Nursing Care of Patients with Lower Gastrointestinal Disorders Chapter 34 Nursing Care of Patients with Lower Gastrointestinal Disorders

Lower Gastrointestinal System Small Intestines Large Intestines Rectum Anus

Constipation Fecal Mass Held In Rectum Feces Become Dry, Hard Many Causes Prevention: High-fiber Diet, Fluids, Exercise Obstipation

Constipation (cont’d) Signs and Symptoms Abdominal Pain Distention Indigestion Rectal Pressure Incomplete Emptying Headache Fatigue Decreased Appetite

Constipation (cont’d) Complications Impaction Ulcers Straining Megacolon Chronic Laxative Abuse – Fibrosis

Constipation (cont’d) Therapeutic Interventions High-fiber Diet, 2 to 3 L Fluid Daily Strengthen Abdominal Muscles Exercise Bulk-forming Agents Stool Softeners Education

Constipation (cont’d) Data Collection Establish Rapport History Auscultate Bowel Sounds Inspect/Palpate Abdomen

Constipation (cont’d) Nursing Diagnoses Constipation Anxiety Perceived Constipation Deficient Knowledge

Diarrhea Fecal Matter Passes Rapidly Decreased Absorption Causes Bacterial/Viral Infection Food Allergies Prevention

Diarrhea (cont’d) Signs And Symptoms Fever Foul Odor Abdominal Cramping Distention Anorexia Intestinal Rumbling

Diarrhea (cont’d) Therapeutic Interventions Identify Cause Replace Fluids/Electrolytes Increase Fiber/Bulk Diphenoxylate (Lomotil), Loperamide (Imodium) Lactinex Restores Normal Flora Antimicrobial Agents

Diarrhea (cont’d) Nursing Diagnoses Acute Pain Diarrhea Risk for Deficient Fluid Volume Risk for Infection Risk for Impaired Skin Integrity

Appendicitis Inflammation of the Appendix Fever, Nausea/Vomiting, Anorexia, Pain Right Lower Quadrant Increased White Blood Cells NPO, Surgery Postoperative Care

  McBurney’s Point

Peritonitis Inflammation/Infection of Peritoneal Cavity Signs and Symptoms Abdominal Pain Abdominal Rigidity Nausea/Vomiting Fever

Peritonitis (cont’d) Therapeutic Interventions NPO Fluid/Electrolyte Replacement Naso/Orogastric Tube Antibiotics Surgery Pain Control

Peritonitis (cont’d) Complications Intestinal Obstruction Hypovolemia Septicemia

Peritonitis (cont’d) Nursing Diagnoses Acute Pain Deficient Fluid Volume Imbalanced Nutrition: Less Than Body Requirements

Diverticulosis/Diverticulitis Diverticulum Outpouching of Bowel Mucous Membrane Diverticulosis Multiple Diverticula Diverticulitis Inflammation/Infection of Diverticulum

  Diverticulum

Diverticulosis/Diverticulitis (cont’d) Causes Chronic Constipation Decreased Intake of Dietary Fiber

Diverticulosis/Diverticulitis (cont’d) Therapeutic Interventions Prevent Constipation Intravenous Antibiotics Pain Control Surgery

Nursing Diagnoses: Inflammatory or Infectious Disorder Acute Pain Risk for Deficient Fluid Volume

Crohn’s Disease Inflammatory Bowel Disease Any Part of the Intestine Remissions and Exacerbations Cause Unknown Hereditary

Crohn’s Disease (cont’d) Signs and Symptoms Abdominal Pain or Cramping Weight Loss Diarrhea Fluid and Electrolyte Imbalance

Crohn’s Disease (cont’d) Complications Malnutrition Fissures Abscesses Fistulas

  Fistulas

Crohn’s Disease (cont’d) Diagnosis Laboratory Testing Endoscopy with Biopsy Ultrasound Multiphase CT Enterography Magnetic Resonance Enterography

Crohn’s Disease (cont’d) Therapeutic Interventions Medications Anti-inflammatories Antidiarrheal Antibiotics Biologics Corticosteriods Immunosuppressants

Crohn’s Disease (cont’d) Therapeutic Interventions (cont’d) Avoid Offending Foods Surgery if Necessary Elemental Formula or TPN if Required Support and Education

Ulcerative Colitis Inflammatory Bowel Disease Colon and Rectum Remissions and Exacerbations

Ulcerative Colitis (cont’d) Signs and Symptoms Abdominal Pain 5 to 20 Stools Daily Rectal Bleeding Fecal Urgency Anorexia Weight Loss Cramping Vomiting Fever Dehydration

Ulcerative Colitis (cont’d) Therapeutic Interventions Avoid Offending Foods Medications Anti-inflammatories Antidiarrheal Immunosuppressants Corticosteriods

Ulcerative Colitis (cont’d) Therapeutic Interventions (cont’d) Surgery if Necessary Elemental Formula or TPN if Required

Nursing Diagnoses: Inflammatory Bowel Disease Acute Pain Diarrhea Deficient Fluid Volume Anxiety Impaired Skin Integrity

Nursing Diagnoses: Inflammatory Bowel Disease (cont’d) Ineffective Nutrition: Less Than Body Requirements Ineffective Coping

Irritable Bowel Syndrome Altered Intestinal Motility/Increased Sensitivity to Visceral Sensations Bowel Mucosa Not Changed Psychological Stress/Food Intolerances More Common in Women

Irritable Bowel Syndrome (cont’d) Signs and Symptoms Gas Bloating Constipation Diarrhea Abdominal Pain Depression, Anxiety

Irritable Bowel Syndrome (cont’d) Diagnosis History Physical Examination

Irritable Bowel Syndrome (cont’d) Therapeutic Interventions High Fiber and Bran Diet Avoid Trigger Foods Smaller, Frequent Meals Stress Management

Irritable Bowel Syndrome (cont’d) Therapeutic Interventions (cont’d) Behavioral Therapy Exercise Medications

Irritable Bowel Syndrome (cont’d) Nursing Diagnoses Constipation Diarrhea Readiness for Enhanced Self-Health Management

Abdominal Hernias Pathophysiology Etiology Protrusion of Organ or Structure Through Weakness or Tear in Wall of Abdomen Etiology Weakness in Abdominal Wall with Increased Intra- abdominal Pressure

Abdominal Hernias (cont’d) Types Inguinal Umbilical Ventral (Incisional)

Types of Hernias

Abdominal Hernias (cont’d) Signs and Symptoms None Bulging Complications Strangulated Incarcerated Hernia

Abdominal Hernias (cont’d) Therapeutic Interventions None Observation Support Devices Surgery Herniorrhaphy Hernioplasty

Abdominal Hernias (cont’d) Nursing Care Education Postoperative No Coughing Activity

Absorption Disorders Inability to Absorb One or More Major Nutrients Types Celiac Disease Lactose Intolerance

Absorption Disorders (cont’d) General Signs and Symptoms Weight Loss Weakness General Malaise

Absorption Disorders (cont’d) Therapeutic Interventions Celiac Disease High-calorie, High-protein, Gluten-free Diet Lactose Intolerance Avoid Lactose Foods; Lactaid

Absorption Disorders (cont’d) Nursing Care Monitor Fluids, Electrolytes, Nutritional Status Daily Weight Intake and Output Education

Bowel Obstruction Flow of Intestinal Contents is Blocked Mechanical: Blockage Occurs Within the Intestine Non-mechanical: Peristalsis is Impaired Partial or Complete

Mechanical Bowel Obstructions

Bowel Obstruction (cont’d) Signs and Symptoms Abdominal Pain Blood and Mucus per Rectum Feces and Flatus Cease Fecal Vomiting May Occur Bowel Sounds High-pitched/Tinkling or Absent

Bowel Obstruction (cont’d) Signs and Symptoms Abdominal Distention Fluid/Electrolyte Imbalance

Bowel Obstruction (cont’d) Diagnosis Abdominal X-Ray CT Scan CBC and Electrolytes

Bowel Obstruction (cont’d) Therapeutic Interventions NPO Frequent Mouth Care Nasogastric Tube Fluid and Electrolyte Replacement

Bowel Obstruction (cont’d) Therapeutic Interventions (cont’d) Medications Antibiotics Anti-emetics Analgesics Surgery

Bowel Obstruction (cont’d) Nursing Diagnoses Acute Pain Deficient Fluid Volume Deficient Knowledge

Anorectal Problems Hemorrhoids Anal Fissures Anorectal Abscess

Anorectal Problems (cont’d) Nursing Care Postoperative Pain Control Sitz Baths Dressing Changes Stool Softeners

Lower Gastrointestinal Bleeding Causes Diverticulitis Polyps Anal Fissures Hemorrhoids Inflammatory Bowel Disease Cancer

Lower Gastrointestinal Bleeding Occult Blood, Melena, Bright Red Stools Treat Cause

Lower Gastrointestinal Bleeding (cont’d) Nursing Care Monitor Stools, Bleeding Vital Signs Diagnostic Prep

Colorectal Cancer Major Cause: Lack of Dietary Fiber Signs and Symptoms Change in Bowel Habits Blood or Mucus In Stools Abdominal or Rectal Pain Weight Loss Anemia Obstruction

Colorectal Cancer (cont’d) Major Cause: Lack of Dietary Fiber Signs and Symptoms Anemia Obstruction

Colorectal Cancer (cont’d) Diagnosis Colonoscopy with Biopsy Sigmoidoscopy with Biopsy Proctosigmoidoscopy CT Scan

Colorectal Cancer (cont’d) Diagnosis (cont’d) Abdominal and Rectal Examination Immunological Tests Fecal Occult Blood CEA

Colorectal Cancer (cont’d) Therapeutic Interventions Surgery Resection Abdominoperineal Resection Colostomy

Colorectal Cancer (cont’d) Therapeutic Interventions (cont’d) Radiation Chemotherapy Monoclonal Antibody Therapy Analgesics TPN as Necessary

Colorectal Cancer (cont’d) Nursing Diagnoses Acute Pain Anxiety Imbalanced Nutrition: Less Than Body Requirements

Colorectal Cancer (cont’d) Nursing Care Support and Education Postoperative Care

Ostomy Management Ostomy Stoma Surgically Created Opening Diverts Stool or Urine to Outside of Body Stoma Portion of Bowel Sutured onto Abdomen Abdominal Ostomies: Ileostomy, Colostomy, Urostomy

Ileostomy Terminal Ileum to Abdominal Wall After Total Colectomy

Ileostomy Types Conventional Ileostomy Continent Ileostomy Small Stoma Right Lower Quadrant Continuous Flow Liquid Effluent Continent Ileostomy Internal Reservoir with Nipple Valve Empty Reservoir 3 to 4 Times Daily

Continent Ileostomy

Ileostomy Types (cont’d) Ileoanal Anastomosis Ileorectal Anastomosis

Ileal–Anal Anastomosis J Pouch

  Types of Stomas

Colostomy Effluent Becomes Less Liquid and More Solid as Location of Ostomy Becomes More Distal in Colon Types End Stoma Proximal Bowel End Brought to Abdominal Wall Loop Stoma Loop of Bowel Outside Abdomen with Bridge Under it

Colostomy Types Double-barrel Stoma Temporary Ostomy Both Ends of Colon Outside Abdominal Wall, Form Two Stomas Proximal Stoma is Functioning Stoma Distal Stoma is Mucous Fistula

Preoperative Ostomy Care Wound Ostomy Continence Nurse Marks Site Emotional, Physical Support Teaching Bowel Prep Antibiotics

Nursing Diagnoses Deficient Knowledge Appliance Change Daily Care and Hygiene Dietary Considerations

Nursing Diagnoses (cont’d) Body Image Disturbance Sexual Dysfunction Ineffective Therapeutic Regimen Management

Nursing Diagnoses (cont’d) Risk for Injury Peristomal Skin Irritation Peristomal Hernia Stomal Prolapse Stomal Necrosis Ileostomy Blockage

Postoperative Ostomy Care Data Collection Vital Signs Stoma Pink to Red, Moist = Normal Bluish = Inadequate Blood Supply Black = Necrosis

Postoperative Ostomy Care (cont’d) Data Collection Skin Around Stoma Monitored for Irritation Stoma Shrinks Over Weeks Ostomy Care Appliance Change Teaching