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 Hard, dry, infrequent stools that are passed with difficulty

Constipation Causes Frequently ignoring the urge to defecate Frequent use of laxatives or enemas Inactivity Inadequate water intake Diet low in fiber and high in cheese, lean meat, pasta Drugs that slow intestinal motility/increase urine output Diseases of the colon or rectum, as well as brain or spinal cord injury; abdominal surgery

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 Complications Valsalva maneuver The rapid changes in blood flow can be fatal to a patient with heart disease Hemorrhoids Fecal impaction Medical treatment Laxatives, suppositories, enemas, or combination for prompt results Stool softeners

Constipation (cont’d) Therapeutic Interventions High-fiber Diet, 2 to 3 L Fluid Daily Strengthen Abdominal Muscles Exercise Bulk-forming Agents Stool Softeners Education Interventions Maintained with diet, fluids, exercise, and regular toilet habits Megacolon Regular enemas for bowel cleansing Fecal impaction Assess for impaction by inserting a gloved, lubricated finger into the rectum Remove impaction following agency protocol or specific physician’s orders

Constipation (cont’d) Data Collection Establish Rapport History Auscultate Bowel Sounds Inspect/Palpate Abdomen Constipation Assessment Usual pattern of bowel elimination, including frequency, amount, color, unusual contents, and pain associated with defecation Information about diet, exercise, and drug therapy Any aids to elimination; type and frequency of use Examine abdomen for distention or visible peristalsis Auscultate for bowel sounds in all four quadrants of the 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 The passage of loose, liquid stools with increased frequency May have cramps, abdominal pain, and a feeling of urgency before bowel movements Causes Spoiled foods, allergies, infections, diverticulosis, malabsorption, cancer, stress, fecal impactions, and tube feedings Adverse effect of some medications Complications Dehydration, electrolyte imbalances, and metabolic acidosis Malnutrition and anemia

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

Diarrhea Assessment Diarrhea and onset, severity, precipitating factors, and measures that bring relief Ask about stool characteristics, including amount, color, odor, and unusual contents, such as blood, mucus, or undigested food Functional assessment focuses on usual diet, dietary changes, recent and current medications, recent travel to a foreign country

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

Diarrhea (cont’d) Therapeutic Interventions Identify Cause Replace Fluids/Electrolytes Increase Fiber/Bulk Diphenoxylate (Lomotil), Loperamide (Imodium) Lactinex Restores Normal Flora Antimicrobial Agents Medical treatment Acute diarrhea usually treated by resting the digestive tract and giving antidiarrheal drugs Severe, persistent diarrhea may require TPN Interventions Deficient Fluid Volume and Imbalanced Nutrition: Less Than Body Requirements Impaired Skin Integrity Pain Self-Care Deficit

Appendicitis Inflammation of the Appendix Fever, Nausea/Vomiting, Anorexia, Pain Right Lower Quadrant Increased White Blood Cells NPO, Surgery Postoperative Care Pathophysiology Inflammation of the appendix A ruptured appendix allows digestive contents to enter the abdominal cavity, causing peritonitis

Appendicitis Signs and symptoms Pain at McBurney’s point, midway between the umbilicus and the iliac crest Temperature elevation, nausea, and vomiting Elevated WBC count (10,000-15,000/mm3 ) Peritonitis: absence of bowel sounds, severe abdominal distention, increased pulse and temperature, nausea/vomiting; rigid abdomen

  McBurney’s Point

Appendicitis Medical treatment Nothing by mouth A cold pack to the abdomen may be ordered Laxatives and heat applications should never be used for undiagnosed abdominal pain Immediate surgical treatment indicated Ruptured appendix: surgery may be delayed 6-8 hours while antibiotics and IV fluids given

Appendicitis Assessment Location, severity, onset, duration, precipitating factors, and alleviating measures in relation to the pain Previous abdominal distress, chronic illnesses, surgeries; record allergies and medications Temperature; abdominal pain, distention, and tenderness; presence and characteristics of bowel sounds

Appendicitis Preoperative interventions Semi-Fowler or side-lying position with the hips flexed Until physician determines the diagnosis, analgesics may be withheld If rupture suspected, elevate patient’s head to localize the infection

Appendicitis Postoperative interventions Administer antibiotics, intravenous fluids, and possibly gastrointestinal decompression Assist the patient in turning, coughing, and deep breathing; incentive spirometry Splint the incision during deep breathing Early ambulation Assess abdominal wound for redness, swelling, and foul drainage Wound care as ordered or according to agency policy

Peritonitis Inflammation/Infection of Peritoneal Cavity Signs and Symptoms Abdominal Pain Abdominal Rigidity Nausea/Vomiting Fever Pathophysiology Inflammation of peritoneum caused by chemical or bacterial contamination of the peritoneal cavity Signs and symptoms Pain over affected area, rebound tenderness, abdominal rigidity and distention, fever, tachycardia, tachypnea, nausea, and vomiting

Peritonitis Assessment Onset, location, and severity of the pain and any related symptoms Record a history of abdominal trauma, including surgery Take and record vital signs Inspect abdomen for distention and auscultate for the presence of bowel sounds

Peritonitis (cont’d) Therapeutic Interventions NPO Fluid/Electrolyte Replacement Naso/Orogastric Tube Antibiotics Surgery Pain Control Medical treatment Gastrointestinal decompression, intravenous fluids, antibiotics, and analgesics Surgery to close a ruptured structure and remove foreign material and fluid from the peritoneal cavity Interventions Acute Pain Decreased Cardiac Output Imbalanced Nutrition: Less Than Body Requirements Anxiety

Peritonitis (cont’d) Complications Intestinal Obstruction Hypovolemia Septicemia

Peritonitis (cont’d) Nursing Diagnoses Acute Pain Deficient Fluid Volume Imbalanced Nutrition: Less Than Body Requirements Medical diagnosis History and physical Complete blood cell count, serum electrolyte measurements, abdominal radiography, computed tomography, and ultrasound Paracentesis

Diverticulosis/Diverticulitis Diverticulum Outpouching of Bowel Mucous Membrane Diverticulosis Multiple Diverticula Diverticulitis Inflammation/Infection of Diverticulum Diverticulosis Pathophysiology Small saclike pouches in intestinal wall: diverticula Weak areas of the intestinal wall allow segments of the mucous membrane to herniate outward Risk factors Lack of dietary residue Age, constipation, obesity, emotional tension

  Diverticulum

Diverticulosis

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

Diverticulosis Signs and symptoms Often asymptomatic, but many people report constipation, diarrhea, or periodic bouts of each Rectal bleeding, pain in left lower abdomen, nausea and vomiting, and urinary problems

Diverticulosis Complications Medical diagnosis Diverticulitis Symptoms Bleeding, obstruction, perforation (rupture), peritonitis, and fistula formation Medical diagnosis Symptoms Abdominal CT and barium enema examination

Diverticulosis/Diverticulitis (cont’d) Therapeutic Interventions Prevent Constipation Intravenous Antibiotics Pain Control Surgery Medical treatment High-residue diet without spicy foods Stool softeners or bulk-forming laxatives; antidiarrheals; broad-spectrum antibiotics; anticholinergics Surgical intervention may be necessary Interventions Fluids as permitted; monitor intake and output Antiemetics, analgesics, anticholinergics as ordered Be alert for signs of perforation Teach patient about diverticulosis, including the pathophysiology, treatment, and symptoms of inflammation

Diverticulosis Medical treatment High-residue diet without spicy foods Stool softeners or bulk-forming laxatives; antidiarrheals; broad-spectrum antibiotics; anticholinergics Surgical intervention may be necessary

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 Inflammatory Bowel Disease Pathophysiology Ulcerative colitis and Crohn’s disease Inflammation and ulceration of intestinal tract lining Exact cause is unknown Possible causes: infectious agents, autoimmune reactions, allergies, heredity, and foreign substances

Crohn’s Disease (cont’d) Signs and Symptoms Abdominal Pain or Cramping Weight Loss Diarrhea Fluid and Electrolyte Imbalance Signs and symptoms Ulcerative colitis Diarrhea with frequent bloody stools, abdominal cramping Crohn’s disease If the stomach and duodenum are involved, symptoms include nausea, vomiting, and epigastric pain Involvement of the small intestine produces pain and abdominal tenderness and cramping An inflamed colon typically causes abdominal pain, cramping, rectal bleeding, and diarrhea Systemic signs and symptoms include fever, night sweats, malaise, and joint pain

Crohn’s Disease (cont’d) Complications Malnutrition Fissures Abscesses Fistulas Complications Hemorrhage, obstruction, perforation (rupture), abscesses in the anus or rectum, fistulas, and megacolon

  Fistulas

Inflammatory Bowel Disease Medical diagnosis History and physical examination Abdominal radiography Barium enema examination with air contrast; colonoscopy with biopsy, ultrasonography, CT, and cell studies Video capsule Medical treatment Drug therapy, diet, and rest

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

Inflammatory Bowel Disease Assessment Onset, location, severity, and duration of pain Note factors that contribute to the onset of pain Onset and duration of diarrhea; presence of blood Vital signs, height and weight, measures of hydration Inspect perianal area for irritation or ulceration Maintain accurate intake and output records Measure diarrhea stools if possible and count as output

Ulcerative Colitis (cont’d) Therapeutic Interventions Avoid Offending Foods Medications Anti-inflammatories Antidiarrheal Immunosuppressants Corticosteriods Interventions Acute Pain Diarrhea Deficient Fluid Volume Imbalanced Nutrition: Less Than Body Requirements Ineffective Coping Risk for Injury

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 Pathophysiology Weakness in the abdominal wall that allows a portion of the large intestine to push through Weak locations include the umbilicus and the lower inguinal areas of the abdomen; may also develop at the site of a surgical incision Classified as reducible or irreducible

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

Types of Hernias

Abdominal Hernia Assessment Chief complaint Ask about pain and vomiting Inspect for abnormalities, and listen for bowel sounds in all four abdominal quadrants

Abdominal Hernias (cont’d) Signs and Symptoms None Bulging Complications Strangulated Incarcerated Hernia Signs and symptoms A smooth lump on the abdomen With incarceration, the patient has severe abdominal pain and distention, vomiting, and cramps

Abdominal Hernias (cont’d) Therapeutic Interventions None Observation Support Devices Surgery Herniorrhaphy Hernioplasty Medical diagnosis Health history and physical examination Medical treatment Surgical repair Herniorrhaphy Hernioplasty

Abdominal Hernias (cont’d) Nursing Care Education Postoperative No Coughing Activity Preoperative interventions Risk for Injury Impaired Skin Integrity Postoperative interventions Impaired Urinary Elimination Constipation Acute Pain

Absorption Disorders Inability to Absorb One or More Major Nutrients Types Celiac Disease Lactose Intolerance Malabsorption One or more nutrients are not digested or absorbed Many causes: bacteria, deficiencies of bile salts or digestive enzymes, alterations in the intestinal mucosa, and absence of all or part of the stomach or intestines

Absorption Disorders (cont’d) General Signs and Symptoms Weight Loss Weakness General Malaise Malabsorption Signs and symptoms Steatorrhea Weight loss, fatigue, decreased libido, easy bruising, edema, anemia, and bone pain Bloating, cramping, abdominal cramps, and diarrhea are symptoms of lactase deficiency

Malabsorption Medical diagnosis Sprue: based on laboratory studies, endoscopy with biopsy, and radiologic imaging studies Lactase deficiency: based on the health history, the lactose tolerance test, a breath test for abnormal hydrogen levels, and if necessary, biopsy of the intestinal

Malabsorption Medical treatment Sprue: diet and drug therapy; foods that aggravate symptoms eliminated from the diet Celiac disease: avoid products that contain gluten Tropical sprue: antibiotics, oral folate, and vitamin B12 injections Lactase deficiency: eliminate milk and milk products

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 Malabsorption Nursing care Document the patient’s symptoms Note stool characteristics In the case of celiac sprue, teach the patient how to eliminate gluten from the diet Give antibiotics as ordered for tropical sprue If folic acid therapy continued, instruct patient in self-medication The effect of therapy is evaluated by the return of normal stool consistency Advise the patient with lactase deficiency of dietary restrictions and alternative products

Bowel Obstruction Flow of Intestinal Contents is Blocked Mechanical: Blockage Occurs Within the Intestine Non-mechanical: Peristalsis is Impaired Partial or Complete Intestinal Obstruction Causes Strangulated hernia, tumor, paralytic ileus, stricture, volvulus (twisting of the bowel), intussusception (telescoping of the bowel into itself), and postoperative adhesions Signs and symptoms Vomiting (possibly projectile), abdominal pain, and constipation Blood or purulent drainage passed rectally Abdominal distention, especially with colon obstruction

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 Complications Fluid and electrolyte imbalances and metabolic alkalosis Gangrene and perforation of the bowel

Intestinal Obstruction Assessment Symptoms, including pain and nausea Onset and progression of symptoms Hernia, cancer of the digestive tract, and abdominal surgeries Ask when the patient’s last bowel movement was and if the characteristics were normal

Bowel Obstruction (cont’d) Diagnosis Abdominal X-Ray CT Scan CBC and Electrolytes Intestinal Obstruction Medical diagnosis History, physical examination, and laboratory studies; confirmed by radiologic studies Medical treatment Gastrointestinal decompression; intravenous fluids; and surgical intervention

Bowel Obstruction (cont’d) Therapeutic Interventions NPO Frequent Mouth Care Nasogastric Tube Fluid and Electrolyte Replacement Interventions Acute Pain Deficient Fluid Volume Risk for Infection Ineffective Breathing Pattern Anxiety

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 (black tarry stools), Bright Red Stools (hematochezia) Treat Cause

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

Colorectal Cancer Pathophysiology Cancer of the large intestine People at greater risk for colorectal cancer are those with histories of inflammatory bowel disease, or family histories of colorectal cancer or multiple intestinal polyps High-fat, low-fiber diet and inadequate intake of fruits and vegetables also contribute to development Can develop anywhere in the large intestine Three fourths of all colorectal cancers are located in the rectum or lower sigmoid colon

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

Colon Cancer

Colorectal Cancer (cont’d) Major Cause: Lack of Dietary Fiber Signs and Symptoms Anemia Obstruction Signs and symptoms Right side of the abdomen Vague cramping until the disease is advanced Unexplained anemia, weakness, and fatigue related to blood loss may be the only early symptoms Left side or in the rectum Diarrhea or constipation and may notice blood in the stool Stools may become very narrow, causing them to be described as pencil-like Feeling of fullness or pressure in the abdomen or rectum

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

Figure 38-21

Colorectal Cancer (cont’d) Therapeutic Interventions Surgery Resection Abdominoperineal Resection Colostomy Medical and surgical treatment Usually treated surgically Combination chemotherapy postoperatively if tumor extends through the bowel wall or if lymph nodes involved Early stage rectal cancer sometimes treated with radiation and surgery

Colorectal Cancer Nursing Assessment Post-op Vital signs, intake and output, breath sounds, bowel sounds, and pain Appearance of wounds and wound drainage If there is a colostomy, measure and describe the fecal drainage

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 Interventions Risk for Injury Ineffective Tissue Perfusion Acute Pain Sexual Dysfunction Ineffective Coping

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