Intestinal and Rectal Disorders

Chapter 41: Management of Patients with Intestinal and Rectal Disorders

Constipation

Definition

  • Defined as fewer than three bowel movements weekly or bowel movements that are:

    • Hard

    • Dry

    • Small

    • Difficult to pass

Manifestations

  • Symptoms indicative of constipation:

    • Fewer than three bowel movements per week

    • Abdominal distention

    • Abdominal pain

    • Bloating

    • Sensation of incomplete evacuation

    • Straining at stool

    • Elimination of small-volume, hard, dry stools

Causes of Pediatric Constipation by Age

  • Newborn/Infant:

    • Meconium plug

    • Hirschsprung disease

    • Cystic fibrosis

    • Congenital anorectal malformations

    • Pseudo-obstruction

    • Endocrine issues (e.g., hypothyroidism)

    • Metabolic issues (e.g., diabetes insipidus, renal tubular acidosis)

    • Withholding behavior

    • Dietary changes

  • Toddler (Ages 2-4):

    • Anal fissures

    • Withholding behavior

    • Toilet refusal

    • Short-segment Hirschsprung disease

    • Neurologic disorders (e.g., spinal cord issues)

  • School Age:

    • Limited or unavailable toilet access

    • Inability to recognize physiological cues; preoccupation with activities

    • Tethered cord

    • Withholding behavior

  • Adolescents:

    • Spinal cord injury due to accidents or trauma

    • Dieting

    • Anorexia

    • Pregnancy-related idiopathic slow transit constipation, especially in females

    • Laxative abuse

    • Irritable bowel syndrome (constipation variant)

  • Any Age:

    • Medication side effects, dietary issues

    • Postoperative states

    • Previous anorectal surgery

    • Withholding behavior and overflow from chronic rectal distention

    • Rapid sedentary lifestyle changes

    • Dehydration

    • Hypothyroidism

Causes of Constipation in Older Adults

  • Factors leading to constipation include:

    • Loose-fitting dentures or lost teeth affecting chewing

    • Preference for soft, processed foods low in fiber

    • Polypharmacy contributing to constipation

    • Reduced mobility and prolonged bed rest

    • Dependency on laxatives

Assessment and Diagnostic Findings of Constipation

  • Chronic constipation is usually idiopathic.

  • Severe, intractable constipation may necessitate further testing such as:

    • Thorough history and physical examination

    • Barium enema

    • Sigmoidoscopy

    • Stool testing

    • Defecography

    • Colonic transit studies

    • MRI

Pediatric Assessment

  • Signs to note in pediatric patients include:

    • Abdomen appearing distended or rounded

    • Inspect anus for fissures or soiling

    • Check child's underwear for stains or smears, indicative of soiling

    • Listen to bowel sounds to determine obstruction potential

    • Assess abdomen for tenderness or masses

    • Recognize that constipation can cause stress for both child and family

Complications of Constipation

  • Possible complications include:

    • Decreased cardiac output

    • Fecal impaction

    • Hemorrhoids

    • Anal fissures

    • Rectal prolapse

    • Megacolon

Patient Learning Needs for Constipation

  • Reference to Chart 41-2 regarding:

    • Recognition of normal bowel pattern variations

    • Establishing a normal bowel pattern

    • Importance of dietary fiber and fluid intake

    • Need to respond to the urge to defecate

    • Encouragement of exercise and activity

    • Guidelines for laxative use

    • Behavior modification strategies for children

Laxative Use Example

  • Question: Which is an example of a laxative osmotic agent?

    • Options:

    • Bisacodyl

    • Ducosate

    • Magnesium hydroxide

    • Polyethylene glycol and electrolytes

Diarrhea

Definition

  • Defined as an increased frequency of bowel movements (more than three per day) with altered stool consistency, typically increased liquidity.

  • Associated symptoms may include urgency, perianal discomfort, incontinence, or a combination thereof.

  • Diarrhea can be classified as:

    • Acute

    • Persistent

    • Chronic

Causes

  • Potential causes include:

    • Infections

    • Medications

    • Tube feeding formulas

    • Metabolic disorders

    • Endocrine disorders

    • Various disease processes

Causes of Diarrhea by Age

  • Infants:

    • Intractable diarrhea of infancy

    • Milk and soy protein intolerance

    • Infectious enteritis

  • Toddlers:

    • Viral enteritis

    • Giardia infection

  • School-Age Children:

    • Chronic nonspecific diarrhea

    • Ulcerative colitis

    • Celiac disease

Manifestations

  • Diarrhea may lead to:

    • Increased stool frequency and fluid content

    • Abdominal cramps

    • Abdominal distention

    • Borborygmus

    • Tenesmus

    • Anorexia and thirst

    • Painful spasmodic contractions of the anus

    • Mental changes: listlessness or lethargy with moderate to severe dehydration

    • Skin turgor and nonelasticity indicative of dehydration

Assessment and Diagnostic Findings

  • Assessment may include:

    • CBC (Complete Blood Count)

    • Serum chemistries

    • Urinalysis

    • Stool examination

    • Endoscopy or barium enema

Complications of Diarrhea

  • Possible complications from diarrhea include:

    • Fluid and electrolyte imbalances

    • Dehydration

    • Cardiac dysrhythmias

    • Chronic diarrhea leading to skin irritations such as dermatitis

Patient Learning Needs for Diarrhea

  • Important learning needs include:

    • Recognition of the need for medical treatment

    • Importance of rest

    • Adequate diet and fluid intake

    • Avoidance of irritating foods (e.g., caffeine, carbonated drinks, hot and cold foods)

    • Possible avoidance of milk, fat, whole grains, fresh fruit, and vegetables

    • Need for perianal skin care

    • Possible use of anti-diarrheal medications

Pediatrics Alert

  • Initial management of a dehydrated child with diarrhea focuses on fluid and electrolyte balance.

  • After dehydration is managed, children should be encouraged to consume their regular diet for growth and development.

  • Avoid fluids high in glucose (e.g., fruit juice, gelatin, soda) that may exacerbate diarrhea.

Older Adult Considerations

  • Older adults are at risk for rapid dehydration due to diarrhea, which may lead to hypokalemia.

  • Monitoring for muscle weakness, decreased peristaltic activity leading to paralytic ileus is essential.

  • Digoxin: be cautious as it can enhance hypokalemia.

  • Skin care becomes critical as older adults' skin is more sensitive; barrier creams and gentle cleansing are recommended to prevent breakdown.

Common Medical Treatments for Diarrhea

  • Treatments may include:

    • Hydration (oral, enteral, and IV routes)

    • Adequate nutrition (oral, enteral, and IV routes)

    • Probiotics to support or replace intestinal microbial flora

Oral Rehydration Therapy: Pediatrics

  • An Oral Rehydration Solution (ORS) should contain:

    • 75 mmol/L sodium chloride

    • 13.5 g/L glucose

  • Standard ORS solutions include:

    • Pedialyte

    • Infalyte

    • Ricelyte

  • Not appropriate for oral rehydration therapy:

    • Tap water

    • Milk

    • Undiluted fruit juice

    • Soup

    • Broth

  • For mild to moderate dehydration, the recommended amount is 50 to 100 mL/kg of ORS over 4 hours.

Question on Diarrhea Management

  • True or False: Most cases of diarrhea are bacterial in nature, and therapeutic management is usually supportive.

Fecal Incontinence

Causes

  • Causes of fecal incontinence include:

    • Anal sphincter weakness

    • Traumatic causes (post-surgical issues with the rectum)

    • Nontraumatic causes (e.g., scleroderma)

    • Neuropathies (e.g., peripheral like pudendal nerve, and generalized like diabetes)

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

    • Inflammatory conditions (e.g., radiation proctitis, inflammatory bowel disease)

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

    • Diarrhea leading to fecal impaction with overflow

    • Behavioral disorders

Manifestations

  • Symptoms of fecal incontinence may range from:

    • Minor soiling

    • Occasional urgency

    • Loss of control

    • Complete incontinence

Assessment and Diagnostic Findings

  • Diagnostic findings for fecal incontinence may include:

    • Detailed history to determine etiology

    • Rectal examination

    • Endoscopic examinations

    • Radiography studies

    • Barium enema

    • CT scans

    • Anorectal manometry

Patient Learning Needs for Fecal Incontinence

  • Educational topics for patients include:

    • Development of a bowel training program

    • Proper skin care techniques

    • Importance of emotional support

Diverticular Disease

Definitions

  • Diverticulum: sac-like herniation of the bowel lining extending through a muscle layer defect.

  • Can occur in any part of the intestine but is most common in the sigmoid colon.

  • Diverticulosis: presence of multiple diverticula without inflammation.

  • Diverticulitis: infection and inflammation of diverticula, typically resulting from diverticulosis.

    • Complication: The incidence of diverticular disease increases with age and is linked to low-fiber diets.

  • Diagnosis is generally performed through colonoscopy.

Nursing Management of Diverticulitis

  • Health management strategies may include:

    • Encourage fluid intake of at least 2 L/day

    • Recommend soft foods with increased fiber (e.g., cooked vegetables)

    • Develop an individualized exercise program

    • Utilize bulk laxatives (e.g., psyllium) and stool softeners

Intestinal Obstruction

Definition

  • An intestinal obstruction occurs when a blockage prevents normal intestinal content flow through the gastrointestinal tract.

    • Mechanical Obstruction:

    • Intraluminal obstruction or mural obstruction due to pressure on the intestinal wall.

    • Functional or Paralytic Obstruction:

    • Occurs when intestinal musculature cannot propel contents along the bowel, can also be temporary post-surgical consequence.

Pediatric Client Considerations

  • Hirschsprung Disease (congenital aganglionic megacolon):

    • Primary sign is the failure to pass stool (meconium).

    • Surgical intervention may be necessary, possibly leading to ostomy creation to divert stool through a stoma.

    • Child and family education are critical in management.

Nursing Management of Intestinal Obstruction

  • Goals include:

    • Maintain function of nasogastric tube

    • Assess and measure nasogastric output

    • Monitor fluid and electrolyte balance

    • Nutritional status assessment

    • Monitor for manifestations indicative of resolution (normal bowel sounds, decreased abdominal distention, subjective improvement in abdominal pain and tenderness, passage of flatus or stool)

Question on Diverticulitis Site

  • True or False: The most common site for diverticulitis is the ileum.

Indications for Parenteral Nutrition

  • Situations warranting parenteral nutrition include:

    • Insufficient intake to maintain an anabolic state

    • Inability to ingest food orally or via tube

    • Lack of interest or willingness to consume adequate nutrients

    • Medical conditions prohibiting oral or tube feeding

    • Prolonged preoperative and postoperative nutritional needs

Total Nutrient Admixture Definition

  • Total nutrient admixture:

    • Method of supplying nutrients to the body intravenously.

    • Consists of an oil-in-water emulsion of oils, egg phospholipids, glycerin, and an admixture of lipid emulsions, proteins, carbohydrates, electrolytes, vitamins, trace minerals, and water.

Assessment of the Patient with Inflammatory Bowel Disease

Health History Considerations

  • Gather health history to define:

    • Onset, duration, and characteristics of pain

    • Diarrhea and urgency patterns

    • Tenesmus, nausea, anorexia, weight loss, bleeding, and family history

    • Dietary patterns; alcohol, caffeine, and nicotine use

    • Assess bowel elimination patterns and stool characteristics

    • Perform abdominal assessments

Collaborative Problems and Potential Complications

  • Common problems include:

    • Electrolyte imbalance

    • Cardiac dysrhythmias

    • GI bleeding with corresponding fluid loss

    • Bowel perforation

Planning and Goals

  • Major goals may include:

    • Achievement of normal bowel elimination patterns

    • Abdominal pain relief

    • Prevention of fluid deficits

    • Maintenance of optimal nutrition and weight

    • Avoidance of fatigue

    • Reduction of anxiety

    • Effective coping strategies

    • Absence of skin breakdown

    • Enhancement of disease knowledge, therapeutic regimen adherence, and complication avoidance

Nursing Interventions

  • For maintaining elimination patterns:

    • Correlate diarrhea with food, activities, emotional stressor responses

    • Ensure bathroom or commode access

    • Advocate for bed rest to minimize peristalsis

    • Administer medications according to prescription

    • Document stool frequency, consistency, character, and amounts

  • For addressing pain:

    • Assess and treat pain/discomfort with anticholinergic medications, analgesics, positioning, diversional activities, and fatigue prevention strategies.

  • For fluid deficit management:

    • Record intake and output, daily weights, dehydration symptoms, encourage oral hydration, and minimize diarrhea episodes.

  • For nutritional support:

    • Provision of optimal nutrition; prepare for possible needs for elemental feedings high in protein, low residue or parenteral nutrition.

  • For anxiety reduction:

    • Engage using a calm approach, listen to patient concerns, and facilitate patient education.

Patient Education

  • Key topics for patient education include:

    • Understanding the disease process

    • Nutrition and dietary guidelines

    • Medication management

    • Resources available including the National Foundation for Ileitis and Colitis

    • Ileostomy care information if applicable

Ostomy Care Procedure

Steps for Perform Ostomy Care

  1. Gather necessary supplies:

    • Warm, wet washcloths or paper towels

    • Clean pouch and clamp

    • Skin barrier powder, paste, and/or sealant

    • Writing utensil

    • Scissors

    • Stoma size measuring pattern

  2. Remove the existing pouch:

    • Use adhesive remover or wet cloth as needed to facilitate removal.

  3. Observe the stoma and surrounding area:

    • Clean and dry as required.

  4. Measure the stoma; adjust and cut new pouch backing as necessary.

  5. Apply the new pouch reliably.

Assessment for Patient Receiving Parenteral Nutrition

  • Important factors for assessment include patients that may need parenteral nutrition due to:

    • Nutrition status deterioration, including decreased oral intake over a week

    • Weight loss of 10% or more from usual weight

    • Muscle wasting and poor tissue healing

    • Persistent nausea and vomiting

    • Monitoring hydration status, electrolytes, and caloric intake

Collaborative Problems and Complications

  • Potential complications for patients receiving parenteral nutrition:

    • Pneumothorax

    • Air embolism

    • Catheter displacement or clotting

    • Sepsis

    • Hyperglycemia

    • Rebound hypoglycemia

    • Fluid overload

  • Reference Table 41-7 for specific indications.

Planning and Goals for Parenteral Nutrition

  • Overall goals include:

    • Achieve optimal nutrition

    • Ensure absence of infection

    • Maintain adequate fluid volume

    • Support active patient engagement and self-care education

    • Prevent complications.

Nursing Interventions for Parenteral Nutrition

Intervention #1: Optimal Nutrition

  • Continuous assessment and management focus on nutrition, including:

    • Daily weight monitoring at consistent times

    • Accurate intake and output documentation

    • Regular caloric counts, ensuring trace elements are included.

Intervention #2: Infection Prevention

  • Ensure infection prevention measures such as:

    • Proper catheter and IV site care

    • Adherence to sterile techniques for dressing changes

    • Wear face masks during dressing changes

    • Regular site evaluations for signs of infection

    • Ensure IV and tubing hygiene.

Intervention #3: Fluid Balance Maintenance

  • To maintain fluid balance, manage IV infusions:

    • Monitor the flow rate carefully to avoid rapid changes. If fluids deplete, switch to a 10% dextrose solution until replenished.

    • Regularly monitor indicators of fluid balance and levels of electrolytes. Manage intake and outputs, including blood glucose level monitoring.

Patient Education on Parenteral Nutrition

  • Educational components include:

    • Explanation of goals and purpose of parenteral nutrition

    • Familiarity with PN components

    • Provision of emergency contact numbers

    • Demonstrations on equipment usage and handling IVs, dressing changes, flushing, or heparinizing catheters

    • Outline potential complications and necessary actions to take.