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  1. GENERAL NUTRITIONAL DEFICIENCIES
    1. Assessment:
      1. Subjective data:
        1. Mental irritability or confusion.
        2. History of poor dietary intake.
        3. History of lack of adequate resources to provide adequate nutrition.
        4. Lack of knowledge about proper diet, food selection, or preparation.
        5. History of eating disorders.
        6. Paresthesia (burning and tingling): hands and feet.
      2. Objective data:
        1. Appearance: listless; posture: sagging shoulders, sunken chest, poor gait.
        2. Muscle: weakness, fatigue, wasted appearance.
        3. GI: indigestion, vomiting, enlarged liver, spleen.
        4. Cardiovascular: tachycardia on minimal exertion; bradycardia at rest; enlarged heart, elevated BP.
        5. Hair: brittle, dry, thin, sparse; lack of natural shine; color changes; can be easily plucked out.
        6. Skin: dryness (xerosis), scaly, dyspigmentation, petechiae, lack of fat under skin.
        7. Mouth:
          1. Teeth: missing, abnormally placed, caries.
          2. Gums: bleed easily, receding.
          3. Tongue: swollen, sore.
          4. Lips: red, swollen, angular fissures at corners.
        8. Eyes: pale conjunctivae, corneal changes.
        9. Nails: brittle, ridged.
        10. Nervous system: abnormal reflexes.
        11. Laboratory data: blood—decreased albumin, iron-binding capacity, lymphocyte, hemoglobin, and hematocrit.
        12. Anthropometric measurements document nutritional deficiencies.
    2. Analysis/nursing diagnosis:
      1. Altered nutrition, less than body requirements, related to poor dietary intake.
      2. Knowledge deficit (learning need) related to nutritional requirements.
      3. Altered health maintenance related to inability to provide own nutritional care.
      4. Ineffective individual coping related to eating disorders.
      5. Ineffective family coping, disabling, related to inadequate resources or knowledge to provide appropriate family nutrition.
    3. Nursing care plan/implementation:
      1. Goal: prevent complications of specific deficiency.
        1. Identify etiology of nutritional deficiency.
        2. Recognize signs of nutritional deficiencies (see Chapter 9. Physiological Integrity: Basic Care and Comfort—Nutrition, Table 9.6. Essential Nutrients and Potential Deficiencies).
        3. Identify foods high in deficient nutrient (see Chapter 9. Physiological Integrity: Basic Care and Comfort—Nutrition).
        4. Evaluate economic resources to purchase appropriate foods.
        5. Identify community resources for assistance.
        6. Monitor progress for potential additional illnesses.
      2. Goal: health teaching.
        1. Effects of nutritional deficiencies on health.
        2. Foods to include in diet to avoid deficits.
    4. Evaluation/outcome criteria:
      1. Complications do not occur.
      2. Client gains weight.
      3. Client selects appropriate foods to alleviate deficiency.
  2. CELIAC DISEASE (gluten enteropathy, nontropical sprue): immune to gluten, causing impaired absorption and digestion of nutrients through the small bowel. Affects adults and children and is characterized by inability to digest and use sugars, starches, and fats.
    1. Pathophysiology: intolerance to the gliadin fraction of grains causing degeneration of the epithelial surface of the intestine, atrophy of the intestinal villi, and impaired absorption of essential nutrients.
    2. Risk factors:
      1. Possible genetic or familial factors.
      2. Hypersensitivity response.
      3. History of childhood celiac disease.
    3. Assessment:
      1. Subjective data: family history.
      2. Objective data:
        1. Loss: weight, fat deposits, musculature.
        2. Anemia.
        3. Vitamin deficiencies.
        4. Abdomen distended with flatus.
        5. Stools : diarrhea, foul smelling, bulky, fatty, float in commode.
        6. Skin condition known as dermatitis herpetiformis.
        7. History of acute attacks of fluid and electrolyte imbalances.
        8. Diagnostic tests: stool for fat; barium enema; antibody tests, including endomysial antibody (EMA); blood studies of: iron, folate, proteins, minerals, and clotting factors; small bowel biopsy.
        9. foodImageGluten-free dietleads to remission of symptoms.
    4. Analysis/nursing diagnosis:
      1. Altered nutrition, less than body requirements, related to inability to digest and use sugars, starches, and fats.
      2. Diarrhea related to intestinal response to gluten in diet.
      3. Fluid volume deficit related to loss through excessive diarrhea.
      4. Knowledge deficit (learning need) related to dietary restrictions to control symptoms.
    5. Nursing care plan/implementation:
      1. Goal: prevent weight loss.
        1. foodImageDiet: high in calories, protein, vitamins, and minerals, and gluten free.
          1. Avoid: wheat, rye, oats, barley.
          2. All other foods permitted.
        2. Daily weights to monitor weight changes.
      2. Goal: health teaching.
        1. Nature of disease.
        2. Dietary restrictions and allowances.
        3. Complications of noncompliance.
    6. Evaluation/outcome criteria:
      1. No further weight loss.
      2. Normal stools.
      3. Fluid/electrolyte balance obtained and maintained.
  3. HEPATITIS: inflammation of the liver.
    1. Pathophysiology:
      1. Infection with hepatitis A(formerly called infectious hepatitis), hepatitis B(formerly called serum hepatitis), hepatitis C(single-stranded RNA virus of the Flaviviridae family; usually asymptomatic), delta hepatitis(infection caused by a defective RNA virus that requires hepatitis B virus to multiply), or hepatitis E (major etiological agent of the enterically transmitted non-A, non-B hepatitis worldwide) → inflammation, necrosis, and regeneration of liver parenchyma. Hepatocellular injury impairs clearance of urobilinogen → elevated urinary urobilinogen; and, as injury increases → conjugated bilirubin not reaching the intestines → decreased urine and fecal urobilinogen → increased serum bilirubin → jaundice.
      2. Failure of liver to detoxify products → increased toxic products of protein metabolism → gastritis and duodenitis.
    2. Risk factors:
      1. Exposure to virus.
      2. Exposure to carriers of virus.
      3. Exposure to hepatotoxins such as dry-cleaning agents.
      4. Nonimmunized.
    3. Assessment:
      1. Subjective data:
        1. Anorexia, nausea.
        2. Malaise, dull ache in right upper quadrant, abdominal pain.
        3. Repugnance to: food, cigarette smoke, strong odors, alcohol.
        4. Headache.
      2. Objective data:
        1. Fever.
        2. Liver: enlarged (hepatomegaly), tender, smooth.
        3. Skin: icterus in sclerae of eyes, jaundice; rash; pruritus; petechiae, bruises.
        4. Urine: normal, dark.
        5. Stool: normal, clay colored, loose.
        6. Vomiting, weight loss.
        7. Lymph nodes: enlarged.
        8. Laboratory data:
          1. Blood—leukocytosis.
          2. Increased AST (SGOT), alanine aminotransferase (ALT, or serum glutamic-pyruvic transaminase [SGPT]), and bilirubin levels, alkaline phosphatase.
          3. Urine—increased urobilinogen.
        9. See Table 6-24. Etiology, Incidence, and Epidemiological and Clinical Comparison of Hepatitis a, Hepatitis B, Hepatitis C, and Delta Hepatitis for comparison of hepatitis A, B, C, and D.
    4. Analysis/nursing diagnosis:
      1. Pain related to inflammation of liver.
      2. Impaired skin integrity related to pruritus.
      3. Activity intolerance related to fatigue.
      4. Risk for infection to others related to incubation/infectious period.
      5. Altered nutrition, less than body requirements, related to repugnance of food.
      6. Social isolation related to isolation precautions.
    5. Nursing care plan/implementation:
      1. Goal: prevent spread of infection to others.
        1. Isolation according to type
          1. Hepatitis A:
            1. Contact precautions (see Chapter 3. Safe, Effective Care Environment, Safety and Infection Control: Guidelines for Isolation and Standard Precautions, Table 3-3. Contact Precautions—Summary, Table 3-7. Infection Control When Caring for Infants, Children, and Adolescents , and (Table 3.8. Summary: Types of Precautions and Illnesses Requiring the Precautions)).
            2. Private room preferred.
            3. Gown/gloves for direct contact with feces.
            4. Hand washing when in direct contact with feces.
          2. Hepatitis B: blood and body fluid precautions.
            1. Needle/dressing precautions.
            2. Private room not necessary.
            3. Gown: only if enteric precautions also necessary.
            4. Hand washing: use gloves when in direct contact with blood.
          3. Hepatitis C: blood and body fluid precautions—same as hepatitis B, except when in countries with fecal-oral form, then use hepatitis A precautions also.
          4. Delta: same as hepatitis B.
        2. pillImagePassive immunity for contacts.
          1. Hepatitis A: hepatitis A vaccine (Havrix, VAQTA), immune serum globulin (ISG), administered before and after exposure.
          2. Hepatitis B: hepatitis B immune globulin (HBIG) (Recombivax HB, Energix-B) or ISG.
          3. Hepatitis C: prophylaxis not as effective; ISG may be given.
          4. Delta: same as for hepatitis B.
      2. Goal: promote healing.
        1. foodImageDiet as tolerated:
          1. NPO with parenteral infusions, when in acute stage.
          2. High protein, high carbohydrate, low fat, offered in frequent small meals.
          3. Push fluids, if not contraindicated; I&O
        2. pillImageMedications:
          1. Antiviral for clients with persistently elevated ALT levels.
          2. Interferon for initial treatment of hepatitis C.
      3. Goal: monitor for worsening of disease process, failure to respond to prescribed treatment.
        1. Observe urine—dark due to presence of bile and stool, clay colored.
        2. Observe sclerae, laboratory tests for increasing jaundice.
        3. Mental confusion, unusual somnolence may indicate decreased liver function.
        4. Weigh daily—increase indicates fluid retention and possible ascites.
      4. Goal: health teaching.
        1. Diet and fluid intake to promote liver regeneration.
        2. Importance of rest and limited activity to reduce metabolic workload of liver.
        3. Personal hygiene practices to prevent contamination.
        4. Avoid: alcohol, blood donations, and contact with communicable infections.
        5. Follow-up case referral; may take 6 months for full recovery.
        6. Teach contacts about available immunizations.
      5. Goal: promote comfort.
        1. infoImageBedrest to combat fatigue and reduce metabolic needs until hepatomegaly subsides; semi-Fowler's or supine positioning.
        2. Oral hygiene q1–2h to decrease nausea.
        3. ROM exercises to maintain muscle strength.
        4. Measures to reduce pruritus:
          1. Mild, oil-based lotion to reduce itching.
          2. Nails cut short, cotton gloves, long-sleeved clothing to prevent skin injury from scratching.
          3. Environment: cool and dry.
          4. Cool wet soaks to skin.
          5. Diversional activities.
          6. pillImageMedications as ordered:
            1. Emollients to relieve dry skin.
            2. Topical corticosteroids to reduce inflammation.
            3. Antihistamines to reduce itch.
            4. Tranquilizers and sedatives to allow rest and prevent exhaustion.
    6. Evaluation/outcome criteria:
      1. Tolerates food; nausea and vomiting decreased.
      2. Signs of infection/inflammation absent.
      3. No complications, hemorrhage, liver damage, ascites.
      4. No jaundice noted.
  4. PANCREATITIS: inflammatory disease of the pancreas that may result in autodigestion of the pancreas by its own enzymes.
    1. Pathophysiology: proteolytic enzymes within the pancreas are activated by endotoxins, exotoxins, ischemia, anoxia, or trauma. Pancreatic enzymes begin process of autodigestion of pancreas and surrounding tissues; also activate other enzymes that digest cellular membranes. Autodigestion leads to: edema, hemorrhage, vascular damage, coagulation necrosis, and fat necrosis.
    2. Risk factors:
      1. Obesity.
      2. Alcoholism, alcohol consumption.
      3. Biliary tract disease.
      4. Abdominal trauma.
      5. Surgery.
      6. Drugs.
      7. Metabolic disease.
      8. Intestinal disease.
      9. Obstruction of the pancreatic ducts.
      10. Infections.
      11. Carcinoma.
      12. Adenoma.
      13. Hypercalcemia.
    3. Assessment:
      1. Subjective data:
        1. Pain:
          1. Sudden onset; severe, widespread, constant, and incapacitating.
          2. Location—epigastrium, right upper quadrant (RUQ) and left upper quadrant (LUQ) of abdomen; radiates to back, flanks, and substernal area.
        2. Nausea.
        3. History of risk factors.
        4. Dyspnea.
      2. Objective data:
        1. Elevated: temperature, pulse, respirations, BP (unless in shock).
        2. Decreased breath sounds related to atelectasis/pleural effusion.
        3. Increased crackles, cyanosis.
        4. Hemorrhage, shock.
        5. Vomiting.
        6. Fluid and electrolyte imbalances, dehydration.
        7. Decreased bowel sounds; abdominal tenderness with guarding.
        8. Stools: bulky, pale, foul smelling, steatorrhea (excessive fat in stools).
        9. Skin: pale, moist, cold; may be jaundiced.
        10. Muscle rigidity.
        11. Supine position leads to increased pain.
        12. Fluid accumulation in the abdomen.
        13. Laboratory data:
          1. Elevated:
            1. Amylase, serum, and urine.
            2. Serum lipase, AST (SGOT).
            3. Alkaline phosphatase.
            4. Bilirubin, glucose; serum and urine.
            5. Urine protein, WBC count.
            6. Leukocytes.
            7. BUN.
            8. LDH (liver function).
          2. Decreased:
            1. Serum calcium.
            2. Protein.
        14. Ultrasound for gallstones, CT scan.
    4. Analysis/nursing diagnosis:
      1. Altered nutrition, less than body requirements, related to nausea and vomiting.
      2. Pain related to inflammatory and autodigestive processes of pancreas.
      3. Fluid volume deficit related to inflammation, decreased intake, and vomiting.
      4. Ineffective breathing pattern related to pain and pleural effusion.
      5. Knowledge deficit (learning need) related to risk factors and disease management.
    5. Nursing care plan/implementation:
      1. Goal: control pain.
        1. pillImageMedications: analgesics—meperidine ( not morphine or codeine due to spasmodic effect).
        2. infoImagePosition: sitting with knees flexed.
      2. Goal: rest injured pancreas.
        1. NPO.
        2. Nasogastric (NG) tube to low suction.
        3. pillImageMedications:
          1. Antiulcers.
          2. Antibiotics.
          3. Antiemetics.
          4. Antispasmodics.
          5. Anticholinergics.
          6. Histamine2 receptors (cimetidine).
      3. Goal: prevent fluid and electrolyte imbalance.
        1. Monitor: vitals, CVP.
        2. IVs, fluids, blood, albumin, plasma.
      4. Goal: prevent respiratory and metabolic complications.
        1. Cough, deep breathe, change position.
        2. Monitor: blood sugar as ordered.
        3. Monitor calcium levels: Chvostek's and Trousseau's signs positive when calcium deficit exists (see ENDOCRINE SYSTEM, IV. THYROIDECTOMY, Physiological Integrity, for description of tests).
      5. foodImageGoal: provide adequate nutrition.
        1. Low-fat diet.
        2. Bland, small, frequent meals
        3. Vitamin supplements.
        4. Avoid alcohol.
      6. Goal: prevent complications.
        1. Monitor for signs of:
          1. Peritonitis.
          2. Perforation.
          3. Respiratory complications.
          4. Hypotension, shock.
          5. DIC.
          6. ARDS.
          7. Hemorrhage from ulcers, varices.
          8. Anemia.
          9. Encephalopathy.
      7. Goal: health teaching.
        1. Food selections for low-fat, bland diet.
        2. Necessity of vitamin therapy.
        3. Importance of avoiding alcohol.
        4. Signs and symptoms of recurrence.
        5. pillImageImportance of rest, to prevent relapse.
        6. Desired effects and side effects of prescribed medications:
          1. Narcotics for pain.
          2. Antiemetics for nausea and vomiting.
          3. Pancreatic hormone and enzymes to replace enzymes not reaching duodenum.
    6. Evaluation/outcome criteria:
      1. Pain is relieved.
      2. No complications (e.g., peritonitis, respiratory).
      3. States dietary allowances and restrictions.
      4. Takes medications as ordered; states purposes, side effects.
  5. CIRRHOSIS: chronic inflammation and fibrosis (irreversible scarring) of the liver in which some liver cells (hepatocytes) undergo necrosis and others undergo proliferative regeneration.
    1. Pathophysiology: progressive destruction of hepatic cells → loss of normal metabolic function of the liver and formation of scar tissue. Regeneration and proliferation of fibrous tissue → obstruction of the portal vein → increased portal hypertension, ascites, liver failure, and eventual death.
    2. Risk factors:
      1. Alcohol abuse most common cause.
      2. Nutritional deficiency with decreased protein intake.
      3. Hepatotoxins.
      4. Virus.
      5. Hepatitis B and C.
    3. Assessment:
      1. Subjective data:
        1. Chronic feeling of malaise.
        2. Anorexia, nausea.
        3. Abdominal pain.
        4. Pruritus.
      2. Objective data:
        1. GI:
          1. Malnutrition, weight loss.
          2. Vomiting.
          3. Flatulence.
          4. Ascites.
          5. Enlarged liver and spleen.
          6. Glossitis.
          7. Fetid breath (sweet, musty odor).
        2. Blood—coagulation defects, possible esophageal varices, portal hypertension, bleeding from gums and injection sites.
        3. Skin and hair—edema, jaundice, spider angioma (telangiectasias); palmar erythema, decreased pubic and axillary hair.
        4. Reproductive—menstrual abnormalities, gynecomastia, testicular atrophy, impotence.
        5. Neurological deficits—memory loss, hepatic coma, decreased level of consciousness: flapping tremor, grimacing.
        6. Laboratory data:
          1. Decreased: albumin, potassium, magnesium, blood urea nitrogen (BUN).
          2. Elevated: prothrombin time, globulins, ammonia, AST (SGOT), bromsulphalein (BSP), alkaline phosphate, uric acid, blood sugar.
        7. Diagnostic tests:
          1. Celiac angiography, hepatoportography.
          2. Liver biopsy.
          3. Paracentesis.
    4. Analysis/nursing diagnosis:
      1. Altered nutrition, less than body requirements, related to decreased intake, nausea, and vomiting.
      2. Risk for injury related to decreased prothrombin production.
      3. Activity intolerance related to fatigue.
      4. Fatigue related to anorexia and nutritional deficiencies.
      5. Self-esteem disturbance related to physical body changes.
      6. Risk for impaired skin integrity related to pruritus.
    5. Nursing care plan/implementation:
      1. Goal: provide for special safety needs.
        1. Monitor vitals (including neurological) frequently for hemorrhage from esophageal varices (may have Sengstaken-Blakemoreor Linton tube inserted).
        2. Prepare client for LeVeen shuntsurgery for portal hypertension as needed.
        3. Assist with paracentesis performed for ascites; monitor vitals to prevent shock during procedure.
      2. Goal: relieve discomfort caused by complications.
        1. infoImagePosition: semi-Fowler's or Fowler's to decrease pressure on diaphragm due to ascites.
        2. Deep breathing q2h to prevent respiratory complications.
        3. pillImageSkin care, topical medications to relieve pruritus; nail care to decrease possibility of further skin injury.
        4. Frequent oral hygiene related to nausea, vomiting, and fetid breath.
      3. Goal: improve fluid and electrolyte balance.
        1. pillImageIV fluids and vitamins.
        2. I&O, hourly urines during acute attacks.
        3. Daily: girths, weights to monitor fluid balance.
        4. pillImageDiuretics as ordered to decrease edema.
        5. pillImage May receive serum albumin to promote adequate vascular volume, prevent azotemia and encephalopathy, and promote diuresis (observe carefully, because albumin could escape quickly through cell walls and cause increase in ascites).
      4. foodImageGoal: promote optimum nutrition within dietary restrictions.
        1. NPO during acute episodes.
        2. Small, frequent meals when able to eat.
        3. Low protein (to decrease the amount of nitrogenous materials in the intestines) and sodium (to decrease fluid retention).
        4. Moderate carbohydrate (to meet energy demands) and fat (to make diet more palatable to clients who are anorexic).
      5. Goal: provide emotional support.
        1. Quiet environment during acute episodes to decrease external stimuli.
        2. Refer to community agencies for assistance for client (e.g., Alcoholics Anonymous; for family, Al-Anon/Alateen).
      6. Goal: health teaching.
        1. Avoid alcohol, exposure to infections.
        2. foodImageDietary allowances, restrictions (see Chapter 9. Physiological Integrity: Basic Care and Comfort—Nutrition, Sodium-restricted diet, Special Diets, and purinerestricted diet, Special Diets).
        3. Drugs: names, purposes.
        4. Signs, symptoms of disease; complications.
        5. Stress-management techniques.
    6. Evaluation/outcome criteria:
      1. No complications.
      2. Nutritional status improves; lists dietary restrictions.
      3. No alcohol consumption.
      4. Lists signs and symptoms of progression of disease and complications.
      5. Complies with discharge plan, becomes involved with an alcohol treatment program.
  6. ESOPHAGEAL VARICES: life-threatening hemorrhage from tortuous dilated, thin-walled veins in submucosa of lower esophagus. May rupture when chemically or mechanically irritated, or when pressure is increased because of sneezing, coughing, use of the Valsalva maneuver, or excessive exercise.
    1. Pathophysiology: portal hypertension related to cirrhosis of the liver → distended branches of the azygos vein and inferior vena cava where they join the smaller vessels of the esophagus.
    2. Risk factors for hemorrhage:
      1. Exertion that increases abdominal pressure.
      2. Trauma from ingestion of coarse foods.
      3. Acid pepsin erosion.
    3. Assessment:
      1. Subjective data:
        1. Fear.
        2. Dysphagia.
        3. History: alcohol ingestion, liver dysfunction.
      2. Objective data:
        1. Hematemesis.
        2. Hemorrhage: sudden, often fatal.
        3. Decreased BP; increased pulse, respirations.
        4. Melena (occult blood in stool).
        5. Diagnostic endoscopy.
    4. Analysis/nursing diagnosis:
      1. Fluid volume deficit related to blood loss.
      2. Risk for injury related to hemorrhage.
      3. Fear related to massive blood loss.
      4. Ineffective individual coping related to complications of cirrhosis.
    5. Nursing care plan/implementation:
      1. Goal: provide safety measures related to hemorrhage.
        1. Recognize signs of shock; vitals q15 min.
        2. Assist with insertion of Sengstaken-Blakemore (or Minnesota) or Linton tube(tube is large and uncomfortable for client during insertion); explain procedure briefly to decrease fear and attempt to gain client's cooperation.
        3. While tube is in place, observe for respiratory distress; if present, deflate the balloon by releasing pressure; do not cut the tube.
        4. Deflate the balloon as ordered to prevent necrosis.
        5. NG tube to low gastric suction; monitor for amount of bright-red blood; irrigate only as ordered using tepid, not iced, solutions.
        6. pillImageVitamin K as ordered to control bleeding.
      2. Goal: promote fluid balance.
        1. pillImageIV fluids, expanders.
        2. Fresh blood as ordered to avoid increased ammonia; aids in coagulation.
      3. pillImageGoal: prevent complications of hepatic coma.
        1. Saline cathartics as ordered to remove old blood from GI tract.
        2. Antibiotics as ordered to prevent infection.
        3. Reduce portal hypertension; give propranolol (Inderal), vasopressin (Pitressin).
      4. Goal: provide emotional support.
        1. Stay with client.
        2. Calm atmosphere.
      5. Goal: health teaching.
        1. Explain use of tube to client and family.
        2. Bland diet instructions.
        3. Recognize signs of bleeding.
        4. Avoid straining at stool.
        5. Avoid aspirin because of increased bleeding tendency.
    6. Evaluation/outcome criteria:
      1. Survives acute bleeding episode.
      2. Further episodes prevented by avoiding irritants, especially alcohol.
      3. Improves nutritional status.
      4. Recognizes symptoms of complications (e.g., bleeding).
      5. Demonstrates knowledge of medications by avoiding aspirin.
  7. DIAPHRAGMATIC (HIATAL) HERNIA: protrusion of part of stomach through diaphragm and into thoracic cavity (Figure. 6.8. Hiatal Hernia).Types: sliding (most common); paraesophageal "rolling."
    1. Pathophysiology: weakening of the musculature of the diaphragm, aggravated by increased intraabdominal pressure → protrusion of the abdominal organs through the esophageal hiatus → reflux of gastric contents → esophagitis.
    2. Risk factors:
      1. Congenital abnormality.
      2. Penetrating wound.
      3. Age (middle-aged or elderly).
      4. Women more than men.
      5. Obesity.
      6. Ascites.
      7. Pregnancy.
      8. History of constipation.
    3. Assessment:
      1. Subjective data:
        1. Pressure: substernal.
        2. Pain: epigastric, burning.
        3. Eructation, heartburn after eating.
        4. Dysphagia.
        5. Symptoms aggravated when recumbent.
      2. Objective data:
        1. Cough, dyspnea.
        2. Tachycardia, palpitations.
        3. Bleeding: hematemesis, melena, signs of anemia due to gastroesophageal irritation, ulceration, and bleeding.
        4. Diagnostic tests:
          1. Chest x-rays, showing protrusion of abdominal organs into thoracic cavity.
          2. Barium swallow (upper GI series) to show presence of hernia.
          3. Endoscopy.
        5. Symptoms parallel those of gastroesophageal reflux disease (GERD).
    4. Analysis/nursing diagnosis:
      1. Pain related to irritation of lining of GI tract.
      2. Altered nutrition, less than body requirements, related to dysphagia.
      3. Sleep pattern disturbance related to increase in symptoms when recumbent.
      4. Risk for aspiration related to reflux of gastric contents.
      5. Activity intolerance related to dyspnea.
      6. Anxiety related to palpitations.
    5. Nursing care plan/implementation:
      1. Presurgical:
        1. Goal: promote relief of symptoms.
          1. foodImageDiet:
            1. Small, frequent feedings of soft, bland foods, to reduce abdominal pressure and reflux.
            2. Fluid when swallowing solids may push food into stomach; hot fluid may work best.
            3. Avoid eating 2 hours before bedtime.
            4. High-protein, low-fat foods to decrease heartburn.
          2. infoImagePositioning: head elevated to increase movement of food into stomach. Symptoms may decrease if head of bed at home is elevated on 8-inch blocks.
          3. Weight reduction to decrease abdominal pressure.
          4. pillImageMedications as ordered:
            1. 30 mL antacid 1 hour after meals and at bedtime.
            2. Avoid anticholinergic drugs, which decrease gastric emptying.
      2. Postsurgical:
        1. Goal: provide for postoperative safety needs.
          1. Respiratory: deep breathing, coughing, splint incision area.
          2. Nasogastric (NG) tube: check patency.
            1. Drainage: should be small amount.
            2. Color: dark brown 6 to 12 hours after surgery, changing to greenish-yellow.
            3. Do not disturb tube placement to avoid traction on suture line.
          3. infoImagePosition: initially head of bed elevated slightly, then semi-Fowler's; turn side to side frequently, to prevent pressure on diaphragm.
          4. Maintain closed chest drainage if indicated (see Table 11-5. Review of the Use of Common Tubes ).
          5. Check for return of bowel sounds.
        2. Goal: promote comfort and maintain nutrition.
          1. pillImageIVs for hydration and electrolytes.
          2. Initiate feeding through gastrostomy tube if present.
            1. Usually attached to intermittent, low suction after surgery.
            2. Aspirate gastric contents before feeding—delay if 75 mL or more is present; report these findings to physician.
            3. infoImageFeed in high Fowler's or sitting position; keep head elevated for 30 minutes after eating.
            4. Warm feeding to room temperature; dilute with H2O if too thick.
            5. Give 50 mL H2O before feeding; 200 to 500 mL feeding by gravity over 10 to 15 minutes; follow with 50 mL H2O.
            6. Give frequent mouth care.
        3. Goal: health teaching.
          1. Avoid constricting clothing and activities that increase intra-abdominal pressure (e.g., lifting, bending, straining at stool).
          2. foodImageWeight reduction.
          3. Dietary needs: small, frequent, soft, bland meals.
          4. Chew thoroughly.
          5. infoImageUpright position for at least 1 hour after meals.
    6. Evaluation/outcome criteria:
      1. Obtains relief from symptoms; is comfortable.
      2. Receives adequate, balanced nutrition.
      3. Describes dietary changes, recommended positioning, and activity limitations to prevent recurrence.
  8. GASTROESOPHAGEAL REFLUX DISEASE (GERD): inappropriate relaxation of the lower esophageal sphincter (LES) in response to unknown stimulus.
    1. Pathophysiology: gastric volume or intraabdominal pressure elevated, or LES tone decreased → frequent episodes of acid reflux → breakdown of mucosal barrier → esophageal inflammation, hyperemia, and erosion → fibrotic tissue formation → esophageal stricture → impaired swallowing.
    2. Risk factors:
      1. Hiatal hernia.
      2. Diet—foods that lower pressure of LES (fatty foods, chocolate, cola, coffee, tea).
      3. Smoking.
      4. Drugs (calcium channel blockers, NSAIDs, theophylline).
      5. Elevated intra-abdominal pressure (obesity, pregnancy, heavy lifting).
    3. Assessment:
      1. Subjective data:
        1. Heartburn (pyrosis)—substernal or retrosternal; may mimic angina; 20 minutes to 2 hours after eating.
        2. Regurgitation—sour or bitter taste not associated with belching or nausea.
        3. Dysphagia or odynophagia (difficult or painful swallowing)—severe cases.
        4. Belching, feeling bloated.
        5. Nocturnal cough.
      2. Objective data:
        1. Hoarseness, wheezing.
        2. Diagnostic tests: 24-hour pH monitoring; barium swallow with fluoroscopy; endoscopy.
    4. Analysis/nursing diagnosis:
      1. Pain related to acid reflux and esophageal inflammation.
      2. Knowledge deficit (learning need) related to modifications needed to control reflux.
    5. Nursing care plan/implementation:
      1. Goal: promote comfort and reduce reflux episodes.
        1. pillImageMedications as ordered:
          1. Antacidsto neutralize gastric acid.
          2. Histamine2 (H2) receptor antagonists (cimetidine, ranitidine, famotidine) to reduce gastric acid secretion and support tissue healing.
          3. Proton pump inhibitor (omeprazole [Prilosec]) to inhibit gastric enzymes and suppress gastric acid secretion.
        2. foodImageDiet: avoid strong stimulants of acid secretion (caffeine, alcohol); avoid foods that reduce LES competence (fatty foods, onions, tomato-based foods); increase protein; restrict spicy, acidic foods until healing occurs.
        3. Activity: avoid heavy lifting, straining, constrictive clothing, bending over.
        4. infoImagePosition: elevate head of bed 6 to 12 inches for sleeping. Reflux more likely on right side.
      2. Goal: health teaching.
        1. Weight reduction if indicated.
        2. Smoking cessation.
        3. Diet modification: avoid overeating—eat 4 to 6 small meals.
        4. Medication administration.
        5. Potential complications if uncontrolled (hemorrhage, aspiration).
    6. Evaluation/outcome criteria:
      1. No heartburn reported.
      2. Changes diet as instructed.
      3. No complications of continued reflux.
  9. PEPTIC ULCER DISEASE: circumscribed loss of mucosa, submucosa, or muscle layer of the gastrointestinal tract caused by a decreased resistance of gastric mucosa to acid-pepsin injury. Peptic ulcer disease is a chronic disease and may occur in the distal esophagus, stomach, upper duodenum, or jejunum. Gastric ulcers, located on the lesser curvature of the stomach, are larger and deeper than duodenal ulcers and tend to become malignant. Duodenal ulcers are located on the first part of the duodenum and are more common than gastric ulcers. Esophageal ulcersoccur in the esophagus. Stress ulcers, an acute problem, occur after a major insult to the body.
    1. Pathology: failure of the body to regenerate mucous epithelium at a sufficient rate to counterbalance the damage to tissue during the breakdown of protein; decrease in the quantity and quality of the mucus; poor local mucosal blood flow, along with individual susceptibility to ulceration. A peptic ulcer is a hole in the lining of the stomach, duodenum, or esophagus. This hole occurs when the lining of these organs is corroded by the acidic digestive juices secreted by the stomach cells. Excess acid is still considered to be significant in ulcer formation. The leading cause of ulcer disease is currently believed to be infection of the stomach by Helicobacter pylori (H. pylori). Another major cause of ulcers is chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs). Cigarette smoking is also an important cause of ulcers.
    2. Risk factors:
      1. Gastric ulcers.
        1. Infection with H. pylori.
        2. Decreased resistance to acid-pepsin injury.
        3. Increased histamine release → inflammatory reaction.
        4. Ulcerogenic drugs (aggravate preexisting conditions).
        5. Cigarette smoking.
        6. Increased alcohol and caffeine use (aggravates preexisting conditions).
        7. Gastric ulcer is thought to be a risk for gastric cancer.
        8. Difficulty coping with stressful situations.
      2. Duodenal ulcers.
        1. Infection with H. pylori.
        2. Elevated gastric acid secretory rate.
        3. Elevated gastric acid levels postprandially (after eating).
        4. Increased rate of gastric emptying → increased amount of acid in duodenum → irritation and breakdown of duodenal mucosa.
        5. Ulcerogenic medication use (aggravates preexisting conditions).
        6. Cigarette smoking.
        7. Alcohol and caffeine use (aggravates preexisting condition).
        8. Difficulty coping with stressful situations.
      3. Stress ulcers.
        1. Severe trauma or major illness.
        2. Severe burns (Curling's ulcer); develop in 72 hours with majority of persons with burns over more than 35% of the body surface.
        3. Head injuries or intracranial disease (Cushing's ulcer).
        4. pillImageMedications in large doses: corticosteroids, salicylates, ibuprofen, indomethacin, phenylbutazone (Butazolidin).
        5. Shock.
        6. Sepsis.
    3. Assessment:
      1. Subjective data:
        1. Gastric ulcers.
          1. Pain:
            1. Type: gnawing, aching, burning.
            2. Location: epigastric, left of midline, localized.
            3. Occurrence: periodic pain, often 2 hours after eating.
            4. pillImageRelief: antacids; may be aggravated, not relieved, by food.
            5. Some clients report no discomfort at all.
          2. Weakness.
          3. History of risk factors as above.
        2. Duodenal ulcers.
          1. Pain:
            1. Type: gnawing, aching, burning, hungerlike, boring.
            2. Location: right epigastric, localized; steady pain near midline of back may indicate perforation.
            3. Occurrence: 1 to 3 hours after eating, worse at end of day or during the night; initial attack occurs spring or fall; history of remissions and exacerbations.
            4. pillImageRelief: food, antacids, or both.
            5. Some clients report no discomfort at all.
          2. Nausea.
          3. History of risk factors (see IX. B.).
        3. Stress ulcers.
          1. Pain: often painless until serious complication (hemorrhage, perforation) occurs.
          2. History of risk factors as above.
      2. Objective data:
        1. Gastric ulcer.
          1. Vomiting blood (hematemesis).
          2. Melena (tarry stools).
          3. Weight loss.
          4. X-ray (upper GI series) confirms "crater" (punched-out appearance, clean base).
          5. Endoscopy confirms presence of ulcer; biopsy for cytology.
          6. Monitor for blood loss: CBC, stool for occult blood.
          7. Orthostatic hypotension.
          8. Laboratory data: positive for H. pylori.
        2. Duodenal ulcer.
          1. Eructation.
          2. Vomiting blood (hematemesis).
          3. Regurgitation of sour liquid into back of mouth.
          4. Constipation.
          5. X-ray (upper GI series) confirms ulcer craters and niches, as well as outlet deformities: round or oval funnel-like lesion extending into musculature.
          6. Endoscopy for direct visualization.
          7. Monitor for blood loss: CBC, stool for occult blood.
          8. Orthostatic hypotension.
          9. Laboratory data: positive for H. pylori.
        3. Stress ulcer.
          1. GI bleeding.
          2. Multiple, superficial erosions affecting large area of gastric mucosa.
    4. Analysis/nursing diagnosis (all types):
      1. Pain related to erosion of gastric lining.
      2. Ineffective individual coping related to inability to change lifestyle.
      3. Altered nutrition, less than body requirements, related to inadequate intake.
      4. Knowledge deficit (learning need) regarding preventive measures.
      5. Risk for injury related to possible hemorrhage or perforation.
    5. Nursing care plan/implementation (all types):
      1. Goal: promote comfort.
        1. pillImageMedications as ordered to decrease pain (see E.4. Goal: health teaching ); sedatives to decrease anxiety.
        2. Prepare for diagnostic tests.
          1. X-rays; upper GI series (barium swallow); lower GI (barium enema).
          2. Endoscopy.
          3. Gastric analysis, to determine amount of hydrochloric acid in GI tract.
      2. Goal: prevent/recognize signs of complications.
        1. Monitor vitals for shock.
        2. Check stool for occult blood/hemorrhage.
        3. Palpate abdomen for perforation (rigid, boardlike); arterial bleeding.
      3. Goal: provide emotional support.
        1. Stress-management techniques.
        2. Restful environment.
        3. Prepare for surgery, if necessary.
      4. Goal: health teaching.
        1. pillImageMedications:
          1. Antibiotics. Sometimes antibiotics work best if given in combination with omeprazole (Prilosec), H2 blockers, or bismuth (Pepto-Bismol). Caution: use of antibiotic treatment can cause allergic reactions, diarrhea, and severe antibioticinduced colitis.
            1. Tetracycline.
            2. Amoxicillin.
            3. Metronidazole (Flagyl).
            4. Clarithromycin (Biaxin).
          2. Histamine antagonists: given with meals/bedtime to block the action of histamine-stimulated gastric secretions (basal and stimulated); inhibit pepsin secretion and reduce the volume of gastric secretions.
            1. Cimetidine (Tagamet) inhibits gastrin release; can be given PO, IV, or IM; cannot be given within 1 hour of antacid therapy.
            2. Ranitidine (Zantac) has greater reduction of acid secretion, longer duration, less frequent administration (twice daily versus 4 times a day), and fewer side effects than cimetidine.
            3. Nizatidine (Axid).
            4. Famotidine (Pepcid).
          3. Proton pump inhibitors(gastric acid inhibitors): superior in treating esophageal ulcers; equal to other H2 receptors for gastric and duodenal ulcers.
            1. Omeprazole (Prilosec).
            2. Lansoprazole (Prevacid).
            3. Pantoprazole.
          4. Antiulcers: give 1 to 3 hours after meals and at bedtime to decrease pain by lowering acidity; monitor for:
            1. Diarrhea (seen most often with magnesium carbonate and magnesium oxide [Maalox, Mylanta]).
            2. Constipation (seen most often with calcium carbonate [Tums] or aluminum hydroxide [Amphojel]).
            3. Electrolyte imbalance (seen with systemic antacid, soda bicarbonate).
            4. Best 1 to 3 hours after meals.
            5. Liquids more effective than tablets; if taking tablets, chew slowly.
          5. Sucralfate(Carafate) and misoprostol (Cytotec): given 1 hour before meals and at bedtime.
            1. Locally active topical agent that forms a protective coat on mucosa, prevents further digestive action of both acid and pepsin.
            2. Must not be given within 30 minutes of antacids.
          6. Anticholinergic—when used, given before meals to decrease gastric acid secretion and delay gastric emptying.
          7. Important: avoid aspirin (could increase bleeding possibility).
        2. foodImage  Diet:
          1. Change diet only to relieve symptoms; diet may not influence ulcer formation.
          2. Avoid foods that increase acidity—caffeine and alcohol in moderation.
          3. Plan:
            1. Small, frequent meals (to prevent exacerbations of symptoms related to an empty stomach).
            2. Weight control.
        3. Complications—signs and symptoms:
          1. Gastric ulcers may be premalignant.
          2. Perforation.
          3. Hemorrhage.
          4. Obstruction.
        4. Lifestyle changes:
          1. Decrease:
            1. Smoking.
            2. Noise.
            3. Rush.
            4. Confusion.
          2. Increase:
            1. Communication.
            2. Mental/physical rest.
            3. Compliance with medical regimen.
    6. Evaluation/outcome criteria:
      1. Avoids foods/liquids that cause irritation.
      2. Takes prescribed medications.
      3. Pain decreases.
      4. No complications.
      5. States signs and symptoms of complications.
      6. Participates in stress-reduction activities.
      7. Stops smoking.
  10. GASTRIC SURGERY: peformed when ulcer medical regimen is unsuccessful, ulcer is determined to be precancerous, or complications are present.
    1. Types:
      1. Subtotal gastrectomy: removal of a portion of the stomach.
      2. Total gastrectomy: removal of the entire stomach.
      3. Antrectomy: removal of entire antrum (lower) portion of the stomach.
      4. Pyloroplasty: repair of the pyloric opening of the stomach.
      5. Vagotomy: interruption of the impulses carried by the vagus nerve, which results in reduction of gastric secretions and decreased physical activity of the stomach (being done less often).
      6. Combination of vagotomy and gastrectomy.
    2. Analysis/nursing diagnosis:
      1. Pain related to surgical incision.
      2. Ineffective breathing pattern related to high surgical incision.
      3. Risk for trauma related to possible complications postgastrectomy.
      4. Knowledge deficit (learning need) regarding medication regimen and factors that aggravate condition.
      5. Fear related to possible precancerous lesion.
      6. Ineffective individual coping related to adjustments in lifestyle needed to lessen symptoms.
    3. Nursing care plan/implementation:
      1. Goal: promote comfort in the postoperative period.
        1. pillImageAnalgesics: to relieve pain and allow client to cough, deep breathe to prevent pulmonary complications.
        2. infoImagePosition: semi-Fowler's to aid in breathing.
      2. Goal: promote wound healing.
        1. Keep dressings dry.
        2. NG tube to low intermittent suction (Levin) or low continuous suction (Salem sump).
          1. Check drainage from NG tube; normally bloody first 2 to 3 hours postsurgery, then brown to dark green.
          2. Excessive bright-red blood drainage: take vital signs; report vital signs, color and volume of drainage to physician immediately.
          3. Irrigate gently with saline in amount ordered; do not irrigate against resistance; may not be done in early postoperative period.
          4. Tape tube securely to face, but prevent obstructed vision.
          5. Frequent mouth and nostril care.
      3. Goal: promote adequate nutrition and hydration.
        1. pillImageAdminister parenteral fluids as ordered.
        2. Accurate I&O.
        3. foodImageCheck bowel sounds, at least q4h; NPO 1 to 3 days; bowel sounds normally return in 21 to 36 hours; oral fluids as ordered when bowel sounds present—usually 30 mL, then small feedings, then bland liquids to soft diet.
        4. Observe for nausea and vomiting due to suture line edema, food intake (too much, too fast).
      4. Goal: prevent complications.
        1. pillImageCheck dressing q4h for bleeding.
        2. Vitamin B12 and iron replacement as indicated to avoid pernicious anemia and iron-deficiency anemia.
        3. Avoid dumping syndrome.
    4. Evaluation/outcome criteria:
      1. Hemorrhage, dumping syndrome avoided.
      2. Healing begins.
      3. Adjust lifestyle to prevent recurrence/marginal ulcer.
  11. DUMPING SYNDROME: hypoglycemic-type episode; occurs postoperatively after gastric resection (may also occur after vagotomy, antrectomy, or gastroenterostomy), when food and fluids that are more hyperosmolar than the jejunal secretions pass quickly into jejunum, producing fluid shifts from bloodstream to jejunum. This is a mild problem for about 20% of clients and will disappear in a few months to a year. Symptoms cause serious problem for about 7% of clients. This discomfort may occur during a meal or up to 30 minutes after the meal and last from 20 to 60 minutes. The reaction is greatest after the ingestion of sugar.
    1. Assessment:
      1. Subjective data:
        1. Feeling of fullness, weakness, faintness.
        2. Palpitations.
        3. Nausea.
        4. Discomfort during or after eating.
      2. Objective data:
        1. Diaphoresis.
        2. Diarrhea.
        3. Fainting.
        4. Symptoms of hypoglycemia.
    2. Analysis/nursing diagnosis:
      1. Altered nutrition, more than body requirements, related to body's inability to properly digest high-carbohydrate, high-sodium foods.
      2. Diarrhea related to food passing into jejunum too quickly.
      3. Risk for injury related to hypoglycemia.
      4. Knowledge deficit (learning need) related to dietary restrictions.
    3. Nursing care plan/implementation:
      1. Goal: health teaching.
        1. foodImageInclude:
          1. Increased fat, protein to delay emptying.
          2. Rest after meals.
          3. Small, frequent meals.
          4. Fluids between meals.
        2. foodImageAvoid:
          1. Foods high in salt, carbohydrate.
          2. Large meals.
          3. Stress at mealtime.
          4. Fluids at mealtime.
    4. Evaluation/outcome criteria:
      1. No complications.
      2. Client heals.
      3. No further ulcers.
      4. Incorporates health teaching into lifestyle and prevents syndrome.
  12. CHOLECYSTITIS/CHOLELITHIASIS: inflammation of gallbladder due to bacterial infection, presence of cholelithiasis (stones, cholesterol, calcium, or bile in the gallbladder), or choledocholithiasis (stone in the common bile duct) and/or obstruction. Acute cholecystitis is abrupt in onset, but the client usually has a history of several attacks of fatty food intolerance. The client with chronic cholecystitis has a history of several attacks of moderate severity and has usually learned to avoid fatty foods to decrease symptoms.
    1. Pathophysiology: calculi from increased concentration of bile salts, pigments, or cholesterol due to metabolic or hemolytic disorders, biliary stasis → precipitation of salts into stones, or inflammation causing bile constituents to become altered.
    2. Risk factors:
      1. Adult women.
      2. Obesity.
      3. Pregnancy or previous pregnancies.
      4. Use of birth control pills or hormone replacement therapy.
      5. High-fat, low-fiber diets.
      6. Rapid weight loss.
      7. History of Crohn's disease.
      8. Genetics.
      9. Age: increased risk over 40.
      10. Certain drugs to lower lipids; clofibrate (Atromid-S).
      11. Other diseases: cirrhosis of liver.
    3. Assessment:
      1. Subjective data:
        1. Pain:
          1. Type—severe colic, radiating to the back under the scapula and to the right shoulder.
          2. Positive Murphy's sign—a sign of gallbladder disease consisting of pain on taking a deep breath when pressure is placed over the location of the gallbladder.
          3. Location—right upper quadrant, epigastric area, flank (Figure. 6.9. Abdominal Pain by Location).
          4. Duration—spasm of duct attempting to dislodge stone lasts until dislodged or relieved by medication, or sometimes by vomiting.
        2. GI—anorexia, nausea, feeling of fullness, indigestion, intolerance of fatty foods.
      2. Objective data:
        1. GI—belching, vomiting, clay-colored stools.
        2. Vital signs—increased pulse, fever.
        3. Skin—chills, jaundice.
        4. Urine—dark amber.
        5. Laboratory data—elevated:
          1. WBC count.
          2. Alkaline phosphatase.
          3. Serum amylase, lipase.
          4. AST (SGOT).
          5. Bilirubin.
        6. Diagnostic studies:
          1. Ultrasound.
          2. Cholangiography.
          3. Computed tomography (CT) scan.
          4. Endoscopic retrograde cholangiopancreatography (ERCP).
    4. Analysis/nursing diagnosis:
      1. Pain related to obstruction of bile duct due to cholelithiasis.
      2. Altered nutrition, more than body requirements, related to ingestion of fatty foods.
      3. Altered nutrition, less than body requirements, related to hesitancy to eat due to anorexia and nausea.
      4. Risk for fluid volume deficit related to episodes of vomiting.
      5. Knowledge deficit (learning need) related to dietary restrictions.
    5. Nursing care plan/implementation:
      1. Nonsurgical interventions:
        1. Goal: promote comfort.
          1. pillImageMedications as ordered: meperidine, antibiotics, antispasmodics, electrolytes.
          2. Avoid morphine due to spasmodic effect.
          3. NG tube to low suction.
          4. foodImageDiet: fat free when able to tolerate food.
          5. Lithotripsy: gallstones fragmented by shock waves.
          6. pillImageOral dissolution therapy: ursodeoxycholic acid (ursodiol [Actigall]).
        2. Goal: health teaching:
          1. Signs, symptoms, and complications of disease.
          2. Fat-free diet.
          3. Desired effects and side effects of prescribed medications.
          4. Prepare for possible removal of gallbladder (cholecystectomy) if conservative treatment unsuccessful.
      2. Surgical interventions:
        1. Preoperative—Goal: prevent injury (see I. PREOPERATIVE PREPARATION, The Perioperative Experience).
        2. Postoperative—Goal: promote comfort (see III. POSTOPERATIVE EXPERIENCE, The Perioperative Experience).
          1. Laparoscopic laser cholecystectomy—tiny incisions/puncture wounds; gallbladder is removed using a video-guided system with a camera; client is discharged that day or next day, able to resume normal diet and work activities in a few days.
          2. Endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy—removes stones from bile duct. No incision; done under sedation, not anesthesia.
          3. Open-incision cholecystectomy.
            1. Promote tube drainage:
              1. NG tube to low suction.
              2. T-tubeto closed-gravity drainage, to preserve patency of edematous common duct and ensure bile drainage; usual amount 500 to 1,000 mL/24 hr; dark brown drainage.
              3. Provide enough tubing to allow turning without tension.
              4. Empty and record bile drainage q8h.
            2. infoImagePosition: low Fowler's to semi-Fowler's to facilitate T-tube drainage.
            3. Dressing: dry to protect skin (because bile excoriates skin).
            4. Clamp T-tube as ordered.
              1. Observe for: abdominal distention, pain, nausea, chills, or fever.
              2. Unclamp tube and notify physician if symptoms appear.
        3. Goal: prevent complications.
          1. pillImageIV fluids with vitamins.
          2. Cough, turn, and deep breathe with open incision, particularly with removal of gallbladder (prone to respiratory complication because of high incision).
          3. Early ambulation to prevent vascular complications and aid in expelling flatus.
          4. Monitor for jaundice: skin, sclerae, urine, stools.
          5. Monitor for signs of hemorrhage, infection.
        4. Goal: health teaching.
          1. pillImageDiet: fat free for 6 weeks.
          2. Signs of complications of food intolerance, pain, infection, hemorrhage.
    6. Evaluation/outcome criteria:
      1. No complications.
      2. Able to tolerate food.
      3. Plans follow-up care.
      4. Possible weight reduction.
  13. OBESITY—more calories consumed than expended leading to fat accumulation. Most common nutritional/metabolic disease in the United States.
    1. Definition: Women—more than 45% above ideal body weight. Men—more than 35% above ideal body weight. Determined by body mass index (BMI) formula: divide weight in kilograms by height in meters squared (or divide weight in pounds by height in inches squared) and multiply by 703:
      Wt (lb)/Ht (in2) × 703 or: Wt (kg)/Ht (m2) × 703
    2. Risk factors:
      1. Genetics (e.g., ↓ BMI), hormonal.
      2. Environmental (e.g., ↓ physical activity).
      3. Diet (e.g., ↑ fat, calories).
      4. Some medications (e.g., tricyclic antidepressants [TCAs], insulin, sulfonylurea agents).
    3. Comorbidity:
      1. Cardiovascular disease; hypertension.
      2. Type 2 diabetes.
      3. Gallbladder disease.
      4. Arthritis.
      5. Cancer (colorectal, breast, prostate).
      6. Stroke.
      7. Emotional distress.
      8. Surgical risk.
    4. Assessment:
      1. Overweight—BMI 25.0 to 29.9 kg/m2.
      2. Obese—BMI ≥30.0 kg/m2.
      3. Morbid obesity—BMI greater than 40 kg/m2.
    5. Analysis/nursing diagnosis:
      1. Altered nutrition, more than body requirements, related to genetics, environmental, or dietary factors.
      2. Chronic low self-esteem/body image disturbance related to view of self in contrast to societal values; control, sex, and love issues (see also Chapter 10. Psychosocial Integrity, Body Image Disturbance, Psychosocial Integrity).
      3. Activity intolerance related to imbalance between oxygen supply and demand, and to sedentary lifestyle.
    6. Nursing care plan/implementation—Goal: decrease weight, initially 10% from baseline.
      1. foodImageModify eating pattern (quality vs. quantity); ↓ portion size; modify composition: ↓ calories, fat, and cholesterol; ↓ daily kcal by 500 to 1,000.
      2. Increase activity—moderate activity 30 minutes daily.
      3. Behavioral therapy—change eating behaviors; motivation and readiness to lose weight.
      4. Weight-loss drugs in combination with lifestyle changes.
      5. Surgery—gastric stapling, bariatric (Roux-en-Y).
    7. Evaluation/outcome criteria:
      1. Weight loss of 1 to 2 lb/wk for 6 months.
      2. Reduction in kcal by 500 to 1,000/day.
      3. Increased daily physical activity.
      4. Expressed commitment to lose weight.
  14. APPENDICITIS: obstruction of appendiceal lumen and subsequent bacterial invasion of appendiceal wall; acute emergency.
    1. Pathophysiology: when obstruction is partial or mild, inflammation begins in mucosa with slight appendiceal swelling, accompanied by periumbilical pain. As the inflammatory process escalates and/or obstruction becomes more complete, the appendix becomes more swollen, the lumen fills with pus, and mucosal ulceration begins. When inflammation extends to the peritoneal surface, pain is referred to the right lower abdominal quadrant. Danger: rigidity over the entire abdomen is usually indicative of ruptured appendix; the client is then prone to peritonitis.
    2. Risk factors:
      1. Men more than women.
      2. Most frequently seen between ages 10 and 30 years.
    3. Assessment:
      1. Subjective data:
        1. Pain: generalized, then right lower quadrant at McBurney's point, with rebound tenderness.
        2. Anorexia, nausea.
      2. Objective data:
        1. Vital signs: elevated temperature, shallow respirations.
        2. Either diarrhea or constipation.
        3. Vomiting, fetid breath odor.
        4. Splinting of abdominal muscles, flexion of knees onto abdomen.
        5. Laboratory data:
          1. WBC count elevated (>10,000).
          2. Neutrophil count elevated (>75%).
        6. Diagnostic studies:
          1. Ultrasound.
          2. CT scan.
    4. Analysis/nursing diagnosis:
      1. Pain related to inflammation of appendix.
      2. Risk for trauma related to ruptured appendix.
      3. Knowledge deficit (learning need) related to possible surgery.
    5. Nursing care plan/implementation:
      1. Goal: promote comfort.
        1. Preoperative:
          1. Explain procedures.
          2. Assist with diagnostic work-up.
        2. Postoperative:
          1. Relieve pain related to surgical incision.
          2. Prevent infection: wound care, dressing technique.
          3. Prevent dehydration: IVs, I&O, fluids to solids by mouth as tolerated.
          4. Promote ambulation to prevent postoperative complications.
    6. Evaluation/outcome criteria:
      1. No infection.
      2. Tolerates fluid; bowel sounds return.
      3. Heals with no complications.
  15. HERNIA: protrusion of the intestine through a weak portion of the abdominal wall.
    1. Types:
      1. Reducible: visceral contents return to their normal position, either spontaneously or by manipulation.
      2. Irreducible, or incarcerated: contents cannot be returned to normal position.
      3. Strangulated: blood supply to the structure within the hernia sac becomes occluded (usually a loop of bowel).
      4. Most common hernias: umbilical, femoral, inguinal, incisional, and hiatal.
    2. Pathophysiology: weakness in the wall may be either congenital or acquired. Herniation occurs when there is an increase in intra-abdominal pressure from: coughing, lifting, crying, straining, obesity, or pregnancy.
    3. Assessment:
      1. Subjective data:
        1. Pain, discomfort.
        2. History of feeling a lump.
      2. Objective data:
        1. Soft lump, especially when straining or coughing.
        2. Sometimes alteration in normal bowel pattern.
        3. Swelling.
    4. Analysis/nursing diagnosis:
      1. Activity intolerance related to pain and discomfort.
      2. Risk for trauma related to lack of circulation to affected area of bowel.
      3. Pain related to protrusion of intestine into hernia sac.
    5. Nursing care plan/implementation:
      1. Goal: prevent postoperative complications.
        1. Monitor bowel sounds.
        2. Prevent postoperative scrotal swelling with inguinal hernia by applying ice and support to scrotum.
      2. Goal: health teaching.
        1. Prevent recurrence with correct body mechanics.
        2. Gradual increase in exercise.
    6. Evaluation/outcome criteria: healing occurs with no further hernia recurrence.
  16. DIVERTICULOSIS: A diverticulum is a small pouch or sac composed of mucous membrane that has protruded through the muscular wall of the intestine. The presence of several of these is called diverticulosis. Inflammation of the diverticula is called diverticulitis.
    1. Pathophysiology: weakening in a localized area of muscular wall of the colon (especially the sigmoid colon), accompanied by increased intraluminal pressure.
    2. Risk factors:
      1. Diverticulosis:
        1. Age: seldom before 35 years; 60% incidence in older adults.
        2. History of constipation.
        3. Diet history: low in vegetable fiber, high in carbohydrate.
      2. Diverticulitis: highest incidence between ages 50 and 60 years.
    3. Assessment:
      1. Subjective data: pain: cramplike; left lower quadrant of abdomen.
      2. Objective data:
        1. Constipation or diarrhea, flatulence.
        2. Fever.
        3. Rectal bleeding.
        4. Diagnostic procedures:
          1. Palpation reveals tender colonic mass.
          2. Barium enema (done only in absence of inflammation) reveals presence of diverticula.
          3. Sigmoidoscopy/colonoscopy.
    4. Analysis/nursing diagnosis:
      1. Constipation related to dietary intake.
      2. Pain related to inflammatory process of intestines.
      3. Risk for fluid volume deficit related to episodes of diarrhea or bleeding.
      4. Risk for injury related to bleeding.
      5. Knowledge deficit (learning need) related to prevention of constipation.
    5. Nursing care plan/implementation:
      1. Goal: bowel rest during acute episodes.
        1. foodImageDiet: soft, liquid.
        2. Fluids, IVs if oral intake not adequate.
        3. pillImageMedications:
          1. Antibiotics: ciprofloxacin (Cipro), metronidazole (Flagyl), cephalexin (Keflex), doxycycline (Vibramycin).
          2. Antispasmodics: chlordiazepoxide (Librax), dicyclomine (Bentyl), Donnatal, hyoscyamine (Levsin).
        4. Monitor stools for signs of bleeding.
      2. Goal: promote normal bowel elimination.
        1. foodImageDiet: bland, high in vegetable fiber if no inflammation.
          1. Include: fruits, vegetables, whole-grain cereal, unprocessed bran.
          2. Avoid: foods difficult to digest (corn, nuts).
        2. pillImageBulk-forming agents as ordered: methylcellulose, psyllium.
        3. Monitor: abdominal distention, acute bowel symptoms.
      3. Goal: health teaching.
        1. Methods to avoid constipation.
        2. Foods to include/avoid in diet.
        3. Relaxation techniques.
        4. Signs and symptoms of complications of chronic inflammation: abscess, obstruction, fistulas, perforation, or hemorrhage.
    6. Evaluation/outcome criteria:
      1. Inflammation decreases.
      2. Bowel movements return to normal.
      3. Pain decreases.
      4. No perforation, fistulas, or abscesses noted.
  17. ULCERATIVE COLITIS: inflammation of mucosa and submucosa of the large intestine. Inflammation leads to ulceration with bleeding. Involved areas are continuous. Disease is characterized by remissions and exacerbations.
    1. Pathophysiology: Currently believed to be an autoimmune disease. The body's immune system is called on to attack the inner lining of the large intestine, causing inflammation and ulceration. Edema and hyperemia of colonic mucous membrane → superficial bleeding with increased peristalsis, shallow ulcerations, abscesses; bowel wall thins and shortens and becomes at risk for perforation. Increased rate of flow of liquid ileal contents → decreased water absorption and diarrhea.
    2. Risk factors:
      1. Highest occurrence in young adults (ages 20 to 40 years).
      2. Genetic predisposition: higher in whites, Jews.
      3. Autoimmune response.
      4. Infections.
      5. More common in urban areas (upper-middle incomes and higher educational levels).
      6. Nonsmokers/ex-smokers.
      7. Genetic, inherited, or familial tendencies.
      8. Chronic ulcerative colitis is a risk factor for colon cancer.
    3. Assessment:
      1. Subjective data:
        1. Urgency to defecate, particularly when standing.
        2. Loss of appetite, nausea.
        3. Colic-like abdominal pain.
        4. History of intolerance to dairy products.
        5. Emotional depression.
      2. Objective data:
        1. Diarrhea: 10 to 20 stools/day; can be chronic or intermittent, episodic or continual; stools contain blood, mucus, and pus.
        2. Weight loss and malnutrition, dehydration.
        3. Fever.
        4. Rectal bleeding.
        5. Laboratory data: decreased: RBC count, potassium, sodium, calcium, bicarbonate related to excessive diarrhea.
        6. Lymphadenitis.
        7. Diagnostic tests:
          1. Sigmoidoscopy/colonoscopy for visualization of lesions.
          2. Barium enema.
    4. Analysis/nursing diagnosis:
      1. Diarrhea related to increased flow rate of ileal contents.
      2. Self-esteem disturbance related to progression of disease and increased number and odor of stools.
      3. Pain (acute) related to inflammatory process.
      4. Fluid volume deficit related to frequent episodes of diarrhea.
      5. Knowledge deficit (learning need) related to methods to control symptoms.
      6. Social isolation related to continual diarrhea episodes.
    5. Nursing care plan/implementation:
      1. Goal: prevent disease progression and complications.
        1. pillImageAdminister medications:
          1. Salicylates: sulfasalazine (Azulfidine), olsalazine (Dipentum), mesalamine (Asacol, Pentasa). All given PO in high doses. Mesalamine (Rowasa) is given in enema or suppository form.
          2. Corticosteroids: prednisone, PO or IV. Hydrocortisone (Cortenema) is given by enema.
          3. Immunosuppressants: azathioprine (Imuran), and 6-mercaptopurine (Purinthol), cyclosporine (Sandimmune), and methotrexate (Rheumatrex).
          4. Nicotine.
          5. Sedatives and tranquilizers to produce rest and comfort.
          6. Absorbents: kaolin/pectin (Kaopectate).
          7. Anticholinergics and antispasmotics to relieve cramping and diarrhea: atropine sulfate, phenobarbital, diphenoxylate/atropine sulfate (Lomotil).
          8. Anti-infective agents to relieve bacterial overgrowth in bowel and limit secondary infections: metronidazole (Flagyl).
          9. Potassium supplements to relieve deficiencies related to excessive diarrhea.
          10. Calcium folate and vitamin B12 when malabsorption is present.
      2. Goal: reduce psychological stress.
        1. Provide quiet environment.
        2. Encourage verbalization of concerns.
      3. Goal: health teaching.
        1. foodImageDiet:
          1. Avoid: coarse-residue, high-fiber foods (e.g., raw fruits and vegetables), whole milk, cold beverages (because of inflammation).
          2. Include: bland, high-protein, high-vitamin, high-mineral, high calorie foods.
          3. Parenteral hyperalimentation for severely ill.
          4. Force fluids by mouth.
        2. Monitor for colon cancer, especially 8 to 10 years after incidence.
      4. Goal: prepare for surgery if medical regimen unsuccessful.
        1. Possible surgical procedures:
          1. Permanent ileostomy (J pouch).
          2. Continent ileostomy(Kock pouch).
          3. Total colectomy, anastomosis with rectum.
          4. Total colectomy, anastomosis with anal sphincter.
    6. Evaluation/outcome criteria:
      1. Fluid balance is obtained and maintained.
      2. Alterations in lifestyle are managed.
      3. Stress-management techniques are successful.
      4. Complications such as fistulas, obstruction, perforation, and peritonitis are avoided.
      5. Client is prepared for surgery if medical regimen is unsuccessful or complications develop.
  18. CROHN'S DISEASE: a chronic inflammatory disease causing ulcerations in the small and large intestines. The immune system seems to react to a variety of substances and/or bacteria in the intestines, causing inflammation, ulceration, and bowel injury. Called Crohn's colitis when only large intestine is involved; Crohn's enteritis when only small intestine is involved; terminal ileitis when lowest part of small intestine is involved; Crohn's enterocolitisor ileocolitis when both small and large intestines are involved.
    1. Pathophysiology: one of two conditions called "inflammatory bowel disease" (ulcerative colitis is the other) that affects all layers of the ileum, the colon, or both, causing patchy, shallow, longitudinal mucosal ulcers; possible correlation with autoimmune disease and adenocarcinoma of the bowel. Small, scattered, shallow crater-like areas cause scarring and stiffness of the bowel → bowel becomes narrow → obstruction, then pain, nausea, and vomiting.
    2. Risk factors:
      1. Age: 15 to 20, 55 to 60 years.
      2. Whites, especially Jews.
      3. Familial predisposition.
      4. Possible virus involvement.
      5. Possible psychosomatic involvement.
      6. Possible hormonal or dietary influences.
    3. Assessment:
      1. Subjective data:
        1. Abdominal pain.
        2. Anorexia.
        3. Nausea.
        4. Malaise.
        5. History of isolated, intermittent, or recurrent attacks.
      2. Objective data:
        1. Diarrhea.
        2. Weight loss, vomiting.
        3. Fever, signs of infection.
        4. Fluid/electrolyte imbalances.
        5. Malnutrition, malabsorption.
        6. Occult blood in feces.
    4. Analysis/nursing diagnosis, Nursing care plan/implementation, Evaluation/outcome criteria (see XVII. ULCERATIVE COLITIS, Physiological Integrity).
  19. INTESTINAL OBSTRUCTION: blockage in movement of intestinal contents through small or large intestine.
    1. Pathophysiology:
      1. Mechanical causes—physical impediments to passage of intestinal contents (e.g., adhesions, hernias, neoplasms, inflammatory bowel disease, foreign bodies, fecal impactions, congenital or radiational strictures, intussusception, or volvulus).
      2. Paralytic causes—passageway remains open, but peristalsis ceases (e.g., after abdominal surgery, abdominal trauma, hypokalemia, myocardial infarction, pneumonia, spinal injuries, peritonitis, or vascular insufficiency).
    2. Assessment:
      1. Subjective data: pain related to:
        1. Proximal loop obstruction: upper abdominal, sharp, cramping, intermittent pain.
        2. Distal loop obstruction: poorly localized, cramping pain.
      2. Objective data:
        1. Bowel sounds: initially loud, high pitched; then when smooth muscle atony occurs, bowel sound absent.
        2. Increased peristalsis above level of obstruction in attempt to move intestinal contents through the obstructed area.
        3. Obstipation (no passage of gas or stool through obstructed portion of bowel; no reabsorption of fluids).
        4. Distention.
        5. Vomiting:
          1. Proximal loop obstruction: profuse nonfecal vomiting.
          2. Distal loop obstruction: less frequent fecal-type vomiting.
        6. Urinary output: decreased.
        7. Temperature: elevated; pulse: tachycardia; BP: hypotension → shock if untreated.
        8. Dehydration, hemoconcentration, hypovolemia.
        9. Laboratory data:
          1. Leukocytosis.
          2. Decreased: sodium (<138 mEq/L), potassium (<3.5 mEq/L).
          3. Increased: bicarbonate (>26 mEq/L), BUN (>18 mg/dL).
          4. pH: If obstruction is at gastric outlet, pH will be elevated, indicating metabolic alkalosis; if obstruction is distal duodenal or proximal jejunal, the pH will drop and metabolic acidosis occurs.
    3. Analysis/nursing diagnosis:
      1. Fluid volume deficit related to vomiting.
      2. Pain related to increased peristalsis above the level of obstruction.
      3. Altered nutrition, less than body requirements, related to vomiting.
      4. Risk for trauma related to potential perforation.
    4. Nursing care plan/implementation:
      1. Goal: obtain and maintain fluid balance.
        1. Nursing care of client with nasogastric tube (see Table 11-5. Review of the Use of Common Tubes ,Review of the Use of Common Tubes).
          1. Miller-Abbott tube: dual lumen, balloon inflated with air after insertion. Caution: do not tape tube to face until tube reaches point of obstruction.
          2. Cantor tube: has mercury in distal sac, which helps move tube to point of obstruction. Caution: do not tape tube to face until tube reaches point of obstruction.
        2. Nothing by mouth, IV therapy, strict I&O.
        3. Take daily weights (early morning), monitor CVP for hydration status.
        4. Monitor abdominal girth for signs of distention and urinary output for signs of retention or shock.
      2. Goal: relieve pain and nausea.
        1. Medications as ordered:
          1. Analgesics, antiemetics.
          2. If problem is paralytic: medical treatment includes neostigmine to stimulate peristalsis.
        2. Observe for bowel sounds, flatus (tape intestinal tube to face once peristalsis begins).
        3. Skin and frequent mouth care.
      3. Goal: prevent respiratory complications.
        1. Encourage coughing and deep breathing.
        2. Semi-Fowler's or position of comfort.
      4. Goal: postoperative nursing care (if treated surgically) (see III. POSTOPERATIVE EXPERIENCE, The Perioperative Experience).
    5. Evaluation/outcome criteria:
      1. Fluid balance obtained and maintained.
      2. Shock prevented.
      3. Obstruction resolved.
      4. Pain decreased.
      5. Fluids tolerated by mouth.
      6. Complications such as perforation and peritonitis avoided.
  20. FECAL DIVERSION—stomas: performed because of disease or trauma; may be temporary or permanent.
    1. Types (Table 6.25. Comparison of Ileostomy and Colostomy).
      1. Temporary—fecal stream rerouted to allow GI tract to heal or to provide outlet for stool when obstructed.
      2. Permanent—intestine cannot be reconnected. Rectum and anal sphincter removed (abdominal perineal resection). Often performed for cancer of the colon and/or rectum.
      3. Continent ileostomy—pouch is created inside the wall of the intestine. The pouch serves as a reservoir similar to a rectum. The pouch is emptied on a regular basis with a small tube.
      4. Ileoanal anastomosis (J pouch, S reservoir, or ileoperistaltic reservoir)—the large intestine is removed and the small intestine is inserted into the rectum and attached just above the anus. The muscles of the rectum remain intact and the normal route of stool elimination is maintained.
    2. Analysis/nursing diagnosis:
      1. Bowel incontinence related to lack of sphincter in newly formed stoma.
      2. Altered health maintenance related to knowledge of ostomy care.
      3. Body image disturbance related to stoma.
      4. Fear related to medical condition requiring stoma.
      5. Fluid volume deficit related to increased output through stoma.
    3. Nursing care plan/implementation:
      1. Preoperative period:
        1. Goal: prepare bowel for surgery.
          1. pillImageAdminister neomycin as ordered to reduce colonic bacteria.
          2. pillImageAdminister cathartics, enemas as ordered to cleanse the bowel of feces.
          3. foodImageAdminister low-residue or liquid diet as ordered.
        2. Goal: relieve anxiety and assist in adjustment to surgery.
          1. Provide accurate, brief, and reassuring explanations of procedures; allow time for questions.
          2. Referral: have enterostomal nurse visit to discuss ostomy management and placement of stoma appliance.
          3. Referral: offer opportunity for a visit with an Ostomy Association Visitor.
        3. Goal: health teaching.
          1. Determine knowledge of surgery and potential impact.
          2. Begin teaching regarding ostomy.
      2. Postoperative period:
        1. Goal: maintain fluid balance.
          1. Monitor I&O because large volume of fluid is lost through stoma.
          2. pillImageAdminister IV fluids as ordered.
          3. Monitor losses through NG tube.
        2. Goal: prevent other postoperative complications.
          1. Monitor for signs of intestinal obstruction.
          2. Maintain sterility when changing dressings; avoid fecal contamination of incision.
          3. Observe appearance of stoma: rosy pink, raised (Figure. 6.10. Colostomy Sites).
        3. Goal: initiate ostomy care.
          1. Protect skin around stoma: use commercial preparation to toughen skin and use protective barrier wafer (Stomahesive) or paste (Karaya or substitute) to keep drainage (which can cause excoriation) off the skin.
          2. Keep skin around stoma clean and dry; empty appliance frequently. Check for drainage in appliance at least twice during each shift. If drainage present (diarrheatype stool):
            1. Unclip bottom of bag.
            2. Drain into bedpan.
            3. Use a squeeze-type bottle filled with warm water to rinse inside of appliance.
            4. Clean clamp, if soiled.
            5. Put a few drops of deodorant in appliance if not odor-proof.
            6. Fasten bottom of appliance securely (fold bag over clamp two or three times before closing).
            7. Check for leakage under appliance every 2 to 4 hours.
          3. Change appliance when drainage leaks around seal, or approximately every 2 to 3 days. Initially, size of stoma will be large due to edema. Pouch opening should be slightly larger than stoma so it will not constrict. Stoma will need to be measured for each change until swelling subsides to ensure appropriate fit.
            1. Gather equipment: gloves, skin prep packet, colostomy appliance measured to fit stoma properly (use stoma measuring guide), skin barrier, warm water and soap, face cloth/towel, plastic bag for disposal of old equipment.
            2. Remove old appliance carefully, pulling from area with least drainage to area with most drainage.
            3. Wash skin area ( not stoma) with soap and water. Be careful not to: irritate skin, put soap on stoma, irritate stoma; do not put anything dry onto stoma. Remember: bowel is very fragile; working near bowel increases peristalsis so that feces and flatulence may be expelled.
            4. Observe skin area for potential breakdown.
            5. Use packet of skin prep on the skin around the stoma. Do not put this solution onto stoma, because it will cause irritation. Allow skin prep solution to dry on skin before applying colostomy appliance.
            6. Apply skin barrier you have measured and cut to size.
            7. Put appliance on so that bottom of appliance is easily accessible for emptying (e.g., if client is out of bed most of the time, put the bottom facing the feet; if client is in bed most of the time, have bottom face the side). Picture-frame the adhesive portion of the appliance with 1-inch tape.
            8. Put a few drops of deodorant in appliance if not odor-proof.
            9. Use clamp to fasten bottom of appliance.
            10. Talk to client (or communicate in best way possible during and after procedure). This is a very difficult alteration in body image.
            11. Use good hand-washing technique.
          4. Use deodorizing drops in appliance and provide adequate room ventilation to decrease odors. Caution: deodorizing drops must be safe for mucous membranes. No pinholes in pouch.
          5. If continent ileostomy (a Kock pouch) has been constructed, the client does not have to wear an external pouch. The stool is stored intra-abdominally. The client drains the pouch several times daily, when there is a feeling of fullness, using a catheter. The stoma is flat and on the right side of the abdomen.
        4. Goal: promote psychological comfort.
          1. Support client and family—accept feelings and behavior.
          2. Recognize that such a procedure may initiate the grieving process.
        5. Goal: health teaching.
          1. Self-care management skills related to ostomy appliance, skin care, and irrigation, if indicated (Table 6.26. Colostomy Irrigation).
          2. foodImageDiet: adjustments to control character of feces; avoid foods that increase flatulence.
          3. Signs of complications of infection, obstruction, or electrolyte imbalance.
          4. Community referral for follow-up care.
    4. Evaluation/outcome criteria:
      1. Demonstrates self-care skill for independent living.
      2. Makes dietary adjustments.
      3. Ostomy functions well.
      4. Adjusts to alteration in bowel elimination pattern.
  21. foodImageHEMORRHOIDS: enlarged vein/veins in mucous membrane of rectum. Hemorrhoids can be internal or external. Bleeding internal hemorrhoids can be painful and are best treated by: rubber band ligation, injection sclerotherapy, infrared coagulation, or surgery (scalpel, cautery, or laser). Laser surgery is usually done on an outpatient basis and causes minimal discomfort. High-fiber diets can minimize constipation and prevent hemorrhoids.
    1. Pathophysiology: venous congestion and interference with venous return from hemorrhoidal veins → increase in pelvic pressure, swelling, and distortion.
    2. Risk factors:
      1. Straining to expel constipated stool.
      2. Pregnancy.
      3. Intra-abdominal or pelvic masses.
      4. Interference with portal circulation.
      5. Prolonged standing or sitting.
      6. History of low-fiber, high-carbohydrate diet, which contributes to constipation.
      7. Family history of hemorrhoids.
      8. Enlarged prostate.
    3. Assessment:
      1. Subjective data: discomfort, anal pruritus, pain.
      2. Objective data:
        1. Bleeding, especially on defecation.
        2. Narrowing of stool.
        3. Grapelike clusters around anus (pink, red, or blue).
        4. Diagnostic test:
          1. Visualization for external hemorrhoids.
          2. Digital examination or proctoscopy for internal hemorrhoids.
    4. Analysis/nursing diagnosis:
      1. Pain related to defecation.
      2. Constipation related to dietary habits and pain at time of defecation.
      3. Knowledge deficit (learning need) related to foods to prevent constipation.
    5. Nursing care plan/implementation:
      1. Goal: reduce anal discomfort.
        1. Sitz baths, as ordered; perineal care to prevent infection.
        2. Hot or cold compresses as ordered to reduce inflammation and pruritus.
        3. pillImageTopical medications as ordered:
          1. Anti-inflammatory: hydrocortisone cream (Anusol).
          2. Astringents: witch hazel–impregnated pads.
          3. Topical anesthetics: pramoxine (Procto-Foam); dibucaine (Nupercainal).
        4. pillImageBulk laxatives: psyllium (Metamucil), Konsyl, polycarbophil (FiberCon).
      2. Goal: prevent complications related to surgery.
        1. Encourage postoperative ambulation.
        2. Pain relief until packing removed.
        3. Monitor for: bleeding, infection, pulmonary emboli, phlebitis.
        4. pillImageFacilitate bowel evacuation: stool softeners, laxatives, suppositories, oil enemas as ordered.
        5. Monitor for: syncope/vertigo during first postoperative bowel movement.
        6. foodImageDiet:
          1. Low residue (postoperative)—until healing has begun.
          2. High fiber to prevent constipation after healing.
        7. Increase fluid intake.
      3. Goal: health teaching—methods to avoid constipation.
    6. Evaluation/outcome criteria:
      1. No complications.
      2. Client has bowel movement.
      3. Incorporates knowledge of correct foods into lifestyle.