ACUTE INFLAMMATORY
INTESTINAL DISORDERS
Any part of the lower GI tract is susceptible to acute inflammation
caused by bacterial, viral, or fungal infection.Two such conditions are appendicitis and diverticulitis,both of which may lead to peritonitis, an inflammation ofthe lining of the abdominal cavity.
Appendicitis
The appendix is a small, fingerlike appendage about 10 cm(4 in) long that is attached to the cecum just below the ileocecalvalve. The appendix fills with
food and empties regularlyinto the cecum. Because it empties inefficiently and itslumen is small, the appendix is prone to obstruction and isparticularly vulnerable to infection (ie, appendicitis).
, is the most common reasonfor emergency abdominal surgery. Although it can occur atany age, it more commonly occurs between the ages of 10and 30 years (NIH, 2007).
Pathophysiology
The appendix becomes inflamed and edematous as a result of becoming kinked or occluded by a fecalith (ie, hardened mass of stool), tumor, or foreign body. The inflammatoryprocess increases intraluminal pressure, initiating a progressively severe, generalized, or per umbilical pain that becomes localized to the right lower quadrant of the abdomen
within a few hours. Eventually, the inflamed appendix fillswith pus.
Clinical Manifestations
Vague epigastric or periumbilical pain (ie, visceral pain thatis dull and poorly localized) progresses to right lower quadrantpain (ie, parietal pain that is sharp, discrete, and welllocalized) and is usually accompanied by a low-grade feverand nausea and sometimes by vomiting. Loss of appetite iscommon. In up to 50% of presenting cases, local tenderness
is elicited at McBurney’s point when pressure is applied. Rebound tenderness (ie, production or intensificationof pain when pressure is released) may be present. The extent of tenderness and muscle spasm and the existenceof constipation or diarrhea depend not so much onthe severity of the appendiceal infection as on the locationof the appendix. If the appendix curls Pain on defecation suggests that the tipof the appendix is resting against the rectum; pain on urinationsuggests that the tip is near the bladder or impingeson the ureter. Some rigidity of the lower portion of the rightrectus muscle may occur. Rovsing’s sign may be elicited by
palpating the left lower quadrant; this paradoxically causeSpain to be felt in the right lower quadrant Ifthe appendix has ruptured, the pain becomes more diffuse;
abdominal distention develops as a result of paralytic ileus, and the patient’s condition worsens. Constipation can also occur with appendicitis. Laxatives administered in this instance may result in perforation of the inflamed appendix. In general, a laxative or cathartic
should never be given when a person has fever, nausea, and abdominal pain.
Assessment and Diagnostic Findings
Diagnosis is based on results of a complete physical examination
and on laboratory findings and imaging studies. Thecomplete blood cell count demonstrates an elevated whiteblood cell count with an elevation of the neutrophils. Abdominal
x-ray films, ultrasound studies, and CT scans mayreveal a right lower quadrant density or localized distentionof the bowel. A pregnancy test may be performed for women
of childbearing age to rule out ectopic pregnancy and beforex-rays are obtained. A diagnostic laparoscopy may be used torule out acute appendicitis in equivocal cases.
Complications
The major complication of appendicitis is perforation of the
appendix, which can lead to peritonitis, abscess formation
(collection of purulent material), or portal pylephlebitis,
which is septic thrombosis of the portal vein caused by vegetative
emboli that arise from septic intestines. Perforation
generally occurs 24 hours after the onset of pain. Symptoms
include a fever of 37.7_C (100_F) or greater, a toxic appearance,
and continued abdominal pain or tenderness.
Medical Management
Immediate surgery is typically indicated if appendicitis is diagnosed.
To correct or prevent fluid and electrolyte imbalance,dehydration, and sepsis, antibiotics and IV fluids are administered until surgery is performed. Appendectomy (ie surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation. It may be performed using general or spinal anesthesia with a low abdominal
incision (laparotomy) or by laparoscopy. Both laparotomy and laparoscopy are safe and effective in the treatment of appendicitis with perforation. However, recovery
after laparoscopic surgery is generally quicker. Consequently, laparoscopic appendectomy is more common. When perforation of the appendix occurs, an abscess may
form. If this occurs, the patient may be initially treated with antibiotics, and the surgeon may place a drain in the abscess. After the abscess is drained and there is no further evidence
of infection, an appendectomy is then typically performed.
Nursing Management
Goals include relieving pain, preventing fluid volume
deficit, reducing anxiety, eliminating infection due to the
potential or actual disruption of the GI tract, maintaining
skin integrity, and attaining optimal nutrition. The nurse prepares the patient for surgery, which includesan IV infusion to replace fluid loss and promote adequaterenal function and antibiotic therapy to prevent infection.If there is evidence or likelihood of paralytic ileus,a nasogastric tube is inserted. An enema is not administeredbecause it can lead to perforation. After surgery, the nurse places the patient in a semi sitting position.
1Gastric and Duodenal Ulcers
A peptic ulcer is an excavation (hollowed-out area) that forms in
the mucosal wall of the stomach, in the pylorus (opening between
stomach and duodenum), in the duodenum (first part of
small intestine), or in the esophagus. A peptic ulcer is frequently
referred to as a gastric, duodenal, or esophageal ulcer, depending
on its location, or as peptic ulcer disease. Erosion of a circumscribed
area of mucous membrane is the cause (Fig. 37-2).
Table 37-2 page 1015 differences between duodenal and gastric ulcer
Stress ulcer
is the term given to the acute mucosal ulceration of
the duodenal or gastric area that occurs after physiologically stressful
events, such as burns, shock, severe sepsis, and multiple organ
traumas.
Clinical Manifestations
Symptoms of an ulcer may last for a few days, weeks, or months
and may disappear only to reappear, often without an identifiable
cause. Many people have symptomless ulcers, and in 20% to 30%
perforation or hemorrhage may occur without any preceding
manifestations.
As a rule, the patient with an ulcer complains of dull, gnawing
pain or a burning sensation in the midepigastrium or in the
back. It is believed that the pain occurs when the increased acid
content of the stomach and duodenum erodes the lesion and
stimulates the exposed nerve endings. Another theory suggests
that contact of the lesion with acid stimulates a local reflex mechanism
that initiates contraction of the adjacent smooth muscle.
Pain is usually relieved by eating, because food neutralizes.
Sharply localizedtenderness can be elicited by applying gentle pressure to the
epigastrium at or slightly to the right of the midline.
Other symptoms include pyrosis(heartburn), vomiting, constipation
or diarrhea, and bleeding. Pyrosis is a burning sensation
in the esophagus and stomach that moves up to the mouth.
it may be a symptom of a peptic ulcer complication. It results
from obstruction of the pyloric orifice, thepassage of tarry stools.
Medical Management
Methods used include medications, lifestyle changes, and surgical
intervention.
Currently, the most commonly used therapy in the treatment of
ulcers is a combination of antibiotics, proton pump inhibitors,
and bismuth salts that suppresses or eradicates H. pylori; histamine
2 (H2) receptor antagonists and proton pump inhibitors are
used to treat NSAID-induced and other ulcers not associated
with H. pylori ulcers.
STRESS REDUCTION AND REST
Reducing environmental stress requires physical and psychological
modifications on the patient’s part as well as the aid and cooperation
of family members and significant others,
SMOKING CESSATION
Studies have shown that smoking decreases the secretion of bicarbonate
from the pancreas into the duodenum, resulting in increased
acidity of the duodenum.
DIETARY MODIFICATION
The intent of dietary modification for patients with peptic ulcers
is to avoid oversecretion of acid and hypermotility in the GI tract.
These can be minimized by avoiding extremes of temperature
and overstimulation from consumption of meat extracts, alcohol,
coffee (including decaffeinated coffee, which also stimulates acid
secretion) and other caffeinated beverages, and diets rich in milk
and cream (which stimulate acid secretion). In addition, an effort
is made to neutralize acid by eating three regular meals a day.
Small, frequent feedings are not necessary as long as an antacid or
a histamine blocker is taken. Diet compatibility becomes an individual
matter: the patient eats foods that can be tolerated and
avoids those that produce pain.
.
SURGICAL MANAGEMENT
The introduction of antibiotics to eradicate H. pylori and of H2
receptor antagonists as treatment for ulcers has greatly reduced the
need for surgical interventions. However, surgery is usually recommended
for patients with intractable ulcers (those that fail to heal
after 12 to 16 weeks of medical treatment
include vagotomy, with or without pyloroplasty, and the Billroth I
NURSING DIAGNOSES
Based on the assessment data, the patient’s nursing diagnoses may
include the following:
• Acute pain related to the effect of gastric acid secretion on
damaged tissue
• Anxiety related to coping with an acute disease
• Imbalanced nutrition related to changes in diet
• Deficient knowledge about prevention of symptoms and
management of the condition
Nursing Interventions
RELIEVING PAIN
Pain relief can be achieved with prescribed medications. The patient
should avoid aspirin, foods and beverages that contain caffeine, and
decaffeinated coffee, and meals should be eaten at regularly paced
intervals in a relaxed setting. Some patients benefit from learning
relaxation techniques to help manage stress and pain and to enhance
smoking cessation efforts.
REDUCING ANXIETY
The nurse assesses the patient’s level of anxiety. Patients with peptic
ulcers are usually anxious, but their anxiety is not always obvious.
Appropriate information is provided at the patient’s level of
understanding
MAINTAINING OPTIMAL NUTRITIONAL STATUS
The nurse assesses the patient for malnutrition and weight loss.
After recovery from an acute phase of peptic ulcer disease, the patient
is advised about the importance of complying with the medication
regimen and dietary restrictions
MONITORING AND MANAGING
POTENTIAL COMPLICATIONS
Hemorrhage
Perforation and Penetration
Perforation is the erosion of the ulcer through the gastric serosa
into the peritoneal cavity without warning
Pyloric Obstruction
Pyloric obstruction, also called gastric outlet obstruction (GOO),
occurs when the area distal to the pyloric sphincter becomes
scarred and stenosed from spasm or edema or from scar tissue