Chapter 38
Digestive Tract
Disorders
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Learning Objectives
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Identify the nursing responsibilities in the care of patients
undergoing diagnostic tests and procedures for disorders of the digestive
tract.
List the data to be included in the nursing assessment of
the patient with a digestive disorder.
Describe the nursing care of patients with gastrointestinal
intubation and decompression, tube feedings, total
parenteral nutrition, digestive tract surgery, and drug
therapy for digestive disorders.
Describe the pathophysiology, signs and symptoms,
complications, and medical treatment of selected digestive
disorders.
Assist in developing nursing care plans for patients receiving
treatment for digestive disorders.
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Anatomy and Physiology of the
Digestive Tract
• Mouth
• Where teeth, tongue, and salivary glands begin food digestion
• Pharynx
• Muscular structure shared by the digestive and respiratory
tracts
• It joins the mouth and nasal passages to the esophagus
• Esophagus
• Long muscular tube that passes through the diaphragm into
the stomach
• Stomach
• Churns and mixes food with gastric secretions until a
semiliquid mass called chyme
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Anatomy and Physiology of the
Digestive Tract
• Small intestine
• Chemical digestion and absorption of nutrients take
place
• Approximately 20 feet long and consists of three
sections: the duodenum, the jejunum, and the ileum
• Liver and pancreatic secretions enter the digestive
tract in the duodenum
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Anatomy and Physiology of the
Digestive Tract
• Large intestine and anus
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The first section of the large intestine is the cecum
Ascending colon goes up right side of the abdomen
Transverse colon crosses abdomen just below waist
Descending colon goes down left side of abdomen
The last 6 to 8 inches of the large intestine is the
rectum, which ends at the anus, where wastes leave
the body
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Figure 38-1
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Age-Related Changes
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Teeth are mechanically worn down with age
The jaw may be affected by osteoarthritis
A significant loss of taste buds with age
Xerostomia (dry mouth) is common
Walls of esophagus and stomach thin with aging, and
secretions lessen
Production of hydrochloric acid and digestive enzymes
decreases
Gastric motor activity slows
Movement of contents through the colon is slower
Anal sphincter tone and strength decrease
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Health History
• Chief complaint and history of present illness
• A detailed description of the present illness
• Complaints include weight changes, problems with
food ingestion, symptoms of digestive disturbances,
or changes in bowel elimination
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Health History
• Past medical history
• Recent surgery, trauma, burns, or infections
• Serious illnesses, such as diabetes, hepatitis,
anemia, peptic ulcers, gallbladder disease, and
cancer
• Alternative methods of feeding or fecal diversion
• Prescription and over-the-counter medications
• Food allergy or intolerance
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Health History
• Review of systems
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Description of the patient’s general health state
Changes in skin: dryness, bruising, and pruritus
Whether the patient has any mouth problems
Document if the patient has dentures, partial plates,
or natural teeth, and record the last dental
examination
Problems with chewing or swallowing
Changes in appetite, food intake, and weight
Nausea, vomiting, dyspepsia, heartburn, flatus,
abdominal distention, or pain
Assessment of elimination
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Health History
• Functional assessment
• Information about general dietary habits should
include the daily pattern of food intake
• Attitudes and beliefs about food, and changes in
dietary habits related to health problems
• Effects of chief complaint on usual functioning
• Note whether the patient is able to obtain and
prepare food, and eat independently
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Physical Examination
• Head and neck
• Inspect the mouth
• Abdomen
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Inspection
Auscultation
Percussion
Palpation
• Rectum and anus
• Palpate for lumps and tenderness in the rectum
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Figure 38-2
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Diagnostic Tests and Procedures
• Radiographic studies
• Upper gastrointestinal (UGI or GI) series
• Small bowel series
• Barium enema examination
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Diagnostic Tests and Procedures
• Endoscopic examinations
• Upper GI
• Esophagoscopy, gastroscopy, gastroduodenoscopy,
esophagogastroduodenoscopy, endoscopic retrograde
cholangiography
• Lower GI
• Colonoscopy, proctoscopy, and sigmoidoscopy
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Diagnostic Tests and Procedures
• Laboratory studies
• Gastric analysis
• Occult blood test
• Stool examination
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Figure 38-3
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Figure 38-4
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Therapeutic Measures
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Gastrointestinal Intubation
• Tube feedings
• Delivered by gravity flow or by infusion pump
• Gastrointestinal decompression
• For the relief or prevention of distention
• Levin and gastric sump tubes
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Total Parenteral Nutrition
• Bypasses digestive tract by delivering nutrients
directly to the bloodstream
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Figure 38-5
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Figure 38-6
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Figure 38-7
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Figure 38-9
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Gastrointestinal Surgery
• Preoperative nursing care
• The digestive tract is usually cleansed
• Magnesium citrate or large-volume cathartic (laxative)
solutions; enemas
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Diet limited to liquids 24 hours before surgery
Intravenous fluids
Oral antibiotics
Nasogastric tube inserted and attached to suction
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Gastrointestinal Surgery
• Postoperative nursing care
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Be sure gastrointestinal suction is draining
Inspect, describe, and measure the drainage
Abdomen for distention and bowel sounds
Administer intravenous fluids
Keep strict intake and output records
Drug therapy
• Emetics, antiemetics, laxatives, cathartics, antidiarrheals,
antacids, anticholinergics, mucosal barriers, histamine-2
(H2)-receptor blockers, prostaglandins, and antibiotics
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Disorders of the Digestive Tract
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Anorexia
• Causes
• Nausea, decreased sense of taste or smell, mouth
disorders, and medications
• Emotional problems such as anxiety, depression, or
disturbing thoughts
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Anorexia
• Medical diagnosis
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Physician assesses for malnutrition
Weight may be monitored over several weeks
Complete history and physical examination
Serum hemoglobin, iron, total iron-binding capacity,
transferrin, calcium, folate, B12, zinc
• Thyroid function tests
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Anorexia
• Medical treatment
• Correctable causes of anorexia are treated, but
sometimes no physical cause is found
• Nutritional supplements
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Anorexia
• Assessment
• Record chronic and recent illnesses,
hospitalizations, medications, and allergies
• Female patient’s obstetric history
• Symptoms: pain, nausea, dyspnea, extreme fatigue
• The functional assessment reveals patterns of
activity and rest, usual dietary patterns, current
stressors, and coping strategies—all can affect
appetite
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Anorexia
• Interventions
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Assist with oral hygiene before and after meals
Teach proper oral hygiene; refer for dental care
Relieve nausea before presenting a meal tray
Before serving meal tray, remove bedpans/emesis
basins from sight, conceal drains and drainage
collection devices, deodorize room if necessary
• Socialization during mealtime
• Respect food likes and dislikes
• Position patient comfortably with easy access to
food
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Feeding Problems
• Patients with paralysis, arthritis, neuromuscular
disorders, confusion, weakness, or visual
impairment are likely to need assistance
• Medical diagnosis and treatment
• Identifying problems, prescribing treatment
• Patients often referred to physical therapy and
occupational therapy
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Feeding Problems
• Assessment
• Assess each patient’s ability to feed self
• Determine nature of patient’s difficulty and identify
remaining abilities
• Assess visual acuity, range of motion and muscle
strength in both arms, and range of motion and grip
strength in both hands; ability to follow instructions
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Feeding Problems
• Interventions
• Proper positioning and arrangement of the meal tray
• Provide assistive devices
• Open milk cartons, cut meat, butter bread, and
season food
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Stomatitis
• A general term for inflammation of the oral
mucosa
• Medical treatment is directed toward
determining the cause and eliminating it; a soft,
bland diet may be ordered
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Vincent’s Infection
• Bacterial infection that causes a metallic taste
and bleeding ulcers in the mouth, foul breath,
and increased salivation
• Topical antibiotics and mouthwashes to treat
infection; rest, a nutritious diet, and good oral
hygiene
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Herpes Simplex
• Caused by the herpes simplex virus, type 1
• Ulcers and vesicles in mouth and on lips
• Occur with upper respiratory tract infections,
excessive sun exposure, or stress
• Spirits of camphor, topical steroids, and
antiviral agents as treatment
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Aphthous Stomatitis (“Canker Sore”)
• May be caused by a virus
• Characterized by ulcers of the lips and mouth
that recur at intervals
• Topical or systemic steroids may be used
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Candida albicans
• Yeastlike fungus causes the oral condition
known as thrush or candidiasis
• Bluish white lesions on the mucous
membranes
• Patients at high risk include those on steroid or
long-term antibiotic therapy
• Treated with oral or topical antifungal agents;
vaginal nystatin tablets can be used like
lozenges and allowed to dissolve in the mouth
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Nursing Care
• Assessment
• Pain location, onset, and precipitating factors
• Record any known illnesses and treatments,
including drugs and radiation therapy
• Describe habits, including diet, oral care practices,
alcohol intake, and use of tobacco
• Assess patient’s stress level
• Inspect lips and oral cavity for redness, swelling,
and lesions
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Nursing Care
• Interventions
• Gentle oral hygiene, prescribed mouthwashes
• The teeth and tongue can be cleansed with a softbristle toothbrush, sponge, or cotton-tipped
applicator
• Medications must be given as ordered
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Dental Caries
• A destructive process of tooth decay
• The only treatment for dental caries is removal
of the decayed part of the tooth, followed by
filling the cavity with a restorative material
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Periodontal Disease
• Begins with gingivitis; progresses to involve the
other structures that support the teeth
• Gums red, swollen, painful, and bleed easily
• Primarily from inadequate oral hygiene
• Treatment in early stage: dental care for teeth
cleaning and correction of contributing
problems
• Untreated, abscesses develop around the
roots, the teeth loosen, and extraction is
necessary
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Figure 38-10
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Nursing Care
• Assessment
• Observe condition of teeth and gums
• Document missing or broken teeth, caries, redness
or lesions of the gums, and gum recession
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Nursing Care
• Interventions
• Most patients are treated for dental and gum
conditions in dentists’ offices
• Interventions directed at minimizing pain until the
problem can be corrected by a dentist
• Provide oral care for patients who cannot do it
themselves
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Oral Cancer
• Squamous cell carcinoma and basal cell
carcinoma
• Risk factors
• Cancer of the lip related to prolonged exposure to
irritants, including sun, wind, and pipe smoking
• Factors that increase the risk of cancers inside the
mouth include tobacco and alcohol use, poor
nutritional status, and chronic irritation
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Oral Cancer
• Signs and symptoms
• Tongue irritation, loose teeth, and pain in the tongue
or ear
• Malignant lesions may appear as ulcerations,
thickened or rough areas, or sore spots
• Leukoplakia: hard, white patches in the mouth;
premalignant
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Oral Cancer
• Medical diagnosis and treatment
• A biopsy of suspicious lesions
• Treatment includes surgery, radiation, or
chemotherapy, or a combination of these
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Oral Cancer
• Assessment
• History of prolonged sun exposure, tobacco use, or
alcohol consumption
• Assess for difficulty swallowing or chewing,
decreased appetite, weight loss, change in fit of
dentures, and hemoptysis
• The physical examination should focus on
examination of the mouth for lesions
• Assess the neck for limitation of movement and
enlarged lymph nodes
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Figure 38-11
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Oral Cancer
• Interventions
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Impaired Oral Mucous Membrane
Ineffective Breathing Pattern
Pain
Imbalanced Nutrition: Less Than Body
Requirements
Impaired Verbal Communication
Disturbed Body Image
Risk for Infection
Ineffective Tissue Perfusion
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Parotitis
• Inflammation of the parotid glands
• Causes painful swelling of the salivary glands
below the ear next to the lower jaw; pain
increases during eating
• Treated with antibiotics, mouthwashes, and
warm compresses; surgical drainage or
removal may be necessary
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Achalasia
• Progressively worsening dysphagia
• Failure of the lower esophageal muscles and
sphincter to relax during swallowing
• Thought to be a neuromuscular defect affecting
the esophageal muscles
• Treatment includes drug therapy, dilation, and
surgical measures
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Esophageal Cancer
• Pathophysiology
• No known cause, but predisposing factors are
cigarette smoking, excessive alcohol intake, chronic
trauma, poor oral hygiene, and eating spicy foods
• Signs and symptoms
• Progressive dysphagia
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Esophageal Cancer
• Medical diagnosis
• Barium swallow, computed tomography,
esophagoscopy, and endoscopic ultrasonography
• Medical and surgical treatment
• Surgery, radiation, chemotherapy, or various
combinations
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Figure 38-12
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Esophageal Cancer
• Assessment
• Dysphagia, pain, and choking
• Hoarseness, cough, anorexia, weight loss, and
regurgitation
• The functional assessment documents the use of
alcohol and tobacco and dietary practices
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Esophageal Cancer
• Interventions
• Pain
• Imbalanced Nutrition: Less Than Body
Requirements
• Anxiety
• Risk for Injury
• Impaired Gas Exchange
• Deficient Knowledge
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Nausea and Vomiting
• Nausea: sometimes referred to as queasiness
• Vomiting: forceful expulsion of stomach
contents through the mouth
• Complications
• Significant losses of fluids and electrolytes
• Aspiration
• Medical treatment
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Antiemetics
Intravenous fluids
Oral fluids may be limited to clear liquids or withheld
Nasogastric tube
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Nausea and Vomiting
• Assessment
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Onset, frequency, and duration of present illness
Conditions under which nausea and vomiting occur
Amount, color, odor, and contents of the vomitus
Surgeries, chronic illnesses, allergies, and
medications
• General appearance; record vital signs,
height/weight
• Assess pulse and blood pressure, tissue turgor,
mental status, and muscle tone
• Inspect, auscultate, and palpate the abdomen for
distention, bowel sounds, and tenderness
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Nausea and Vomiting
• Interventions
• Imbalanced Nutrition and Deficient Fluid Volume
• Risk for Aspiration
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Hiatal Hernia
• Pathophysiology
• Protrusion of lower esophagus and stomach up
through the diaphragm and into the chest
• Causes
• Weakness of diaphragm muscles where esophagus
and stomach join, but exact cause is not known
• Factors are excessive intra-abdominal pressure,
trauma, and long-term bed rest in a reclining
position
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Hiatal Hernia
• Signs and symptoms
• Many people have no symptoms at all; others report
feelings of fullness, dysphagia, eructation,
regurgitation, and heartburn
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Figure 38-13
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Hiatal Hernia
• Medical diagnosis
• Barium swallow examination with fluoroscopy
• Esophagoscopy
• Esophageal manometry
• Medical treatment
• Drug therapy, diet, and measures to avoid increased
intra-abdominal pressure
• Surgery: fundoplication and placement of the
synthetic Angelchik prosthesis
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Figure 38-14
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Figure 38-15
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Hiatal Hernia
• Assessment
• Document symptoms
• Record factors that trigger symptoms as well as
measures that aggravate or relieve them
• Patient’s dietary habits, use of alcohol and tobacco,
and medication history
• Interventions
• Chronic Pain
• Risk for Aspiration
• Imbalanced Nutrition: Less Than Body
Requirements
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Hiatal Hernia
• Postoperative care
• Turning, coughing, and deep breathing
• Patient might have nasogastric tube in place and
connected to suction for a day or two
• Until bowel function returns, the patient is given only
intravenous fluids
• Tell the patient to expect mild dysphagia for several
weeks
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GERD
• Backward flow of gastric contents from the
stomach into the esophagus
• Pathophysiology
• Abnormalities around the LES, gastric or duodenal ulcer,
gastric or esophageal surgery, prolonged vomiting, and
prolonged gastric intubation
• Eventually causes esophagitis
• Signs and symptoms
• Painful burning sensation that moves up and down,
commonly occurs after meals, and is relieved by antacids
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GERD
• Medical diagnosis
• Suggested by the signs and symptoms
• Endoscopy, biopsy, gastric analysis, esophageal
manometry, 24-hour monitoring of esophageal pH,
and acid perfusion tests
• Medical treatment and nursing care
• Like those described earlier for hiatal hernia
• Drug therapy may include H2-receptor blockers,
prokinetic agents, and proton pump inhibitors
• If medical care unsuccessful, surgical fundoplication
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Gastritis
• Pathophysiology
• Inflammation of the lining of the stomach
• Mucosal barrier that normally protects the stomach
from autodigestion breaks down
• Hydrochloric acid, histamine, and pepsin cause
tissue edema, increased capillary permeability,
possible hemorrhage
• Helicobacter pylori thought to be prime culprit
• Signs and symptoms
• Nausea, vomiting, anorexia, a feeling of fullness,
and pain in the stomach area
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Gastritis
• Medical diagnosis
• Gastroscopy
• Laboratory studies to detect occult blood in the
feces, low blood hemoglobin and hematocrit, and
low serum gastrin levels; H. pylori can be confirmed
by breath, urine, stool, or serum tests, or by gastric
tissue biopsy
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Gastritis
• Medical treatment
• Oral fluids and foods withheld until the acute
symptoms subside; IV fluids administered
• Medications to reduce gastric acidity and relieve
nausea
• Analgesics for pain relief and antibiotics for H. pylori
• Surgical intervention may be needed
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Gastritis
• Assessment
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Patient’s present illness
Pain, indigestion, nausea, and vomiting
Determine the onset, duration, and location of pain
Note factors that trigger or relieve the symptoms
Diet, use of alcohol and tobacco, activity/rest patterns
Patient’s general appearance for signs of distress
Compare vital signs, height, weight to previous readings
Note the skin color and check turgor
Inspect abdomen for distention; palpate for tenderness
Auscultate abdomen for increased bowel sounds
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Gastritis
• Interventions
• Pain
• Imbalanced Nutrition: Less Than Body
Requirements
• Deficient Fluid Volume
• Ineffective Coping
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Peptic Ulcer
• Pathophysiology
• Loss of tissue from lining of the digestive tract
• Classified as gastric or duodenal
• Causes
• Contributing factors: drugs, infection, stress
• Most ulcers are caused by the microorganism H.
pylori
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Peptic Ulcer
• Signs and symptoms
• Burning pain
• Nausea, anorexia, weight loss
• Complications
• Hemorrhage, perforation, or pyloric obstruction
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Peptic Ulcer
• Medical diagnosis
• Barium swallow examination, gastroscopy, and
esophagogastroduodenoscopy
• H. pylori can be detected by antibodies in the blood
or stool, and by a breath test
• Medical treatment
• Drug therapy
• Diet therapy
• Managing complications
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Peptic Ulcer
• Care of the patient managed medically
• Assessment
• Pain, including location, aggravating factors, and measures
that bring relief; relationship between pain and food intake
• Recent serious illnesses, previous peptic ulcer disease,
and a medication history
• Functional assessment: patient’s usual diet, use of alcohol
and tobacco, activities, sleep patterns, and stressors
• Vital signs; height and weight; skin and mucous
membranes for turgor and moisture
• Inspect abdomen for distention and palpate for tenderness
• Auscultate for bowel sounds
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Peptic Ulcer
• Care of the patient managed medically
• Interventions
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Pain
Imbalanced Nutrition: Less Than Body Requirements
Risk for Injury
Ineffective Coping
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Peptic Ulcer
• Care of the patient managed surgically
• Assessment
• Pain, nausea, and vomiting
• Measure vital signs at frequent intervals
• Note the amount and type of IV fluids, and check the infusion site
for swelling or redness
• Document patency of the nasogastric tube as well as the color
and amount of drainage
• Breath sounds; inspect the wound dressing for bleeding
• Inspect abdomen for distention and auscultate for bowel sounds
• Monitor urine output and palpate for bladder distention
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Peptic Ulcer
• Care of the patient managed surgically
• Interventions
• Risk for Injury
• Imbalanced Nutrition: Less Than Body Requirements
• Decreased Cardiac Output
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Stomach Cancer
• Pathophysiology
• Begins in the mucous membranes, invades the
gastric wall, and spreads to the regional lymphatics,
liver, pancreas, and colon
• No specific signs or symptoms in the early stages
• Late signs and symptoms are vomiting, ascites, liver
enlargement, and an abdominal mass
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Stomach Cancer
• Risk factors
• H. pylori infection, pernicious anemia, chronic
atrophic gastritis, and achlorhydria, type A blood,
and a family history
• Cigarette smoking, alcohol abuse, and a diet high in
starch, salt, pickled foods, salted meats, and
nitrates
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Stomach Cancer
• Medical diagnosis
• Gastroscopy, endoscopic ultrasound, upper GI
series, CT, PET scan, MRI, laparoscopy
• Laboratory studies include hemoglobin and
hematocrit, serum albumin, liver function tests, and
carcinoembryonic antigen
• Medical treatment
• Surgery, chemotherapy, and radiation therapy
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Figure 38-16
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Stomach Cancer
• Preoperative care of the patient with stomach
cancer
• Inform about the nasogastric tube and IV fluids;
teach coughing, deep breathing, and leg exercises
• Identify/support patient’s coping methods
• Include sources of support, such as family members
or a spiritual counselor, in the preoperative care
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Stomach Cancer
• Postoperative care of the patient with stomach
cancer
• Assessment
• Comfort, appetite, and nausea and vomiting
• Monitor weight changes and determine dietary preferences
• Identify the patient’s support system and coping strategies
• Interventions
• Pain
• Imbalanced Nutrition: Less Than Body Requirements
• Ineffective Coping
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Obesity
• Increased weight caused by excessive body fat
• Causes
• Heredity, body build/metabolism, psychosocial
factors
• Basic problem: caloric intake exceeds metabolic
demands
• Complications
• Cardiovascular and respiratory problems,
polycythemia, diabetes mellitus, cholelithiasis
(gallstones), infertility, endometrial cancer, and fatty
liver infiltration
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Obesity
• Medical diagnosis
• Standard weight tables
• Measuring skinfold thickness
• Endocrine function tests
• Medical and surgical treatment
• Weight reduction diet accompanied by a planned
exercise program
• Drug therapy
• Bariatric surgery
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Obesity
• Assessment
• Identify factors that contribute to obesity
• Ask about usual dietary practices
• Identify factors that trigger overeating and reactions
to overeating
• Collect data about previous efforts to lose weight
and current interest in losing weight
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Obesity
• Interventions for the obese patient managed
nonsurgically
• Imbalanced Nutrition: More Than Body
Requirements
• Ineffective Tissue Perfusion
• Ineffective Breathing Pattern
• Disturbed Body Image
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Obesity
• Interventions after bariatric surgery
•
•
•
•
Impaired Gas Exchange
Impaired Tissue Perfusion
Impaired Skin Integrity
Imbalanced Nutrition: Less Than Body
Requirements
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Malabsorption
• One or more nutrients are not digested or
absorbed
• Many causes: bacteria, deficiencies of bile
salts or digestive enzymes, alterations in the
intestinal mucosa, and absence of all or part of
the stomach or intestines
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Malabsorption
• Signs and symptoms
• Steatorrhea
• Weight loss, fatigue, decreased libido, easy bruising,
edema, anemia, and bone pain
• Bloating, cramping, abdominal cramps, and
diarrhea are symptoms of lactase deficiency
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Malabsorption
• Medical diagnosis
• Sprue: based on laboratory studies, endoscopy with
biopsy, and radiologic imaging studies
• Lactase deficiency: based on the health history, the
lactose tolerance test, a breath test for abnormal
hydrogen levels, and if necessary, biopsy of the
intestinal
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Malabsorption
• Medical treatment
• Sprue: diet and drug therapy; foods that aggravate
symptoms eliminated from the diet
• Celiac disease: avoid products that contain gluten
• Tropical sprue: antibiotics, oral folate, and vitamin
B12 injections
• Lactase deficiency: eliminate milk and milk products
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Malabsorption
• Nursing care
• Document the patient’s symptoms
• Note stool characteristics
• In the case of celiac sprue, teach the patient how to
eliminate gluten from the diet
• Give antibiotics as ordered for tropical sprue
• If folic acid therapy continued, instruct patient in
self-medication
• The effect of therapy is evaluated by the return of
normal stool consistency
• Advise the patient with lactase deficiency of dietary
restrictions and alternative products
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Diarrhea
• The passage of loose, liquid stools with
increased frequency
• May have cramps, abdominal pain, and a
feeling of urgency before bowel movements
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Diarrhea
• Causes
• Spoiled foods, allergies, infections, diverticulosis,
malabsorption, cancer, stress, fecal impactions, and
tube feedings
• Adverse effect of some medications
• Complications
• Dehydration, electrolyte imbalances, and metabolic
acidosis
• Malnutrition and anemia
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Diarrhea
• Medical treatment
• Acute diarrhea usually treated by resting the
digestive tract and giving antidiarrheal drugs
• Severe, persistent diarrhea may require TPN
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Diarrhea
• Assessment
• Diarrhea and onset, severity, precipitating factors,
and measures that bring relief
• Ask about stool characteristics, including amount,
color, odor, and unusual contents, such as blood,
mucus, or undigested food
• Functional assessment focuses on usual diet,
dietary changes, recent and current medications,
recent travel to a foreign country
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Diarrhea
• Interventions
• Deficient Fluid Volume and Imbalanced Nutrition:
Less Than Body Requirements
• Impaired Skin Integrity
• Pain
• Self-Care Deficit
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Constipation
• Hard, dry, infrequent stools that are passed
with difficulty
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Constipation
• Causes
•
•
•
•
•
Frequently ignoring the urge to defecate
Frequent use of laxatives or enemas
Inactivity
Inadequate water intake
Diet low in fiber and high in cheese, lean meat,
pasta
• Drugs that slow intestinal motility/increase urine
output
• Diseases of the colon or rectum, as well as brain or
spinal cord injury; abdominal surgery
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Constipation
• Complications
• Valsalva maneuver
• The rapid changes in blood flow can be fatal to a patient
with heart disease
• Hemorrhoids
• Fecal impaction
• Medical treatment
• Laxatives, suppositories, enemas, or combination
for prompt results
• Stool softeners
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Constipation
• Assessment
• Usual pattern of bowel elimination, including
frequency, amount, color, unusual contents, and
pain associated with defecation
• Information about diet, exercise, and drug therapy
• Any aids to elimination; type and frequency of use
• Examine abdomen for distention or visible
peristalsis
• Auscultate for bowel sounds in all four quadrants of
the abdomen
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Constipation
• Interventions
• Maintained with diet, fluids, exercise, and regular
toilet habits
• Megacolon
• Regular enemas for bowel cleansing
• Fecal impaction
• Assess for impaction by inserting a gloved, lubricated
finger into the rectum
• Remove impaction following agency protocol or specific
physician’s orders
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Intestinal Obstruction
• Causes
• Strangulated hernia, tumor, paralytic ileus, stricture,
volvulus (twisting of the bowel), intussusception
(telescoping of the bowel into itself), and
postoperative adhesions
• Signs and symptoms
• Vomiting (possibly projectile), abdominal pain, and
constipation
• Blood or purulent drainage passed rectally
• Abdominal distention, especially with colon
obstruction
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Intestinal Obstruction
• Complications
• Fluid and electrolyte imbalances and metabolic
alkalosis
• Gangrene and perforation of the bowel
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Figure 38-17
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Intestinal Obstruction
• Medical diagnosis
• History, physical examination, and laboratory
studies; confirmed by radiologic studies
• Medical treatment
• Gastrointestinal decompression; intravenous fluids;
and surgical intervention
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Intestinal Obstruction
• Assessment
• Symptoms, including pain and nausea
• Onset and progression of symptoms
• Hernia, cancer of the digestive tract, and abdominal
surgeries
• Ask when the patient’s last bowel movement was
and if the characteristics were normal
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Intestinal Obstruction
• Interventions
•
•
•
•
•
Acute Pain
Deficient Fluid Volume
Risk for Infection
Ineffective Breathing Pattern
Anxiety
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Appendicitis
• Pathophysiology
• Inflammation of the appendix
• A ruptured appendix allows digestive contents to
enter the abdominal cavity, causing peritonitis
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Appendicitis
• Signs and symptoms
• Pain at McBurney’s point, midway between the
umbilicus and the iliac crest
• Temperature elevation, nausea, and vomiting
• Elevated WBC count (10,000-15,000/mm3 )
• Peritonitis: absence of bowel sounds, severe
abdominal distention, increased pulse and
temperature, nausea/vomiting; rigid abdomen
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Figure 38-18
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Appendicitis
• Medical treatment
• Nothing by mouth
• A cold pack to the abdomen may be ordered
• Laxatives and heat applications should never be
used for undiagnosed abdominal pain
• Immediate surgical treatment indicated
• Ruptured appendix: surgery may be delayed 6-8
hours while antibiotics and IV fluids given
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Appendicitis
• Assessment
• Location, severity, onset, duration, precipitating
factors, and alleviating measures in relation to the
pain
• Previous abdominal distress, chronic illnesses,
surgeries; record allergies and medications
• Temperature; abdominal pain, distention, and
tenderness; presence and characteristics of bowel
sounds
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Appendicitis
• Preoperative interventions
• Semi-Fowler or side-lying position with the hips
flexed
• Until physician determines the diagnosis, analgesics
may be withheld
• If rupture suspected, elevate patient’s head to
localize the infection
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Appendicitis
• Postoperative interventions
• Administer antibiotics, intravenous fluids, and
possibly gastrointestinal decompression
• Assist the patient in turning, coughing, and deep
breathing; incentive spirometry
• Splint the incision during deep breathing
• Early ambulation
• Assess abdominal wound for redness, swelling, and
foul drainage
• Wound care as ordered or according to agency
policy
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Peritonitis
• Pathophysiology
• Inflammation of peritoneum caused by chemical or
bacterial contamination of the peritoneal cavity
• Signs and symptoms
• Pain over affected area, rebound tenderness,
abdominal rigidity and distention, fever, tachycardia,
tachypnea, nausea, and vomiting
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Peritonitis
• Medical diagnosis
• History and physical
• Complete blood cell count, serum electrolyte
measurements, abdominal radiography, computed
tomography, and ultrasound
• Paracentesis
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Peritonitis
• Medical treatment
• Gastrointestinal decompression, intravenous fluids,
antibiotics, and analgesics
• Surgery to close a ruptured structure and remove
foreign material and fluid from the peritoneal cavity
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Peritonitis
• Assessment
• Onset, location, and severity of the pain and any
related symptoms
• Record a history of abdominal trauma, including
surgery
• Take and record vital signs
• Inspect abdomen for distention and auscultate for
the presence of bowel sounds
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Peritonitis
• Interventions
• Acute Pain
• Decreased Cardiac Output
• Imbalanced Nutrition: Less Than Body
Requirements
• Anxiety
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Abdominal Hernia
• Pathophysiology
• Weakness in the abdominal wall that allows a
portion of the large intestine to push through
• Weak locations include the umbilicus and the lower
inguinal areas of the abdomen; may also develop at
the site of a surgical incision
• Classified as reducible or irreducible
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Abdominal Hernia
• Signs and symptoms
• A smooth lump on the abdomen
• With incarceration, the patient has severe
abdominal pain and distention, vomiting, and
cramps
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Figure 38-19
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Abdominal Hernia
• Medical diagnosis
• Health history and physical examination
• Medical treatment
• Surgical repair
• Herniorrhaphy
• Hernioplasty
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Abdominal Hernia
• Assessment
• Chief complaint
• Ask about pain and vomiting
• Inspect for abnormalities, and listen for bowel
sounds in all four abdominal quadrants
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Abdominal Hernia
• Preoperative interventions
• Risk for Injury
• Impaired Skin Integrity
• Postoperative interventions
•
•
•
•
Impaired Urinary Elimination
Constipation
Acute Pain
Risk for Injury
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Inflammatory Bowel Disease
• Pathophysiology
• Ulcerative colitis and Crohn’s disease
• Inflammation and ulceration of intestinal tract lining
• Exact cause is unknown
• Possible causes: infectious agents, autoimmune
reactions, allergies, heredity, and foreign
substances
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Inflammatory Bowel Disease
• Signs and symptoms
• Ulcerative colitis
• Diarrhea with frequent bloody stools, abdominal cramping
• Crohn’s disease
• If the stomach and duodenum are involved, symptoms
include nausea, vomiting, and epigastric pain
• Involvement of the small intestine produces pain and
abdominal tenderness and cramping
• An inflamed colon typically causes abdominal pain,
cramping, rectal bleeding, and diarrhea
• Systemic signs and symptoms include fever, night sweats,
malaise, and joint pain
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Inflammatory Bowel Disease
• Complications
• Hemorrhage, obstruction, perforation (rupture),
abscesses in the anus or rectum, fistulas, and
megacolon
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Inflammatory Bowel Disease
• Medical diagnosis
• History and physical examination
• Abdominal radiography
• Barium enema examination with air contrast;
colonoscopy with biopsy, ultrasonography, CT, and
cell studies
• Video capsule
• Medical treatment
• Drug therapy, diet, and rest
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Inflammatory Bowel Disease
• Assessment
•
•
•
•
Onset, location, severity, and duration of pain
Note factors that contribute to the onset of pain
Onset and duration of diarrhea; presence of blood
Vital signs, height and weight, measures of
hydration
• Inspect perianal area for irritation or ulceration
• Maintain accurate intake and output records
• Measure diarrhea stools if possible and count as
output
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Inflammatory Bowel Disease
• Interventions
•
•
•
•
Acute Pain
Diarrhea
Deficient Fluid Volume
Imbalanced Nutrition: Less Than Body
Requirements
• Ineffective Coping
• Risk for Injury
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Diverticulosis
• Pathophysiology
• Small saclike pouches in intestinal wall: diverticula
• Weak areas of the intestinal wall allow segments of
the mucous membrane to herniate outward
• Risk factors
• Lack of dietary residue
• Age, constipation, obesity, emotional tension
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Diverticulosis
• Signs and symptoms
• Often asymptomatic, but many people report
constipation, diarrhea, or periodic bouts of each
• Rectal bleeding, pain in left lower abdomen, nausea
and vomiting, and urinary problems
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Figure 38-20
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Diverticulosis
• Complications
• Diverticulitis
• Bleeding, obstruction, perforation (rupture), peritonitis, and
fistula formation
• Medical diagnosis
• Symptoms
• Abdominal CT and barium enema examination
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Diverticulosis
• Medical treatment
• High-residue diet without spicy foods
• Stool softeners or bulk-forming laxatives;
antidiarrheals; broad-spectrum antibiotics;
anticholinergics
• Surgical intervention may be necessary
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Diverticulosis
• Assessment
• Assess patient’s comfort and stool characteristics;
note nausea and vomiting
• Monitor patient’s temperature
• Assess abdomen for distention and tenderness
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Diverticulosis
• Interventions
•
•
•
•
Fluids as permitted; monitor intake and output
Antiemetics, analgesics, anticholinergics as ordered
Be alert for signs of perforation
Teach patient about diverticulosis, including the
pathophysiology, treatment, and symptoms of
inflammation
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Colorectal Cancer
• Pathophysiology
• Cancer of the large intestine
• People at greater risk for colorectal cancer are
those with histories of inflammatory bowel disease,
or family histories of colorectal cancer or multiple
intestinal polyps
• High-fat, low-fiber diet and inadequate intake of
fruits and vegetables also contribute to development
• Can develop anywhere in the large intestine
• Three fourths of all colorectal cancers are located in the
rectum or lower sigmoid colon
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Figure 38-21
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Colorectal Cancer
• Signs and symptoms
• Right side of the abdomen
• Vague cramping until the disease is advanced
• Unexplained anemia, weakness, and fatigue related to
blood loss may be the only early symptoms
• Left side or in the rectum
• Diarrhea or constipation and may notice blood in the stool
• Stools may become very narrow, causing them to be
described as pencil-like
• Feeling of fullness or pressure in the abdomen or rectum
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Colorectal Cancer
• Medical and surgical treatment
• Usually treated surgically
• Combination chemotherapy postoperatively if tumor
extends through the bowel wall or if lymph nodes
involved
• Early stage rectal cancer sometimes treated with
radiation and surgery
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Colorectal Cancer
• Assessment
• Vital signs, intake and output, breath sounds, bowel
sounds, and pain
• Appearance of wounds and wound drainage
• If there is a colostomy, measure and describe the
fecal drainage
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Colorectal Cancer
• Interventions
•
•
•
•
•
Risk for Injury
Ineffective Tissue Perfusion
Acute Pain
Sexual Dysfunction
Ineffective Coping
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Polyps
• Small growths in the intestine
• Most benign but can become malignant
• Inherited syndromes: familial polyposis and
Gardner’s syndrome
• Usually asymptomatic; found on routine testing
• Complications are bleeding and obstruction
• Diagnosed by barium enema or endoscopic
exam
• Colectomy for familial polyposis or Gardner’s
syndrome because of the high risk of
malignancy
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Hemorrhoids
• Internal or external dilated veins in the rectum
• Thrombosed
• Blood clots form in external hemorrhoids; become
inflamed and very painful
• Risk factors
• Constipation, pregnancy, prolonged sitting or
standing
• Signs and symptoms
• Rectal pain and itching
• Bleeding with defecation
• External hemorrhoids easy to see; appear red/bluish
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Figure 38-22
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Hemorrhoids
• Medical diagnosis and treatment
• Diagnosed by visual inspection
• Nonsurgical treatment
• Topical creams, lotions, or suppositories soothe and shrink
inflamed tissue
• Sitz baths often comforting
• The physician may order heat or cold applications
• Outpatient procedures: ligation, sclerotherapy.
Thermocoagulation/electrocoagulation, laser
surgery
• Hemorrhoidectomy
• The surgical excision (removal) of hemorrhoids
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Hemorrhoids
• Assessment
• After hemorrhoidectomy, monitor vital signs, intake
and output, and breath sounds. Assess the perianal
area for bleeding and drainage
• Interventions
• Acute Pain
• Impaired Skin Integrity
• Constipation
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Anorectal Abscess
• An infection in the tissue around the rectum
• Signs and symptoms are rectal pain, swelling, redness,
and tenderness
• Treated with antibiotics followed by incision and
drainage
• Preoperatively, pain is treated with ice packs, sitz baths,
and topical agents as ordered
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Anorectal Abscess
• Postoperatively, pain treated with opioid
analgesics
• Patient teaching emphasizes importance of
thorough cleansing after each bowel movement
• Advise patient to consume adequate fluids and a
high-fiber diet to promote soft stools
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Anal Fissure
• Laceration between the anal canal and the perianal
skin
• May be related to constipation, diarrhea, Crohn’s
disease, tuberculosis, leukemia, trauma, or childbirth
• Signs and symptoms include pain before and after
defecation and bleeding on the stool or tissue
• If fissure chronic, the patient may experience pruritus,
urinary frequency or retention, and dysuria
• Usually heal spontaneously, but can become chronic
• Conservative treatment: sitz baths, stool softeners, and
analgesics
• Surgical excision may be necessary
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Anal Fistula
• Abnormal opening between anal canal and perianal
•
•
•
•
•
•
skin
Develops from anorectal abscesses or related to
inflammatory bowel disease or tuberculosis
Patient typically complains of pruritus and discharge
Sitz baths provide some comfort
Surgical treatment is excision of fistula and
surrounding tissue
Sometimes a temporary colostomy to allow the surgical
site to heal
Postoperative care: analgesics and sitz baths for pain
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Pilonidal Cyst
• Located in the sacrococcygeal area
• Results from an infolding of skin, causing a
sinus that is easily infected because of its
closeness to the anus
• Once infected, it is painful and swollen and
may form an abscess
• Surgical excision usually recommended
• Care is similar to that for the patient having a
hemorrhoidectomy
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Patient Education to Promote
Normal Bowel Function
• Good hand washing and proper food handling
• People who recognize that stress affects their
gastrointestinal function may benefit from relaxation
techniques and stress management training
• Signs and symptoms of digestive problems should be
reported for prompt diagnosis and treatment if
indicated
• Teaching patients what is normal, how to promote
normal function, and how to detect problems can help
to avoid serious gastrointestinal dysfunction
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