Chapter 48

Concepts of Care for Patients with Noninflammatory Intestinal Conditions

Lower Gastrointestinal System

  • Small Intestine

    • Jejunum:

    • Function: Absorbs sugars, amino acids, and fatty acids.

    • Ileum:

    • Function: Absorbs any remaining nutrients, particularly Vitamin B12 and bile acids for reuse by the body.

  • Large Intestine:

    • Functions:

    • Absorbs water and salts into the body.

    • Synthesizes and absorbs vitamins, including niacin, vitamin B1, and vitamin K.

    • Solidifies indigestible waste into formed stool and holds feces until ready for elimination.

  • Rectum and Anus:

    • Conclude the lower gastrointestinal tract, involved in the elimination process.

Concepts

  • Priority Concepts in Chapter 48:

    • Elimination

  • Interrelated Concepts:

    • Pain

    • Fluid and Electrolyte Balance

Did you know?

  • Small bowel obstruction is one of the most common surgical emergencies in Western countries.

  • Approximately 75% of clients admitted to acute care settings may have a small bowel obstruction, often due to intra-abdominal adhesions from previous surgeries.

  • Other causes include inflammatory bowel disease and cancer.

  • Obstructions can occur from:

    • Constriction due to adhesions or scarring.

    • Blockages from tumors or masses.

    • Impacted feces.

    • Hernias or strictures related to Crohn's disease, ulcerative colitis, or diverticulitis.

Elimination Concept Exemplar: Intestinal Obstruction

  • Definition: Obstruction occurs when intestinal contents cannot pass through the gastrointestinal (GI) tract.

    • Types of Obstruction:

    • Partial: Allows fluid and gas to pass; typically responds well to conservative treatment.

    • Complete: Fully blockades the lumen; generally necessitates surgical intervention.

    • Simple vs. Strangulated:

    • Simple: Intact blood supply.

    • Strangulated: Compromised blood supply.

    • Mechanical vs. Nonmechanical:

    • Mechanical: Physical obstruction (e.g., tumors, hernias).

    • Nonmechanical: Reduced or absent peristalsis.

Complications of Obstruction

  • Nonmechanical Intestinal Obstruction Types:

    • Paralytic ileus:

    • Characterized by lack of intestinal peristalsis and bowel sounds.

    • Common post-surgery, also caused by peritonitis, inflammatory responses, electrolyte abnormalities, or spinal fractures.

    • Pseudo-obstruction:

    • Mechanical obstruction with no identifiable cause visible on x-ray.

    • Vascular obstruction:

    • Rare, occurs when blood supply to the intestine (e.g., mesenteric ischemia or emboli) is disrupted.

Intestinal Obstruction: Symptoms

  • What to Expect from Intussusception:

    • Symptoms such as decrease in pulse, singultus (hiccups), frequent bloody stools, or extremely elevated body temperature.

  • Intussusception Defined: Telescoping of the intestine within itself.

  • Singultus: Common symptom associated with all types of intestinal obstruction, linked to intraabdominal pressure affecting the phrenic nerve.

Mechanical Obstruction Types

  • Mechanical obstruction types depicted:

    • Intussusception: Bowel telescoping.

    • Volvulus: 180-degree twisting of the bowel.

Intestinal Obstruction: Pathophysiology and Etiology

  • Pathophysiology Overview:

    • Contents accumulate proximal to the obstruction.

    • Distal bowel collapses and empties; leading to increased capillary permeability, fluid and electrolyte extravasation into the peritoneal cavity.

    • Exhaustion of intestinal muscles leads to peristalsis failure.

    • Retention of fluids results in decreased circulating blood volume, hypotension, and shock.

    • Risk of intestinal infarction; potential necrosis may result from inadequate blood flow leading to infection or septic shock.

  • Etiology:

    • Mechanical Causes: Adhesions, tumors, appendicitis complications, hernias, fecal impactions, strictures, intussusception, volvulus, fibrosis.

    • Nonmechanical Causes: Handling of intestines during surgeries.

Intestinal Obstruction: Incidence and Prevalence

  • Often not well documented; common in:

    • Patients with a history of bowel surgery or intestinal tumors.

    • Older adults exhibit a higher likelihood of bowel obstructions.

Clinical Presentation of Bowel Obstruction

  • Common symptoms include:

    • Sharp or cramping abdominal pain.

    • Bloating and distention.

    • Diarrhea or inability to pass gas/stool.

    • Loss of appetite, nausea, and vomiting.

    • Watery diarrhea may occur even in partial obstructions due to continuous mucus secretion.

    • Condition requires urgent medical evaluation to avoid life-threatening complications.

Assessment of Intestinal Obstruction: Clinical Manifestations

  • Key Symptoms:

    • Abdominal pain (colicky in nature).

    • Vomiting (varies by obstruction type):

    • Proximal: projectile/bilious developing rapidly.

    • Distal: gradual onset presenting with fecal, foul-smelling characteristics.

    • Distention and constipation.

    • Significant changes in bowel function.

    • Lack of flatus.

  • Diagnosis Techniques:

    • Imaging: CT scan, abdominal x-ray, sigmoidoscopy, colonoscopy.

    • Laboratory Tests:

    • Complete blood count (CBC).

    • Hemoglobin & hematocrit (H/H).

    • Electrolytes; BUN, Creatinine.

Diagnostic Assessment

  • Laboratory assessments include:

    • WBC count.

    • Hemoglobin, hematocrit.

    • Creatinine and BUN.

    • Serum electrolytes (sodium, chloride, potassium) and amylase.

  • Other diagnostic methods:

    • CT or MRI.

    • Abdominal ultrasound.

Analyzing Cues and Prioritizing Hypotheses

  • Collaborative Problem: Prioritize potential for life-threatening complications due to intestinal flow being blocked or reduced.

Treatment Options for Intestinal Obstruction

  • Management Approaches:

    • Nonsurgical Management:

    • Bowel rest (NPO status).

    • Use of nasogastric tubes for decompression.

    • IV fluid replacement and maintenance.

    • Administer analgesics as needed.

    • Surgical Management:

    • Exploratory laparotomy if necessary.

  • Nutritional Support & Adaptation: Implement universal adaptors when required.

Planning and Implementation

  • Goals: Reduce the risk of danger from potential complications.

  • Common Complications:

    • Fluid, electrolyte, and acid-base imbalances.

    • These differ based on obstruction location:

    • High (upper duodenum): risk for metabolic alkalosis from vomiting and NG tube aspiration.

    • Small intestine: dehydration risks (most fluid absorption occurs in this area).

    • Colon: solid fecal retention leading to complications.

Small Bowel Obstruction: X-Ray Findings

  • Key Observations on X-ray:

    • Demonstration of proximal bowel contents build-up unable to pass obstruction.

    • Significant dilation of small bowel loops (>3cm) found centrally situated relative to the large bowel.

    • Distension of bowel walls from accumulated contents (gas, fluid).

  • Air-fluid levels and Related Signs:

    • Gas observed above fluid in an erect or upright study.

    • 'Gasless' abdomen indicates absence of gas, presenting as fluid-only visibility on x-ray.

    • Additional sign: "String of pearls" pattern may indicate small gas bubble arrangements.

Nursing Management: Assessment & Interventions

  • Key Nursing Responsibilities:

    • Regular assessment of bowel function.

    • Maintain nasogastric (NG) tube as needed.

    • Administer intravenous fluid (IVF) and analgesics to manage pain.

    • Provide frequent oral care.

    • Monitor for any deterioration in hypovolemic shock.

    • Vigilantly monitor fluid and electrolyte status.

    • Maintain strict input/output (I/O) records.

Evaluate Outcomes

  • Goals for Patient Outcomes:

    • Relief from obstruction without signs of life-threatening complications.

    • Restoration and return to usual bowel elimination patterns.

Irritable Bowel Syndrome (IBS)

  • Prevalence: Most common digestive disorder affecting one in five people in the U.S.

  • Symptoms: Chronic abdominal pain/discomfort combined with alterations in bowel patterns.

  • Classifications:

    • IBS-D: Diarrhea dominant.

    • IBS-C: Constipation dominant.

    • IBS-M: Mixed diarrhea/constipation.

  • Etiology:

    • Unclear; may be linked to gastrointestinal infections and food intolerances.

    • Role of food allergies is ambiguous, alongside factors such as fermentable oligosaccharides and polyols.

Recognition of IBS Cues

  • Common Symptoms:

    • Fatigue, malaise, abdominal pain, and changes in bowel patterns.

  • Interventions:

    • Health education, drug therapy, and stress reduction techniques.

  • Manifestations Regarding GI:

    • Symptoms include abdominal pain, diarrhea or constipation, distention, excessive flatulence, bloating, urgency, and sensation of incomplete evacuation.

  • Signs NOT Associated with IBS:

    • Anemia, fever, persistent diarrhea, rectal bleeding, severe constipation, and weight loss.

Classic Manifestations of IBS

  • Symptoms:

    • Changes in bowel habits (constipation and diarrhea) potentially described as uncontrollable or violent.

    • Include abdominal pain, cramping, bloating, flatulence, and potentially mucous or bloody stools.

  • Diagnosis Confirmation:

    • Symptoms must occur weekly for at least three months or frequently within six months.

Psychosocial Factors in IBS

  • Psychological Stressors:

    • Associated with the development and exacerbation of IBS symptoms.

  • Common Psychosocial Conditions:

    • Anxiety disorders, panic disorder, depression, posttraumatic stress disorder, and history of sexual abuse.

Diagnostic Studies for IBS

  • Diagnosis Based on Symptoms:

    • Must include abdominal pain duration for at least three months combined with two additional symptoms:

    • Improvement upon defecation.

    • Changes in stool frequency or appearance at onset.

  • Criteria: Based on Rome III guidelines.

Differential Diagnoses

  • Conditions to Consider:

    • Malabsorption/Dietary Factors: gluten intolerance, lactose intolerance.

    • Infections, colorectal cancer, inflammatory bowel disease, and endometriosis.

Treatment for IBS

  • Focus Areas for Treatment:

    • Address psychological factors: Encourage patients to express concerns.

    • Suggest diary for identifying triggers related to symptoms.

    • Dietary modifications.

    • Use medications to regulate output and alleviate discomfort.

Nutritional Therapy for IBS

  • Gradually increase dietary fiber intake targeting 20 g/day.

  • Use stool bulking agents.

  • Eliminate gas-producing foods: brown beans, Brussels sprouts, cabbage, cauliflower, raw onions, plums, raisins, grapes.

  • Consider yogurt tolerance over milk products.

  • Probiotics may alleviate symptoms by altering intestinal bacteria.

Drug Therapy for IBS (OTC)

  • Loperamide:

    • Treat instances of diarrhea; acts as a synthetic opioid decreasing intestinal transit.

    • Brand Name: Imodium.

    • Multi-Symptom Relief: See on packaging for indications and usage instructions (e.g., 30 Caplets).

Drug Therapy for IBS (Prescription)

  • Alosetron:

    • Available only through restricted access for women not responsive to other treatments due to serious side effects including severe constipation and ischemic colitis.

  • Lubiprostone:

    • Approved specifically for the treatment of IBS-related constipation in women.

  • Linaclotide:

    • Approved for use in both men and women facing IBS-related constipation.

Additional Drug Therapies for IBS

  • Antidepressants:

    • Low doses of tricyclic antidepressants can be beneficial.

    • Mechanism relates to decreasing peripheral nerve sensitivity.

Psychologic Therapies for IBS

  • Examples include:

    • Cognitive-behavioral therapy.

    • Stress management techniques.

    • Acupuncture and hypnosis as complementary treatments.

Case Study Question

  • Client with Positive Fecal Occult Blood Test:

    • Correct response: Need for two samples over three consecutive days for thorough assessment; acknowledges that one positive test may not confirm colon cancer or GI tract bleeding and could yield false positives due to medications like aspirin.

Hemorrhoids

  • Description: Swollen, distended veins located in the anorectal region, categorized as internal, external, or prolapsed.

  • Prevention Strategies: Focus on alleviating constipation and avoiding straining during bowel movements.

  • Symptoms: Bleeding, swelling, and possible prolapse.

  • Management: Pain relief, increase dietary fiber intake, and consider hemorrhoidectomy as needed.