Chapter 46-Caring for Clients With Disorders of the Lower Gastrointestinal Tract

constipation

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

peristalsis and distention

what of the colon facilitates the signal to release stool?

gastrocolic reflex

which reflex facilitates stool passage by accelerating peristalsis?

constipation

-insufficient dietary fiber/water

-ignoring and resisting urge to defecate

-emotional stress

-use of drugs

-anatomical disorders (strictures, anal stenosis, anterior displacement of anus)

-chronic use of laxatives

-impaired GI motility

-systemic disorders

constipation

-bloated feeling

-abdomen may be tympanic or distended

-bowel sounds: hypoactive

-rectal fullness, pressure, pain when trying to eliminate stool

-rectal bleeding

-encopresis

scybala

stool may feel like small rocks

encopresis

passing of liquid stool around an obstructive stool mass

constipation

-treatment depends on history/physical exam

-barium enema

-defecography

-anorectal/colonic motility studies

defecography

a thick barium paste is inserted into the rectum

constipation

-enema

-laxative

-prophylactic administration of a stool softener

-fiber supplements

-stimulants

-lubricants

-stool softeners

-dietary management

diarrhea

is the frequent passage of larger than normal amounts liquid or semiliquid stool (more than 3 bowel mvmts per day)

diarrhea

-increased peristalsis

-can lead to dehydration, electrolyte imbalances, vitamin deficiencies

-malabsorption

-may be related to bacteria or virus

-lactose intolerance

-fructose intolerance

-food allergies

-artificial sweeteners

-uremia

-diverticulitis

-ulcerative colitis

-infection from bacterial, parasitic, or viral agents

-metabolic disorders

diarrhea

-watery and stools are frequent

-urgency (tenesmus)

-abdominal comfort

-hyperactive bowel sounds

-skin around anus may be excoriated

-fever may be present

tenesmus

urgency to move bowels

diarrhea

-stool culture

-colonoscopy

-upper GI series

diarrhea

-IV

-TPN

-antidiarrheal agents

-dietary adjustments

IBS

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

IBS

-cause is not understood

-fluctuating intestinal motility

IBS

-chronic constipation with sporadic diarrhea

-various degrees of abdominal pain that defecation may relieve

-belching

-flatulence

-no blood in stool

-stable weight

IBS

-barium enema

-colonoscopy

IBD

is a chronic illness characterized by exacerbations and remissions. Refers to several chronic digestive disorders believed to result from the immune system attacking the bowel

crohn's disease

also called regional enteritis. This chronic inflammatory condition can occur in any portion of the GI tract but predominantly affects the bowel in the terminal portion of the ileum

crohn's disease

-inflammation of the submucosal layer

-hyperemia, edema, ulcerations

-skip lesions

-bowel has cobble stone appearance

-fistula

-genetic predisposition

-allergy

-autoimmune

-stress

skip lesions

inflamed areas alternating with healthy tissue

fistula

inflammatory channels containing blood, mucus, pus, or stool may develop

crohn's disease

-abdominal pain

-distention

-tenderness in the lower abdominal quadrants especially on the right side

-growth failure in children

-chronic diarrhea and fatigue

-fever

-anorexia

-weight loss

-dehydration

-signs of nutritional deficiencies

-systemic manifestations

crohn's disease

-stool analysis

-CBC

-ESR elevated

-barium enema

-colonoscopy with biopsy

crohn's disease

-supportive treatment

-high fiber diet or low fiber diet

-elemental diet formula such as Tolerex, Vivonex, Peptamen

-TPN

-IV fluids

-drugs therapy involves supplementary vitamins, iron, antidiarrheal and antiperistaltic drugs, anti inflammatory, corticosteroids and 5-ASA, immune modulating agents, antibiotics

crohn's disease

-surgical treatment reserved for complications such as intestinal obstruction, perforation, fistula formation

-intestinal transplant

-total colectomy with permanent ileostomy

ulcerative colitis

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

ulcerative colitis

-exact cause unknown

-genetics

-infection

-allergy

-abnormal immune response

toxic megacolon

a complication in which the colon dilates and become atonic

ulcerative proctitis

when inflammation remains confined to the most distal area of the large intestine

pancolitis

occurs wen a client's entire colon is affected with ulcerative colitis and he or she experiences severe bouts of bloody diarrhea, pain, cramps, fatigue and weight loss

fulminant colitis

affecting the entire colon, is a progression of severity of the ulcerations, with severe pain, copious diarrhea, and potential dehydration and shock

ulcerative colitis

-severe diarrhea and expel blood and mucus along with fecal matter

-cramps

-abdominal pain in left lower quadrant accompany diarrhea

-eating precipitates cramping and diarrhea resulting in anorexia, dehydration and fatigue

-weight loss

ulcerative colitis

-barium enema

-colonoscopy

ulcerative colitis

-diet modifications

-TPN

-corticosteroids

-surgery if does not respond to medical treatment

appendicitis

is inflammation of the narrow, blind protrusion called the vermiform appendix laced at the tip of the cecum in the RLQ

appendicitis

-obstruction

-fecalith

-foreign body

-local edema

-tumor

-inflammation leading to a bacterial infection

fecalith

a hard fecal mass

appendicitis

-abdominal pain

-RLQ at McBurney's point, an area midway between the umbilicus and the right iliac crest

-rebound tenderness

-positive Rovsing's sign

-fever

-n/v

-abdominal tension and flexion of hip relieves discomfort

appendicitis

-elevated WBC

-CT scan

-abdominal ultrasound

appendicitis

-antibiotics

-NPO

-IV fluids

-appendectomy

peritonitis

the peritoneum, a serous sac lining the abdominal cavity, becomes inflamed.

peritonitis

-perforation of peptic ulcer, bowel, appendix, abdominal trauma, gunshot, knife wounds

-IBD

-ruptured ectopic pregnancy

-infection introduced during peritoneal dialysis

-spillage of chemical contents and bacteria

-ruptured internal organ

peritonitis

-severe abdominal pain, distention, tenderness, nausea, vomiting

-fever with infection

-lack of bowel motility

-abdomen feels ridged and boardlike as it distends with gas and intestinal contents

-bowel sound absent

-pulse elevated, respiration shallow and rapid

peritonitis

-wbc count

-abdominal xrays

-ct scan

-ultrasonography

peritonitis

-NPO

-NGT

-iv fluids

-electrolytes

-antibiotics

-analgesics

-antiemetics

-surgically close perforation

intestinal obstruction

occurs when a block interferes with the normal progression of intestinal contents through the intestinal tract

small bowel

where does intestinal obstruction often occur?

intestinal obstruction

-narrowing of the bowel lumen with or without a space occupying mass

-mass may include: tumor, adhesions, incarcerated or strangulated hernias, volvulus, intussusception

intestinal obstruction

-mechanical or functional

-adynamic: lacking peristalsis

intestinal obstruction

(UGI, mechanical)

-nausea

-abdominal distention

(Perforation)

-sudden sustain pain

-fever

-absent bowel sounds

(functional)

-absent bowel sounds

(lower GI mechanical

-signs of shock

(large bowel)

-constipation

-abdominal distention

-cramping

-fecal vomiting

intestinal obstruction

-KUB

-UGI

-Small bowel

-Barium enema xrays

intestinal obstruction

(functional)

-NPO

-NGT

-NIT

-IV fluids

-electrolytes

-antibiotics

(mechanical)

-surgery: bowel resection with anastomosis; ostomy

diverticula

are sacs or pouches caused by herniation of the intestine or other structure. Most commonly in sigmoid colon.

diverticulosis

asymptomatic diverticula

diverticulitis

when diverticula become inflamed

diverticula

-low intake of dietary fiber

-genetic predisposition

-weakness in the muscular coat associated with aging

-inflammation leading to abscesses

diverticula

-constipation

-alternating with diarrhea

-flatulence

-pain or tenderness in the LLQ

-fever

-rectal bleeding

-palpable mass

-maroon and currant jelly stools

diverticula

-barium enema

-colonoscopy

-CT scan

-CBC

-stool specimen

diverticula

-high fiber diet

-bulking formula agent

-NPO

-IV fluids

-avoid food containing seeds

-antibiotics

-bowel resection

-temporary colostomy

abdominal hernia

refers to the protrusion of any organ from the cavity that normally confines it, the term most commonly is used to describe the protrusion of the intestine through a defect in the abdominal wall

abdominal hernias

vulnerable areas:

-inguinal ring: the point on the abdominal wall where the inguinal canal begins

-femoral ring: at the abdominal opening of the femoral canal

-umbilicus

irreducible or incarcerated hernia

is one in which the intestine cannot be replaced in the abdominal cavity because of the edema of the protruding segment and constriction of the muscle opening through which it has emerged.

strangulated hernia

when the blood supply to the trapped segment of bowel can be cut off, leading to gangrene.

inguinal, umbilical, femoral, incisional

most common types of abdominal hernias?

hernias

develop when intra abdominal pressure increases, such as while straining to lift something heavy, having a bowel movement, or coughing or sneezing forcefully.

hernias

-swelling on the abdomen

-coughing or bearing down makes protrusion more obvious

-swelling may be painful

-protrusion leads to intestinal obstruction

hernia

-surgery

-may be required to wear a truss

-herniorrhapy

-hernioplasty

colon, rectal cancer

-develop from benign adenomas in the mucosal and submucosal intestinal layers

-benign polyp may become malignant

-genetics

-environmental

-lifestyle factors

-catalysts seem to include chronic bowel inflammation

-low fiber intake, high fat foods

colon, rectal cancer

-change in bowel habits such as alternating constipation and diarrhea

-occult or frank blood

-vague abdominal discomfort

-pain: late sign

colon, rectal cancer

-fecal occult blood test

-sigmoidoscopy

-barium enema

-colonoscopy

-digital rectal examination

-genetic screening

-elevated CEA marker

-CBC

colon, rectal cancer

-removal of polyps

-periodic radiographic and endoscopic examination

-surgical

-radiation therapy

-chemotherapy

-colectomy

-segmental resection

-abdominoperineal resection

-colostomy

hemorrhoids

are dilated veins outside or inside the anal sphincter

hemorrhoids

-chronic straining to have bowel movements or frequent defecation with chronic diarrhea likely weakens the tissue supporting the veins

-prolonged sitting

-pregnancy, prolonged labor, portal hypertension

hemorrhoids

-pain

-itching

-soreness or anal area

-small, reddish blue lumps are the edge of the anus

-internal bleeding: less likely to cause pain

-anemia

hemorrhoids

-anoscope

-procosimoidoscope

-colonoscopy

hemorrhoids

-hemorrhoidectomy

-warm soaks or sitz bath

-administer stool softeners, local anesthetics

-promote high fiber diet

-removal anal packing when ordered; assess postop site

-teaching to prevent recurrence

anorectal abscess

is an infection with a collection of pus in an area between the internal and external sphincters

anal fissure

is a linear tear in the anal canal tissue

anal fistula

is a tract that forms in the anal canal

pilonidal sinus

is an infection in the hair follicles in the sacrococcygeal area above the anus

pilonidal sinus

-deep intergluteal cleft

-abundant hair in the perianal and lower back regions

-inadequate personal hygiene

-obesity

-trauma to the area

pilonidal sinus

-pain and swelling at the base of the spine and purulent drainage

-dilated pits of the hair follicles in the sinus

pilonidal sinus