Nursing Care of Patients With Lower Gastrointestinal Disorders

Lower Gastrointestinal System

• Components:
  • Small intestines
  • Large intestines
  • Rectum
  • Anus

Constipation

• Definition: Fecal mass held in rectum, feces become dry and hard, difficult to pass.
• Prevention:
  • High-fiber diet
  • Adequate fluids
  • Exercise
• Obstipation: Prolonged constipation
• Causes:
  • Medications
  • Hemorrhoids or fissures
  • Low intake of fiber and fluids
• Signs and Symptoms:
  • Abdominal pain
  • Distention
  • Indigestion
  • Intestinal rumbling
  • Rectal pressure
  • Hard stool
  • Headache
  • Fatigue
  • Decreased appetite
  • Straining
• Complications:
  • Impaction
  • Ulcers
  • Straining
  • Megacolon
• Diagnostic Tests:
  • Self-diagnosis
  • History and physical with rectal examination
  • Radiographic and imaging procedures
• Therapeutic Interventions:
  • High-fiber diet
  • 2 to 3 liters fluid daily
  • Strengthen abdominal muscles
  • Activity
  • Bulk-forming agents
  • Stool softeners
  • Education
  • Footstool
• Data Collection:
  • Establish rapport
  • Determine history
  • Auscultate bowel sounds
  • Inspect/palpate abdomen
• Nursing Diagnosis:
  • Constipation

Diarrhea

• Definition: Fecal matter passes rapidly, decreased absorption of water and nutrients.
• Causes:
  • Bacterial/viral infection
  • Food allergies
• Prevention: Important
• Signs and Symptoms:
  • Frequent, watery stools
  • Abdominal cramping
  • Distention
  • Anorexia
  • Intestinal rumbling
  • Fever
  • Foul odor
• Therapeutic Interventions:
  • Identify cause
  • Replace fluids/electrolytes
  • Diphenoxylate (Lomotil), loperamide (Imodium)
  • Probiotic (Culturelle) restores normal flora
  • Antimicrobial agents for infection
  • Fecal transplant

Case Study for SBAR Hand-Off Report : Mr. Kasprzyk

• 70-year-old white male
• Admitted to telemetry with hypokalemia secondary to diarrhea.
• Hypertension: 128/72
• Potassium level: $2.5 mEq/L$
• IV fluids: D5 ½ NS with 40 mEq KCL running at 125 mL/hour
• Potassium level ordered every 4 hours, next one due in 1 hour.
• Loose stool 30 minutes ago.
• Stool culture sent, awaiting results.

SBAR Hand-Off Report Activity

• Preparing to give a hand-off report at the end of shift to the oncoming nurse.
• Think about the information should include in the hand-off report.
• Communicate a hand-off report using SBAR.

SBAR Hand-Off Report Suggested Answers

• Situation: Mr. Kasprzyk is a 70-year-old male admitted with hypokalemia and diarrhea.
• Background: He has a history of hypertension.
• Assessment of Situation: His potassium is 2.5, IV infusing of D5 ½ NS with 40 mEq/hour. His last stool was 30 minutes ago. BP 128/72.
• Recommendation: He needs to be placed on a cardiac monitor and monitor potassium levels. The next potassium level is due in 1 hour.

Appendicitis

• Definition: Inflammation of the appendix
• Signs and Symptoms:
  • Fever, nausea/vomiting, anorexia
  • Pain right lower quadrant: McBurney’s point
• Diagnostic Tests:
  • Complete blood count (CBC)
  • Ultrasound, computed tomography (CT) scan, or magnetic resonance imaging (MRI)
• Therapeutic Interventions:
  • NPO
  • Surgery
  • Early detection to minimize complications
• Complications:
  • Perforation
  • Abscess

McBurney's Point

• Location of McBurney's point (illustration).

Activity: Cue Recognition 34.1 - Lynda

• Lynda: 40-year-old Black woman presenting at an urgent care facility.
• Reports severe lower right-sided abdominal pain, nausea, vomiting, and anorexia
• Woke up with the pain a couple of hours ago, rates it 7 out of 10 on a 0 to 10 scale.

Cue Recognition 34.1 Answer

• Gather more data:
  • Vital signs
  • Bowel sounds
  • Tenderness
  • Location of the pain
  • Last bowel movement (any blood or mucus)
  • Food intake
  • Nausea, or vomiting
• Note the location of the pain, such as McBurney’s point.
• Notify the health-care provider (HCP) now with the results.

Cue Recognition 34.1 Answer Rationale

• The HCP can order tests to help determine the cause of Lynda’s abdominal pain, including laboratory work and radiologic tests.
• She may be experiencing an acute appendicitis.

Case Study for ISBARR Communication - Lynda

• Lynda: 40-year-old Black woman presenting at an urgent care facility.
• Reports severe lower right-sided abdominal pain with rebound tenderness over McBurney’s point, abdominal guarding, nausea, vomiting, and anorexia.
• Woke up with the pain a couple of hours ago and rates it 7 out of 10 on a 0 to 10 scale.
• Vital Signs:
  • Temp $101.2°F (38.4°C)$
  • Pulse 90 beats/minute
  • Respirations 20/minute
  • BP 130/80

ISBARR Communication: Activity

• Preparing to communicate with the patient’s HCP.
• Think about the information should include in the communication.
• Communicate using ISBARR.

ISBARR Communication Suggested Answers

• Identify: Hi Dr. (name), I am (your name), LVN.
• Situation: Lynda has right-sided abdominal pain rating it 7 on 0 to 10 pain scale, rebound tenderness over McBurney’s point, guarding, nausea and vomiting.
• Background: She is a 40-year-old who woke up with the pain. Temperature is $101.2°F (38.4°C)$.
• Assessment of Situation: She has severe pain and fever and needs to be seen by you.
• Recommendation: I recommend you see her immediately.
• Read back: Read back any orders the HCP may give you.

Peritonitis

• Definition: Inflammation/infection of peritoneum
• Causes:
  • Ruptured appendix
  • Peptic ulcer
  • Pancreatitis
  • Diverticulitis
• Signs and Symptoms:
  • Abdominal pain
  • Abdominal rigidity
  • Nausea/vomiting
  • Fever
• Diagnostic Tests:
  • White blood cells (WBCs)
  • Abdominal x-ray or CT scan
  • Exploratory surgery
• Therapeutic Interventions:
  • NPO
  • Fluid/electrolyte replacement
  • Nasogastric (NG) or orogastric tube
  • Antibiotics
  • Surgery
  • Pain management
• Complications:
  • Intestinal obstruction
  • Hypovolemia: Fluid shift into peritoneal cavity
  • Sepsis
  • Shock/death

Diverticulosis/Diverticulitis

• Diverticulum: Outpouching of bowel mucous membrane
• Diverticulosis: Multiple diverticula
• Diverticulitis: Inflammation/infection of diverticulum
• Causes:
  • Chronic constipation
  • Decreased intake of dietary fiber
• Risk Factors:
  • Increasing age
  • Low-fiber and high animal -fat diet
  • Obesity
  • Sedentary lifestyle
  • Smoking
  • Medications
• Signs and Symptoms:
  • No symptoms
  • Constipation, possibly diarrhea
  • Cramping
  • Bleeding
  • Abdominal tenderness
• Diagnostic Tests:
  • Flexible sigmoidoscopy or colonoscopy
  • CT scan
• Therapeutic Interventions:
  • Mild: Tylenol, antibiotic, liquid diet
  • Severe:
  • Pain control
  • NPO
  • IV antibiotics
  • IV fluids/nutrition
  • Surgery

Crohn’s Disease

• Commonly called Crohn’s disease
• Autoimmune inflammatory bowel disease
• Involves any part of the intestine; skip lesions
• Remissions and exacerbations
• Cause unknown
• Hereditary
• Signs and Symptoms:
  • Abdominal pain or cramping
  • Weight loss
  • Diarrhea
  • Fluid and electrolyte imbalance
  • Inflammatory symptoms outside of gastrointestinal (GI) tract
• Diagnostic Tests:
  • Laboratory testing
  • Endoscopy with biopsy
  • Ultrasound
  • Multiphase CT enterography
  • Magnetic resonance enterography
• Therapeutic Interventions:
  • Medications:
  • 5-aminosalicylates
  • Biologic response modifiers
  • Corticosteroids
  • Immunomodulators
  • Antidiarrheals
  • Avoid offending foods
  • Surgery if necessary
  • Elemental formula or parenteral nutrition if required
  • Support and education
• Complications:
  • Malnutrition
  • Obstruction
  • Fissures
  • Abscess
  • Fistula
  • Perforation
  • Bleeding

Ulcerative Colitis

• Inflammatory bowel disease
• Affects large intestine and rectum
• Remissions and exacerbations occur
• Causes:
  • Exact cause unknown
  • Infection, allergy, and autoimmune response possible causes
• Signs and Symptoms:
  • Abdominal pain
  • 4 to 10 liquid stools daily
  • Rectal bleeding
  • Fecal urgency
  • Anorexia
  • Weight loss
  • Cramping
  • Vomiting
  • Fever
  • Dehydration
  • Fluid and electrolyte imbalances
• Complications:
  • Hemorrhage
  • Toxic megacolon
  • Perforation
  • Peritonitis
  • Osteoporosis
  • Increased risk for colorectal cancer
• Diagnostic Tests:
  • CBC
  • Stool specimen
  • Electrolytes
  • Protein level
  • Colonoscopy with biopsy
  • Leukocyte scintigraphy
• Therapeutic Interventions:
  • Avoid offending foods.
  • Medications:
  • 5-aminosalicylates
  • Biologic response modifiers
  • Corticosteroids
  • Immunomodulators
  • Antidiarrheals
  • Surgery if necessary

Activity: Cue Recognition 34.2

• Patient in the emergency department with abdominal pain and a history of Crohn’s disease.
• He has been resting comfortably in bed when suddenly he reports extreme abdominal pain and is curled up in a fetal position on the bed.

Cue Recognition 34.2: Answer

• Assess the abdomen for tenderness, firmness, and bowel sounds.
• Obtain a set of vital signs.
• A sudden worsening of the patient could indicate complications and you should notify the HCP immediately.

Cue Recognition 34.2: Answer Rationale

• A sudden change in the patient’s status, including increased abdominal pain, could indicate many complications, such as a perforation.
• Gathering data and communicating with the HCP will ensure prompt identification and treatment of the cause of the increased pain.

Irritable Bowel Syndrome

• Functional problem
• Bowel mucosa not changed
• Altered intestinal motility
• Bowel patterns:
  • Irritable bowel syndrome (IBS) with diarrhea
  • IBS with constipation
  • IBS mixed (diarrhea and constipation)
  • Unclassified
• Etiology:
  • More common in women
  • Hereditary
  • Bowel nerves more sensitive
  • Triggers: Psychological stress/food intolerances, Infection, Menstruation
• Signs and Symptoms:
  • Abdominal pain
  • Constipation
  • Diarrhea
  • Mucus with stools
  • Depression, anxiety
• Therapeutic Interventions:
  • Low FODMAP diet
  • Diet high in fiber and bran
  • Avoid trigger foods
  • Smaller, frequent meals
  • Stress management
  • Behavioral therapy
  • Exercise
  • Medications depend on type of IBS
• Medications:
  • IBS with constipation:
  • Increase fluid secretion into bowel: Linaclotide (Linzess), lubiprostone (Amitiza)
  • Increase colonic motility: Tegaserod (Zelnorm)
  • Enhance intestinal volume and movement of stool: Tenapanor (Ibsrela)
  • IBS with diarrhea:
  • Antidiarrheals: Loperamide (Imodium)
  • Low-dose tricyclic antidepressants: Desipramine (Norpramine), imipramine (Tofranil), nortriptyline (Pamelor)
  • Antispasmodics: Hyoscyamine (Levbid), dicyclomine (Bentyl)
  • Antibiotics: Rifaximin (Xifaxan) for those who do not respond to other treatments

Abdominal Hernias

• Pathophysiology: Protrusion of organ or structure through weakness or tear in wall of abdomen
• Etiology: Weakness in abdominal wall with increased intra-abdominal pressure
• Types:
  • Umbilical
  • Inguinal: Direct, indirect
  • Femoral
• Signs and Symptoms:
  • None
  • Bulging
• Complications:
  • Strangulated incarcerated hernia
• Therapeutic Interventions:
  • None
  • Observation
  • Support devices
  • Surgery: Herniorrhaphy, Hernioplasty
• Nursing Care:
  • Education: No coughing or lifting, Complication signs, Support garments
  • Postoperative: No coughing or lifting, Activity limits, Education

Absorption Disorders

• Inability to absorb one or more major nutrients
• Types:
  • Celiac disease: Gluten sensitivity
  • Lactose intolerance: Lactase deficiency
• General Signs and Symptoms:
  • Weight loss
  • Weakness
  • General malaise
• Complications:
  • Bleeding due to hypoprothrombinemia
  • Bone pain and neuromuscular hyperirritability due to calcium deficiency
• Diagnostic Tests:
  • Hematocrit
  • Mean corpuscular volume
  • Upper GI series
  • Sudan stain
  • Stool collection
  • Biopsy
• Therapeutic Interventions:
  • Celiac disease: High-calorie, high-protein, gluten-free diet, Dietitian consult
  • Lactose intolerance: Avoid lactose foods; use Lactaid

Intestinal Obstruction

• Flow of intestinal contents is blocked
• Partial or complete blockage
• Mechanical: Blockage occurs within the intestine, Bowel sounds high-pitched/tinkling
• Nonmechanical: Peristalsis impaired, Bowel sounds absent
• Signs and Symptoms:
  • Abdominal pain
  • Nausea and vomiting
  • Blood and mucus per rectum
  • Feces and flatus cease
  • Fecal vomiting may occur
  • Abdominal distention
  • Fluid/electrolyte imbalance
• Diagnostic Tests:
  • Abdominal x-ray
  • CT scan
  • CBC and electrolytes
• Therapeutic Interventions:
  • NPO with oral care
  • NG tube to suction
  • Fluid and electrolyte replacement
  • Medications: Antiemetics, Analgesics
  • Surgery

Activity: Prioritization - Siraio

• Siraio returned from a 2-week vacation with reports of diarrhea for 2 days, anorexia, leg cramps, and some fluttering in the chest.
• The HCP has ordered
  • NG tube
  • Stool for culture and sensitivity
  • Continuous cardiac monitoring
  • IV

Prioritization: Answer

• Continuous cardiac monitoring
• IV
• NG tube
• Stool for culture and sensitivity

Prioritization: Answer Rationale

• The patient has had diarrhea and could have fluid and electrolyte imbalances that are affecting his heart, especially with reports of a fluttering chest.
• Starting an IV will help improve his fluid status.
• The NG tube can be inserted after the electrocardiogram (ECG) and IV because the patient is not vomiting and his airway is not compromised.
• Obtain the stool sample last.

Anorectal Problems

• Hemorrhoids
• Anal fissures
• Anorectal abscess
• Nursing Care: Postoperative:
  • Pain control
  • Sitz baths
  • Dressing changes
  • Stool softeners

Lower Gastrointestinal Bleeding

• Causes:
  • Diverticulitis
  • Polyps
  • Anal fissures
  • Hemorrhoids
  • Inflammatory bowel disease
  • Cancer
• Signs and Symptoms:
  • Occult blood, melena, bright-red stools
• Treat cause
• Nursing Care:
  • Monitor stools/bleeding
  • Vital signs
  • Shock signs
  • Diagnostic and/or surgical prep

Colorectal Cancer

• Major cause: Lack of dietary fiber
• Signs and Symptoms:
  • Change in bowel habits
  • Blood or mucus in stools
  • Abdominal or rectal pain
  • Obstruction
• Diagnostic Tests:
  • Colonoscopy with biopsy
  • Sigmoidoscopy with biopsy
  • Proctosigmoidoscopy
  • CT scan
  • Abdominal and rectal examination
  • Fecal occult blood
  • Carcinoembryonic antigen
• Therapeutic Interventions:
  • Surgery: Resection, Abdominoperineal resection, Colostomy
  • Radiation
  • Chemotherapy
  • Monoclonal antibody therapy

Ostomy Management

• Ostomy: Surgically created opening diverts stool or urine to outside of body
• Stoma: Portion of bowel sutured onto abdomen
• Abdominal ostomies: Ileostomy, Colostomy, Urostomy

Ileostomy

• Terminal ileum to abdominal wall after total protocolectomy
• Types:
  • Conventional ileostomy: Small stoma in right lower quadrant, Continuous flow of liquid effluent
  • Continent ileostomy: Kock pouch, Internal reservoir with nipple valve, Empty reservoir 3 to 4 times daily
  • Ileoanal or ileorectal anastomosis

Colostomy

• Effluent becomes less liquid and more solid as location of ostomy becomes more distal in colon.

Preoperative Ostomy Care

• Wound ostomy continence nurse: Marks site, Emotional, physical support
• Teaching
• Bowel prep
• Antibiotics

Postoperative Ostomy Care

• Data collection:
  • Vital signs
  • Stoma: Pink to red, moist = normal, Bluish = inadequate blood supply, Black = necrosis

Review Question #1

• The nurse noticed that the patient has not had a bowel movement for 4 days, the abdomen is distended, and patient reports bloating. Which of these interventions should the nurse implement? Select all that apply.
  • Add fiber to diet.
  • Ambulate frequently.
  • Elevate head of the bed.
  • Increase fluids.
  • Notify the HCP immediately.
• Correct Answer: 1, 2, 4

Review Question #2

• The nurse if preparing to administer budesonide (Entocort EC) with the patient’s breakfast. Which intervention should the nurse complete prior to administration?
  • Check morning laboratory values.
  • Remove grapefruit from breakfast tray.
  • Obtain daily weight.
  • Crush the pill and give with food.
• Correct Answer: 2

Review Question #3

• The nurse is caring for a patient with uc who reports anorexia, five stools daily, and rectal bleeding. Which action should the nurse take first?
  • Discuss the patient’s food preferences.
  • Ask the patient the characteristics of the stool.
  • Inspect anus for fissures.
  • Obtain vital signs.
• Correct Answer: 4

Review Question #4

• The nurse is admitting a patient with celiac disease. Which data should be reported immediately to the registered nurse or physician?
  • Reports of fatigue
  • Blood in stool
  • Foul-smelling stool
  • Diarrhea
• Correct Answer: 2

Review Question #5

• The nurse notes decreased bowel sounds, clear lung sounds, pink/red stoma, and no drainage from the stoma for a postoperative patient who had a colostomy placed 6 hours ago. What action should the nurse take? Select all that apply.
  • Notify the HCP that the stoma is pink/red.
  • Continue to monitor the patient’s status.
  • Encourage turn, cough, deep breathing hourly.
  • Ambulate with assistance as ordered.
  • Monitor for flatus from stoma.
• Correct Answer: 2, 3, 4, 5