MED-SURG: Chapter 46...Caring for Clients with Disorders of the Lower Gastrointestinal Tract

Is a condition in which stool becomes dry, compact, and difficult and painful to pass

Constipation

Causes of constipation:

-ignoring urge

-low fiber diet

-medication

-laxative abuse

-change in routine

-diseases

Constipation S/S:

-feeling bloated

-distended abdomen

-dry hard stools

-passing liquid stool

Constipation TX:

-Fiber

-Increased fluids

-Exercise

-Treat cause

-Quick relief

-Enema/Laxative

-Prophylactic

-Stool softeners

Is the frequent passage of larger than normal amounts of liquid or semi liquid stool

Diarrhea

Diarrhea may be related to:

-bacterial or viral infections affecting the intestine

-lactose intolerance

-fructose intolerance

-food allergies

-toxin producing organisms

-disease

Diarrhea S/S:

-watery

-frequent stools with blood/mucus

-urgency

-hyperactive B/S

-abdominal pain

-possible fever

-anal excoriation

Diarrhea DX:

-Stool cultures

-O&P(3)

-Hemoccult

-UGI/Colonoscopy

Diarrhea TX:

-Rest bowel

-Clear liquid or BRAT diet with advance as tolerance

-Fluid & electrolyte replacement

-Antidiarrheal if not caused by organism

-Dietary changes

-Severe/Prolonged - TPN

Depletes bowel of good organisms, so need to replace with probiotics

Chronic diarrhea

Also known as spastic bowel, is a functional motility disorder primarily affecting the colon.

IBS

Believed to affect function of nerves & muscles.

IBS

No inflammation. It refers to a cluster of symptoms that occur despite the absence of an identifiable disease process.

IBS

Other factors may be involved with IBS:

Food or hormonal cause

IBS S/S:

-Chronic constipation & diarrhea

-Abdomen pain relieved with defecation

-Belching

-Flatulence

-May have anxiety, stress, depression

-"NO"weight loss or blood in stools

IBS TX:

-Dietary changes to decrease gas

-High fiber diet

-Anti diarrheal

-Effective coping skills for stress

-Treatment for depression

-Dicyclomine for spasms

Chronic illness characterized by exacerbations and remissions

IBD

IBD:

-thought due to immune system attacking the bowel

-More common in young adults

2 MOST common Inflammatory Bowel Disease

1. Crohns

2. Ulcerative colitis

This chronic inflammatory condition can occur in any portion of the GI tract but affects the bowel in the terminal portion of the ileum

Crohn's disease

Inflammation occurs in all layers but submucosal layer is most involved

Crohn's

Facts about Crohns

-skip lesions

-fistulas

-cause unknown

-?genetics

-exaggerated immune response

?stress

Crohn's S/S

-Insiduous onset

-Pain with eating

-abdominal pain, tenderness, distention

-chronic diarrhea

-fatigue

-fever

-weight loss

-nutritional deficiency

-Spontaneous remission

Crohn's S/S outside GI tract

-Arthritis

-Arthralgia

-Eye inflammation

-Skin lesions

-Liver & GB problems

Crohn's DX:

-Barium enema shows inflammation of large intestine

-Confirmation with endoscopy & biopsy

Crohn's TX:

-supportive

-high fiber diet when bulk needed for stools

-low fiber when inflammation

-high calorie & high protein diet

-IV fluids/TPN

-electrolytes

Vivonex -have put disease in remission

Drugs used for Crohn's

-vitamin & iron

-Antidiarrheal

-antispasmodics

-short term corticosteroids

The chronic inflammation usually is limited to the mucosal and submucosal layers of the colon

Ulcerative Colitis

Ulcerative Colitis:

-exact cause unknown

-chronic inflammation of mucous

The disease is MOST common in young and middle aged adults but can occur at any age

Ulcerative Colitis

Some clients experience prolonged remission, whereas others experience mild to severe (and potentially life threatening) exacerbations of symptoms

Ulcerative Colitis

Risk factors that may trigger Ulcerative Colitis:

-genetic predisposition

-infection

-allergy

-stress

-emotional tension

-abnormal immune response

Inflammation often begins in rectum & extends proximally

Ulcerative Colitis

Unlike Crohn's - No healthy tissue between inflamed areas

Ulcerative Colitis

Ulcerative Colitis:

-muscle layer may inflame

-abscess

Toxic megacolon, which can rupture and cause peritonitis

Ulcerative Colitis

S/S of Ulcerative Colitis:

-Often abrupt onset

-Severe diarrhea with blood/mucus

-Cramps/Abdomen pain LLQ

-Eating makes worse

-Urge to defecate strong & often are incontinent

-Incontinence may occur at HS

-Very little stool expelled (10-20 stools/day)

Ulcerative Colitis DX:

-Colonoscopy with BX

-Not done if mega colon due to danger of perforation

Ulcerative Colitis TX:

-Remission is the goal

-Controversial low residue diet during exac

-TPN to rest bowel

-Same meds used to treat Crohn's

-Surgery if no response to above

Colon is removed and rectal pouch made from rectal mucosa.

1st stage surgery for Ulcerative Colitis

Ileostomy closed, Intestine is connected to rectum

2nd stage surgery for Ulcerative Colitis

Is an inflammation of the "vermiform appendix" located at tip of cecum in RLQ

Appendicitis

Common in adolescence & young adults

Appendicitis

Fills with food and empties digested material regularly

Appendix

Inflammation begins when the opening of the appendix narrows or becomes obstructed:

Appendicitis

Can not empty & it enlarges and swells

Appendix

Gangrenous and possible rupture - peritonitis

Appendix

Appendicitis S/S:

-At first, the pain is generalized throughout the abdomen

-Pain localizes in the RLQ at McBurney's Point

-Rebound tenderness

-Fever - low grade

-N/V

Appendicitis facts:

-Perforation - often occurs 24 hours after onset of pain

-Pain becomes more diffuse

-Distention

-Paralytic ileus

-Leukocytosis

-CT scan or Ultrasound shows enlarged cecum

Management of Appendicitis:

-NPO

-Antibiotics

-IV line

-NO analgesia

A serous sac lining the abdominal cavity, becomes inflamed

Peritonitis

Peritonitis causes:

-Perforation of peptic ulcer

-Bowel

-Appendix

-Abdominal trauma (gunshot, knife wounds)

-Ectopic pregnancy rupture

-Peritoneal dialysis

At first the GI track is hypermotil then _____________ occurs

Paralytic ileus

Shock can occur - Hypovolemic/Septic - Death can occur

Peritonitis

Peritonitis S/S:

-Severe abdominal pain

-Distention

-Tenderness

-N/V

-Fever

-Rigid hard abdomen

-Absence of bowel sounds

Peritonitis DX:

WBC increases

-XRay shows air/fluid in the peritoneum

Peritonitis TX:

-NG tube

-IV with electrolytes

-Large doses of IV antibiotics

-Demerol/MS

-Surgery to close perforation

Nursing Care of Peritonitis:

-Monitor IV

-Administer antibiotics

-N/G suction

-Monitor vital signs

-Catheter

-Postop abdomen surgery care

-Monitor & treat pain

-Assess s/s of WD infection

-Semi fowler's position for comfort

Occurs when a blockage interferes with the normal progression of intestinal contents through the intestinal tract

Intestinal Obstruction

More common in small intestine

Intestinal Obstruction

Intestinal Obstruction causes:

-mechanical

-functional

-lack of peristalsis

**can have a partial or complete blockage

Intestinal obstruction S/S

-similar in both small and large

-nausea

-abdominal distention

-if higher up in tract may vomit bile or fecal material

-lower may not have vomiting

-may have a bowel movement??

-May/May not have BS

-Pulse & Resp increase - B/P decrease

-Higher the obstruction the quicker the S/S

Intestinal obstruction DX:

-XRay shows collection of air/fluid in affected intestine

Intestinal obstruction TX:

-NPO

-IV fluids

-Possible antibiotics

-Intestinal decompression(put tube in to remove contents)

Mechanical causes often require

-Surgery

-Bowel resection & anastomosis

-May need colostomy temporary/permanent

Are sacs or pouches caused by herniation of the mucosa through a weakened portion of the muscular coat of the intestine or other structure

Diverticular Disorders

Commonly occur in colon

Diverticular Disorders

Asymptomatic diverticula are called:

Diverticulosis

When the diverticula become inflamed, the term ______ is used

Diverticulitis

Become inflamed when fecal material is trapped in one or more blind pouchesCau

Diverticula

Diverticulosis/itis:

-Inflammation of these areas is called diverticulitis

-Low fiber diet increases risk

-congenital predisposition

-Occurs normally with aging

Abscesses may form & rupture or cause fistula

Diverticulosis/itis:

Causes swelling & inflammation

Diverticulosis/itis:

May lead to intestinal obstruction

Diverticulosis/itis:

Diverticulosis/itis: S/S

-Constipation alternating with diarrhea

-Change in bowel habits

-Pain & tenderness in LLQ

-Flatulence

-Fever

-Rectal bleeding

-Possible palpation of mass in low abdomen

-Currant Jelly Stools

Diverticulosis/itis: DX

-Barium Enema

-Colonoscopy

Diverticulosis/itis:

Often CT is best because doesn't require as much preparation

Diverticulosis/itis: TX

-None unless inflammation

-Diverticular diet

-High fiber diet

-If inflammation - Then low residual diet till decreases

-Severe inflammation-NPO for a few days with IV's

-Antibiotics

Very similar to low fiber diet but with limited amount of milk and milk products and prune juice

Low Residue Diet

Helps to slow transit time of food thru GI tract

Low Residue Diet

Refers to the protrusion of any organ from the cavity that normally confines it

Abdominal hernia

Areas in the abdominal wall are weaker than other areas and more vulnerable to the development of a

Hernia

Weak areas

-inguinal ring

-femoral ring

-umbilicus

Types of hernia's

-reducible

-irreducible/incarcerated

-strangulated

Most common area for a hernia

inguinal

If the protruding structures can be replaced in the abdominal cavity

Reducible hernia

Is one in which the intestine cannot be replaced in the abdominal cavity

Irreducible or incarcerated hernia

Causes for abdominal hernia

-increased intra abdominal pressure

-lifting

-coughing

-straining with bowel movements

Abdominal hernia S/S:

-Initially swelling of abdomen

-coughs or bears down protrusion becomes worse

-possible pain but reducing it relieves pain

-severe pain occurs wen becomes incarcerated

Abdominal hernia TX:

-Due to fact that hernias continue to enlarge, surgery eventually needed

-Hernia truss

-Self reduction

Surgical repair of a hernia, is the recommended treatment

Herniorrhaphy

Intestine is put back in & abdominal wall repaired

Herniorrhaphy

Weakened area is reinforced with wire, fascia, or mesh

Hernioplasty

Is an emergency situation - surgery quickly to prevent intestine from dying

Strangulation of a hernia

Hernioplasty Post-Op

-Avoid strenuous activity & lifting/coughing

-watch for scrotal edema in male

Cancer of Colon/Rectum:

-Colon Cancer 3rd most common cancer in males/females

-50 > colonscopy every 5-10 years

-Occult blood testing every 1-2 years

-Common metastisis to liver & lungs

Cancer of colon risk factors:

-Low fiber/high fat diet

-chronic bowel inflammation

-Blood relative DX with this

Cancer of Colon: S/S

-Change in bowel habits

-Blood in stool

-Vague abdomen discomfort

-Abdominal distention

Cancer of Colon DX:

-Tissue biopsy

-elevated CEA

-Suggest tumor often not detected in early stage

Cancer of Colon: TX

-Preventive is the best

-colonoscopy if polyps then removed

-tumor is encapsulated just remove tumor

-If not colectomy with segmental resection

-Colostomy may be needed