducing stress,
recommending avoidance of alcohol and
NSAIDs & smoking
 initiating pharmacotherapy (drug combinations) (e.g.
antibiotics; H2 blocker, proton pump inhibitors)
Nursing process for pt with gastritis
 Assessment:
- History including presenting signs and symptoms
+ symptoms occur at any specific time of the day +
& factor+ association. Dietary history and
dietary associations with symptoms (72 hour diet)
- Identifies duration of symptoms, any methods used
by pt to treat it, & if the methods are effective
- Physical examination include abdominal
tenderness, dehydration, and evidence of any
systemic disorder that might be responsible for the
symptoms of gastritis
- Result of diagnostic procedure
Diagnosis:
- Anxiety related to treatment
- Imbalanced nutrition, less than body requirements,
related to inadequate intake of nutrients
- Risk for imbalanced fluid volume related to
insufficient fluid intake and excessive fluid loss
subsequent to vomiting
- Deficient knowledge about dietary management and
disease process
- Acute pain related to irritated stomach mucosa
Planning:
- Reduced anxiety
- Avoidance of irritating foods
- Adequate intake of nutrients
- Maintenance of fluid balance,
- Increased awareness of dietary management
- Relief of pain.
 Implementation:
- Reducing Anxiety :
 offers supportive therapy to the patient and family during
treatment and after the ingested acid or alkali has been
neutralized or diluted
 uses a calm approach to assess the patient and to answer all
questions as completely as possible
 explain all procedures and treatments based on the patient's
level of understanding.
- Promoting Optimal Nutrition:
 N.P.O possibly for a few days—until the acute symptoms
subside
 monitors fluid intake and output along with serum electrolyte
values
 After the symptoms subside, offer ice chips followed by clear
liquids
 Introducing solid food as soon as possible
 discourages the intake of caffeinated beverages,
because caffeine is a central nervous system
stimulant that increases gastric activity and pepsin
secretion
 Discouraging cigarette smoking (nicotine reduce the
secretion of pancreatic bicarbonate which inhibit
neutralization of gastric acid)
- Promoting Fluid Balance :
 Daily fluid intake and output are monitored
 be alert for any indicators of hemorrhagic gastritis,
which include (hematemesis : vomiting of blood),
tachycardia, and hypotension
 IVF administration and monitoring
- Patients Teaching:
inform about stress management, diet, and
medications
Dietary instructions take into account the
patient's daily caloric needs, food
preferences, and pattern of eating
review foods and other substances to be
avoided (e.g., spicy, irritating, or highly
seasoned foods; caffeine; nicotine; alcohol).
Describe medication regimen.
Peptic Ulcer Disease
 A peptic ulcer may be referred to as a gastric, duodenal, or
esophageal ulcer, depending on its location
 Excavation (hollowed-out area) that forms in the mucosal
wall of the stomach, in the pylorus (the opening between the
stomach and duodenum), in the duodenum (the first part of
small intestine), or in the esophagus
 more likely to be in the duodenum than in the stomach
 Peptic ulcer disease occurs with the greatest frequency in
people between 40 and 60 years of age
 uncommon in women of childbearing age, After
menopause, the incidence of peptic ulcers in women is
almost equal to that in men
 result from infection with the gram-negative bacteria ,
which may be acquired through ingestion of food and water
 Other causes for peptic ulcer are: stress, caffeinated
beverages, smoking, and alcohol, eating spicy foods may
make peptic ulcers worse.
 Familial tendency also may be a significant predisposing
factor. People with blood type O are more susceptible to
peptic ulcers than are those with blood type A, B, or AB
 Other predisposing factor chronic use of NSAID’s,
alcohol ingestion and smoking
 severe peptic ulcers, extreme gastric hyperacidity, and
gastrin-secreting benign or malignant tumors of the
pancreas known as Zollinger-Ellison syndrome (ZES)
Deep peptic ulcer
ZES (Zollinger-Ellison syndrome):
- suspected when a patient has several peptic
ulcers or an ulcer that is resistant to standard
medical therapy
- identified by the following: hypersecretion of
gastric juice, duodenal ulcers, and
gastrinomas (islet cell tumors) in the
pancreas (↑release the hormone gastrin)
- The most common symptom is epigastric
pain
- H.Pylori is not a risk factor for ZES
Stress ulcer:
- acute mucosal ulceration of the duodenal or gastric
area that occurs after physiologically stressful
events, such as burns, shock, severe sepsis, and
multiple organ traumas
- endoscopy within 24 hours of trauma or surgery
reveals shallow erosions of the stomach wall; by 72
hours, multiple gastric erosions are observed.
- Mechanism: in shock gastric mucosal blood flow
decrease and the duodenal content reflux to stomach
increase, and amount of pepsin secretion increase (
ischemia + increase acid and pepsin creates an ideal
climate for ulceration)
Pathophysiology
peptic ulcers mainly occur in gastroduodenal
mucosa.
Damaged mucosa cannot secrete enough
mucus to act as a barrier in addition increase
acid and pepsin will cause further damage to
the mucosa and decrease resistance to
bacteria
C\M
dull pain or a burning sensation (gnawing) in the
midepigastrium or in the back
Pain is usually relieved by eating in duodenal ulcer,
while increase in pt with gastric ulcer
 localized tenderness in the epigastric area
pyrosis (heartburn), vomiting, constipation or
diarrhea, and bleeding
Melena, hematomesis
Assessment and Diagnostic Findings
 physical examination may reveal pain, epigastric
tenderness, or abdominal distention
 barium study of the upper GI tract may show an ulcer
 endoscopy is the preferred diagnostic procedure because
it allows direct visualization of inflammatory changes,
ulcers, and lesions
 Stools analysis
 Gastric secretory studies to evaluate a chlorhydria
 Pathogenic/histological examination (for H.pylori)
 serologic testing for antibodies against the antigen
 urea breath test
Management
Medications (combination of antibiotics, proton
pump inhibitors, and bismuth salts that suppress or
eradicate, for 10 to 14 days
lifestyle changes
surgical intervention (vagotomy, Pyloroplasty,
Gastrojejunostomy)
Smoking cessation, stress reduction
Diet modification
Management
surgical intervention:
1. Pyloroplasty: a surgical procedure in which
the pylorus valve at the lower portion of the
stomach is cut and resutured, relaxing and
widening its muscular opening (pyloric sphincter)
into the duodenum
2. vagotomy: disconnecting the nerves that
stimulate acid secretion and opening the
pylorus), The purpose of the procedure is to
disable the acid-producing capacity of the
stomach.
3. Gastrojejunostomy
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Surgical Procedures for Peptic Ulcers
Question
Is the following statement True or False?
The most common site for peptic ulcer
formation is the pylorus.
Answer
False
The most common site for peptic ulcer
formation is not the pylorus. The most
common site for peptic ulcer formation is
the duodenum.
Nursing process
Assessment:
- Assess pain & method to relive it
- Assess vomiting
- Assess pt usual food intake
- Assess pt intake of medication
- V\S
- Review result of the diagnostic test
- P\E for abdominal tenderness
Nursing Diagnoses:
- Acute pain related to the effect of gastric
acid secretion on damaged tissue
- Anxiety related to an acute illness
- Imbalanced nutrition related to changes in
diet amb decreased weight, decreased
required caloric intake/24hs
- Deficient knowledge about prevention of
symptoms and management of the condition
 Collaborative Problems/Potential Complications:
-
Hemorrhage
Perforation
Penetration
Pyloric obstruction (gastric outlet obstruction)
 Intervention:
- Medication to relive pain
- Instruct pt to avoid aspirin, caffeinated beverage, spicy food
- Relaxation technique to manage pain and stress
- Encourage pt to express fear
- Explain any procedure to the pt
- Manage complication ( blood transfusion, monitor V\S,
IVF)
- Instruct the pt about factors that decrease or increase the
condition
- Teach the pt about the diet
Abnormalities of fecal elimination
Abnormalities in fecal elimination are
symptoms of functional disorders or
disease of the GI tract.
It include constipation, diarrhea and
incontinence
Constipation
 It is abnormal hardening of stools that makes their passage
difficult and sometimes painful, a decrease stool volume,
or retention of stool in the rectum for a prolonged period
 Causes:
- Medication (anticholinargeic, antidepressant, iron
preparation, antihypertensive, opioid analgesic)
- Rectal or anal disorders (hemorrhoids)
- Obstruction (bowel tumor)
- Metabolic, neurologic and neuromuscular condition as (
DM, MS)
- Endocrine disorder (hypothyroidism)
- Lead poisoning and connective tissue disorders (SLE)
Other causes: weakness, immobility, emphysema,
dietary habit, lack of exercise, stress, chronic
laxative use
Irritable bowel syndrome & diverticular are
common disease of the colon associated with
constipation
Pathophysiology
Interference with one of the following:
1- mucosal transport ( mucosal secretion that
facilitate the movement of colon content)
2- myoelectric activity( mixing of the rectal mass
and propulsive action)
3- process of defecation
Any causes of the constipation can interfere with
these three processes
If no any organic causes for constipation
idiopathic constipation is diagnosed
C\M:
-
Decrease bowel movement <3\wk
Abdominal distension
Pain & pressure
Headache
dec appetite
Fatigue
indigestion,
strain at stool & elimination of small volume and hard-dry
stool
- Sense of incomplete evacuation
Diagnosis
Pt Hx
Physical examination
Barium enema or sigmiodscopy (to assess is it
from spasm or narrowing of the bowel)
Anorectal manometry: measure the changes in
intraluminal pressure and coordination of
muscle activity in GIT(to assess malfunction of
the sphincter, rectosphincteric reflex.)
Defography: instillation of very thick barium into the rectum then
fluoroscopy done while the pt. is trying to expel the barium, evaluation for the
function of the rectum and anal sphincter
 Complications: HTN, fecal impaction, hemorrhoids and
fissure, megacolon (enlarged colon that is unable to move stool)
 Medical Managements: aim to correct the underlying
cause by:
- Education to increase fiber diet and fluids
- Bowel training habits and discontinuing of laxative use.
- Routine exercise that strengthen abdominal muscles
- Biofeedback is a technique used to help patient learn to
relax the sphincter mechanism to expel the stool.
- 6-12 teaspoon of unprocessed bran.
- If laxative to be used; use bulk forming agents, saline and
osmotic agents, lubricants, stimulants, fecal softeners.
- Enemas and rectal suppositories used for patient with fecal
impaction
Nursing management:
- Pt education how to prevent constipation:
Respond to urge to defecate
Dietary information
Increase ambulation and exercise
Describe abdominal toning exercise ( contracting
Abd muscle 4t\day and leg to chest left 10-20t\day)
Instruct patient about semisquatting position
during defecation
Diarrhea
 increase frequency of bowel movement (> 3 per day),
increase amount more than 200 g per day, altered
consistency (looseness) of stool.
 Associated with urgency, perianal discomfort,
incontinence.
 Any condition that causes ↑ intestinal secreration, ↓
mucosal absorption, or alteration in motility can cause
diarrhea
 It may be acute or chronic
Causes
 (IBS, IBD, lactose intolerance) the main underlying
disease that cause diarrhea. It occurs also from
 Medications as ( thyroid hormone replacement, laxative,
AB, chemotherapy)
 Tube feeding formula
 Metabolic and endocrine disorders (DM, thyrotoxicosis)
 Viral or bacterial infection (food poisoning, dysentery)
 Nutritional and malabsorpative disorders (celiac)
 Anal sphincter defect
 ZES, paralytic ileus, intestinal obstruction, AIDS
Pathophysiology:
- 3 types:
1- Secretory: (high-volume diarrhea, caused by
production and secretion of water and electrolyte by
intestinal mucosa
2- Osmotic: (due to water pulling into the intestine by
the osmotic pressure from unabsorbed particles)
3- Infectious
4- Malabsorption
5- Exudative
C\M: increase frequency and fluid content of
stools, Abd cramp, distention, intestinal rumbling
(borborygmus), anorexia, thirst. Painful spasmodic
contraction of the anus and ineffective straining
(tenesmus). Other symptoms are due to
dehydration and electrolyte imbalance
 Greasy stool suggest intestinal malabsorption;
presence of mucus and pus suggests inflammatory
enteritis or colitis. Oily droplet are almost indicate
pancreatic insufficiency, nocturnal diarrhea may
suggest diabetic neuropathy
Diagnosis: CBC, chemistry, urinalysis, routine stool
examination, and stool exam for infectious or
parasitic organism, Barium enema and endoscopy
Complications: Dysrthymias, Muscle weakness,
drowsiness, anorexia, loss of fluid cause urine
output less than 30 ml/day. Dec K+ level less than 3
mmol/l should be reported
Medical management: use of AB and antiinflammatory agent to reduce the severity & treat
the underlying disease
Nursing management: assessment, in acute episode
encourage bed rest and food and fluid low in bulk,
solid food followed,
avoid caffeine beverages & very hot or cold foods,
restrict milk products, fat, fresh fruit and vegetables
for several days,
administer antidiarrheal medication (diphenoxylate
or loperamide),
IVF,
report evidence of dysrhythmias that may result
from hypokalemia
IBS
Functional disorders of intestinal motility
No known cause, usually hereditary factor,
psychological stress, depression and anxiety,
diet high in fat and stimulating or irritating food,
alcohol consumption and smoking.
More common in women than in men
In IRS the peristaltic waves are affected at
specific segments & the intensity of propel the
fecal pattern, no evidence of inflammation or
tissue changes in intestinal mucosa
 C\M: Alteration in bowel pattern (primary symptoms)
constipation or diarrhea or mixing of both, abdominal pain ( ↑
with eating & ↓ with defecation) , bloating, abd distension
 Diagnosis: Stool studies, contrast X-ray, Barium enema,
colonoscopy (spasm), proctoscopy, manometry, and
electromyography study the intraluminal pressure changes
generated by spasm
 Medical management: Restrict food and then reintroduction of
foods is important to determine type of food that is irritating
(beans, caffeinated products, fried food, alcohol, spicy food)
 Stress reduction techniques
 Manage diarrhea and constipation
 Tegaserod (zelnorm) for women with IBS and complain from
constipation, but it was not recommended lately due to the risk
of MI

Probiotics can be given
Dietary complement
Nursing management: Nurse should educate
family and patient about the importance of good
dietary habits, chewing food slowly and eat
regularly, not taking fluid with meal since it may
cause abd destination, discouraged alcohol and
smoking.
Acute inflammatory intestinal disorders
 Appendicitis: (inflammation of the appendix)
- Appendix is a small, finger-like structure within the abd,
about 10 cm long and attached to the cecum just below
the ileocecal valve
- fills with food and empties into the cecum
- It is prone to obstruction and to infection (appendicitis)
- Common cause of acute abd, and emergency abdominal
surgery
- Occur in all ages but it common between age 10-30
years
Pathophysiology:
- It become inflamed and edematous either by
being kinked or occluded by fecalith, tumor
or Foreign body
- Inflammatory process increases intraluminal
pressure, initiating progressively sever and
generalized or periumblical pain that
becomes localized in the RLQ
- When it flamed it filled with pus
 C\M:
- vague epigastric pain or periumblical pain that progress to
the RLQ
- associated with low grade fever, N & V
- loss of appetite
- Localized tenderness at the Mc Burney’s point ( point
between the umbilicus and the anterior superior iliac spine
- +ve rebound tenderness ,+ve rovsing sign, +ve obtirator, &
psoas sign, and cutaneous hypersthesia
- If it rupture pain become more diffuse, with the
development of abdominal distention
- Constipation may occur, so pt not given laxative
 Diagnosis:
- Complete P\E
- Lab test (CBC, urine analysis)
- Abd x-ray, U\S and CT scan (reveal RLQ density or
localized distension of the bowel
 Complications:
- Perforation (peritonitis): occur 24hr’s from pain
onset
- Abscess formation
- Portal pylephlebitis
 Medical management:
- Immediate surgery (Appendectomy)
- AB pre op
- If it perforated drainage is applied to the abscess, then
appendectomy is performed
 Nursing management:
- Pre surgery
- Relive pain
- Prevent FVD
- Reduce anxiety
- Prepare the pt for surgery
- After surgery :place pt in high fowler position or supine
with leg slightly flexed
-
Give pt opioid analgesic
Give food as tolerated
Teach pt wound care
Instruct pt that he can resume normal physical activity within 24wk’
 Nursing interventions for patient with complications after
appendectomy:
- Peritonitis: observe for abd tenderness, fever, vomiting, abd
rigidity and tachycardia, employ constant NG tube, correct
dehydration, administer antibiotic
- Pelvic abscess: evaluate N & V, chills, fever, diaphoresis,
diarrhea, prepare pt for rectal exam and surgical drainage,
- Subphrenic abscess (under the diaphragm): evaluate for
chills and fever, prepare x-ray exam, prepare pt for surgical
drainage of abscess.
- Paralytic ileus: assess for bowel sounds, employ NG tube
and suction, replace F& E, prepare for surgery
Peritonitis:
- An inflammation of the peritoneum, the serous
membrane lining the abd cavity and covering the
viscera.
- Results from bacteria (E.Coli, klebsiella, Proteus&
pseudomonas) or MO from GI disease, in women it
occur from disease of reproductive organ. It can
result from trauma or injury (gunshot, stab wound)
or kidney inflammation.
- Other common causes are: appendicitis, perforated
ulcer, diverticulitis and bowel perforation, peritoneal
dialysis
Pathophysiology
Occurs when abd organ content leak into the abd
cavity as a result of inflammation, infection,
trauma, tumor & perforation. Result in edema &
exudation of fluid.
Fluid in the abd cavity becomes turbid and then
increasing amount of protein and cellular debris,
blood, WBC, intestinal tract responded
immediately by hypermotility followed by
paralytic ileus with fluid and gas accumulation in
the bowel and.
C\M: depends on the severity and location of
inflammation
- Diffuse pain (then becomes constant, localized, more
intense near the site of inflammation, ↑with movement)
- Then becomes sever tenderness and distention in the
affected area
- Rebound tenderness & paralytic ileus
- N&V, increase temp (37.8- 38.3), increase pulse rate
- Diminished peristaltic movement
- Rigid abdominal muscle
Pain diminished in pt with diabetes, liver cirrhosis and
on analgesic or corticosteroids
Diagnostic finding:
- ↑ WBC’s
- ↓ Hb & HCT if blood lost occurred
- ↓ Na, K, Cl
- Abd x-ray: air, fluid & distended bowel
- CT scan show abscess formation
- Peritoneal aspiration for culture and sensitivity.


-
Complications:
Sepsis (major cause of death )
Shock due to hypovolemia or septicemia
Intestinal obstruction (due to bowel adhesion)
Medical management:
Fluid and electrolyte replacement. Isotonic solution is administered
(several liters) to correct hypovolemia
Analgesic for pain
Antiemetic as prescribed for N & V
Intestinal intubations and suction decrease distension and promote
intestinal function.
O2 therapy is administered
Massive antibiotic therapy: large doses of broad spectrum antibiotic
through IV.
Surgery is aimed to remove the infected material and correct the
cause: excision (appendix), repair (perforation) & drainage (abscess)
 Nursing management: pt is in ICU
- Monitor VS, GI function, F & E balance, urine output
- Assessment of pain
- Positioning (place pt on the side with knee flexed)
- Record I&O
- Administer and monitor IVF
- Assess signs of ↓ peritonitis: ↓ temp, pulse rate, softening of
the abdomen, return of peristaltic sounds, passing of flatus,
and Bowel movement
- Increase food and fluid intake gradually as needed
- Observe and record the ch.ch of the drainage
- Teach pt & family how to care for the drain and the wound
if he will discharge with them
Intestinal obstruction
 Presence of blockage that prevents the normal flow of
intestinal contents through the intestinal tract
 2 types:
1- Mechanical: it is an intraluminal or mural obstruction
from pressure on the intestinal wall (as tumors &
neoplasms, intussusceptions, hernias, stenosis, abscess,
adhesion)
2- Functional: the intestinal musculature cannot propel
the content along the bowel [as muscular dystrophy,
endocrine (DM), neurological (Parkinson's disease)],
can be temporary when the bowel is manipulated due to
surgery
Causes of Intestinal Obstructions
 Obstructions can be partial or complete
 Its severity depends on:
- The region of obstruction
- The degree of obstruction
- The degree to which vascular supply disturbed
 Most bowel obstruction occur in the small intestine (
adhesion then hernias and neoplasms), other causes
intussusceptions, volvulus, paralytic ileus.
 Most obstruction of the large bowel occur in sigmoid
colon, common causes are carcinoma, diverticulitis, IBD,
benign tumor.
.
Intussusception: invagination or
shortening of the colon caused by
movement of one segment of the bowel
into another.
Volvulus of the sigmoid colon: twisted
and with edematous bowel
Hernias: herniated intestinal content
(inguinal hernia).
82
Small bowel obstruction
 Intestinal contents, fluids & gas accumulate above the
intestinal obstruction →Abdominal destination &
retention of fluid → ↓absorption of fluid → stimulate
more gastric secretion.
 With ↑ing destination → ↑intestinal pressure → ↓venous
& arteriolar pressure → Edema, congestion, necrosis,
perforation or rupture of the intestinal wall; peritonitis
may occur
 Metabolic alkalosis (reflux vomiting → loss of H+ & K
ions (stomach)→ ↓ Cl& K (blood)→ MA)
 Dehydration and acidosis (Rt loss of H2O and Na).
 Hypovolemic shock may occur due to acute fluid losses
 Signs and symptoms: initially crampy pain & colicky. Pt
may pass blood & mucus but not fecal matter or flatus.
Vomiting.
 If obstruction complete, intestinal content propelled
toward the mouth instead of the rectum (due to reverse
direction of extremely vigorous peristaltic movement).
 Obstruction of the ileum: fecal vomiting: starting with
vomiting of stomach content → bile-stained content of
the duodenum & jejunum → darker fecal-like content of
the ileum.
 Dehydration signs: intense thirst, drowsiness, malaise,
aching, parched (dry) tongue & mucous membrane.
 The more lower the GI obstruction the more abdominal
distention occurs. End result ….hypovolemic shock (RT
dehydration & loss of plasma volume).
 Diagnosis: S&S, x-ray (abnormal quantities of fluid and
gas), lab studies for (electrolyte &CBC: for signs of
dehydration).
Medical management:
 NG tube (NGT) for decompression of the bowel.
 Surgery (in complete obstruction) as: repairing the
hernias, dividing the adhesion, or removal of affected part
and making anastomosis.
Nursing management:
 Maintain the NGT function; measure/assess its output,
 Assess: F&E, nutritional status, passage of stool or flatus,
return of bowel sounds, improvement in the Abd pain.
 Report: ↑ in pain or abd distension, ↑NGT output and
prepare pt for surgery
Large bowel obstruction
 Accumulation of intestinal contents, fluid
and gas proximal to the obstruction.
 Cause sever destination and perforation
unless release of some fluid and gas through
the ileal valve.
 In sever obstruction→ cut off blood →
necrosis (life threatening).
 Dehydration occur more slowly because
colon can distend beyond its normal capacity
and absorb its fluid content. Slow progression
of symptoms.
C\M:
- If sigmoid colon and rectum obstructed →only
constipation can be seen for months.
- Blood loss in stool → iron deficiency anemia
- Distended abd → visible loops of large
intestine through the abdomen
- Crampy lower Abd pain develop
- Fecal vomiting and shock may occur.
Diagnosis:
- S&S
- Imaging studies (X-ray, Abd CT, MRI): distended
colon
**Barium study is Contra Indicated
Medical management:
-
Correction of F&E,
NGT for immediate aspiration & decompression
Colonoscopy: to untwist & decompress the bowel
Rectal tube to decompress the lower area of the bowel
Surgery to resects and remove the obstructed lesion
Cecostomy to release gas and small amount of
drainage
- Colostomy (temporary or permanent),
- Ileoanal anastemosis (if the entire large bowel
removed)
Nursing management:
- Monitor pt for worsening in obstruction
- Administer IVF and electrolyte replacement
- Prepare the pt for surgery if indicated
Colostomy
Is the surgical creation of an opening into 
the colon , allows the drainage of colon
It could be content to the out side the body.
temporary or permanent fecal diversion.
The consistency of the drainage is related 
to the placement of the colostomy.
Large bowel obstruction, Indications : 
Colorectal cancer. The colostomy begins to
function 3- 6 days after surgery.
Ileostomy
Ileostomy: the surgical creation of an 
opening into the ileum or small intestine,
is commonly performed after a total
colectomy. It allows for drainage of fecal
matter from ileum to the out side of the body
The drainage is liquid to unformed and 
occurs at frequent intervals.
Indication: chronic inflammatory bowel 
disease.
Nursing Management
- Stoma care ( see chart 38-5 changing an
ostomy appliance) & ( See chart 38-11 the
irrigation procedure)
- Teaching patient self care
- Supportive a positive body image
- Continuing care.
Diseases of the Anorectum
 Includes: Anorectal abscess, Anal fistula, Anal fissure,
hemorrhoids, pilonidal sinus or cysts.
 Anal fissure:
- Is a longitudinal tear or ulceration in the lining of the anal
canal
- Causes: trauma, persistent tightening of the anal canal from
stress and anxiety (constipation), childbirth, overuse of
laxative
- C\M: painful defecation, burning and bleeding during
defecation, bright red on the paper toilet
- Rx: dietary modification ( fiber supplement), stool softener,
increase water intake, sitz bath, suppositories with
analgesic, surgery ( lateral internal shpinctretomy with
fissure excision)
-
-
Hemorrhoids
Dilated veins in the anal canal
50 % of people above 50y of age develop hemorrhoids.
Shearing effect on the anal mucosa during defecation
leading to sliding of the anal structure ( hemorrhoidal
and vascular tissue)
Pregnancy may initiate it due to the pressure in the
hemorrhoidal tissue
Classifies as: internal or external
S&S: pain, itching, bright red bleeding with defecation
External: associated with sever pain from inflammation
and edema caused by thrombosis lead to ischemia and
necrosis.
Internal is not painful until they bleed or prolapsed when
they enlarge
Management:
 avoid strain, hygiene, high-fiber diet, fruit, bran and fluid
intake.
 Analgesic, bulk-forming agents such as (Metamucil),,
warm compresses, sitz bath, bed rest allow the
engorgement to subside.
 None surgical treatment: infrared photocoagulation,
bipolar diathermy, laser therapy (to affix the mucosa to
underling muscle) .
 Surgical treatment: rubber-band Ligation procedure after
anoscope. Can be painful and may cause secondary
hemorrhage or infection.
 Cryosurgical hemorrhoidectomy: freezing the hemorrhoid
for sufficient time to cause necrosis, painless, foul
smelling, prolonged healing, not very common.
 For hemorrhoids with thrombosed vein hemorrhoidectomy
is performed, after surgery small tube inserted through the
sphincter to permit flatus and blood drainage
Nursing process
Assessment:
Nsg Dx:
- Constipation R\T ignoring the urge to defecate
secondary to pain
- Anxiety R\T surgery or embarrassment
- Acute pain R\T irritation, pressure
- Knowledge deficit
Potential complication: hemorrhage
Planning: relive constipation, relive pain, anxiety,
increase knowledge
Implementation:
- Encourage fluid intake
- High fiber diet recommendation
- Instruct pt how to use bulk agent
- Give analgesic before bowel movement
- Relaxation exercise
- Inform pt not to ignore the urge to defecate
Explain surgical procedure -
- Maintain pt privacy during care of the pt
- Sitz bath of warm water to relive pain 3-4t\day after
each bowel movement for 1-2 wk post surgery
- Use of topical analgesic agent (xylocaine)
- Place pt in prone position ( reduce edema of the
tissue)
- Check area for rectal bleeding
- Monitor urine output