Chapter 29: Care of Patients with Disorders of the Lower Gastrointestinal System

Overview

  • Nurse: Ms. Donna Richmond, DNP, MSN, RN-BC
  • Focus: Medical-Surgical Nursing

Objectives

  • Understand and discuss the following conditions and treatment strategies:
    • Irritable Bowel Syndrome (IBS)
    • Diverticulitis
    • Strangulated Hernia
    • Intestinal Obstruction
    • Ulcerative Colitis and Crohn’s Disease
    • Appendicitis and Peritonitis
    • Hemorrhoids, Pilonidal Sinus, and Anorectal Fistula

Irritable Bowel Syndrome (IBS)

Characteristics
  • Three main features:
    1. Alteration in bowel elimination (constipation, diarrhea, or both)
    2. Abdominal pain and bloating
    3. Absence of detectable organic disease
  • Additional symptoms: mucorrhea (mucus in stool)
Etiology
  • Various disorders can trigger IBS, leading to hypersensitivity of the bowel wall.
Diagnosis
  • Based on symptoms like abdominal pain or discomfort:
    • Must be relieved by defecation
    • Associated with changes in stool frequency/consistency
    • Must rule out any organic bowel diseases.
Treatment and Nursing Management
  • General health assessment required.
  • Medications:
    • Bulk-forming agents, antidiarrheals, antispasmodics, antidepressants, anticholinergics/sedatives, mild analgesics.
  • Dietary recommendations:
    • High-fiber diet, identify and avoid trigger foods (e.g., gas-forming foods, lactose, gluten if intolerant).
  • Patient education and reassurance are crucial.

Diverticular Disease

Diverticula
  • A small pouch formation due to mucous membrane protrusion.
Diverticulosis vs. Diverticulitis
  • Diverticulosis: May be asymptomatic or lead to symptoms like rectal bleeding, constipation, cramping, left lower abdominal pain, nausea, vomiting.
    • Risk factors include age over 50, obesity, straining to defecate, low-fiber diet.
  • Diverticulitis: Develops from diverticulosis, diagnosed through flexible sigmoidoscopy or colonoscopy, CT scans, barium enemas (with caution).
Treatment
  • Mild cases: Oral antibiotics, liquid diet, and mild pain management (e.g., Tylenol).
  • Severe cases: NPO status, IV antibiotics, and possible surgery for complications such as abscess or perforation.

Intestinal Obstruction

Types
  • Mechanical obstructions: caused by tumors, adhesions, hernias, etc.
  • Non-mechanical obstructions: due to absent peristalsis (e.g., paralytic ileus).
Signs and Symptoms
  • Upper obstructions: nausea/vomiting, dehydration, mild distention.
  • Lower obstructions: distention and abdominal pain that corresponds with peristalsis.
Diagnosis and Treatment
  • Diagnosis made via radiography and examination of symptoms.
  • Treatment may involve NG tube decompression or surgery.
Nursing Management
  • Positioning, monitoring fluid status, measuring abdominal girth.

Hernias

Strangulated Hernia
  • Involves a defect in the abdominal muscular wall where the intestine breaks through, can lead to obstruction.
  • Types include:
    • Reducible: visible bulge that can return to normal position.
    • Irreducible: cannot be pushed back, causing pain.
    • Emergency if obstructed or strangulated.
Diagnosis and Treatment
  • Herniorrhaphy or hernioplasty for repair.

Bowel Ischemia

Pathophysiology
  • Insufficient blood supply to the bowel affecting metabolic needs.
Signs and Symptoms
  • Sudden abdominal pain, nausea, vomiting, diarrhea, and minimal bowel sounds.
Diagnosis
  • Increased white blood count, CT, or MRI for visualization.
Treatment and Nursing Management
  • NPO, NG tube for gastric decompression, IV hydration, surgery if it's necrotic.

Inflammatory Bowel Disease (IBD)

Ulcerative Colitis and Crohn's Disease
  • Etiology: Genetic predisposition, UC more common than CD.
  • Pathophysiology: Results in inflammation of the GI tract mucosa.
Signs and Symptoms
  • Attacks of diarrhea with possible blood or mucus; cramping abdominal pain, malaise, fever, weight loss. Stress often precipitates exacerbations.
Diagnosis
  • History, colonoscopy, sigmoidoscopy, mucosal biopsy, stool analysis.
Treatment
  • Symptomatic management with diet modifications, medications (corticosteroids, aminosalicylates), surgery if necessary.

Appendicitis

Etiology and Pathophysiology
  • Appendiceal inflammation typically presenting with RLQ pain, often at McBurney's point.
Signs and Symptoms
  • Pain, muscle guarding, low-grade fever, nausea/vomiting.
Diagnosis
  • CT scan and ultrasound for pregnant women; lab tests for WBC count.
Treatment
  • Appendectomy and appropriate nursing care pre- and post-surgery including monitoring for complications.

Peritonitis

Etiology
  • Inflammation resulting from infections of abdominal organs, leading to significant clinical concern if untreated.
Signs and Symptoms
  • Abdominal pain, rigidity, distention, fever, nausea.
Diagnosis and Treatment
  • Requires immediate medical attention; treatments include IV antibiotics, fluid management, potential surgical intervention.

Hemorrhoids

Etiology and Pathophysiology
  • Varicosities in rectal veins due to increased venous pressure from constipation, pregnancy, and prolonged sitting/standing.
Signs and Symptoms
  • Local pain, itching, and visible swelling.
Treatment
  • Sitz baths, local anesthetics, scleropathy, hemorrhoidectomy if necessary.

Pilonidal Sinus and Anorectal Abnormalities

Pilonidal Sinus
  • Lesion that may become infected, treated with drainage.
Anorectal Abscess and Fistula
  • Infection leading to pus accumulation; requires incision and drainage.

Patient Education and Nursing Management

  • Assess dietary needs, educate on procedures and self-care, monitor output; support psychological adjustment to life changes such as having an ostomy.

Ostomy Surgery and Care

Colostomy and Ileostomy
  • Types of stomas (ascending, transverse, descending). Discuss care necessary to maintain health and hygiene.
Post-operative Care
  • Dietary adjustments, monitoring stoma output, addressing psychosocial issues.
Patient Teaching
  • Skin care, collection devices, and lifestyle adjustments for patients with ostomies.