1. Description: Examination of the upper gastrointestinal tract under fluoroscopy after the client

drinks barium sulfate

2. Preprocedure: NPO after midnight the day of the test

3. Postprocedure

a. A laxative may be prescribed.

b. Instruct the client to increase oral fluid intake to help pass the barium.

c. Monitor stools for the passage of barium (stools will appear chalky white) because barium can cause a bowel obstruction.

1. Description

a. Gastric analysis requires the passage of a nasogastric tube into the stomach to aspirate gastric

contents for the analysis of acidity (pH), appearance, and volume; the entire gastric contents

are aspirated, and then specimens are collected every 15 minutes for 1 hour.

b. Medication, such as histamine or pentagastrin, may be administered subcutaneously to

stimulate gastric secretions; some medications may produce a flushed feeling.

c. Esophageal reflux of gastric acid may be diagnosed by ambulatory pH monitoring; a probe is

placed just above the lower esophageal sphincter and connected to an external recording

device. It provides a computer analysis and graphic display of results.

2. Preprocedure

a. Fasting for 8 to 12 hours is required before the test.

b. Use of tobacco and chewing gum is avoided for 6 hours before the test.

c. Medications that stimulate gastric secretions are withheld for 24 to 48 hours.

3. Postprocedure

a. Client may resume normal activities.

b. Refrigerate gastric samples if not tested within 4 hours. 

1. Description

a. Also known as esophagogastroduodenoscopy

b. Following sedation, an endoscope is passed down the esophagus to view the gastric wall, sphincters, and duodenum; tissue specimens can be obtained.

2. Preprocedure

a. The client must be NPO for 6 to 12 hours before the test.

b. A local anesthetic (spray or gargle) is administered along with medication that provides conscious sedation and relieves anxiety, such as intravenous (IV) midazolam, just before the scope is inserted.

c. Medication may be administered to reduce secretions, and medication may be administered to relax smooth muscle.

d. Client is positioned on the left side to facilitate saliva drainage and to provide easy access of the endoscope.

e. Airway patency is monitored during the test and pulse oximetry is used to monitor oxygen saturation; emergency equipment should be readily available.

3. Postprocedure

a. Client must be NPO until the gag reflex returns (1 to 2 hours).

b. Monitor for signs of perforation (pain, bleeding, unusual difficulty in swallowing, elevated temperature).

c. Maintain bed rest for the sedated client until alert.

d. Lozenges, saline gargles, or oral analgesics can relieve a minor sore throat (not given to the client until the gag reflex returns).

1. Description

a. Colonoscopy is a fiberoptic endoscopy study in which the lining of the large intestine is

visually examined; biopsies and polypectomies can be performed.

b. Cardiac and respiratory function are monitored continuously during the test.

c. Colonoscopy is performed with the client lying on the left side with the knees drawn up to the

chest; position may be changed during the test to facilitate passing of the scope.

2. Preprocedure

a. Adequate cleansing of the colon is necessary, as prescribed by the health care provider

(HCP).

b. A clear liquid diet is started on the day before the test.

c. Consult with the HCP regarding medications that must be withheld before the test.

d. Client is NPO after midnight on the day of the test.

e. A mild sedative is administered intravenously.

f. Medication may be administered to relax smooth muscle.

3. Postprocedure

a. Provide bed rest until alert.

b. Monitor for signs of bowel perforation and peritonitis

■ Guarding of the abdomen

■ Increased fever and chills

■ Pallor

■ Progressive abdominal distention and abdominal pain

■ Restlessness

■ Tachycardia and tachypnea

c. Instruct the client to report any bleeding to the HCP.

The client receiving enemas is at risk for fluid and electrolyte imbalances.

1. Description

a. Examination of the hepatobiliary system is performed via a flexible endoscope inserted into

the esophagus to the descending duodenum; multiple positions are required during the

procedure to pass the endoscope.

b. If medication is administered before the procedure, the client is monitored closely for signs

of respiratory and central nervous system depression, hypotension, oversedation, and

vomiting.

2. Preprocedure

a. Client is NPO for several hours before the procedure.

b. Sedation is administered before the procedure.

3. Postprocedure

a. Monitor vital signs.

b. Monitor for the return of the gag reflex.

c. Monitor for signs of perforation or peritonitis

■ Guarding of the abdomen

■ Increased fever and chills

■ Pallor

■ Progressive abdominal distention and abdominal pain

■ Restlessness

■ Tachycardia and tachypnea

1. Description: Provides images of the gastrointestinal (GI) wall and digestive organs.

2. Preprocedure

a. Client is NPO for several hours before the procedure.

b. Sedation is administered before the procedure.

3. Postprocedure

a. Monitor vital signs.

b. Monitor for the return of the gag reflex.

c. Monitor for signs of perforation or peritonitis.

■ Guarding of the abdomen

■ Increased fever and chills

■ Pallor

■ Progressive abdominal distention and abdominal pain

■ Restlessness

■ Tachycardia and tachypnea

Following endoscopic procedures, monitor for the return of the gag reflex before giving the client any oral substance. If the gag reflex has not returned, the client could aspirate.

1. Description

a. The examination involves the injection of dye directly into the biliary tree.

b. The hepatic ducts within the liver, the entire length of the common bile duct, the cystic duct,

and the gallbladder are outlined clearly.

2. Preprocedure

a. Client is NPO, usually from midnight preprocedure.

b. Sedating medication is administered.

3. Postprocedure

a. Monitor vital signs.

b. Monitor for signs of bleeding, peritonitis and septicemia; report the presence

of pain immediately.

c. Administer antibiotics as prescribed to reduce the risk of sepsis.

1. Ensure that the client understands the procedure and that informed consent has been obtained.

2. Obtain vital signs, including weight.

3. Have the client void.

4. Position the client upright.

5. Assist the health care provider (HCP), monitor vital signs, and provide comfort and support during the procedure.

6. Apply a dressing to the site of puncture.

7. Monitor vital signs, weigh the client, and maintain the client on bed rest.

8. Measure the amount of fluid removed.

9. Label and send the fluid for laboratory analysis.

10. Document the event, client’s response, and appearance and amount of fluid removed.

Paracentesis is the transabdominal removal of fluid from the peritoneal cavity. The nurse first ensures that the client understands the procedure and that informed consent has been obtained, because the procedure is invasive. The nurse next obtains preprocedure vital signs, including weight, so that a baseline is obtained. Weight is taken before and after the procedure to provide an indication of the effectiveness of the procedure in fluid removal. The client is positioned upright on the edge of a bed with the back supported and the feet resting on a stool, or in a Fowler’s position in bed. The nurse assists the HCP, monitors vital signs per protocol, and provides comfort and support to the client during the procedure. Once the procedure is complete the nurse applies a

dressing to the site of puncture and monitors for leakage or bleeding. The client is placed in a position of comfort, bed rest is maintained as prescribed, and vital signs are monitored to assess for complications. The fluid removed from the client is measured, labeled, and sent to the

laboratory for analysis. The nurse documents the event, the client’s response, the appearance and amount of fluid removed, and any additional pertinent data.

1. Description: Transabdominal removal of fluid from the peritoneal cavity for analysis

2. Preprocedure

a. Have the client void before the start of procedure to empty the bladder and to move the bladder out of the way of the paracentesis needle.

b. Measure abdominal girth, weight, and baseline vital signs.

c. Note that the client is positioned upright on the edge of the bed, with the back supported and the feet resting on a stool (or in Fowler’s position in bed).

The rapid removal of fluid from the abdominal cavity during paracentesis leads to decreased abdominal pressure, which can cause vasodilation and resultant shock.

3. Postprocedure

a. Monitor vital signs.

b. Measure fluid collected, describe, and record.

c. Label fluid samples and send to the laboratory for analysis.

d. Apply a dry sterile dressing to the insertion site; monitor site for bleeding.

e. Measure abdominal girth and weight.

f. Monitor for hypovolemia, electrolyte loss, mental status changes, or encephalopathy.

g. Monitor for hematuria caused by bladder trauma.

h. Instruct the client to notify the HCP if the urine becomes bloody, pink, or red.

1. Description: A needle is inserted through the abdominal wall to the liver to obtain a tissue sample for biopsy and microscopic examination.

2. Preprocedure

a. Assess results of coagulation tests (prothrombin time, partial thromboplastin time, platelet count).

b. Administer a sedative as prescribed.

c. Note that the client is placed in the supine or left lateral position during the procedure to expose the right side of the upper abdomen.

3. Postprocedure

a. Assess vital signs.

b. Assess biopsy site for bleeding.

c. Monitor for peritonitis (see Box 56-3).

d. Maintain bed rest for several hours as prescribed.

e. Place the client on the right side with a pillow (or other agency-approved pressure item such as a sandbag) under the costal margin to decrease the risk of hemorrhage, and instruct the client to avoid coughing and straining.

f. Instruct the client to avoid heavy lifting and strenuous exercise for 1 week.

Following a liver biopsy, place the client on the right side with a pillow under the costal margin at the anatomical location of the liver to decrease the risk of hemorrhage.

1. Testing of stool specimens includes inspecting the specimen for consistency and color and testing for occult blood.

2. Tests for fecal urobilinogen, fat, nitrogen, parasites, pathogens, food substances, and other substances may be performed; these tests require that the specimen be sent to the laboratory.

3. Random specimens are sent promptly to the laboratory.

4. Quantitative 24- to 72-hour collections must be kept refrigerated until they are taken to the laboratory.

5. Some specimens require that a certain diet be followed or that certain medications be withheld; check agency guidelines regarding specific procedures.

1. The urea breath test detects the presence of Helicobacter pylori, the bacteria that cause peptic ulcer disease.

2. The client consumes a capsule of carbon-labeled urea and provides a breath sample 10 to 20 minutes later.

3. Certain medications may need to be avoided before testing; these may include antibiotics or bismuth subsalicylate (Pepto-Bismol) for 1 month before the test; sucralfate (Carafate) and omeprazole (Prilosec) for 1 week before the test; and cimetidine (Tagamet), famotidine (Pepcid), ranitidine (Zantac), and nizatidine (Axid) for 24 hours before breath testing.

4. H. pylori can also be detected by assessing serum antibody levels

1. Alkaline phosphatase is released with liver damage or biliary obstruction.

2. Prothrombin time is prolonged with liver damage.

3. The serum ammonia level assesses the ability of the liver to deaminate protein by-products.

4. Liver enzyme levels (transaminase studies) are elevated with liver damage.

5. An increase in cholesterol level indicates pancreatitis or biliary obstruction.

6. An increase in bilirubin level indicates liver damage or biliary obstruction.

7. Increased values for amylase and lipase levels indicate pancreatitis. 

A. Description

1. Gastroesophageal reflux is the backflow of gastric and duodenal contents into the esophagus.

2. The reflux is caused by an incompetent lower esophageal sphincter, pyloric stenosis, or motility

disorder.

B. Assessment

1. Heartburn

2. Epigastric pain

3. Dyspepsia

4. Nausea; regurgitation

5. Pain and difficulty with swallowing

6. Hypersalivation

C. Interventions

1. Instruct the client to avoid factors that decrease lower esophageal sphincter pressure or cause

esophageal irritation such as peppermint, chocolate, coffee, fried or fatty foods, carbonated

beverages, alcoholic beverages, and cigarette smoking.

2. Instruct the client to eat a low-fat, high-fiber diet and to avoid eating and drinking 2 hours

before bedtime, and wearing tight clothes; also, elevate the head of the bed on 6- to 8-inch

blocks.

3. Avoid the use of anticholinergics, which delay stomach emptying; also, nonsteroidal

antiinflammatory medications and other medications that contain acetylsalicylic acid need to be

avoided.

4. Instruct the client regarding prescribed medications, such as antacids, H2-receptor antagonists,

or proton pump inhibitors.

5. Instruct the client regarding the administration of prokinetic medications, if prescribed, which

accelerate gastric emptying.

6. Surgery may be required in extreme cases when medical management is unsuccessful; this

involves a fundoplication (wrapping a portion of the gastric fundus around the sphincter area of

the esophagus); surgery may be performed by laparoscopy. 

A. Description

1. Inflammation of the stomach or gastric mucosa

2. Acute gastritis is caused by the ingestion of food contaminated with disease-causing

microorganisms or food that is irritating or too highly seasoned, the overuse of aspirin or other

nonsteroidal antiinflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, or

radiation therapy.

3. Chronic gastritis is caused by benign or malignant ulcers or by the bacteria H. pylori, and also

may be caused by autoimmune diseases, dietary factors, medications, alcohol, smoking, or

reflux.

B. Assessment

Acute

■ Abdominal discomfort

■ Anorexia, nausea, and vomiting

■ Headache

■ Hiccupping

■ Reflux

Chronic

■ Anorexia, nausea, and vomiting

■ Belching

■ Heartburn after eating

■ Sour taste in the mouth

■ Vitamin B12 deficiency

C. Interventions

1. Acute gastritis: Food and fluids may be withheld until symptoms subside; afterward, and as

prescribed, ice chips can be given, followed by clear liquids, and then solid food.

2. Monitor for signs of hemorrhagic gastritis such as hematemesis, tachycardia, and hypotension,

and notify the HCP if these signs occur.

3. Instruct the client to avoid irritating foods, fluids, and other substances, such as spicy and highly

seasoned foods, caffeine, alcohol, and nicotine.

4. Instruct the client in the use of prescribed medications, such as antibiotics and antacids.

5. Provide the client with information about the importance of vitamin B12 injections if a

deficiency is present.

A. Description

1. A peptic ulcer is an ulceration in the mucosal wall of the stomach, pylorus, duodenum, or

esophagus in portions accessible to gastric secretions; erosion may extend through the muscle.

2. The ulcer may be referred to as gastric, duodenal, or esophageal, depending on its location.

3. The most common peptic ulcers are gastric ulcers and duodenal ulcers.

B. Gastric ulcers

1. Description

a. A gastric ulcer involves ulceration of the mucosal lining that extends to the submucosal layer

of the stomach.

b. Predisposing factors include stress, smoking, the use of corticosteroids, NSAIDs, alcohol,

history of gastritis, family history of gastric ulcers, or infection with H. pylori.

c. Complications include hemorrhage, perforation, and pyloric obstruction.

2. Assessment

Gastric

Gnawing, sharp pain in or to the left of the mid-epigastric region occurs 30 to 60 minutes after a

meal (food ingestion accentuates the pain).

Hematemesis is more common than melena.

3. Interventions

a. Monitor vital signs and for signs of bleeding.

b. Administer small, frequent bland feedings during the active phase.

c. Administer H2-receptor antagonists or proton pump inhibitors as prescribed to decrease the

secretion of gastric acid.

d. Administer antacids as prescribed to neutralize gastric secretions.

e. Administer anticholinergics as prescribed to reduce gastric motility.

f. Administer mucosal barrier protectants as prescribed 1 hour before each meal.

g. Administer prostaglandins as prescribed for their protective and antisecretory actions.

4. Client education

a. Avoid consuming alcohol and substances that contain caffeine or chocolate.

b. Avoid smoking.

c. Avoid aspirin or NSAIDs.

d. Obtain adequate rest and reduce stress.

5. Interventions during active bleeding

a. Monitor vital signs closely.

b. Assess for signs of dehydration, hypovolemic shock, sepsis, and respiratory insufficiency.

c. Maintain NPO status and administer IV fluid replacement as prescribed; monitor intake and

output.

d. Monitor hemoglobin and hematocrit.

e. Administer blood transfusions as prescribed.

f. Prepare to assist with administering medications as prescribed to induce vasoconstriction and

reduce bleeding.

6. Surgical interventions

a. Total gastrectomy: Removal of the stomach with attachment of the esophagus to the jejunum or duodenum; also called esophagojejunostomy or esophagoduodenostomy

b. Vagotomy: Surgical division of the vagus nerve to eliminate the vagal impulses that stimulate

hydrochloric acid secretion in the stomach

c. Gastric resection: Removal of the lower half of the stomach and usually includes a

vagotomy; also called antrectomy

d. Billroth I: Partial gastrectomy, with the remaining segment anastomosed to the duodenum; also called gastroduodenostomy

e. Billroth II: Partial gastrectomy, with the remaining segment anastomosed to the jejunum; also

called gastrojejunostomy

f. Pyloroplasty: Enlargement of the pylorus to prevent or decrease pyloric obstruction, thereby

enhancing gastric emptying

7. Postoperative interventions

a. Monitor vital signs.

b. Place in a Fowler’s position for comfort and to promote drainage.

c. Administer fluids and electrolyte replacements intravenously as prescribed; monitor intake

and output.

d. Assess bowel sounds.

e. Monitor nasogastric suction as prescribed.

f. Maintain NPO status as prescribed for 1 to 3 days until peristalsis returns.

g. Progress the diet from NPO to sips of clear water to six small bland meals a day, as

prescribed when bowel sounds return.

h. Monitor for postoperative complications of hemorrhage, dumping syndrome, diarrhea, hypoglycemia, and vitamin B12 deficiency.

Following gastric surgery, do not irrigate or remove the nasogastric (NG) tube unless specifically prescribed because of the risk for disruption of the gastric sutures. Monitor closely to ensure proper functioning of the NG tube to prevent strain on the anastomosis site.

Contact the HCP if the tube is not functioning properly.

1. Description

a. A duodenal ulcer is a break in the mucosa of the duodenum.

b. Risk factors and causes include infection with H. pylori; alcohol intake; smoking; stress;

caffeine; the use of aspirin, corticosteroids, and NSAIDs.

c. Complications include bleeding, perforation, gastric outlet obstruction, and intractable

disease.

2. Assessment

Burning pain occurs in the mid-epigastric area 1 1/2 to 3 hours after a meal and during the night (often

awakens the client).

Melena is more common than hematemesis.

Pain is often relieved by the ingestion of food.

3. Interventions

a. Monitor vital signs.

b. Instruct the client about a bland diet, with small frequent meals.

c. Provide for adequate rest.

d. Encourage the cessation of smoking.

e. Instruct the client to avoid alcohol intake, caffeine, the use of aspirin, corticosteroids, and

NSAIDs.

f. Administer medications to treat H. pylori and antacids to neutralize acid secretions as

prescribed.

g. Administer H2-receptor antagonists or proton pump inhibitors as prescribed to block the

secretion of acid.

4. Surgical interventions: Surgery is performed only if the ulcer is unresponsive to medications or

if hemorrhage, obstruction, or perforation occurs.

1. Description: The rapid emptying of the gastric contents into the small intestine that occurs

following gastric resection

2. Assessment

a. Symptoms occurring 30 minutes after eating

b. Nausea and vomiting

c. Feelings of abdominal fullness and abdominal cramping

d. Diarrhea

e. Palpitations and tachycardia

f. Perspiration

g. Weakness and dizziness

h. Borborygmi (loud gurgles indicating hyperperistalsis)

3. Client education

Avoid sugar, salt, and milk.

Eat a high-protein, high-fat, low-carbohydrate diet.

Eat small meals and avoid consuming fluids with meals.

Lie down after meals.

Take antispasmodic medications as prescribed to delay gastric emptying.

A. Description

1. Vitamin B12 deficiency results from an inadequate intake of vitamin B12 or a lack of absorption

of ingested vitamin B12 from the intestinal tract.

2. Pernicious anemia results from a deficiency of intrinsic factor, necessary for intestinal

absorption of vitamin B12; gastric disease or surgery can result in a lack of intrinsic factor.

B. Assessment

1. Severe pallor

2. Fatigue

3. Weight loss

4. Smooth, beefy red tongue

5. Slight jaundice

6. Paresthesias of the hands and feet

7. Disturbances with gait and balance

C. Interventions

1. Increase dietary intake of foods rich in vitamin B12 if the anemia is the result of a dietary deficiency

■ Brewer’s yeast

■ Citrus fruits

■ Dried beans

■ Green, leafy vegetables

■ Liver

■ Nuts

■ Organ meats

2. Administer vitamin B12 injections as prescribed, weekly initially and then monthly for maintenance (lifelong) if the anemia is the result of a deficiency of intrinsic factor or disease or surgery of the ileum.

A. Description

1. Surgical reduction of gastric capacity that may be performed on a client with morbid obesity to produce long-term weight loss

2. Surgery may be performed by laparoscopy; the decision is based on the client’s weight, body build, history of abdominal surgery, and current medical disorders.

3. Obese clients are at increased postoperative risk for pulmonary and thromboembolic complications and death.

4. Surgery can prevent the complications of obesity, such as diabetes mellitus, hypertension and other cardiovascular disorders, or sleep apnea.

5. The client needs to agree to modify his or her lifestyle, lose weight and keep the weight off, and obtain support from available community resources

C. Postoperative interventions

1. Care is similar to that for the client undergoing abdominal surgery.

2. As prescribed, clear liquids are introduced slowly once bowel sounds have returned and the client passes flatus.

3. As prescribed, clear fluids are followed by puréed foods, juices, thin soups, and milk 24 to 48 hours after clear fluids are tolerated (the diet is usually limited to liquids or puréed foods for 6 weeks); then the diet is progressed to nutrient-dense regular food.

D. Client teaching points about diet

Avoid alcohol, high-protein foods, and foods high in sugar and fat.

Eat slowly and chew food well.

Progress food types and amounts as prescribed.

Take nutritional supplements as prescribed, which may include calcium, iron, multivitamins, and vitamin B12.

Monitor and report signs and symptoms of complications, such as dehydration.

A. Description

1. A hiatal hernia is also known as esophageal or diaphragmatic hernia.

2. A portion of the stomach herniates through the diaphragm and into the thorax.

3. Herniation results from weakening of the muscles of the diaphragm and is aggravated by factors

that increase abdominal pressure such as pregnancy, ascites, obesity, tumors, and heavy lifting.

4. Complications include ulceration, hemorrhage, regurgitation and aspiration of stomach contents,

strangulation, and incarceration of the stomach in the chest with possible necrosis, peritonitis,

and mediastinitis.

B. Assessment

1. Heartburn

2. Regurgitation or vomiting

3. Dysphagia

4. Feeling of fullness

C. Interventions

1. Medical and surgical management are similar to those for gastroesophageal reflux disease.

2. Provide small frequent meals and limit the amount of liquids taken with meals.

3. Advise the client not to recline for 1 hour after eating.

4. Avoid anticholinergics, which delay stomach emptying. 

A. Description

1. Inflammation of the gallbladder that may occur as an acute or chronic process

2. Acute inflammation is associated with gallstones (cholelithiasis).

3. Chronic cholecystitis results when inefficient bile emptying and gallbladder muscle wall

disease cause a fibrotic and contracted gallbladder.

4. Acalculous cholecystitis occurs in the absence of gallstones and is caused by bacterial invasion

via the lymphatic or vascular system.

B. Assessment

1. Nausea and vomiting

2. Indigestion

3. Belching

4. Flatulence

5. Epigastric pain that radiates to the scapula 2 to 4 hours after eating fatty foods and may persist

for 4 to 6 hours

6. Pain localized in right upper quadrant

7. Guarding, rigidity, and rebound tenderness

8. Mass palpated in the right upper quadrant

9. Murphy’s sign (cannot take a deep breath when the examiner’s fingers are passed below the

hepatic margin because of pain)

10. Elevated temperature

11. Tachycardia

12. Signs of dehydration

C. Biliary obstruction

1. Jaundice

2. Dark orange and foamy urine

3. Steatorrhea and clay-colored feces

4. Pruritus

D. Interventions

1. Maintain NPO status during nausea and vomiting episodes.

2. Maintain nasogastric decompression as prescribed for severe vomiting.

3. Administer antiemetics as prescribed for nausea and vomiting.

4. Administer analgesics as prescribed to relieve pain and reduce spasm.

5. Administer antispasmodics (anticholinergics) as prescribed to relax smooth muscle.

6. Instruct the client with chronic cholecystitis to eat small, low-fat meals.

7. Instruct the client to avoid gas-forming foods.

8. Prepare the client for nonsurgical and surgical procedures as prescribed.

E. Surgical interventions

1. Cholecystectomy is the removal of the gallbladder.

2. Choledocholithotomy requires incision into the common bile duct to remove the stone.

3. Surgical procedures may be performed by laparoscopy.

F. Postoperative interventions

1. Monitor for respiratory complications caused by pain at the incisional site.

2. Encourage coughing and deep breathing.

3. Encourage early ambulation.

4. Instruct the client about splinting the abdomen to prevent discomfort during coughing.

5. Administer antiemetics as prescribed for nausea and vomiting.

6. Administer analgesics as prescribed for pain relief.

7. Maintain NPO status and nasogastric tube suction as prescribed.

8. Advance diet from clear liquids to solids when prescribed and as tolerated by the client.

9. Maintain and monitor drainage from the T-tube, if present 

Purpose and Description

A T-tube is placed after surgical exploration of the common bile duct. The tube preserves the patency of the duct and ensures drainage of bile until edema resolves and bile is effectively draining into the duodenum. A gravity drainage bag is attached to the T-tube to collect the drainage.

Interventions

Place the client in a semi-Fowler’s position to facilitate drainage.

Monitor the output amount, color, consistency, and odor of the drainage.

Report sudden increases in bile output to the health care provider (HCP).

Monitor for inflammation and protect the skin from irritation.

Keep the drainage system below the level of the gallbladder.

Monitor for foul odor and purulent drainage and report its presence to the HCP.

Avoid irrigation, aspiration, or clamping of the T-tube without an HCP’s prescription.

As prescribed, clamp the tube before a meal and observe for abdominal discomfort and distention, nausea, chills, or fever; unclamp the tube if nausea or vomiting occurs.

Laënnec’s Cirrhosis

Cirrhosis is alcohol-induced, nutritional, or portal.

Cellular necrosis causes eventual widespread scar tissue, with fibrotic infiltration of the liver.

Postnecrotic Cirrhosis

Cirrhosis occurs after massive liver necrosis.

Cirrhosis results as a complication of hepatitis or exposure to hepatotoxins.

Scar tissue causes destruction of liver lobules and entire lobes.

Biliary Cirrhosis

Cirrhosis develops from chronic biliary obstruction, bile stasis, and inflammation, resulting in

severe obstructive jaundice.

Cardiac Cirrhosis

Cirrhosis is associated with severe, right-sided heart failure and results in an enlarged, edematous, congested liver.

The liver becomes anoxic, resulting in liver cell necrosis and fibrosis.

A. Description

1. A chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes

2. Repeated destruction of hepatic cells causes the formation of scar tissue.

B. Complications

1. Portal hypertension: A persistent increase in pressure in the portal vein that develops as a result of obstruction to flow

2. Ascites

a. Accumulation of fluid in the peritoneal cavity that results from venous congestion of the hepatic capillaries

b. Capillary congestion leads to plasma leaking directly from the liver surface and portal vein.

3. Bleeding esophageal varices: Fragile, thin-walled, distended esophageal veins that become irritated and rupture

4. Coagulation defects

a. Decreased synthesis of bile fats in the liver prevents the absorption of fat-soluble vitamins.

b. Without vitamin K and clotting factors II, VII, IX, and X, the client is prone to bleeding.

5. Jaundice: Occurs because the liver is unable to metabolize bilirubin and because the edema, fibrosis, and scarring of the hepatic bile ducts interfere with normal bile and bilirubin secretion

6. Portal systemic encephalopathy: End-stage hepatic failure characterized by altered level of consciousness, neurological symptoms, impaired thinking, and neuromuscular disturbances; caused by failure of the diseased liver to detoxify neurotoxic agents such as ammonia.

7. Hepatorenal syndrome

a. Progressive renal failure associated with hepatic failure

b. Characterized by a sudden decrease in urinary output, elevated blood urea nitrogen and creatinine levels, decreased urine sodium excretion, and increased urine osmolarity

C. Assessment

[image]

D. Interventions

1. Elevate the head of the bed to minimize shortness of breath.

2. If ascites and edema are absent and the client does not exhibit signs of impending coma, a highprotein diet supplemented with vitamins is prescribed.

3. Provide supplemental vitamins (B complex, vitamins A, C, and K, folic acid, and thiamine) as prescribed.

4. Restrict sodium intake and fluid intake as prescribed.

5. Initiate enteral feedings or parenteral nutrition as prescribed.

6. Administer diuretics as prescribed to treat ascites.

7. Monitor intake and output and electrolyte balance.

8. Weigh client and measure abdominal girth daily

9. Monitor level of consciousness; assess for precoma state (tremors, delirium).

10. Monitor for asterixis, a coarse tremor characterized by rapid, nonrhythmic extensions and flexions in the wrist and fingers

11. Monitor for fetor hepaticus, the fruity, musty breath odor of severe chronic liver disease.

12. Maintain gastric intubation to assess bleeding or esophagogastric balloon tamponade to control bleeding varices if prescribed.

13. Administer blood products as prescribed.

14. Monitor coagulation laboratory results; administer vitamin K if prescribed.

15. Administer antacids as prescribed.

16. Administer lactulose (Constulose, Enulose, Generlac) as prescribed, which decreases the pH of the bowel, decreases production of ammonia by bacteria in the bowel, and facilitates the excretion of ammonia.

17. Administer antibiotics as prescribed to inhibit protein synthesis in bacteria and decrease the production of ammonia.

18. Avoid medications such as opioids, sedatives, and barbiturates and any hepatotoxic medications or substances.

19. Instruct the client about the importance of abstinence of alcohol intake.

20. Prepare the client for paracentesis to remove abdominal fluid.

21. Prepare the client for surgical shunting procedures if prescribed to divert fluid from ascites into the venous system.

A. Description

1. Dilated and tortuous veins in the submucosa of the esophagus.

2. Caused by portal hypertension, often associated with liver cirrhosis; are at high risk for rupture if portal circulation pressure rises

3. Bleeding varices are an emergency.

4. The goal of treatment is to control bleeding, prevent complications, and prevent the recurrence of bleeding.

B. Assessment

1. Hematemesis

2. Melena

3. Ascites

4. Jaundice

5. Hepatomegaly and splenomegaly

6. Dilated abdominal veins

7. Signs of shock

Rupture and resultant hemorrhage of esophageal varices is the primary concern because it is a life-threatening situation.

C. Interventions

1. Monitor vital signs.

2. Elevate the head of the bed.

3. Monitor for orthostatic hypotension.

4. Monitor lung sounds and for the presence of respiratory distress.

5. Administer oxygen as prescribed to prevent tissue hypoxia.

6. Monitor level of consciousness.

7. Maintain NPO status.

8. Administer fluids intravenously as prescribed to restore fluid volume and electrolyte imbalances; monitor intake and output.

9. Monitor hemoglobin and hematocrit values and coagulation factors.

10. Administer blood transfusions or clotting factors as prescribed.

11. Assist in inserting a nasogastric tube or a balloon tamponade as prescribed; balloon tamponade is not used frequently because it is very uncomfortable for the client and its use is associated with complications.

12. Prepare to assist with administering medications to induce vasoconstriction and reduce bleeding.

13. Instruct the client to avoid activities that will initiate vasovagal responses.

14. Prepare the client for endoscopic procedures or surgical procedures as prescribed.

D. Endoscopic injection (sclerotherapy)

1. The procedure involves the injection of a sclerosing agent into and around bleeding varices.

2. Complications include chest pain, pleural effusion, aspiration pneumonia, esophageal stricture, and perforation of the esophagus.

E. Endoscopic variceal ligation

1. The procedure involves ligation of the varices with an elastic rubber band.

2. Sloughing, followed by superficial ulceration, occurs in the area of ligation within 3 to 7 days.

F. Shunting procedures

1. Description: Shunt blood away from the esophageal varices

2. Portacaval shunt involves anastomosis of the portal vein to the inferior vena cava, diverting blood from the portal system to the systemic circulation

3. Distal splenorenal shunt

a. The shunt involves anastomosis of the splenic vein to the left renal vein.

b. The spleen conducts blood from the high-pressure varices to the low-pressure renal vein.

4. Mesocaval shunting involves a side anastomosis of the superior mesenteric vein to the proximal end of the inferior vena cava.

5. Transjugular intrahepatic portosystemic shunt

a. This procedure uses the normal vascular anatomy of the liver to create a shunt with the use of a metallic stent.

b. The shunt is between the portal and systemic venous system in the liver and is aimed at relieving portal hypertension.

A. Description

1. Inflammation of the liver caused by a virus, bacteria, or exposure to medications or

hepatotoxins

2. The goals of treatment include resting the inflamed liver to reduce metabolic demands and

increasing the blood supply, thus promoting cellular regeneration and preventing complications.

B. Types of hepatitis

1. Hepatitis A virus (HAV)

2. Hepatitis B virus (HBV)

3. Hepatitis C virus (HCV)

4. Hepatitis D virus (HDV)

5. Hepatitis E virus (HEV)

C. Stages of viral hepatitis

Preicteric Stage

■ The first stage of hepatitis, preceding the appearance of jaundice; includes flulike symptoms

Icteric Stage

■ The second stage of hepatitis; includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay colored stools

Posticteric Stage

■ The convalescent stage of hepatitis, in which the jaundice decreases and the color of the urine and stool returns to normal

D. Assessment

1. Preicteric stage

a. Flulike symptoms—malaise, fatigue

b. Anorexia, nausea, vomiting, diarrhea

c. Pain—headache, muscle aches, polyarthritis

d. Serum bilirubin and enzyme levels are elevated.

2. Icteric stage

a. Jaundice

b. Pruritus

c. Dark or tea-colored urine

d. Clay-colored stools

e. Decrease in preicteric-phase symptoms

3. Posticteric stage

a. Increased energy levels

b. Subsiding of pain

c. Minimal to absent gastrointestinal symptoms

d. Serum bilirubin and enzyme levels return to normal.

E. Laboratory assessment

1. Alanine aminotransferase (ALT) level: Elevated into the thousands (normal, 10 to 40 units/L)

2. Aspartate aminotransferase (AST) level: Elevated into the thousands (normal, 10 to 30 units/L)

3. Ammonia: Elevated levels may lead to encephalopathy (normal, 10 to 80 mcg/dL)

4. Total bilirubin levels: Elevated in the serum and urine (normal, lower than 1.5 mg/dL)

A. Description

1. Formerly known as infectious hepatitis

2. Commonly seen during the fall and early winter

B. Individuals at increased risk

1. Commonly seen in young children

2. Individuals in institutionalized settings

3. Health care personnel

C. Transmission

1. Fecal-oral route

2. Person-to-person contact

3. Parenteral

4. Contaminated fruits, vegetables, or uncooked shellfish

5. Contaminated water or milk

6. Poorly washed utensils

D. Incubation and infectious period

1. Incubation period is 2 to 6 weeks.

2. Infectious period is 2 to 3 weeks before and 1 week after development of jaundice.

E. Testing

1. Infection is established by the presence of HAV antibodies (anti-HAV) in the blood.

2. Immunoglobulin M (IgM) and IgG are normally present in the blood, and increased levels indicate infection and inflammation.

3. Ongoing inflammation of the liver is evidenced by the presence of elevated levels of IgM antibodies, which persist in the blood for 4 to 6 weeks.

4. Previous infection is indicated by the presence of elevated levels of IgG antibodies.

F. Complication: Fulminant (severe acute and often fatal) hepatitis

G. Prevention

1. Strict hand washing

2. Stool and needle precautions

3. Treatment of municipal water supplies

4. Serological screening of food handlers

5. Hepatitis A vaccine (HAVRIX, VAQTA)

6. Immune globulin: For individuals exposed to HAV who have never received the hepatitis A vaccine; administer immune globulin during the period of incubation and within 2 weeks of exposure.

7. Immune globulin and hepatitis A vaccine are recommended for household members and sexual contacts of individuals with hepatitis A.

8. Preexposure prophylaxis with immunoglobulin is recommended to individuals traveling to countries with poor or uncertain sanitation conditions.

Strict and frequent hand washing is key to preventing the spread of all types of hepatitis.

A. Description

1. Hepatitis B is nonseasonal.

2. All age groups are affected.

B. Individuals at increased risk

1. IV drug users

2. Clients undergoing long-term hemodialysis

3. Health care personnel

C. Transmission

1. Blood or body fluid contact

2. Infected blood products

3. Infected saliva or semen

4. Contaminated needles

5. Sexual contact

6. Parenteral

7. Perinatal period

8. Blood or body fluids contact at birth

D. Incubation period: 6 to 24 weeks

E. Testing

1. Infection is established by the presence of hepatitis B antigen–antibody systems in the blood.

2. The presence of hepatitis B surface antigen (HBsAg) is the serological marker establishing the diagnosis of hepatitis B.

3. The client is considered infectious if these antigens are present in the blood.

4. If the serological marker (HBsAg) is present after 6 months, it indicates a carrier state or chronic hepatitis.

5. Normally, the serological marker (HBsAg) level declines and disappears after the acute hepatitis B episode.

6. The presence of antibodies to HBsAg (anti-HBs) indicates recovery and immunity to hepatitis B.

7. Hepatitis B early antigen (HBeAg) is detected in the blood about 1 week after the appearance of HBsAg and its presence determines the infective state of the client.

F. Complications

1. Fulminant hepatitis

2. Chronic liver disease

3. Cirrhosis

4. Primary hepatocellular carcinoma

G. Prevention

1. Strict hand washing

2. Screening blood donors

3. Testing of all pregnant women

4. Needle precautions

5. Avoiding intimate sexual contact if test for hepatitis B surface antigen (HBsAg) is positive.

6. Hepatitis B vaccine: Engerix-B (adult), Recombivax HB (pediatric); there is also an adult vaccine that protects against hepatitis A and B known as Twinrix.

7. Hepatitis B immune globulin is for individuals exposed to HBV through sexual contact or through the percutaneous or transmucosal routes who have never had hepatitis B and have never received hepatitis B vaccine.

A. Description

1. Hepatitis C virus infection occurs year-round.

2. Infection can occur in any age group.

3. Infection with HCV is common among IV drug users and is the major cause of posttransfusion hepatitis.

4. Risk factors are similar to those for HBV because hepatitis C is also transmitted parenterally.

B. Individuals at increased risk

1. Parenteral drug users

2. Clients receiving frequent transfusions

3. Health care personnel

C. Transmission: Same as for HBV, primarily through blood

D. Incubation period: 5 to 10 weeks

E. Testing: Anti-HCV is the antibody to HCV and is measured to detect chronic states of hepatitis C.

F. Complications

1. Chronic liver disease

2. Cirrhosis

3. Primary hepatocellular carcinoma

G. Prevention

1. Strict hand-washing

2. Needle precautions

3. Screening of blood donors

A. Description

1. Hepatitis D is common in the Mediterranean and Middle Eastern areas.

2. Hepatitis D occurs with hepatitis B and causes infection only in the presence of active HBV infection.

3. Coinfection with the delta agent (HDV) intensifies the acute symptoms of hepatitis B.

4. Transmission and risk of infection are the same as for HBV, via contact with blood and blood products.

5. Prevention of HBV infection with vaccine also prevents HDV infection, because HDV depends on HBV for replication.

B. High-risk individuals

1. Drug users

2. Clients receiving hemodialysis

3. Clients receiving frequent blood transfusions

C. Transmission: Same as for HBV

D. Incubation period: 7 to 8 weeks

E. Testing: Serological HDV determination is made by detection of the hepatitis D antigen (HDAg) early in the course of the infection and by detection of anti-HDV antibody in the later disease stages.

F. Complications

1. Chronic liver disease

2. Fulminant hepatitis

G. Prevention: Because hepatitis D must coexist with hepatitis B, the precautions that help prevent hepatitis B are also useful in preventing delta hepatitis.

A. Description

1. Hepatitis E is a waterborne virus.

2. Hepatitis E is prevalent in areas where sewage disposal is inadequate or where communal bathing in contaminated rivers is practiced.

3. Risk of infection is the same as for HAV.

4. Infection with HEV presents as a mild disease except in infected women in the third trimester of pregnancy, who have a high mortality rate.

B. Individuals with increased risk

1. Travelers to countries that have a high incidence of hepatitis E such as India, Burma

(Myanmar), Afghanistan, Algeria, and Mexico

2. Eating or drinking of food or water contaminated with the virus

C. Transmission: Same as for HAV

D. Incubation period: 2 to 9 weeks

E. Testing: Specific serological tests for HEV include detection of IgM and IgG antibodies to

hepatitis E (anti-HEV).

F. Complications

1. High mortality rate in pregnant women

2. Fetal demise

G. Prevention

1. Strict hand washing

2. Treatment of water supplies and sanitation measures

Hand washing must be strict and frequent.

Do not share bathrooms unless the client strictly adheres to personal hygiene measures.

Individual washcloths, towels, drinking and eating utensils, and toothbrushes and razors must be labeled and identified.

The client must not prepare food for other family members.

The client should avoid alcohol and over-the-counter medications, particularly acetaminophen (Tylenol) and sedatives, because these medications are hepatotoxic.

The client should increase activity gradually to prevent fatigue.

The client should consume small, frequent meals consisting of high-carbohydrate, low-fat foods.

The client is not to donate blood.

The client may maintain normal contact with persons as long as proper personal hygiene is maintained.

Close personal contact such as kissing should be discouraged until hepatitis B surface antigen test results are negative.

The client is to avoid sexual activity until hepatitis B surface antigen results are negative.

The client needs to carry a Medic-Alert card noting the date of hepatitis onset.

The client needs to inform other health professionals, such as medical or dental personnel, of the onset of hepatitis.

The client needs to keep follow-up appointments with the health care provider.

A. Description

1. Acute or chronic inflammation of the pancreas, with associated escape of pancreatic enzymes into surrounding tissue

2. Acute pancreatitis occurs suddenly as one attack or can be recurrent, with resolutions.

3. Chronic pancreatitis is a continual inflammation and destruction of the pancreas, with scar tissue replacing pancreatic tissue.

4. Precipitating factors include trauma, the use of alcohol, biliary tract disease, viral or bacterial disease, hyperlipidemia, hypercalcemia, cholelithiasis, hyperparathyroidism, ischemic vascular disease, and peptic ulcer disease.

B. Acute pancreatitis

1. Assessment

a. Abdominal pain, including a sudden onset at a mid-epigastric or left upper quadrant location with radiation to the back

b. Pain aggravated by a fatty meal, alcohol, or lying in a recumbent position

c. Abdominal tenderness and guarding

d. Nausea and vomiting

e. Weight loss

f. Absent or decreased bowel sounds

g. Elevated white blood cell count, and glucose, bilirubin, alkaline phosphatase, and urinary amylase levels

h. Elevated serum lipase and amylase levels

i. Cullen’s sign

j. Turner’s sign

Cullen’s sign is the discoloration of the abdomen and periumbilical area. Turner’s sign is the bluish discoloration of the flanks. Both signs are indicative of pancreatitis.

2. Interventions

a. Maintain NPO status and maintain hydration with IV fluids as prescribed.

b. Administer parenteral nutrition for severe nutritional depletion.

c. Administer supplemental preparations and vitamins and minerals to increase caloric intake if prescribed.

d. Maintain nasogastric tube to decrease gastric distention and suppress pancreatic secretion.

e. Administer opiates as prescribed for pain.

f. Administer antacids as prescribed to neutralize gastric secretions.

g. Administer H2-receptor antagonists or proton pump inhibitors as prescribed to decrease hydrochloric acid production and prevent activation of pancreatic enzymes.

h. Administer anticholinergics as prescribed to decrease vagal stimulation, decrease gastrointestinal motility, and inhibit pancreatic enzyme secretion.

i. Instruct the client in the importance of avoiding alcohol.

j. Instruct the client in the importance of follow-up visits with the HCP.

k. Instruct the client to notify the HCP if acute abdominal pain, jaundice, clay-colored stools, or dark-colored urine develops.

C. Chronic pancreatitis

1. Assessment

a. Abdominal pain and tenderness

b. Left upper quadrant mass

c. Steatorrhea and foul-smelling stools that may increase in volume as pancreatic insufficiency

increases

d. Weight loss

e. Muscle wasting

f. Jaundice

g. Signs and symptoms of diabetes mellitus

2. Interventions

a. Instruct the client in the prescribed dietary measures (fat and protein intake may be limited).

b. Instruct the client to avoid heavy meals.

c. Instruct the client about the importance of avoiding alcohol.

d. Provide supplemental preparations and vitamins and minerals to increase caloric intake.

e. Administer pancreatic enzymes as prescribed to aid in the digestion and absorption of fat and protein.

f. Administer insulin or oral hypoglycemic medications as prescribed to control diabetes mellitus, if present.

g. Instruct the client in the use of pancreatic enzyme medications.

h. Instruct the client in the treatment plan for glucose management.

i. Instruct the client to notify the HCP if increased steatorrhea, abdominal distention or cramping, or skin breakdown develops.

j. Instruct the client in the importance of follow-up visits.

A. Description

1. An ulcerative and inflammatory disease of the bowel that results in poor absorption of nutrients.

2. Commonly begins in the rectum and spreads upward toward the cecum

3. The colon becomes edematous and may develop bleeding lesions and ulcers; the ulcers may

lead to perforation.

4. Scar tissue develops and causes loss of elasticity and loss of the ability to absorb nutrients.

5. Colitis is characterized by various periods of remissions and exacerbations.

6. Acute ulcerative colitis results in vascular congestion, hemorrhage, edema, and ulceration of

the bowel mucosa.

7. Chronic ulcerative colitis causes muscular hypertrophy, fat deposits, and fibrous tissue, with

bowel thickening, shortening, and narrowing.

B. Assessment

1. Anorexia

2. Weight loss

3. Malaise

4. Abdominal tenderness and cramping

5. Severe diarrhea that may contain blood and mucus

6. Malnutrition, dehydration, and electrolyte imbalances

7. Anemia

8. Vitamin K deficiency

C. Interventions

1. Acute phase: Maintain NPO status and administer fluids and electrolytes intravenously or via

parenteral nutrition as prescribed.

2. Restrict the client’s activity to reduce intestinal activity.

3. Monitor bowel sounds and for abdominal tenderness and cramping.

4. Monitor stools, noting color, consistency, and the presence or absence of blood.

5. Monitor for bowel perforation, peritonitis (see Box 56-3), and hemorrhage.

6. Following the acute phase, the diet progresses from clear liquids to a low-fiber diet as

tolerated.

7. Instruct the client about diet; usually a low-fiber, high-protein diet with vitamins and iron

supplements are prescribed.

8. Instruct the client to avoid gas-forming foods, milk products, and foods such as whole wheat

grains, nuts, raw fruits and vegetables, pepper, alcohol, and caffeine-containing products.

9. Instruct the client to avoid smoking.

10. Administer medications as prescribed, which may include a combination of medications such as

salicylate compounds, corticosteroids, immunosuppressants, and antidiarrheals.

D. Surgical interventions: Performed in extreme cases if medical management is unsuccessful.

1. Total proctocolectomy with permanent ileostomy

a. The procedure is curative and involves the removal of the entire colon (colon, rectum, and

anus, with anal closure).

b. The end of the terminal ileum forms the stoma, which is located in the right lower quadrant.

2. Kock ileostomy (continent ileostomy)

a. The Kock ileostomy is an intraabdominal pouch that stores the feces and is constructed from

the terminal ileum.

b. The pouch is connected to the stoma with a nipple-like valve constructed from a portion of

the ileum; the stoma is flush with the skin.

c. A catheter is used to empty the pouch, and a small dressing or adhesive bandage is worn over

the stoma between emptyings.

3. Ileoanal reservoir

a. Creation of an ileoanal reservoir is a two-stage procedure that involves the excision of the

rectal mucosa, an abdominal colectomy, construction of a reservoir to the anal canal, and a

temporary loop ileostomy.

b. The ileostomy is closed in 3 to 4 months after the capacity of the reservoir is increased and

has had time to heal.

4. Ileoanal anastomosis (ileorectostomy)

a. Ileorectostomy does not require an ileostomy.

b. A 12- to 15-cm rectal stump is left after the colon is removed, and the small intestine is

inserted into this rectal sleeve and anastomosed.

c. Ileorectostomy requires a large, compliant rectum.

5. Preoperative colostomy and ileostomy interventions

a. Consult with the enterostomal therapist to help identify optimal placement of the ostomy.

b. Instruct the client to eat a low-fiber diet for 1 to 2 days before surgery as prescribed.

c. Administer intestinal antiseptics and antibiotics as prescribed to cleanse the bowel and to

decrease the bacterial content of the colon.

d. Administer laxatives and enemas as prescribed.

6. Postoperative colostomy interventions

a. Place a petrolatum gauze dressing over the stoma as prescribed to keep it moist, followed by

a dry sterile dressing if a pouch (external) system is not in place.

b. Place a pouch system on the stoma as soon as possible.

c. Monitor the stoma for size, unusual bleeding, or necrotic tissue.

d. Monitor for color changes in the stoma.

e. Note that the normal stoma color is pink to bright red and shiny, indicating high vascularity.

f. Note that a pale pink stoma indicates low hemoglobin and hematocrit levels and a purpleblack

stoma indicates compromised circulation, requiring HCP notification.

g. Assess the functioning of the colostomy.

h. Expect that stool is liquid in the immediate postoperative period but becomes more solid

depending on the area of the colostomy—ascending colon, liquid; transverse colon, loose to

semiformed; and descending colon, close to normal.

i. Monitor the pouch system for proper fit and signs of leakage.

j. Empty the pouch when it is one-third full.

k. Fecal matter should not be allowed to remain on the skin.

l. Administer analgesics and antibiotics as prescribed.

m. Irrigate the perineal wound (if present) as prescribed and monitor for signs of infection.

n. Instruct the client to avoid foods that cause excess gas formation and odor.

o. Instruct the client about stoma care and irrigations as prescribed

p. Instruct the client that normal activities may be resumed when approved by the HCP.

7. Postoperative ileostomy interventions

a. Note that normal stool is liquid.

b. Monitor for dehydration and electrolyte imbalance.

A stoma that is purple-black in color indicates compromised circulation, requiring immediate HCP notification.

Purpose

An enema is given through the stoma to stimulate bowel emptying.

Description

Irrigation is performed by instilling 500 to 1000 mL of lukewarm tap water through the stoma and

allowing the water and stool to drain into a collection bag.

Procedure

If ambulatory, position the client sitting on the toilet.

If on bed rest, position the client on his or her side.

Hang the irrigation bag so that the bottom of the bag is at the level of the client’s shoulder or

slightly higher.

Insert the irrigation tube carefully without force.

Begin the flow of irrigation.

Clamp the tubing if cramping occurs; release the tubing as cramping subsides.

Avoid frequent irrigations, which can lead to loss of fluids and electrolytes.

Perform irrigation at about the same time each day.

Perform irrigation preferably 1 hour after a meal.

To enhance effectiveness of the irrigation, massage the abdomen gently. 

A. Description

1. An inflammatory disease that can occur anywhere in the gastrointestinal tract but most often

affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas,

ulcerations, and abscesses

2. Characterized by remissions and exacerbations

B. Assessment

1. Fever

2. Cramplike and colicky pain after meals

3. Diarrhea (semisolid), which may contain mucus and pus

4. Abdominal distention

5. Anorexia, nausea, and vomiting

6. Weight loss

7. Anemia

8. Dehydration

9. Electrolyte imbalances

10. Malnutrition (may be worse than that seen in ulcerative colitis)

C. Interventions: Care is similar to that for the client with ulcerative colitis; however, surgery may be

necessary but is avoided for as long as possible because recurrence of the disease process in the

same region is likely to occur. 

A. Description

1. Inflammation of the appendix.

2. When the appendix becomes inflamed or infected, rupture may occur within a matter of hours,

leading to peritonitis and sepsis.

B. Assessment

1. Pain in the periumbilical area that descends to the right lower quadrant

2. Abdominal pain that is most intense at McBurney’s point

3. Rebound tenderness and abdominal rigidity

4. Low-grade fever

5. Elevated white blood cell count

6. Anorexia, nausea, and vomiting

7. Client in side-lying position, with abdominal guarding and legs flexed

8. Constipation or diarrhea

C. Peritonitis: Inflammation of the peritoneum (see Box 56-3)

D. Appendectomy: Surgical removal of the appendix

1. Preoperative interventions

a. Maintain NPO status.

b. Administer fluids intravenously to prevent dehydration.

c. Monitor for changes in level of pain.

d. Monitor for signs of ruptured appendix and peritonitis (see Box 56-3).

e. Position the client in a right side-lying or low to semi-Fowler’s position to promote comfort.

f. Monitor bowel sounds.

g. Avoid the application of heat to the abdomen.

h. Apply ice packs to the abdomen for 20 to 30 minutes every hour as prescribed.

i. Administer antibiotics as prescribed.

j. Avoid laxatives or enemas.

Avoid the application of heat to the abdomen of a client with appendicitis. Heat can cause

rupture of the appendix leading to peritonitis, a life-threatening condition.

2. Postoperative interventions

a. Monitor temperature for signs of infection.

b. Assess incision for signs of infection such as redness, swelling, and pain.

c. Maintain NPO status until bowel function has returned.

d. Advance diet gradually as tolerated and as prescribed, when bowel sounds return.

e. If rupture of the appendix occurred, expect a Penrose drain to be inserted, or the incision may

be left open to heal from the inside out.

f. Expect that drainage from the Penrose drain may be profuse for the first 12 hours.

g. Position the client in a right side-lying or low to semi-Fowler’s position, with legs flexed, to

facilitate drainage.

h. Change the dressing as prescribed and record the type and amount of drainage.

i. Perform wound irrigations if prescribed.

j. Maintain nasogastric suction and patency of the nasogastric tube if present.

k. Administer antibiotics and analgesics as prescribed. 

A. Description

1. Diverticulosis

a. Diverticulosis is an outpouching or herniation of the intestinal mucosa.

b. The disorder can occur in any part of the intestine but is most common in the sigmoid colon.

2. Diverticulitis

a. Diverticulitis is the inflammation of one or more diverticula that occurs from penetration of fecal matter through the thin-walled diverticula; it can result in local abscess formation and perforation.

b. A perforated diverticulum can progress to intraabdominal perforation with generalized peritonitis.

B. Assessment

1. Left lower quadrant abdominal pain that increases with coughing, straining, or lifting

2. Elevated temperature

3. Nausea and vomiting

4. Flatulence

5. Cramplike pain

6. Abdominal distention and tenderness

7. Palpable, tender rectal mass may be present.

8. Blood in the stools

C. Interventions

1. Provide bed rest during the acute phase.

2. Maintain NPO status or provide clear liquids during the acute phase as prescribed.

3. Introduce a fiber-containing diet gradually, when the inflammation has resolved.

4. Administer antibiotics, analgesics, and anticholinergics to reduce bowel spasms as prescribed.

5. Instruct the client to refrain from lifting, straining, coughing, or bending to avoid increased

intraabdominal pressure.

6. Monitor for perforation (see Box 56-3), hemorrhage, fistulas, and abscesses.

7. Instruct the client to increase fluid intake to 2500 to 3000 mL daily, unless contraindicated.

8. Instruct the client to eat soft high-fiber foods, such as whole grains; the client should avoid highfiber foods when inflammation occurs because these foods will irritate the mucosa further.

9. Instruct the client to avoid gas-forming foods or foods containing indigestible roughage, seeds, or nuts because these food substances become trapped in diverticula and cause inflammation.

10. Instruct the client to consume a small amount of bran daily and to take bulk-forming laxatives as prescribed to increase stool mass.

D. Surgical interventions

1. Colon resection with primary anastomosis may be an option.

2. Temporary or permanent colostomy may be required for increased bowel inflammation.

A. Description

1. Dilated varicose veins of the anal canal

2. May be internal, external, or prolapsed

3. Internal hemorrhoids lie above the anal sphincter and cannot be seen on inspection of the

perianal area.

4. External hemorrhoids lie below the anal sphincter and can be seen on inspection.

5. Prolapsed hemorrhoids can become thrombosed or inflamed.

6. Hemorrhoids are caused from portal hypertension, straining, irritation, or increased venous or

abdominal pressure.

B. Assessment

1. Bright red bleeding with defecation

2. Rectal pain

3. Rectal itching

C. Interventions

1. Apply cold packs to the anal-rectal area followed by sitz baths as prescribed.

2. Apply witch hazel soaks and topical anesthetics as prescribed.

3. Encourage a high-fiber diet and fluids to promote bowel movements without straining.

4. Administer stool softeners as prescribed.

D. Surgical interventions: May include ultrasound, sclerotherapy, circular stapling, band ligation, or

simple resection of the hemorrhoids (hemorrhoidectomy)

E. Postoperative interventions following hemorrhoidectomy

1. Assist the client to a prone or side-lying position to prevent bleeding.

2. Maintain ice packs over the dressing as prescribed until the packing is removed by the HCP.

3. Monitor for urinary retention.

4. Administer stool softeners as prescribed.

5. Instruct the client to increase fluids and high-fiber foods.

6. Instruct the client to limit sitting to short periods of time.

7. Instruct the client in the use of sitz baths three or four times a day as prescribed.