In-Class Notes Lower GI

Management of Patients with Intestinal and Rectal Disorders

Objectives

• By the end of this session, the learner will be able to:

  • Assess and diagnose normal and abnormal findings of the lower gastrointestinal tract in adult and geriatric clients.

  • Explain the pathophysiology, risk factors, clinical manifestations, complications, and nursing management of common lower gastrointestinal conditions (e.g., constipation, diarrhea, fecal incontinence, celiac disease, irritable bowel syndrome).

  • Describe the pathophysiology, risk factors, clinical manifestations, complications, and nursing management of lower gastrointestinal diseases (e.g., appendicitis, diverticular disease, inflammatory bowel disease, intestinal obstruction and diversion, colorectal cancer).

  • Discuss the pathophysiology, risk factors, clinical manifestations, complications, and nursing management of obesity.

  • Understand common medical therapies and surgical interventions for lower gastrointestinal disorders and obesity.

Constipation

Causes

• Poor diet leading to inadequate fluid or fiber intake.

• Slow intestinal transit due to lack of exercise.

• Dysfunction of pelvic floor or anal sphincter.

• Drug-induced issues (e.g., opioids, anticholinergics).

Manifestations

• Less than 3 bowel movements per week.

• Abdominal distention.

• Decreased appetite.

• Headaches and fatigue.

• Indigestion and straining.

• Elimination of small-volume, hard, dry stools.

Assessment & Diagnosis

• Endoscopy.

• MRI or imaging studies.

• Barium enema.

• Defecography studies.

• Colonic transit studies.

• Stool testing.

Complications

• Decreased cardiac output.

• Fecal impaction.

• Hemorrhoids and fissures.

• Rectal prolapse.

• Megacolon.

Management

• Laxatives:

  • Bulk-Forming (1-3 days).

  • Surfactant (1-3 days).

  • Stimulant (6-12 hrs).

  • Osmotic (2-6 hrs).

  • Miscellaneous (15-60 min).

Polyethylene Glycol-Electrolyte (GoLytely®)

• Bowel "Clean-Out" with antibiotics; administration involves a large volume (4 L), requiring patients to drink 1-2 glasses every 10 min for 2-3 hours.

• Bowel movements begin in about 1 hour.

• No solid food within 3 hours prior; only clear liquids.

• Adverse Effects: Profound diarrhea, fullness, bloating, irritation of the anal area.

Nursing Interventions

• Monitor stool frequency and consistency.

• Encourage adequate fluid intake.

• Encourage exercise after meals.

• Only use laxatives when necessary (overuse can lead to loss of defecatory reflexes).

• Take bulk-forming and surfactant agents with a full glass of water or juice to prevent obstruction.

• Avoid taking osmotic laxatives or stimulant agents at night due to rapid action.

Diarrhea

Causes

• Maldigestion.

• Bowel disorders.

• Inflammation.

• Infection.

• Drug-induced (e.g., antibiotics).

Manifestations

• Excessive stool volume and fluidity (>3 times/day, >200 grams).

• Electrolyte depletion and dehydration.

• Abdominal cramps and distention.

• Painful spasmodic contractions of the anus, borborygmus, tenesmus.

Assessment & Diagnosis

• CBC and electrolytes.

• Stool examinations.

• Endoscopy.

• Barium enema.

Complications

• Fluid and electrolyte imbalance.

• Dehydration.

• Cardiac dysrhythmias.

• Skin breakdown and dermatitis.

Management

• Opioids: diphenoxylate plus atropine (Lomotil®), difenoxin plus atropine (Motofen®), loperamide (Immodium®), opium tincture, paragoric.

Nursing Interventions

• Monitor stool frequency and consistency.

• Contact a provider if diarrhea lasts >2 days.

• Avoid irritating foods and beverages (caffeine, carbonated drinks, milk, fat).

• Reduce gastrointestinal irritation with the BRAT diet.

• Encourage adequate fluid intake (up to 2-3 liters per day).

• Take antidiarrheals exactly as prescribed (opiate use can lead to dependence).

Fecal Incontinence

Causes

• Anal sphincter weakness.

• Trauma from surgical procedures or scleroderma.

• Neuropathies (e.g., pudendal, diabetes).

• Disorders of the pelvic floor (e.g., rectal prolapse).

• Inflammation (radiation proctitis, IBD).

• Central nervous system disorders (e.g., dementia, stroke, spinal cord injury).

• Fecal impaction with overflow diarrhea.

Manifestations

• Soiling and urgency.

• Loss of control leading to complete incontinence.

Management

• Determine etiology.

• Implement bowel training and regimens.

Celiac Disease

Overview

• Celiac disease is a malabsorption disorder triggered by an autoimmune response to gluten, commonly found in wheat, barley, rye, and other grains.

• It has become more prevalent over the last decade, affecting about 1% of the U.S. population.

• Women are diagnosed twice as often as men and it is commonly associated with other conditions such as Type 1 diabetes and Down syndrome.

Manifestations

• Diarrhea, steatorrhea, abdominal pain, distention, flatulence, and weight loss.

Management

• Total avoidance of gluten exposure.

Appendicitis

Overview

• The most common cause of acute abdomen in the U.S. and the leading reason for emergency abdominal surgery.

• The appendix becomes inflamed due to obstruction by fecaliths or lymphoid hyperplasia, leading to edema and bacterial overgrowth.

Diverticulitis of the Colon

Causes

• Small pouches (diverticula) develop in the colon due to high intraluminal pressure.

• Diverticulosis is asymptomatic; diverticulitis involves infection and inflammation of these pouches.

Manifestations

• Abdominal pain, bloating, constipation, abscess formation, perforation, high fever, chills, peritonitis.

Management

• Bowel Rest: Limit intake to low residue foods (white bread, refined pasta, well-cooked vegetables, lean meats).

• Foods to Avoid: Whole grains, raw vegetables, tough meats, nuts, and spicy foods.

Irritable Bowel Syndrome (IBS)

Overview

• A chronic, intermittent condition affecting 15% of adults in the U.S.

• Manifestations include large intestine spasms, cramping abdominal pain, and symptoms of diarrhea or constipation.

Risk Factors

• Heredity, psychological stress, high-fat diets, alcohol consumption, and smoking.

Assessment & Diagnosis

• Stool studies, imaging, and bowel examinations (colonoscopy, proctoscopy).

Management

• Medications such as antispasmodics, bulk-forming agents, serotonin antagonists, and dietary changes.

Inflammatory Bowel Disease (IBD)

Overview

• Two primary types: Crohn’s disease (can affect any part of the GI tract) and Ulcerative colitis (limited to the large intestine).

Diagnosis & Manifestations

• Diagnosed via colonoscopy, with symptoms including diarrhea, malabsorption, weight loss, and anemia.

Intestinal Obstruction

Overview

• Exists when a blockage prevents normal flow through the intestinal tract, classified as either mechanical or functional.

• Common causes include adhesions, volvulus, intussusception, and incarcerated hernias.

Intestinal Diversion Care

Preoperative and Postoperative Care

• Comprehensive care including emotional support, skin and stoma care, diet management, and irrigation techniques.

Colorectal Cancer (CA)

Overview

• The third most common cancer in both genders with a significant incidence after age 50.

• Slow progression and local growth if detected early.

Risk Factors

• Include age, diet, genetic factors, and personal medical history.

Manifestations

• May be asymptomatic initially, later causing rectal bleeding, changes in bowel habits, and abdominal pain.

Management

• Diagnostics include DRE, fecal occult blood tests, colonoscopy, and imaging studies.

• Treatment may involve chemotherapy, radiation, and surgery, particularly for tumor removal.

Nursing Implications

Patient Personal and Psychosocial Issues

• The identification of cancer can cause anxiety and fear, with significant implications for body image and daily activities.

Obesity

Overview

• Defined as a BMI over 30; impacts a significant portion of the U.S. population.

Assessment

• Determining BMI, waist circumference, and conducting lab studies for associated health risks.

Nonsurgical Interventions

• Options include vagal blocking and intragastric balloon therapy, each with respective benefits and risks.

Bariatric Surgery

• Typically reserved for patients failing nonsurgical methods, with potential for significant weight loss and improvement of comorbid conditions.

Post-Op Management for Bariatric Surgery

Considerations

• Include dietary modifications, management of potential complications such as dumping syndrome, and ensuring adequate nutrition.